A S M E R E T A N D E B R I A H N ( M D,

P S YC H I AT R Y )

NEURO P S YC H I AT R I S T AT C H U K
A D V I S O R TO R B C

DEVELOPMENTAL FOR
U N D E R G R A D U AT E M E D I C A L S T U D E N T S
J U LY 2023

DISORDERS
OUTLINE OF PRESENTATION

• Introduction to Child and adolescent disorders

• Normal Child Development

• Intellectual Disability
• Autistic Spectrum Disorder
• Attention Deficit Hyperactivity Disorder (ADHD)
• Learning Disorders
• Communication Disorders
• Motor Disorders.
• Summary
QUESTIONS ?

• What do you think are the factors contributing to a healthy child?

• Do you know a person in your community who has an intellectual disability or MR if
yes, think of the ways they differ from their peers.
• You see, a 3 year old child exhibits a lack of interest in social interaction in playing
with his friends or other kids; why do you think
• Some children are restless and energetic. Is there a condition where this can be
abnormal?
• Your friend or family member struggles with reading, reverses words and struggles to
write sentences. Is it because he is not smart enough?
CHILD AND ADOLESCENT PSYCHIATRIC
DISORDERS

• Concerns with mental, emotional, and behavioral disorders in children and adolescents.

• Age segmentation

Infancy -from birth to 15 months;

Toddler - from 15 months to 2½ years
Preschool - from 2½ years to 6 years
Middle years, from 6 to 12 years.

• Developmental outcomes evolve from interactions between particular biological

substrates and specific environmental events. Impacts of maternal anxiety affecting child
status
FACTORS AFFECTING CHILD
DEVELOPMENT
CHILD AND ADOLESCENT PSYCHIATRIC
DISORDERS

• Concerns with mental, emotional, and behavioral disorders in children and adolescents.

Age segmentation

Infancy -from birth to 15 months;

Toddler - from 15 months to 2½ years
Preschool - from 2½ years to 6 years
Middle years, from 6 to 12 years.

Developmental outcomes evolve from interactions between particular biological substrates

and specific environmental events. Impacts of maternal anxiety affecting child status
 TYPE OF DISORDERS

Disruptive, impulse Depressive disorders, anxiety

Neurodevelopmental Feeding and eating
control and conduct disorders, obsessive compulsive
disorders disorders
disorders and related

Trauma and Stressor related disorders, somatic

Elimination disorders
symptom and related disorders
 TITLE 6
GLOBAL, REGIONAL, AND
NATIONAL BURDEN OF 12
MENTAL DISORDERS IN 204
COUNTRIES

GBD 2019 for 12 mental disorders, males

and females, 23 age groups, 204 countries
and territories, between 1990 and 2019.

Interpretation GBD 2019 showed that

mental disorders remained among the top
ten leading causes of burden worldwide,
with no evidence of global reduction in the
burden since 1990.
DEVELOPMENTAL MILESTONE
NEURODEVELOPMENTAL DISORDERS

These disorders are usually first diagnosed in infancy, childhood, or adolescence.

1. Intellectual Disability or Intellectual Developmental Disorder (previously called

mental retardation in DSM-IV).
2. Autistic Spectrum Disorder
3. Attention Deficit Hyperactivity Disorder (ADHD)
4. Learning Disorders
5. Communication Disorders
6. Motor Disorders.
KEY QUESTIONS
Symptoms
What sort of problem is it?
For some cases, it may be more appropriate to focus on parenting
difficulties or problems of the family system as a whole rather than
on the problems of the presenting individual.
Impact
How much distress or impairment does it cause?
Risks
What factors have initiated and maintained the problem?
Strengths
What assets are there to work with?
Explanatory model
What beliefs and expectations do the family bring with them?
KEY QUESTIONS
Lack of developmental progress vs. specific symptoms that are
pathognomonic of adult psychiatric disorders
language disorder, separation anxiety disorder
Developmental states affect the presentation
depression
Distressing emotions and behaviors may be a normal part of development
separation anxiety, oppositional behavior
KEY QUESTIONS
Need for treatment
Normal development or not
Level of distress, impairment in functioning,
persistence and effect on the child and others

Comorbidity is a rule

Adult definitions of psychopathology may not work

Childhood symptoms affect the development of skills in multiple
areas
Biological and environmental interaction
NEURODEVELOPMENTAL DISORDERS

These disorders are usually first diagnosed in infancy, childhood, or adolescence.

