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 • The Diagnostic and Statistical
Classification of Diseases”, The Manual of Mental Disorders (5th
World Health Organization ed.; DSM–5) American Psychiatric
- 10th edition (ICD -10): Geneve, Association, Washington 2013
1992
- 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 Clinical disorders
I disorders 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

V Intellectual level Global Assessment of Functioning

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
Intellectual Disability (Intellectual Development
F70 -F79 Mental retardation
Disorder)
F80 – F89 Disorders of psychological development Communication Disorders
F80 Specific developmental disorders of speech and − Language Disorder
language − Speech Sound Disorder
− Childhood-Onset Fluency Disorder (Stuttering)
F81 Specific developmental disorders of scholastic − Social (Pragmatic) Communication Disorder
Specific Learning Disorders
skills
Autism Spectrum Disorders
F84 Pervasive developmental 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 - Tic disorders
childhood - Feeding and Eating Disorders
⮚ F94 Disorders of social functioning with onset - Elimination disorders
specific to childhood and adolescence
⮚ 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 through
• 6 months – sits up crying

• After 8th month – starts crawling • 3 months - cooing

• 10 months – starts to walk with
• 6 months – first syllables, babbling
help

• 11 months – standing without help • 7 months – babbles in repetitive syllables

(mamama, bababa)
• 1 year – starts walking without help
• After 10 months – first words
 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 • Names common objects
any help • Starts putting 2 words together
• Starts using prepositions (on, in),
• Turns page by page pronouns (me, you),
verbs(„come!”, „go!”);
• Starts scribbling, drawing lines and • Can execute simple indications
later drawing a circle 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

Autism Spectrum Disorders

 Definitions and classification

• Qualitative, severe and pervasive deterioration in the following areas

of development:
- social interaction
- communication
- behavior

• The qualitative impairments are clearly deviant in relation to the

developmental level or mental age of the individual

• Usually noticeable in the first years of life (onset before the age of 3)
 L. Kanner L. Wing
S. Baron- Cohen

⮚ The root of the term "autism" is derived from the Greek word "autos" meaning "self“

⮚ Leo Kanner (1943): “Autistic Disturbance of Affective Disorder”;

⮚ Hans Asperger (1944): “Autistic Psychopathy in Childhood”;

⮚ Andreas Rett (1964): Rett Disorder;

⮚ Wing and Cohen (2005): introducing the concept of

Autistic Spectrum Disorders (ASD)
Pervasive Developmental Disorders - classification

science20.com
ASD = “Umbrella” term
Diagnosis - history
 299.00 Autistic Disorder
299.0x Infantile Autism
299.80 Rett's Disorder
299.9x Childhood Onset
299.10 Childhood
Pervasive Developmental
Disorder Disintegrative Disorder
299.80 Asperger's Disorder
299.8x Atypical Pervasive
Developmental Disorder 299.80 PDD -NOS (Including
Atypical Autism)
 Neurodevelopmental disorders

• Intellectual Disabilities
• Communication Disorders

• Autism Spectrum Disorder

• Attention-Deficit/Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders
• Other Neurodevelopmental Disorders
 An Autism Spectrum Disorder implies

mandatory specifications

“Specify if:

❑ With or without accompanying intellectual impairment

❑ With or without accompanying language impairment

❑ Associated with a known medical or genetic condition or environmental factor

❑ Associated with another neurodevelopmental, mental, or behavioral disorder”

ICD 10 (F 84): Pervasive Developmental
Disorders

• Autism
• Rett Syndrome
• Childhood Disintegrative Disorder
• Asperger’s Syndrome
• Pervasive Developmental Disorder-Not
Otherwise Specified (PDD-NOS, or
atypical autism)
 
Epidemiology – Autism on the rise

(CDC, 2021)
Why such a rate?

