CHILD PSYCHIATRY 2

INTRODUCTION 
TICS

DISORDER  ATTENTION DEFICIT HYPERACTIVITY DISORDER  CONDUCT DISORDER  ANXIETY DISORDER  ELIMINATION DISORDER

TICS DISORDER 

Tic disorders are characterized by the persistent presence of tics, which are
abrupt, repetitive involuntary movements and sounds that have been described as caricatures of normal physical acts. 

They can be suppressed but only for a short time and only with
conscious effort.

EPIDEMIOLOGY
Tic disorders have been reported in people of all races, ethnic groups, and socioeconomic classes.  As many as 1 in 100 people may experience some form of tic disorder, usually 

before the onset of puberty.

which are present for more than a year. For a diagnosis of chronic tic disorder.  Chronic tic disorder is either single or multiple motor or phonic tics.CLASSIFICATION Tic disorders are classified as follows:  Transient tic disorder consists of multiple motor and/or phonic tics with duration of at least 4 weeks. . The majority of tics seen in this disorder are motor tics. but less than 12 months. but not both. symptoms must begin before a child is 18 years of age. though vocal tics may also be present.

 Tourette's disorder is diagnosed when both motor and phonic tics are present for more than a year. .  Tic Disorder NOS is diagnosed when tics are present. but do not meet the criteria for any specific tic disorder. Symptoms typically begin when children are between 5 and 18 years old.

Streptococcal infections have been associated with the development of tics . Abnormal neurotransmitters (dopamine. Recreational drugs or prescription medications. Commonly involved are psychomotor stimulants (methylphenidate. serotonin. .CAUSES      The causes of tics and tic disorders are not fully understood but most researchers believe that they are multifactorial. pemoline. and cyclic) contribute to the disorders. Genetic or transmitted within families. amphetamines and cocaine).

SYMPTOMS 

The diagnostic criteria of all tic disorders specify that the symptoms must appear before the age of 18 and that they cannot result from ingestion of such substances as stimulants or from general medical conditions as Huntington's disease. In transient tic disorder -there may be single or multiple motor and/or vocal tics that occur many times a day nearly every day for at least four weeks, but
not for longer than one year. 



Chronic motor or vocal tic disorder -is characterized by either motor tics or vocal tics, but not both. -The tics occur many times a day nearly every day, or intermittently for a period of more than one year. -During that time, the patient is never without symptoms for more than three consecutive months. Touretts syndrome -experienced both multiple motor and one or more vocal tics at some time during the illness -The tics occur many times a day, usually in bouts, nearly every day or intermittently for a period of more than one year. -The patient is never symptom-free for more than three months at a time. 

DIAGNOSIS 

HISTORY TAKING -family history of tics or tic disorders -whether the child has been diagnosed with other childhood developmental or psychiatric disorders -whether he or she has recently had strep throat or a similar infection.

 
       

GENERAL EXAMINATION -doctor rule out such other possible diagnoses : seizure disorders encephalitis Wilson's disease schizophrenia carbon monoxide poisoning cocaine intoxication brain injuries caused by trauma cerebral palsy side effects particularly stimulants and antiepileptic drugs.

which include such medications as fluoxetine and sertraline can be used to treat the obsessive-compulsive behaviors associated with Tourette's disorder. They can also be helpful with depression and impulse control difficulties. including haloperidol and pimozide .  Atypical antipsychotics and other agents that block dopamine receptors include risperidone and clozapine . .TREATMENT PHARMACOLOGICAL  Typical neuroleptics (antipsychotic medications)..  Selective serotonin reuptake inhibitors (SSRIs).

It is supposed to reduce the frequency of tic bouts by increasing the child's awareness of them.  Competing response training: This is a form of treatment of motor tics in which the child is taught to make the opposite movement to the tic. small notebook. Specific behavioral approaches include the following:  Massed negative practice: In this form of behavioral treatment. Contingency management: This approach works best in the home and is usually carried out by the parents.   . the child keeps a diary. Self-monitoring: In awareness training. the child is asked to perform the tic intentionally for specified periods of time interspersed with rest periods. The child is praised or rewarded for not performing the tics and for replacing them with acceptable alternative behaviors.NON-PHARMACOLOGICAL  Cognitive-behavioral approaches are the most common type of individual psychotherapy used to treat tics and tic disorders. or wrist counter for recording tics.

the tics diminish in severity and eventually disappear as the child grows older. In the majority of cases.PROGNOSIS tics and tic disorders is quite  The prognosis for most  good. Factors associated with a poorer prognosis:      History of complications during the child's birth Chronic physical illness in childhood Physical or emotional abuse in the family or a history of family instability Exposure to anabolic steroids or cocaine Co-morbid psychiatric or developmental disorders .