1. Intellectual Disability or Intellectual Developmental Disorder (previously called

mental retardation in DSM-IV).
2. Autistic Spectrum Disorder
3. Attention Deficit Hyperactivity Disorder (ADHD)
4. Learning Disorders
5. Communication Disorders
6. Motor Disorders.
NEURODEVELOPMENTAL DISORDERS

These disorders are usually first diagnosed in infancy, childhood, or adolescence.

1. Intellectual Disability or Intellectual Developmental Disorder (previously called

mental retardation in DSM-IV).
2. Autistic Spectrum Disorder
3. Attention Deficit Hyperactivity Disorder (ADHD)
4. Learning Disorders
5. Communication Disorders
6. Motor Disorders.
INTELLECTUAL DISABILITY
NEURODEVELOPMENTAL DISORDERS

1. Intellectual Disability
characterized by significant, below average intelligence and impairment it Includes both
intellectual and adaptive functioning deficits in comparison to an individual's age, gender,
and socio-culturally matched peers

• Adaptive functioning. Adaptive functioning refers to how effective individuals are in

achieving age-appropriate common demands of life in areas such as communication,
self-care, and interpersonal skills.
In DSM-5, ID is classified as mild, moderate, severe, or profound based on overall
functioning; Borderline intellectual functioning is used in DSM-5 but is not clearly
differentiated from mild ID. In DSM-IV, it meant an IQ of about 70, but in DSM-5, it is
categorized as a condition that may be the focus of clinical attention, but no criteria are
given.
INTELLECTUAL DISABILITY

• Reasoning, problem-solving, planning, abstract thinking, judgment, learning from

instruction and experience, and practical understanding
• Verbal comprehension, working memory, perceptual reasoning, quantitative reasoning,
abstract thought, and cognitive efficacy
• Measured by tests of intelligence
INTELLECTUAL DISABILITY

Adaptive Functioning

• How well a person meets community standards of personal independence and social
responsibility in comparison to others of similar age and socio-cultural background
• Limit functioning in one or more daily life activities, such as communication, social
participation, and independent living across multiple environments, such as home,
school, work, and community.
INTELLECTUAL DISABILITY

• Point prevalence
1 -3 %
• Incidence is difficult to calculate
• 1.5 times more common among men than women
• In older persons, prevalence is lower
INTELLECTUAL DISABILITY

Point prevalence
1 -3 %
• Incidence is difficult to calculate
• 1.5 times more common among men than women
• In older persons, prevalence is lower
• In the developmental period
• Age and characteristic features at onset depend on the etiology and severity of brain
dysfunction.
• Generally non-progressive
INTELLECTUAL DISABILITY

Risk

Prenatal
exposure to toxins or infectious agents, genetic and chromosomal abnormalities,
maternal malnutrition…
Perinatal
infections, delivery complication, complications of prematurity…
Postnatal
environmental/social, toxins, trauma, infections, malnutrition…
INTELLECTUAL DISABILITY

Diagnostic evaluation
• History
• Physical examination
• Laboratory evaluation
• chromosomal analysis
• urine and blood testing for metabolic disorders and infections
• neuroimaging
• Hearing and speech evaluations
• Psychological assessment
• Intellectual capacity and adaptive functioning
INTELLECTUAL DISABILITY

Other developmental problems

• Behavioral problems
• Emotional problems
• Abuse
• Suicide
• Accidental injury
• Neurological problems
TREATMENT

• Based on an assessment of social, educational, psychiatric, and environmental need

• Treatment of comorbid conditions
• Preventative measures (primary, secondary, tertiary)
• Comprehensive educational program
• Behavioral and Cognitive therapies
• Family education
• Social Intervention
• Pharmacology
AUTISTIC SPECTRUM DISORDER
ASD

• Autism Spectrum Disorder. The autistic spectrum includes a range of behaviors characterized by
severe difficulties in multiple developmental areas, including social relatedness;
communication; range of activity and repetitive and stereotypical Patterns of behavior,
including speech.