• changing diagnostic
patterns
• evaluation by specialists
• availability of services
• age at diagnosis
• population awareness
• case reporting
• actual increased frequency
 Etiology
⮚ numerous studies
⮚ multifactorial etiology (F. Happe, 2006)
⮚ the exact causes of ASD have not been established
⮚ over 60 different entities (genetic, infectious, toxic) -
correlated with ASD

⮚Buxbaum (2005):
• 90-95% ASD is idiopathic
• 5-10% secondary ASD (environmental factors, chromosomal
abnormality or well-identified gene)
 Etiological theories

⮚ Biological theories: ASD = syndrome caused by multiple conditions

affecting the CNS; biological abnormalities often remain unknown

⮚Genetic theories: studies on twins raise the hypothesis that family

aggregation in ASD is better explained by shared genetics than by
exposure to the same environmental factors
− genetically complex disorder (a disorder for which more than one gene is responsible
− 5% of ASD can be attributed to chromosomal anomalies
− causal genetic variations (e.g. Prader Willi / Angelman syndrome, fragile X syndrome)
− susceptible loci
− assorted marriage theory (Baron-Cohen)
 Genetics, epigenetics

Epigenetic mechanisms
National Institutes of Health
 Etiological theories

⮚ Neuroanatomical theories: certain affected areas of the brain (frontal,

temporal lobes, amygdala, hippocampus, cerebellum; dysfunction of the
left hemisphere; studies of brain volume)
⮚ Psychosocial theories (Kanner - psychogenic influences: parental
attitudes contribute to the "emotional freezing of autistic children")
⮚ Neuropsychological theories:
− facial expression and perception of social stimuli
− Theory of Mind
− Hypersystematization/ hypoempathy
− Central coherence theory
− Intense world theory
Early detection
• ASD is observable at 12 months; parents start to worry around 18 months and visit
a specialist at ~ 24 months

9 ALARM SIGNS

⮚ Poor eye contact / no eye-to-eye contact

⮚ Not expressing joy
⮚ Not sharing joy or interests / lack of joint attention
⮚ No response to their name
⮚ Lack of consistency and coordination between eyes,
facial expressions, gestures
⮚ Not pointing at objects
⮚ Particular voice tone and prosody
⮚ Repetitive body moves and postures
⮚ Repetitive behaviors and use of objects Courchesne et al, 2005
 Clinical aspects

Qualitative impairments in social interaction

⮚lack of/ inconsistency of visual contact

⮚marked impairment in the use of nonverbal behaviors: eye-to-eye gaze, facial

expressions, gestures, body postures

⮚deficits in developing, maintaining, and understanding peer relationships: no interest

for other peers, no friends, they fail to initiate conversations or games, they don’t join
group activities
⮚a lack of spontaneous seeking to share enjoyment,
interests or achievements 

Bergeson et al, 2003; DSM-5 (APA 2013)

 Clinical aspects

Qualitative impairments in social interaction

⮚No expression of interests, emotions, wishes

⮚Not expressing worry or interest for other people

⮚Not expressing the need to be touched, consoled, praised or appreciated

⮚Lack of social and emotional reciprocity

⮚Sometimes they don’t differentiate between close people and strangers;

other times they can manifest marked anxiety towards strangers

⮚Restrictive area and pattern of emotions; lack of emotion expression

Bergeson et al, 2003; DSM-5 (APA 2013)

Clinical aspects
Qualitative impairments in social interaction
⮚May have particular phobias or they fail to manifest fear in dangerous
situations; lack of attention to danger

⮚May laugh or scream inadequately

⮚Failing to understand how others express mental and emotional states

⮚Their pattern of play is repetitive; lack of imaginative or role play

Bergeson et al, 2003;

DSM-5 (APA 2013)
Clinical aspects

Qualitative impairments in communication

⮚delay in, or total lack of the development of spoken language (not
accompanied by an attempt to compensate through alternative methods
of communication such as gestures)

⮚no response when called

⮚can leave the impression of a hearing problem

⮚unexpectedly quiet

Bergeson et al, 2003; DSM-5 (APA 2013)

Clinical aspects

Qualitative impairments in communication

⮚In individuals with adequate speech, marked impairment in the ability to

initiate or sustain a conversation with others

⮚No interest in starting a conversation or communicate with other people

⮚Inadequate responses to questions

⮚Lack of understating humor, sarcasm, irony, metaphors

Bergeson et al, 2003; DSM-5 (APA 2013)

Clinical aspects

Qualitative impairments in communication

⮚Stereotyped and repetitive use of language or idiosyncratic language

⮚ Soliloquy (talking by himself)
⮚Echolalia (repeating the same words or phrases over and over again)
⮚Difficulties with pronouns
⮚Robotic or singsong voice

