Child and Adolescent Psychiatry Department,

“Carol Davila” University of Medicine and Pharmacy, Bucharest

Child and Adolescent

Psychiatry
 History

• Child neuropsychiatry has existed in Romania since 1948, when the first ward
for children was established at the Socola Psychiatry Hospital in Iaşi
• In Bucharest, the first Child Neuropsychiatry clinic was built in 1950 at “Prof.
Dr. Al. Obregia” Clinical Psychiatry hospital (currently our V-B clinical ward)
• The year 1996 marks the separation of Child Neuropsychiatry into 2 medical
specialties:
❑ Pediatric Neurology
❑ Pediatric Psychiatry
 Mental health
• Health the condition of complete physical, mental and social well-being
it does not refer only to the absence of a disease or infirmity

• Mental health: subjective well-being of an individual/ community that can be

achieved through a harmonious personal development, respectively through a
balanced collective life, in which people communicate freely and share the same
values.

• The normal (adapted) person: the person who corresponds as much as possible to
the statistical and ideal norm of a given socio-cultural setting, managing to fulfill at
the same time their functional role within the socio-professional system of which
they are part.

• An individual with mental health disorders: a person with a type of mental imbalance or
who is insufficiently intellectually-developed or dependent on psychoactive substances,
whose manifestations fall within the current diagnostic criteria for psychiatric disorders
Mental Heath Law ( No. 487/2002)
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy, Bucharest

Classification of mental health disorders

in children and adolescents
 Taxonomic systems
European American
• ICD = “International Classification of • The Diagnostic and Statistical Manual
Diseases”, The World Health of Mental Disorders (5th ed.; DSM–5)
Organization American Psychiatric Association,
- 10th edition (ICD -10): Geneve, 1992 Washington 2013
- 11th edition (ICD -11): approved in
2019, currently on-line version, to be in
use from 2022
 Axial diagnostic system
Axis ICD 10 DSM IV-TR
Emotional and behavioral disorders Clinical disorders
I with childhood onset

Developmental disorders Personality disorders

II
Intellectual disability
III Associated medical conditions Associated medical conditions
Associated special psycho-social Associated special family and
IV
circumstances psycho-social circumstances
Intellectual level Global Assessment of Functioning
V

Use of the axes system in ICD 10 şi DSM IV-TR (Graham, 1999)

Classification of mental health disorders - diagnostic categories
ICD-10 DSM 5
F70 -F79 Mental retardation Intellectual Disability (Intellectual Development Disorder)
F80 – F89 Disorders of psychological development Communication Disorders
F80 Specific developmental disorders of speech and − Language Disorder
language − Speech Sound Disorder
F81 Specific developmental disorders of scholastic skills − Childhood-Onset Fluency Disorder (Stuttering)
− Social (Pragmatic) Communication Disorder
F84 Pervasive developmental disorders
Specific Learning Disorders
Autism Spectrum Disorders
F90-98 Behavioural and emotional disorders with onset - Attention-Deficit/Hyperactivity Disorder
usually occurring in childhood and adolescence - Disruptive, Impulse-Control, and Conduct Disorders
F90 Hyperkinetic disorders - Separation anxiety
F91 Conduct disorders - Elective mutism
F93 Emotional disorders with onset specific to childhood - Tic disorders
F94 Disorders of social functioning with onset specific to - Feeding and Eating Disorders
childhood and adolescence - Elimination disorders
F95 Tic disorders
F98 Other behavioural and emotional disorders with
onset usually occurring in childhood and adolescence
(enuresis, encopresis, pica)
Etiology of mental health disorders in children and adolescents

Trauma

Stress factors

Social deprivation /
institutionalization

Abuse / neglect

O. Issler, Neuroscience, 2015

Epidemiology of mental health disorders in children and adolescents

CDC (USA):
- 1 in 6 children at some point
in their life have a mental
disorder
- 13% of children aged
between 8 and 15 had a
diagnosable mental health
disorder in 2015

NHS (UK), 2017:

- 12.8% (1 in 8) of children
aged 5 to 19 had a
diagnosable mental
disorder
- - emotional disorders
were the most common
type of disorder in
children aged 5 to 19
years (8.1%)
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy, Bucharest