@ ADHD (Attention Deficit Hyperactivity Disorder) Sever forms of overactivity ± ass with marked inattetion *ICD 10 Hyperkinetic is classified more severe form of ADHD .

Cardinal features:  Extreme and persistent restlessness  Sustained & prolonged motor activity  Difficulty in maintaining attention  Impulsiveness & difficulty in withholding responses  Features are persuasive ± vary in different situations  Reckless & prone to accidents  Poor attention & lack of persistence with tasks ± learning difficulty .

 Antisocial behaviours:  -disobidience  -temper tantrums  -aggression  Children are socially socially disinhibited & unpopular  Mood:  -Fluctuating mood  -Low self esteem  -Depressive mood .

 Cardinal features existing >6 months ± maladapative & inconsistent with development level DSM IV Symptoms < 7 yrs old ICD 10 Symptoms <6 yrs old Hyperactivity AND impaired attention Hyperactivity with impulsions OR inattention Criteria at home AND school Criteria at home OR school .

Anxiety disorder .Depressive disorder .Conduct disorder .Language impairment * Hyperactivity not diagnosed in addition to autism . Comorbidity: .Learning dissability .

5% according to ICD 10  Frequent in areas of social deprivation & among children raised in institution . Boys : girls = 3 : 1  3 .

suggestive of higher cognitive excutive function ± abnormality in nuerotransmitter in prefrontal & subcortical  Genetic  Environmental  Uncertain ..

Neurological findings:  Suggestive of neurodevelopmental delay  Occur in quarter of children following TBI Neuroimaging studies:  Functional abnormalities in prefrontal & cerebellum Genetic studies:  Seen in first degree relatives  Monozygotic > Dizygotic  Biological paretns > adopted parents .

Social factors:  Poor social environment  Institutions Other suggested causes:  Zinc deficiency  Food additives .

ass learning difficulties .antisocial behaviour (worst)  Persists into adult life ± antisocial disorder & drug misuse .Prognosis  Gradually lessens as child grows esp puberty  Poor prognosis: .

Treatment Non pharmacological Pharmacological .

parents .teachers  Family theraphy  Behaviour theraphy  Group theraphy .Non Pharmacological Support & psychological treatment  Who needs? .

Dexamphetamine * Short term effect only  ADR: .Methylphenidate .Pharmacological 1) Stimulant drugs ± severe restlessness & attention deficit  dopamine & noradrenaline activity .depression .irritability .insomnia .poor appetite  High dosage: growth in child .

nausea .abdominal pain .severe liver damage (rare) *no addiction .loss of appetite .2) Noradrenaline reuptake inhibitor  Atomoxtine  ADR: .sleep disturbance .

Conduct disorders .

most of them will learn quickly. a child will have a temper tantrum. but this is nothing to worry about. or an outburst of aggressive behaviour. All children will sometimes disobey adults. .Introduction     It takes time for children to learn how to behave properly. Occasionally. With help and encouragement from parents and teachers.

the signs    Behavioural problems can occur in children of all ages very often they start in early life. and aggressive. When behaviour is this much of a problem.Behavioural problems . Some children have serious behavioural problems. is repeatedly being disobedient. They can be rude. it is called a conduct disorder**  . this is much more than ordinary childish mischief or adolescent rebelliousness. and have tantrums. Hitting and kicking other people is common. **This sort of behaviour can affect a child's development. in spite of being asked many times. Toddlers and young children may refuse to do as they are asked by adults. and seriously breaks the rules accepted in their family and community. and can interfere with their ability to lead a normal life. if their behaviour is out of the ordinary. The signs of this to look out for are:  if the child continues to behave badly for several months or longer.

Largest single group of psychiatry disorder in older children and adolescent. They refuse to follow rules and may start to break the law. Children with a conduct disorder may get involved in more violent physical fights. without any sign of guilt when they are found out. and may steal or lie.     .Definition   It is characterized by severe and persistent antisocial behaviour. They may start to stay out all night and truant from school during the day. Teenagers with conduct disorder may also take risks with their health and safety by taking illegal drugs.