⮚Difficulties imitating others or using non-verbal language (gestures,

mimics)

⮚Doesn’t point to objects or persons; doesn’t wave “goodbye” or use

clapping gestures
Bergeson et al, 2003; DSM-5 (APA 2013)
 Clinical aspects

Behaviour
⮚strong preoccupation with one or more stereotyped and restricted patterns
of interest that is abnormal either in intensity or focus

⮚inflexible adherence to specific nonfunctional routines or rituals

⮚stereotyped and repetitive motor mannerisms (e.g. hand flapping, finger

flipping or complex whole-body movements)

⮚persistent preoccupation with parts of objects

Bergeson et al, 2003; DSM-5 (APA 2013)

 Clinical aspects

Behaviour

⮚Can be bothered by touch or when hugged

⮚May avoid human contact, preferring to play with objects

⮚Hypersensitivity to certain sounds/ loud sounds

⮚Persevering in the same activities; inflexible to changes in routine

⮚Using his/her own bizarre ways for exploring the environment: smelling,
licking, touching

Bergeson et al, 2003; DSM-5 (APA 2013)

 Infantile autism Asperger’s Syndrome

⮚ Echolalia ⮚ Normally developed language ; can use

⮚ Difficulties with pronouns (talking in language for communication; particular
2nd or 3rd persons) speech
⮚ Low empathy
⮚ Bizarre, repetitive interests and ⮚ No delays in intellectual development; can
behaviors have above average intelligence
⮚ Motor and vocal stereotypies
⮚ Poor, repetitive play ⮚ Difficulties in initiating and maintaining social
⮚ Unusual pattern of learning (can have relationships
a particular attention to details or
good memory for certain things) ⮚ Highly invested in restricted interests
 ASD/ PDD-
Infantile NOS
autism

Infantile ADHD
autism
Autistic-like
traits
ADHD
Intellectual
disabilities
ADHD
Language
developmental
disorders
 Screening and early diagnosis

⮚The American Academy of Pediatrics recommends that all children

should be periodically screened with standard diagnosis/screening
instruments and questionnaires (testing development and identifying
early autistic signs)

⮚Recommendation for screening at 9, 18, 24 and 30 months.

Primary Screening :

⮚CHAT (Checklist for Autism in Toddlers)

⮚M-CHAT (The Modified Checklist for Autism in Toddlers)
⮚ESAT (Early Screening for Autistic Traits)
⮚CSBS checklist (Communication and Symbolic Behavior Scales Checklist)
Secondary Screening:

⮚CSBS Behavior sample/SORF (Communication and Symbolic Behavior Scale

Developmental Profile-Behavior Sample/Systematic Observation of Red
Flags)
⮚SCQ (Social Communication Questionnaire)
⮚STAT (Screening Tool for Autism in Toddlers and Young Children)
⮚GARS (Gilliam Autism Rating Scale)
⮚CARS (Childhood Autism Rating Scale)
Screening in Romania:

⮚ASD screening is performed by the general practitioner/ family doctor/

paediatrician using a screening questionnaire which was developed by the
Ministry of Health’s Child and Adolescent Psychiatry Committee

⮚The questionnaire includes questions for parents and clinical observations

of the doctor

⮚Applied at 12, 18 , 24 and 36 months

Questions for parents: YES NO Sometimes
Does your child look at you when you speak with him/her? 0 2 1
Were you ever afraid he/she has hearing problems? 2 0 1
Is your child a picky eater? Does he/she have lacks appetite? 2 0 1
Does he/she extend the hands to be picked up/taken in your arms? 0 2 1

Does he/she oppose to being picked up/taken in your arms? 2 0 1

Does he/she play hide and seek? 0 2 1

Does he/she smile as a response to your smile? – after 24 months old replace with question: Does he
use the word “mom/mother/mommy” when calling you? 0 2 1

Can he/she stay alone when awake? 2 0 1

Does he/she always react/respond when called by name? Does he/she turn his/her head when called?
0 2 1

Clinical observations (by the doctor)