• Prevalence has increased

around 1%
‘Classical’ autism accounts for between 25-60%
ASD

• M:F ~4:1
• No clear relation to socioeconomic status

They are divided into 3 levels:

• Level 1 is
characterized by the ability to speak with reduced social interaction
• Level 2
which is characterized by minimal speech and minimal social interaction
• Level 3
marked by a total lack of speech and no social interaction.
 ASD - SOCIAL IMPAIRMENT

• Quality of reciprocal interactions with others

• Aloof, poor eye contact, a lack of interest in people as people,

fails to seek comfort when hurt

• poor capacity for empathy

• limited ability to form close friendships

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 ASD - COMMUNICATION
IMPAIRMENT
• comprehension as well as expression
• gesture as well as spoken language
• babble may be reduced
• 30% of individuals with classical autism never acquire useful speech
• milestones are typically markedly delayed
• loss of acquired skills
• deviant speech

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 ASD - COMMUNICATION
IMPAIRMENT
Echolalia, pronominal reversal, neologisms, primary talks at other people
use speech mainly for demanding things
talk at length about one of their current preoccupations
Speech
abnormal in intonation or pitch
Gestures
reduced and poorly integrated

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 RESTRICTED AND REPETITIVE ACTIVITIES
AND INTERESTS
• Resistance to change
• insistence on routines and rituals
• stereotypies
• ordering play
• attachment to unusual objects
• fascination with unusual aspects of the world
• intense preoccupations with restricted subjects
• pretend play is typically lacking

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 ASD - EARLY ONSET

• core diagnostic features are evident in the developmental period

• intervention, compensation, and current supports may mask difficulties in at least
some contexts
• manifestations of the disorder vary greatly depending on the severity of the autistic
condition, developmental level, and chronological age

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 ASD - TREATMENT
• Appropriate educational placement
• Specific interventions
• Provision of adequate support for parents
• Treatment of comorbidities
• seizure
• emotional problems
• behavioral problems

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 ASD - TREATMENT
10% of individuals who initially had the full autistic syndrome are working
and able to look after themselves
fewer have good friends, marry, or become parents
the best predictors of long-term social independence
ID
whether the speech was presented by five years of age
milder variants of ASD

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ATTENTION DEFICIT
HYPERACTIVITY DISORDER (ADHD)
ADHD

• Attention-Deficit/Hyperactivity Disorder (ADHD). Since the 1990s, ADHD has been one of
the most frequently discussed psychiatric disorders in the lay media.
• Unclear line between age-appropriate normal and disordered behavior misdiagnosed and
treated with medication.
• The central features of the disorder are
persistent inattention, hyperactivity and impulsivity, or both that cause clinically significant
impairment in functioning.
ATTENTION-DEFICIT/
HYPERACTIVITY A persistent pattern of inattention and/or
DISORDER (ADHD) hyperactivity-impulsivity that interferes
with functioning or development
prevalence ~ 2–5%
M:F = 3:1
commoner in younger children
linked with various markers of deprivation
commoner in inner cities
very poor rural areas
In families of low socio-economic status
and children reared in institutions

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 DEFINING CHARACTERISTICS
• Marked hyperactivity, inattentiveness and impulsiveness
• Pervasiveness
– In multiple settings
–Chronicity
• At least six months of symptoms
• Early onset
– Symptoms were present prior to age 12 years

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 INATTENTION
Inattention
• Wandering off task
• Lacking persistence
• Having difficulty sustaining focus
• Difficulty being organized
– Easily distracted
– Does not listen
– Loses items
– Forgetful…..

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 HYPERACTIVITY WANDERING OFF TASK

• Motor activity when it is not appropriate

• Excessive fidgeting and tapping
• Wriggle and squirm in their seats
• Fiddle with objects or clothing
• Talkativeness
• Extreme restlessness
• Wearing others out with their activity
- Repeatedly get up and wander about when they should be seated
- Change activity frequently ….