Antisocial behavious among teenage girls include emotional bullying of peers. physical aggression to siblings or adults. reckless behaviour or drug abuse. temper tantrums. sexual promiscuity and running away. The beaviours include disobedience. especially at school as vandalism. This centers around aggression and antisocial acts. . and destructiveness. In the pre-school period. In later childhood. Later it often becomes evident outside. often with over-activity. the disorder manifests as aggressive behaviour at home. it manifests s stealing. together with verbal and physical aggression. lying and disobedience.Clinical features        Persistent abnormal conduct which is more serious then ordinary childhood mischief.

 . There is no sharp dividing line between conduct disorder and ordinary bad behaviour. The cut-off defines the most severe that have the worst outcome and are most in help. instead there is a continuum on which diagnostic criteria define a cut-off point.

conduct disorder is divided into Childhood-onset type (onset before 10 years old) (b) Adolescent-onset type (onset at 10 years of age or later) (a) **DSM-IV has an additional category ³oppositional defiant disorder´ for persistently hostile defiant provocative and disruptive behaviour outside normal range but without aggressive or dyssocial behaviour (mainly children below 10 years old). . In DSM-IV.Classification   Both ICD-10 and DSM-IV reqire the presence of 3 symptoms from a list of 15 and a duration of at least 6 months.

 ICD-10 has 4 subdivision of conduct disorder: (a) (b) (c) (d) Socialized conduct disorder Unsocialized conduct disorder Conduct disorder confined to the family context Oppositional defiant disorder .

insecure. Genetic factor.unstable. Alcoholism and antisocial personality disorder in father re reported to be strongly associated.Aetiology Environmental factor.persistent cases originating in childhood have a stronger genetic causes than those starting in adolescence. . and rejecting families living in deprived areas. It is also related to wider social environment of the neighbourhood and school. Frequent among children from broken homes in which family relationships are poor. There is evident that the variant of the monoamineoxidase A gene predispose to conduct disorder but only when combined with adverse facto in the child¶s environment.

feel stupid and misbehave) Depressed have been bullied or abused `hyperactive' (this causes difficulties with self-control. It is then easy for them to get bored.children with brain damage and epilepsy are more prone to conduct disorder. as they are to psychiatric disorders.Organic factor. Other associations         difficult temperament Child abuse Inadequate parenting Traumatic life experiences learning or reading difficulties (these make it difficult for them to understand and take part in lessons. paying attention and following rules) .

They are also taught how to reinforce normal behaviour by praise or rewards and how to set limits on abnormal behaviour (removing child¶s privileges such as an hour less time to play a game) . Parents are taught how the child¶s antisocial behaviour maybe reinforced unintentionally by their attention to it and how it may be provoked by interactions with members of the family.Treatment Parental training programmes It uses behavioural principles.

and choose inappropriate behaviour rather than more appropriate verbal responces. .Anger management Young people who are habitually aggressive have been shown to misperceive hostile intentions in other people who are not in fact hostile. They also tend to under estimate the level of their own aggressive behaviour. This management seek to correct these ideas by teaching how to inhibit sudden inappropriate responses to angry feelings.

group home and special school. carbamazepine . Drug Lithium.Other methods Remedial teaching should be arranged if there are associated reading difficulties (special educational programme). Group therapy is seldom helpful. Residential care Residential placement may be necessary in a foster home. Treatment of co-morbid condition is also helpful. methylphenidate.

with antisocial personality traits. and criminality. Among females. the symptoms and behaviours in adult life usually resemble those in childhood. the picture in adult life corresponds less closely to that in earlier years. with a range of emotional and personality problems. aggression.Prognosis  Among males. alcohol and drug misuse.  .

onset before age10. learning difficulties  Good predictors-Caring relationship with one adult. absence of truancy. stable per relationships  .Two thirds of children grow up as normal adults  One third develop antisocial personality  Poor predictors.

Factors predisposing poor outcome: In the young person:  Early onset  Many symptoms and behaviours  Severe symptoms and behaviours  Pervasiveness  Associated hyperactivity In the family:  Parental psychiatry disorder  Parental criminality  High hostility/ discord focused on the child .

Separation Anxiety Disorder .

Definition  Development of inappropriate and excessive anxiety emerging or related to separation from the major attachment figure .