Avoiding eye contact / cannot maintain eye contact 1 0 -
Obvious lack of interest for other persons 1 0 -
After 24 months old: motor steretypies (hand fluttering, jumping, tiptoeing, unusual postures, etc)
1 0 -

National Programme for Early Identification of ASD

 Diagnosis

⮚The diagnosis is a clinical one, made by using the specific criteria

Instruments for helping diagnosis

⮚ADI-R (Autism Diagnostic Interview-Revised)
⮚ADOS (Autism Diagnostic Observation Schedule)
 Positive and differential diagnosis

⮚ Physical exam:
⮚ Measuring cranial circumference;
⮚ Identifying eventual physical anomalies; dysmorphic features
⮚ Examining teguments and identifying hypo/hyperpigmented patches or angiofibroma

⮚ Neurological exam
⮚ Psychological testing
⮚ Hearing tests
⮚ Visual acuity tests
⮚ EEG (electroencephalography)
⮚ CT/ MRI
⮚ Genetic exam
Comorbidities

autism360.com
 Therapeutic intervention in ASD

⮚Early intervention is significant for the outcome

⮚There is no single intervention that covers all the needs of an ASD

child

⮚Psychological, educational, non-pharmacologic and pharmacologic

interventions should be complementary
Therapeutic intervention
 Behavioral Intervention

Methods:
• ABA (Applied Behavioral Analysis)
• TEACCH (Treatment and Education of Autistic and other Communication-
Handicapped Children)
• PECS ( Picture Exchange Communication Systems)

Aim:
• Decrease of unwanted behaviors: stereotypies, aggression, self-harm, obsessive
behaviors
• Improving deficit areas: language, social interaction, play, cognitive, self-help
Keys to Success
• Look for STRENGTHS and WEAKNESSES

• Early Diagnosis and Intervention

• Parents’ contribution

• Appropriate use of Behavioral Therapy

• Adding complimentary therapies

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

Developmental disorders of speech and

language/ Communication disorders
 Expressive language disorder
⮚Expressive language skills, as assessed on standardized tests, below the 2 standard
deviation limit for the child's age
⮚Expressive language skills at least 1 standard deviation below nonverbal IQ as assessed
on a standardized test
⮚Receptive language skills, as assessed on standardized tests, within the 2 standard
deviation limit for the child's age
⮚Use and understanding of non-verbal communication and imaginative language
functions within the normal range
⮚Absence of neurological, sensory or physical impairments that directly affect use of
spoken language, or of a pervasive developmental disorder
⮚Exclusion criterion: nonverbal IQ < 70 as assessed on a standardized test
 Expressive language disorder (ELD) – developmental type

It is manifested through varying degrees of speech impairment in terms of

content and quality and quantity

⮚limited vocabulary, sometimes containing just a few words;

⮚short and incomplete sentences;

⮚improper use of grammar (inappropriate plural forms, personal pronouns,

or incorrect use of auxiliary verbs);

⮚the speech is lacking in details, poorly organized, difficult to follow;

 Expressive language disorder (ELD) – developmental type

⮚frequently, these children have comorbidities such as learning (reading or

spelling) disorders, developmental disorder of motor function

⮚associated psychiatric disorders such as ASD, ADHD, Conduct Disorder or

Anxiety and/or Depressive Disorder may occur;

⮚many authors do not exclude the possibility that in the ELD –

Developmental type there is a central cause, namely the impairment of the
motor-language area, Broca
 Expressive language disorder – acquired type

• may occur at any age as a result of neurological conditions such as

intoxication, infection, trauma or epileptic seizures in children who had
previously acquired language skills
• the impairment may initially result in both a change in expression and
reception
• after a period of recovery, sometimes spontaneous, language problems may
continue at expression level
• grammatical knowledge is partially preserved
• changes may be noticed in speech organization and the ability to find the
right words
 Receptive language disorder

⮚Language comprehension, as assessed on standardized tests,

below the 2 standard deviations limit for the child's age
⮚Receptive language skills at least 1 standard deviation below
non-verbal IQ as assessed on a standardized test
⮚Absence of neurological, sensory, or physical impairments that
directly affect receptive language, or of a pervasive
developmental disorder
⮚Exclusion criteria: non-verbal QI below 70