Psychomotor development in children

 Psycho-motor development of children and adolescents

• Childhood:
- "Process of socialization and humanization, of assimilation of the socio-cultural
universe, a complex phenomenon that has its own, specific formulas“
- "The indispensable condition for any effort which, starting from the recognition
of the importance of the development of the child’s mental and emotional sides,
aims to understand, stimulate and direct it in the desired direction, away from
risks and unpleasant surprises“ (Acad. Prof. Dr. Ştefan Milea, 1988)

• Development:
- a complex and unitary process
- psychomotor development parameters = average statistical values
- every child is a unique reality
- the assessment of the significance of deviations from normal can only be made correctly if
one takes into account the entire context of the available clinical and anamnestic data, as
well as the dynamics of their evolution
 Infant
Motor development Language development

• Head control after 3 moths • Before 3 months the only way to

communicate their discomfort is
• 6 months – sits up through crying

th • 3 months - cooing
• After 8 month – starts crawling
• 6 months – first syllables, babbling
• 10 months – starts to walk with
help • 7 months – babbles in repetitive
syllables (mamama, bababa)
• 11 months – standing without help
• After 10 months – first words
• 1 year – starts walking without help
 1 year
Motor development
• Climbing stairs with help,
without alternating feet
• 18 months – alternates feet
when climbing stairs
• Starts turning multiple pages
of books
• Can pick up small objects
Language development
• Recognizes his/her name
• 3-5 words
• 18 months – 20 words
vocabulary
• Starts mixing words with
sound in his/her “own
language”
• Non-verbal communication –
pointing, extending hands
 2 years
Motor development Language development

• Kicks ball • Recognizes 200-300 words

• 2 ½ years – climbing stairs without
any help
• Turns page by page
• Starts scribbling, drawing lines and
later drawing a circle
• Names common objects
• Starts putting 2 words together
• Starts using prepositions (on, in),
pronouns (me, you),
verbs(„come!”, „go!”);
• Can execute simple indications
without needing non-verbal/
gesture explanations
Summary of developmental milestones from zero to two years
Summary of developmental milestones from zero to two years
 3 years
• Recognizes and knows 900-1000
words
• Starts using simple sentences
• Can follow a 2 step command
• Repeats words with 5-7 syllables
• His/her language is understood
by family members
4 years
•Uses more sentences
•Knows 1500-1600 words
•Recounts/narrates recent events
•Understands questions about recent
events
•Starts using conjunctions (if, but,
because)
•His/her language is understood by other
people, outside the family
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy, Bucharest

Neuroanatomy
- the expressive component
- attention, memory, thinking - perception of space
- emotions, behaviors - visual-spatial integration

- sensory functions
- affective-motivational
- integration of visual functions
functions
- visual memory
- attention, vigilance
 Cerebral cortex

• motivation, logic and rational thinking

• writing, reading and mathematical calculations are cortical functions

• the prefrontal cortex develops fully at adult age

• the prefrontal cortex is responsible for :

• decision making Executive

• impulse control functions Implications in
• problem solving disorders such as
• goal setting ADHD
• activity planning
 The limbic system
• hunger;
• thirst;
• temperature regulation; • Dorsal nucleus - affective
• sleep behavior and memory
• Anterior nucleus - affectivity

• anxiety;
• fear; • learning;
• hatred; • memory;
• aggressive behavior • recognition of new elements
https://teenbraintalk.wordpress.com/limbic-system
 Neuroplasticity
• neural circuits are subject to changes and reorganizations throughout their lives

• the neural system has the ability to adapt its structure and function in response to
changes in the external environment

• the ability of the brain to reorganize and adapt neural circuits according to hormonal
alterations and sensory changes = neuroplasticity

• the role of early stressors should be considered in terms of neuroplasticity in children:

- example: in animals that did not receive maternal care at an early age, the impact on
neuroplasticity was observed by shortening the length of the dendrites and low cell
density in the hippocampus

subsequent vulnerability to mental illness

Champagne, 2008
 Child and Adolescent Psychiatry Department,
“Carol Davila” University of Medicine and Pharmacy, Bucharest

Diagnostic Tools in
Child and Adolescent Psychiatry
 Tools for assessing children with neurodevelopmental disorders