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 IMPULSIVITY
• Acting without due reflection
• Engaging in rash and sometimes dangerous behaviors
• Blurting out answers in class
• Not waiting their turn in games
• Social intrusiveness
Interrupting others excessively
• Making important decisions without consideration of long-term consequences
taking a job without adequate information

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 ASSOCIATED FEATURES

Disruptive behavioral disorder

• Problems with social relationships

– Disinhibited
• Lower IQ
• Learning problems
• Coordination problems and neurodevelopmental immaturities
• History of specific developmental delay

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 ADHD - COURSE

• Difficult to diagnose before age 4

• In preschool, the main manifestation is hyperactivity

• In elementary school years, inattention becomes more prominent and impairing

• During adolescence, signs of hyperactivity are less common

– maybe confined to fidgetiness or an inner feeling of jitteriness, restlessness, or impatience

• In adulthood

– Inattention, restlessness and impulsivity may remain problematic

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 ADHD - PROGNOSIS

• Symptoms persist into adolescence or adult life in approximately 50 %

– Over-activity typically wanes in adolescence

– Many have continuing problems with inattentiveness, impulsiveness and an inner sense of
restlessness even in adult life
• Educational attainments are often poor

• Lower occupational status in adult

• ADHD + behavioral disorder

– High risk of antisocial personality disorder and substance abuse in adult life

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 ADHD – TREATMENT

• Education
– Parents and teachers
– Reduce the chances of the child acquiring an additional behavioral disorder
• Psychological treatments
– Behavioral management
– Parent training
• Medication
– Stimulants
– Atomoxetine
– clonidine, bupropion and tricyclics

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 ADHD - PROGNOSIS

• Symptoms persist into adolescence or adult life in approximately

50 %
– Over-activity typically wanes in adolescence
– Many have continuing problems with inattentiveness, impulsiveness and
an inner sense of restlessness even in adult life
• Educational attainments are often poor
• Lower occupational status in adult
• ADHD + behavioral disorder
– High risk of antisocial personality disorder and substance abuse in adult
life
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 LEARNING DISORDER
These are maturational deficits in
development that are associated
with diffi culty in acquiring specific
skills in
Reading (also known as dyslexia), in
written expression, or in
mathematics (also known as
dyscalculia).
Intervention
- Design various learning methods

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 COMMUNICATION DISORDER
There are four types of communication disorders.
(1) language disorder is characterized by a
developmental impairment in vocabulary resulting
in diffi culty producing age-appropriate sentences;
(2) speech sound disorder is marked by diffi culty in
articulation;
(3) childhood-onset fl uency disorder or stuttering
is characterized by diffi culty in fl uency, rate, and
rhythm of speech; and
(4) social or pragmatic communication disorder is
profound diffi culty in social interaction and
communication with peers.

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 MOTOR DISORDERS
Motor coordination is substantially below expectations based on age and intelligence and
when coordination problems signifi cantly interfere with functioning.
Types of motor disorders:
(1) developmental coordination disorder is
an impairment in the development of motor coordination (e.g., delays in crawling or
walking, dropping things, or poor sports performance);
(2) stereotypic movement disorder
consists of repetitive motion activity (e.g., head banging and body rocking); and
(3) tic disorder is characterized by sudden involuntary, recurrent, and stereotyped
movement or vocal sounds. There are two types of tic disorders; The fi rst is Tourette’s
disorder,
characterized by motor and vocal tics, including coprolalia, and the second is persistent
chronic motor or vocal tic disorders marked by a single motor or vocal tic

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 SUMMARY
• Mental health problems aff ect many children and adolescents worldwide.

• Half of all people who develop mental disorders have their first symptoms by the age of
14, and 75% have had their fi rst symptom by their mid-20s.

• The assessment approach needs to be modifi ed for children and adolescents.

• Early identifi cation and early treatment can change the course of a person’s entire life.

• We need to follow a multidisciplinary approach to evaluation and treatment.

Place, setting, professionals, therapeutic modalities

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 REFERENCE

• Kaplan and Sadock’s synopsis of psychiatry, 12th edition, 2022.

• Goodman & Scott’s child and adolescent psychiatry, 3 rd edition, 2012.

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Murakoze Cyane

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