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Transcript of Child Psychiatry 2
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CHILD
PSYCHIATRY 2
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INTRODUCTION
TICS DISORDER
ATTENTION DEFICIT HYPERACTIVITY
DISORDERCONDUCT DISORDER
ANXIETY DISORDER
ELIMINATION DISORDER
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TICS DISORDER Tic disorders are characterized by the
persistent presence of tics, which are
abrupt, repetitive involuntary movements andsounds that have been described as caricaturesof normal physical acts.
They can be suppressed but only for a short
time and only with conscious effort.
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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.
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CLASSIFICATION
Tic disorders are classified as follows:
Transient tic disorderconsists of
multiple motorand/orphonic tics with
duration ofat least 4 weeks, but less than 12 months.
The majority of tics seen in this disorder are motor
tics, though vocal tics may also be present.
Chronic tic disorderis either
single or multiple motor or phonic tics, but not both,which are present
for more than a year. For a diagnosis of chronic tic
disorder, symptoms must begin before a child is 18
years of age.
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Tourette's disorderis diagnosed when
both motorandphonic tics are present formore than a year. Symptoms typically begin
when children are between
5and 18 years old.
Tic Disorder NOS is diagnosed when
tics are present, but do not meet the criteria
for any specific ticdisorder.
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CAUSES The causes of tics and tic disorders are not fullyunderstood but most researchers believe that they are
multifactorial.
Abnormal neurotransmitters (dopamine, serotonin, and
cyclic) contribute to the disorders.
Recreational drugs or prescription medications.
Commonly involved are psychomotor stimulants
(methylphenidate, pemoline, amphetamines and
cocaine).
Genetic or transmitted within families.
Streptococcal infections have been associated with the
development of tics .
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SYMPTOMS The diagnostic criteria of all tic disorders specify that thesymptoms 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.
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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.
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DIAGNOSIS
HISTORY TAKING
-family history of tics or tic disorders
-whether the child has been diagnosed with otherchildhood developmental or psychiatric disorders
-whether he or she has recently had strep throat or
a similar infection.
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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 antiepilepticdrugs.
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TREATMENTPHARMACOLOGICAL
Typical neuroleptics (antipsychotic medications),
including haloperidol and pimozide . Atypical antipsychotics and other agents that block
dopamine receptors include risperidone and clozapine .
Selective serotonin reuptake inhibitors (SSRIs), which
include such medications as fluoxetine and sertralinecan be used to treat the obsessive-compulsive behaviors
associated with Tourette's disorder. They can also be
helpful with depression and impulse control difficulties,.
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NON-PHARMACOLOGICAL
Cognitive-behavioral approaches are the most common type of individual
psychotherapy used to treat tics and tic disorders.
Specific behavioral approaches include the following:
Massed negative practice: In this form of behavioral treatment, the child
is asked to perform the tic intentionally for specified periods of time
interspersed with rest periods.
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.
Self-monitoring: In awareness training, the child keeps a diary, small
notebook, or wrist counter for recording tics. It is supposed to reduce thefrequency of tic bouts by increasing the child's awareness of them.
Contingency management: This approach works best in the home and is
usually carried out by the parents. The child is praised or rewarded for
not performing the tics and for replacing them with acceptable alternativebehaviors.
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PROGNOSIS The prognosis for most tics and tic disorders is quitegood. In the majority of cases, the tics diminish in severity and
eventually disappear as the child grows older.