• Adaptive Behavior Assessment System Third Edition (ABAS-3)

gives a complete picture of adaptive skills across the lifespan
• particularly useful for evaluating those with developmental
delays, autism spectrum disorder, intellectual disability,
learning disabilities, neuropsychological disorders, and sensory
or physical impairments
• Skill areas assessed are: Communication; Community Use;
Functional Academics; Health and Safety; Home or School
Living; Leisure; Self-care; Self-direction; Social; Work; Motor
• Forms: Behavior rating scale typically completed by parent,
caregiver, and/or teacher; self-rating option for adults
• Scores/Interpretation: For the 11 skill areas
assessed—norm-referenced scaled scores. For the 3 adaptive
domains and the General Adaptive Composite
(GAC)—norm-referenced standard scores, confidence intervals
for standard scores, and percentile ranks. In addition, all scores
can be categorized descriptively.
• Age range: Birth–89
• Publication date: 2015

https://www.academictherapy.com
 Tools for assessing children with ASD (Autism Spectrum Disorder)

One of the most widely used observation instruments for the assessment of autism is the Autism Diagnostic Observation
Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 2008)

Semi-structured assessment of social interaction, communication, play, and imaginative use of materials for individuals
who may have autism or an autism spectrum disorder (ASD)

The ADOS 2 consists of 5 “modules,” each of which can be administered in 30-45 minutes; the appropriate module is
selected and administered depending on expressive language level and chronological age
- Module 1 is used for children who are preverbal or have single-word language
- Module 2 is appropriate for individuals with phrase speech abilities
- Module 3 is used for children and adolescents who are verbally fluent
- Module 4: verbally fluent adolescents and adults
- Toddler Module
Communication score, a Reciprocal Social Interaction score, and a
Total score
In Modules 1 through 4, algorithm scores are compared with cutoff
scores to yield one of three classifications: autism, autism spectrum
(ASD), or non-spectrum. In the Toddler Module, algorithms yield
"ranges of concern"

https://bestpracticeautism.blogspot.com/2012/01/best-practice-review-autism-diagnostic.html
 Tools for assessing children with ASD (Autism Spectrum Disorder)
The Autism Diagnostic Interview-Revised (ADI-R)
(Michael Rutter, Ann LeCouteur, Catherine Lord)
• Useful for diagnosing Autism, planning treatment, and
differential diagnosis
• Age Range: Children and Adults with a mental age above 2.0

• Composed of 93 items, the ADI-R focuses on three functional

domains:
✔ Language/Communication
✔ Reciprocal Social Interactions
✔ Restricted, Repetitive and Stereotyped Behaviors and Interests

• Due to the interview format, the ADI-R provides categorical,

rather than scales or norms.
Tools for assessing children with ADHD
Tools for assessing cognitive function
Structured Clinical Interview for DSM-IV, Childhood version
(KID-SCID)
NEPSY is a complex diagnostic tool built to assess the neuropsychological
development of preschoolers and schoolchildren
- target age group: 3-12 years

It evaluates: •Sensory-motor functions

•Visual-spatial processing
•Attention / Executive functions (planning, cognitive inhibition)
•Language
•Memory and learning
The Positive and Negative Syndrome Scale (PANSS) is a medical scale used for
measuring symptom severity of patients with schizophrenia/ psychotic disorders
• it was published in 1987 by Stanley Kay, Lewis Opler, and Abraham Fiszbein.
• the name refers to the two types of symptoms in schizophrenia: positive
symptoms, which refer to an excess or distortion of normal functions
(hallucinations and delusions) and negative symptoms, which represent a
diminution or loss of normal functions, such as normal thoughts, actions, ability
to tell fantasies from reality, and the ability to properly express emotions
• Interview items
Positive scale - 7 Items (minimum score = 7, maximum score = 49): Delusions;
Conceptual disorganization; Hallucinations; Excitement; Grandiosity;
Suspiciousness/persecution; Hostility
Negative scale - 7 Items (minimum score = 7, maximum score = 49): Blunted affect; Emotional withdrawal; Poor
rapport; Passive/apathetic social withdrawal; Difficulty in abstract thinking; Lack of spontaneity and flow of
conversation; Stereotyped thinking
General Psychopathology scale - 16 Items (minimum score = 16, maximum score = 112): Somatic concern; Anxiety;
Guilt feelings; Tension; Mannerisms and posturing; Depression; Motor retardation; Uncooperativeness; Unusual
thought content; Disorientation; Poor attention; Lack of judgment and insight; Disturbance of volition; Poor impulse
control; Preoccupation; Active social avoidance

PANSS Total score minimum = 30, maximum = 210

Opler, 2017