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Childhood psychiatric disorders. Dr. Y R Bhattarai TMU. Normal child development. What is growth and development ? - Process of growing to maturity.
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Childhood psychiatric disorders Dr. Y R Bhattarai TMU
Normal child development • What is growth and development ? -Process of growing to maturity. -Refers to process of biological and psychological changes in human being between birth and end of adolescence as the individual progresses from dependency to increasing autonomy.
What is the rationale behind the knowledge of normal developmental process ? • For the practice of childhood psychiatry. • To identify whether the observed emotional, social, or intellectual functioning is abnormal as it has to be compared with the corresponding normal range for the age group.
Distinct areas of development • Physical • Cognitive • Social • Emotional • Moral • psychosexual
Age related developmental periods newborn (ages 0–1 month) infant (ages 1 month – 1 year) toddler (ages 1–3 years) preschooler (ages 4–6years) school-aged child (ages 6–10 years) adolescent (ages 11–19)
Cognitive development Includes capacity to learn, remember, recognise, solve problems and organize the environment. • Newborn-learns to suck • 8-12 mths-plays peek-a-boo • 2yrs-knows animal sounds, names objects • 3yrs – knows colors • 5-6yrs- understands humor • 7-11yrs- think logically, personal sense of right and wrong
Social development Learn to develop sense of themselves so that they can think and relate their experiences in other situation. • Infant- recognizes care giver, shows stranger anxiety • 2yrs- may separate from care giver • 3-6 yrs – curiosity about sex • 6-12 yrs – rules of the games are key, separation of the sexes, demonstrating competence is key.
Emotional development Recognition and use of their emotions appropriately. • 2mths- social smile • 1-2yrs- likes attention • 5yrs- shows sensitivity to criticism • >7 yrs – can react to feelings of others and are more aware of other’s feeling
Moral development Learning concept of right and wrong • 4-7yrs-self control develops, guilt appears • 7-11 yrs – feels empathy • Early teens- peers considered in principles
Psychosexual development Process of learning to view themselves and others in terms of gender. • 12-18 months: can differentiate play; girls like dolls • 2-3 yrs: child can label self, picture, other children’s sex using clothes, toys, hair etc. • 3-6 yr: same sex peers favored • 6-11 yrs: heterosexual play • >12 yrs: sexual activity begins
What leads to developmenat process? The basic mechanisms or causes of developmental change are genetic factors and environmental factors. Genetic factors - responsible for cellular changes like overall growth, changes in proportion of body and brain parts, and the maturation of aspects of function such as vision and dietary needs. Environmental factors affecting development may include both diet and disease exposure, as well as social, emotional, and cognitive experiences. Rather than acting as independent mechanisms, genetic and environmental factors often interact to cause developmental change.
Classification of childhood psychiatric disorders-DSM-IV TR • Mental retardation* • Learning disorders • Motor skill disorders • Communication disorders • Pervasive developmental disorders- Autism* • Attention-Deficit/ Hyperactivity Disorders* • Tic disorders • Feeding and eating disorders of infancy & childhood • Elimination disorders- Enuresis* • Other disorders of infancy, childhood & adolescence
Enuresis Term derived from Greek word – enourein-to void urine Definition Enuresis is defined as the involuntary or intentional voiding of urine.
Normal continence development • normal process of continence -achievement of night time bowel continence -achievement of day time bowel continence -achievement of day time bladder continence -At last achievement of night time bladder continence • By three years 98% are dry in day and 78 % dry at night. However other children may take as much as 13 to 14 years or more to acquire complete control.
Types • According to achievement of continence Continence is said to be achieved if child is dry for 6mths to 1year • primary- child has never maintained urinary continence for more than 1 year • Secondary- child achieved continence for 1 year or more but lost it again
According to timing of the episodes • Nocturnal • Diurnal • Nocturnal and diurnal
etiology • Genetic factor- • 75% of enuretic child had affected 1st degree biological relative • Child risk- 5.2 times if mother had disorder,7.1 times if father had disorder • Psychological factor- • Low socio-economic • Onset after loss of parents • Sleep physiology- dream, deep sleep • Urine osmolality - enuretic child have decreased ability to concentrate urine at night thus leading to increased volume of urine
diagnosis • Repeated voiding of urine into beds or clothes involuntarily or intentional. • Frequency-2/week for 3 consecutive months, if less frequent must produce significant distress or functional impairment • Age- chronological age of at least 5yrs(or equivalent developmental age) • Not due to other know causes
Differential diagnosis • UTI • Urinary tract malformations • Seizures • Diabetes • Substance- diuretics
Treatment Behavior therapy • bell and pad method of conditioning • external ultrasonic monitor attached to waist
Pharmacotherapy • Other -Limit fluids before bedtime. -Have your child go to the bathroom at the beginning of the bedtime routine and then again right before going to sleep. -A reward system for dry nights. -Asking your child to change the bed sheets when he or she wets. -Bladder training: having your child practice holding his or her urine for longer and longer times during the day, in effort to stretch the bladder so it can hold more urine. -Do not punish or ridicule the child for bedwetting as it may worsen the problem. • Imipramine • Desmopressin acetate (synthetic vasopressin)
ADHD is characterized by inattention, hyperactivity and impulsivity with social or academic functions. • Symptoms last for at least 6 months and the onset occurs before 7 yrs of age. • Symptoms are present in multiple settings e.g. in home and school
Prevalence and etiology • 5% of school age children • Occurs at a 9:1 male to female ratio • No specific etiologies have been identified. • Some associated conditions are perinatal injuries, malnutrition and substance exposure
Onset and symptoms • Usually first recognized when a child enters school and symptoms usually persist throughout childhood. • Symptoms : short attention span, inability to wait in lines, failure to stay quiet or sit still in class, disobedience, fighting, poor academic performance, carelessness and poor relationship with siblings.
Associated problems • Conduct disorder • Learning disorders • Motor skills disorders • Communication disorders • Drug abuse • School failure • And physical trauma due to impulsivity
Evaluation • Careful history from parents and teachers • Given a simple puzzle to solve • Recognize letters traced on palms • IQ tests • Physical and neurological examination are normal.
Differential diagnosis • Mental retardation • Autistic disorders • Mood disorders • Oppositional defiant disorders • Rule out -Age appropriate behaviors -Response to environmental problems
Management Combination of somatic and behavioral treatments. • Psychostimulants such as methylphenidate and other amphetamines are effective in decreasing hyperactivity, inattention and impulsivity. Given only during school days. • Behavioral management techniques include minimization of classroom distractions, reducing stimulation e.g. 1 playmate at a time, short and focused tasks.