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
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@ ADHD (Attention Deficit Hyperactivity
Disorder)
Sever forms of overactivity ass with markedinattetion
*ICD 10 Hyperkinetic is classified more severeform of ADHD
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Antisocial behaviours:
-disobidience
-temper tantrums
-aggression
Children are socially socially disinhibited &
unpopular
Mood: -Fluctuating mood
-Low self esteem
-Depressive mood
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Cardinal features existing >6 months maladapative &inconsistent with development level
ICD 10 DSM IV
Symptoms
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Comorbidity:
- Conduct disorder- Depressive disorder
-Anxiety disorder
- Learning dissability
- Language impairment
* Hyperactivity not diagnosed in addition to
autism
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Boys : girls = 3 : 1
3 - 5% according to ICD 10Frequent in areas of social deprivation &
among children raised in institution
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Uncertain - suggestive of higher cognitive
excutive function abnormality in
nuerotransmitter in prefrontal & subcortical
Genetic
Environmental
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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
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Social factors:
Poor social environment
Institutions
Other suggested causes:Zinc deficiency
Food additives
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Gradually lessens as child grows esp
puberty
Poor prognosis:
- ass learning difficulties
- antisocial behaviour (worst)
Persists into adult life antisocial disorder
& drug misuse
Prognosis
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Treatment
Non pharmacological Pharmacological
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Non PharmacologicalSupport & psychological treatment
Who needs?
- parents
- teachers
Family theraphy Behaviour theraphy
Group theraphy
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Pharmacological1) Stimulant drugs severe restlessness & attention
deficit
dopamine & noradrenaline activity
- Methylphenidate
- Dexamphetamine* Short term effect only
ADR:
- irritability- insomnia
- depression
- poor appetite
Hi h dosa e: rowth in child
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2) Noradrenaline reuptake inhibitor
AtomoxtineADR:
- nausea
- abdominal pain- loss of appetite
- sleep disturbance
- severe liver damage (rare)
*no addiction
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Conduct disorders
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Introduction
It takes time for children to learn how to behave
properly.
With help and encouragement from parents and
teachers, most of them will learn quickly.
All children will sometimes disobey adults.
Occasionally, a child will have a temper tantrum,
or an outburst of aggressive behaviour, but thisis nothing to worry about.
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Behavioural problems - the signs
Behavioural problems can occur in children of all ages very often they start
in early life. Toddlers and young children may refuse to do as they are asked by adults,
in spite of being asked many times.
They can be rude, and have tantrums. Hitting and kicking other people iscommon.
Some children have serious behavioural problems. The signs of this to look
out for are:
if the child continues to behave badly for several months or longer, isrepeatedly being disobedient, and aggressive.
if their behaviour is out of the ordinary, and seriously breaks the rulesaccepted in their family and community, this is much more than ordinarychildish mischief or adolescent rebelliousness.
**This sort of behaviour can affect a child's development, and can interferewith their ability to lead a normal life. When behaviour is this much of aproblem, it is called a conduct disorder**
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Definition
It is characterized by severe and persistent antisocial behaviour.
Largest single group of psychiatry disorder in older children andadolescent.
Children with a conduct disorder may get involved in more violentphysical fights, and may steal or lie, without any sign of guilt whenthey are found out.
They refuse to follow rules and may start to break the law.
They may start to stay out all night and truant from school during theday.
Teenagers with conduct disorder may also take risks with theirhealth and safety by taking illegal drugs.
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Clinical features Persistent abnormal conduct which is more serious thenordinary childhood mischief.
This centers around aggression and antisocial acts.
In the pre-school period, the disorder manifests asaggressive behaviour at home, often with over-activity.
The beaviours include disobedience, temper tantrums,physical aggression to siblings or adults, anddestructiveness.
In later childhood, it manifests s stealing, lying anddisobedience, together with verbal and physicalaggression.
Later it often becomes evident outside, especially atschool as vandalism, reckless behaviour or drug abuse.
Antisocial behavious among teenage girls includeemotional bullying of peers, sexual promiscuity andrunning away.
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There is no sharp dividing line between
conduct disorder and ordinary badbehaviour; instead there is a continuum on
which diagnostic criteria define a cut-off
point.
The cut-off defines the most severe that
have the worst outcome and are most in
help.
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Classification
Both ICD-10 and DSM-IV reqire the presenceof 3 symptoms from a list of 15 and a durationof at least 6 months.