Epidemiology 4%in children and young adolescents  Boys=girls  Onset most common: 7-8years old  .

  Biopsychosocial Factors There is neurophysiological correlation of behavioral inhibition(extreme shyness) Children with this constellation are shown to have higher resting heart rate and acceleration of heart rate with tasks requiring cognitive concentration .Etiology 1.

Additional physiological correlation of behavioral inhibition :  Elevated salivary cortisol level  Elevated urine catecholamine levels  Greater pupillary dilatation during cognitive tasks  .

moving to new neighborhood  .  External life stressors-death of relative. child illness.Mothers with anxiety disorders who show insecure attachment to their children tend to have children with higher rates of anxiety disorder.

2. the child would develop a phobic adaptations to new situations  Overprotection.Learning Factors Phobic anxiety may be communicated from parents to children by direct modelling  If parents are fearful.exaggeration-teach children to be anxious  .

3.Genetic Factors  Parents who have panic disorder with agoraphobia tend to have increased risk of having a child with anxiety disorder .

6. major attachment figures Persistent and excessive worry that untoward event that will lead to separation from a major attachment figure( getting lost or being kidnapped ) Persistent reluctance or refusal to go to school or elsewhere because of fear of separation Persistently and excessive fearful or reluctant to be alone or without major attachment at home or without significant adults in other settings Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home . 2. disorder must characterised 3(or more) A: Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated Persistent and excessive worry about losing or about possible harm befalling. 3. According to DSM IV. 5. 4.Diagnosis and Clinical Features  1.

is not better accounted for by Panic Disorder with Agoraphobia Specify if-Early Onset:before age of 6 years . Repeated nightmares involving the theme of separation 8. Schizophrenia. The onset is before age of 18 years D. other Psychotic Disorder and in adolescents and adults. The duration of disturbance must be at least 4 weeks C.7. nausea. stomachaches. or vomiting) when separation from a major attachment figures occurs or is anticipated B. Repeated complaints of physical symptoms( such as headaches. The disturbance causes clinically significant distress or impairment in social. academic or other important areas of functioning The disturbance does not occur during exclusively during the course of Pervasive Development disorder.

Pathology and Laboratory Examination  Pathology and Laboratory Examinationnone to help in diagnosis of SAD .

Differential Diagnosis Generalized anxiety disorder  Schizophrenia  Depressive disorders  Pervasive development disorders  Major depressive disorders  Panic disorder with agoraphobia  .

Course and prognosis Young children who can attend school generally can attend school have better  Early age onset and later age at diagnosis are factors the predict slow recovery  Significant overlap of separation anxiety disorder and depressive disorders  Children with anxiety disorder are at risk for an adult anxiety disorder ±but link not established clearly yet  .

3. Multimodal treatment plan including: Cognitive-behavioral therapy Family education Family psychosocial intervention Pharmacological . 4. 2.Treatment  1.

Specific cognitive strategies and relaxation exercise ±control anxiety  Family intervention is critical in managing SAD ±especially children who refuse to attend school  .

Pharmacological       SSRI. fluvoxamine Tricyclics ±not recommended-cardiac adr Beta blockers-propanolol used ±no data to support efficacy Diphenhydramine(Benadryl) ±short term to control sleep disturbance Benzodiazepine-alprazolam can control SAD symptoms Clonazepam ±control symptoms panic and other anxiety symptoms .fluoxetine.

Elimination disorders (Enuresis and Encopresis) .

There may be a problem if this behavior occurs repeatedly for longer than 3 months.   . Particularly in children older than 5 years. Occurs in children who have problems going to the bathroom for both defecation and urination.

Functional enuresis .

Therefore the definition of functional enuresis is :  The repeated involuntary voiding of urine occurring after an age at which incontinence is usual in the absence of any identified physical disorder.Functional enuresis Normally.  . most children achieve daytime and night-time continence by age 3 or 4.

2. 3.Enuresis  1. It may be: Nocturnal (bed-wetting) Diurnal (daytime wetting) Both .

if there has been a preceding period of urinary incontinence  .Nocturnal enuresis is often referred to as:  Primary.if there has been no preceding period of urinary incontinence  Secondary.

 .Epidemiology Prevalence: varies  Nocturnal enuresis occurs more frequently in boys  Diurnal enuresis: -Has a lower prevalence -More common in girls than boys More than half of daytime wetter also wet their beds at night.