In DSM-IV, conduct disorder is divided into
(a) Childhood-onset type (onset before 10 years old)(b) Adolescent-onset type (onset at 10 years of age or
later)
**DSM-IV has an additional category oppositional
defiant disorder for persistently hostile defiantprovocative and disruptive behaviour outsidenormal range but without aggressive or dyssocialbehaviour (mainly children below 10 years old).
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ICD-10 has 4 subdivision of conduct
disorder:
(a) Socialized conduct disorder
(b) Unsocialized conduct disorder(c) Conduct disorder confined to the family
context
(d) Oppositional defiant disorder
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Aetiology
Environmental factor- unstable, insecure, and rejectingfamilies living in deprived areas. Frequent amongchildren from broken homes in which family relationships
are poor. It is also related to wider social environment ofthe neighbourhood and school.
Genetic factor- persistent cases originating in childhoodhave a stronger genetic causes than those starting inadolescence. Alcoholism and antisocial personalitydisorder in father re reported to be strongly associated.There is evident that the variant of the monoamine-oxidase A gene predispose to conduct disorder but onlywhen combined with adverse facto in the childsenvironment.
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Organic factor- children with brain damage and epilepsyare more prone to conduct disorder, as they are topsychiatric disorders.
Other associations
difficult temperament
Child abuse Inadequate parenting
Traumatic life experiences
learning or reading difficulties (these make it difficultfor them to understand and take part in lessons. It is then
easy for them to get bored, feel stupid and misbehave) Depressed
have been bullied or abused
`hyperactive' (this causes difficulties with self-control,paying attention and following rules)
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Treatment
Parental training programmes
It uses behavioural principles. Parents are taught howthe childs antisocial behaviour maybe reinforcedunintentionally by their attention to it and how it may beprovoked by interactions with members of the family.
They are also taught how to reinforce normal behaviourby praise or rewards and how to set limits on abnormalbehaviour (removing childs privileges such as an hourless time to play a game)
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Anger management
Young people who are habitually aggressivehave been shown to misperceive hostileintentions in other people who are not in facthostile. They also tend to under estimate thelevel of their own aggressive behaviour, andchoose inappropriate behaviour rather thanmore appropriate verbal responces.
This management seek to correct these ideas byteaching how to inhibit sudden inappropriateresponses to angry feelings.
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Other methods
Remedial teaching should be arranged if there areassociated reading difficulties (special educationalprogramme). Group therapy is seldom helpful. Treatmentof co-morbid condition is also helpful.
Residential care
Residential placement may be necessary in a fosterhome, group home and special school.
Drug
Lithium, methylphenidate, carbamazepine
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Prognosis
Among males, the symptoms and behaviours in
adult life usually resemble those in childhood,
with antisocial personality traits, aggression,alcohol and drug misuse, and criminality.
Among females, the picture in adult life
corresponds less closely to that in earlier years,with a range of emotional and personality
problems.
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Two thirds of children grow up as normaladults
One third develop antisocial personality
Poor predictors- onset before age10,learning difficulties
Good predictors-Caring relationship with
one adult, absence of truancy, stable perrelationships
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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
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Separation Anxiety
Disorder
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Definition
Development of inappropriate and
excessive anxiety emerging or related to
separation from the major attachmentfigure
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Epidemiology
4%in children and young adolescents
Boys=girls
Onset most common: 7-8years old
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Etiology
1. 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 tasksrequiring cognitive concentration
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Additional physiological correlation of
behavioral inhibition :
Elevated salivary cortisol level
Elevated urine catecholamine levels
Greater pupillary dilatation during cognitive
tasks
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Mothers with anxiety disorders who
show insecure attachment to their children
tend to have children with higher rates ofanxiety disorder.
External life stressors-death of relative,
child illness, moving to new neighborhood
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2.Learning Factors
Phobic anxiety may be communicated
from parents to children by direct
modelling
If parents are fearful, the child would
develop a phobic adaptations to new
situations Overprotection,exaggeration-teach
children to be anxious
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3.Genetic Factors
Parents who have panic disorder with
agoraphobia tend to have increased risk of
having a child with anxiety disorder
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Diagnosis and Clinical Features
According to DSM IV, disorder must characterised 3(or more) A:
1. Recurrent excessive distress when separation from home ormajor attachment figures occurs or is anticipated
2. Persistent and excessive worry about losing or about possible
harm befalling, major attachment figures3. Persistent and excessive worry that untoward event that will lead
to separation from a major attachment figure( getting lost or beingkidnapped )
4. Persistent reluctance or refusal to go to school or elsewherebecause of fear of separation
5. Persistently and excessive fearful or reluctant to be alone orwithout major attachment at home or without significant adults inother settings
6. Persistent reluctance or refusal to go to sleep without being neara major attachment figure or to sleep away from home
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7. Repeated nightmares involving the theme of separation
8. Repeated complaints of physical symptoms( such as headaches,stomachaches, nausea, or vomiting) when separation from amajor attachment figures occurs or is anticipated
B. The duration of disturbance must be at least 4 weeksC. The onset is before age of 18 years
D. The disturbance causes clinically significant distress or impairmentin social, academic or other important areas of functioning
The disturbance does not occur during exclusively during the course ofPervasive Development disorder, Schizophrenia, other Psychotic
Disorder and in adolescents and adults, is not better accountedfor by Panic Disorder with Agoraphobia
Specify if-Early Onset:before age of 6 years
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Pathology and Laboratory
Examination Pathology and Laboratory Examination-
none to help in diagnosis of SAD
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Differential Diagnosis
Generalized anxiety disorder
Schizophrenia
Depressive disorders
Pervasive development disorders
Major depressive disorders
Panic disorder with agoraphobia
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Course and prognosis
Young children who can attend schoolgenerally can attend school have better
Early age onset and later age at diagnosisare factors the predict slow recovery
Significant overlap of separation anxietydisorder and depressive disorders
Children with anxiety disorder are at riskfor an adult anxiety disorder but link notestablished clearly yet
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Treatment
Multimodal treatment plan including:
1. Cognitive-behavioral therapy
2. Family education
3. Family psychosocial intervention
4. Pharmacological
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Specific cognitive strategies and relaxation
exercise control anxiety
Family intervention is critical in managingSAD especially children who refuse to
attend school
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Pharmacological
SSRI- fluoxetine, fluvoxamine
Tricyclics not recommended-cardiac adr
Beta blockers-propanolol used no data to supportefficacy
Diphenhydramine(Benadryl) short term to control sleepdisturbance
Benzodiazepine-alprazolam can control SAD symptoms
Clonazepam control symptoms panic and other anxietysymptoms
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Elimination
disorders
(Enuresis and Encopresis)
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Occurs in children who have problems going to
the bathroom for both defecation and urination.
Particularly in children older than 5 years.
There may be a problem if this behavior occurs
repeatedly for longer than 3 months.
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Functional enuresis
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Functional enuresis Normally, most children achieve daytime
and night-time continence by age 3 or 4.
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 ofany identified physical disorder.
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Enuresis
It may be:
1. Nocturnal (bed-wetting)
2. Diurnal (daytime wetting)
3. Both
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Nocturnal enuresis is often referred to as:
Primary- if there has been no preceding
period of urinary incontinence
Secondary- if there has been a preceding
period of urinary incontinence
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Epidemiology
Prevalence: varies
Nocturnal enuresis occurs more
frequently in boys
Diurnal enuresis:
-Has a lower prevalence
-More common in girls than boysMore than half of daytime wetter also wet
their beds at night.
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Aetiology Delay in maturation of the nervous system- may be
alone or in combination with environmental stressors.
Genetic cause- 70% of children with enuresis have a firstdegree relative who has been enuretic.
Concordance rates are twice as high in monozygotic asin dizygotic twins.
Proportion of enuretic children with psychiatric disorderis greater than that of other children.
Large families living in overcrowded conditions.