Stressful events.associated with onset of secondary enuresis.may be alone or in combination with environmental stressors. Proportion of enuretic children with psychiatric disorder is greater than that of other children. Large families living in overcrowded conditions. Genetic cause. Concordance rates are twice as high in monozygotic as in dizygotic twins.Aetiology       Delay in maturation of the nervous system. .70% of children with enuresis have a first degree relative who has been enuretic.

epilepsy.Assessment A careful history Appropriate physical examination -Rule out urinary infections. Psychiatric disorders should be sought Assess any distressing circumstances affecting the child. . diabetes. Attitudes of parents and siblings to the bedwetting are evaluated.

advice about restricting fluid before bedtime.give an explanation to the child and parents that: the condition is common child is not to be blamed punishment and disapproval is are inappropriate and unlikely to be effective encourage to rewards success without drawing attention to failure and not to focus attention on the problem Many younger enuretic children improve spontaneously soon after an explanation like this except those above 6 years of age. 2.   Functional enuresis. 4. Next.Treatment  1. . lifting the child during night and use of star charts to reward success. 3.

Requires 6-8 weeks of treatment.Enuresis alarms:       Modern alarms consist of a detector pad attached to the night clothes. gets up to complete the emptying of bladder. When the child begin to pass urine the detector is activated and alarm sounds. Child turns off the alarm. . Seldom succeeds with children under 6 years old and those who are uncooperative. An alarm buzzer carried in a pocket or on the wrist.

treatment of nocturnal enuresis in children over 5 years of age.arginine vasopressin . Patients relapse when treatment is stopped.Tablet or nasal spray. .D.Medication Synthetic antidiuretic hormone desamino.therefore only use as a temporary relief. ADR: rhinitis.  . nasal pain.

 Next. advice about restricting fluid before bedtime.Many younger enuretic children improve spontaneously soon after an explanation like this except those above 6 years of age.immediate improvement but relapses when stopped.   Imipramine. lifting the child during night and use of star charts to reward success. .

Encopresis .

Decreased interest in physical activity .Abdominal pain .  They may have other symptoms which include:.Loss of appetite . watery stools (bowel movements) .Repeated passing of feces into places other than the toilet (may or may not be done on purpose).Loose.Scratching or rubbing the anal area due to irritation from watery stools .Withdrawal from friends and family .Secretive behavior associated with bowel movements  Encopresis .

.Causes  Commonest cause is chronic (long-term) constipation with resulting overflow incontinence (retentive encopresis).

such as public restrooms .A diet low in fiber . develop fear or frustration related to toilet training.Lack of exercise .Changes in bathroom routines   Other possible causes: physical problem related to the intestine's ability to move stool.Not taking the time to use the bathroom .Fear or reluctance to use unfamiliar bathrooms. stressful events in the child's life or the child simply refuses to use the toilet.Factors contributing to constipation are: . .

at least 4 years old (or the developmental equivalent) and behavior is not caused solely by substance use or by a general medical condition. Approximately 80% of affected children are boys. It is estimated that 1. There are 4 diagnostic criteria: repeated passage of feces into inappropriate places whether accidently or on purpose.Diagnosis and Epidemiology     According to DSM IV there is encopresis with constipation and overflow incontinence and encopresis without constipation and overflow incontinence. once a month for at least 3 months.5% to 10% of children have encopresis. .

In more severe cases.Treatment     Begins by clearing any feces that has become impacted in the colon. Try to keep the child's bowel movements soft and easy to pass. may recommend to use stool softeners or laxatives to help reduce constipation. or loss of selfesteem associated with the disorder. . guilt. Psychotherapy (a type of counseling) may be used to help the child cope with the shame.

  . become depressed. If the child does not develop good bowel habits. do poorly in school. and refuse to socialize with other children. he or she may suffer from chronic constipation. Develop self-esteem problems. including not wanting to go to parties or to attend events requiring them to stay overnight.Other problems associated with Encopresis  At risk for emotional and social problems.

. Being positive and patient with a child will help prevent any fear or negative feelings about using the toilet. May still have an occasional accident until he or she regains muscle tone and control over his or her bowel movements.Prognosis and Prevention     Tends to get better as the child gets older. although the problem can come and go for years. May not be possible to prevent encopresis. getting treatment as soon as symptoms appear may help reduce the frustration and distress as well as the complications related to it.

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