Stressful events- associated with onset of secondaryenuresis.
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AssessmentA careful history
Appropriate physical examination
-Rule out urinary infections, diabetes,
epilepsy.
Psychiatric disorders should be sought
Assess any distressing circumstances
affecting the child.
Attitudes of parents and siblings to the bed-
wetting are evaluated.
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Treatment Functional enuresis- give an explanation to the child and
parents that:
1. the condition is common
2. child is not to be blamed
3. punishment and disapproval is are inappropriate andunlikely to be effective
4. encourage to rewards success without drawing attentionto failure and not to focus attention on the problem
Many younger enuretic children improve spontaneously
soon after an explanation like this except those above 6years of age.
Next, advice about restricting fluid before bedtime, liftingthe child during night and use of star charts to rewardsuccess.
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Enuresis alarms: Modern alarms consist of a detector pad
attached to the night clothes.
An alarm buzzer carried in a pocket or on the
wrist. When the child begin to pass urine the detector
is activated and alarm sounds.
Child turns off the alarm, gets up to complete the
emptying of bladder. Requires 6-8 weeks of treatment.
Seldom succeeds with children under 6 years oldand those who are uncooperative.
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Medication
Synthetic antidiuretic hormone
desamino- D- arginine vasopressin
- treatment of nocturnal enuresis in children
over5 years of age.
- Tablet or nasal spray.
Patients relapse when treatment is stopped.ADR: rhinitis, nasal pain- therefore only use
as a temporary relief.
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Many younger enuretic children improvespontaneously soon after an explanationlike this except those above 6 years ofage.
Next, advice about restricting fluid beforebedtime, lifting the child during night anduse of star charts to reward success.
Imipramine- immediate improvement butrelapses when stopped.
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Encopresis
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Encopresis Repeated passing of feces into places other than the
toilet (may or may not be done on purpose).
They may have other symptoms which include:-
- Loss of appetite
- Abdominal pain
- Loose, watery stools (bowel movements)
- Scratching or rubbing the anal area due to irritation from
watery stools- Decreased interest in physical activity
- Withdrawal from friends and family
- Secretive behavior associated with bowel movements
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Causes C
ommonest cause is chronic (long-term) constipationwith resulting overflow incontinence (retentive
encopresis).
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Factors contributing to constipation are:
- A diet low in fiber
- Lack of exercise- Fear or reluctance to use unfamiliar bathrooms, such as
public restrooms
- Not taking the time to use the bathroom
- Changes in bathroom routines
Other possible causes: physical problem related to the
intestine's ability to move stool, develop fear orfrustration related to toilet training, stressful events in
the child's life or the child simply refuses to use the
toilet.
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Diagnosis and Epidemiology
According to DSM IV there is encopresis with constipationand overflow incontinence and encopresis without
constipation and overflow incontinence.
There are 4 diagnostic criteria: repeated passage of fecesinto inappropriate places whether accidently or on purpose,
once a month for at least 3 months, at least 4 years old (or
the developmental equivalent) and behavior is not caused
solely by substance use or by a general medical condition. It is estimated that 1.5% to 10% of children have
encopresis.
Approximately 80% of affected children are boys.
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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. In more severe cases, may recommend to use stool
softeners or laxatives to help reduce constipation.
Psychotherapy (a type of counseling) may be used to
help the child cope with the shame, guilt, or loss of self-esteem associated with the disorder.
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Other problems associated with
Encopresis
At risk for emotional and social problems.
Develop self-esteem problems, become depressed, dopoorly in school, and refuse to socialize with other
children, including not wanting to go to parties or to
attend events requiring them to stay overnight.
If the child does not develop good bowel habits, he or
she may suffer from chronic constipation.
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Prognosis and Prevention Tends to get better as the child gets older, although the
problem can come and go for years.
May still have an occasional accident until he or she
regains muscle tone and control over his or her bowel
movements. 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.
Being positive and patient with a child will help prevent
any fear or negative feelings about using the toilet.
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THANK YOU