PSYCHIATRIC DISORDERS

IN CHILDREN

ATTENTION-DEFICIT / HYPERACTIVITY DISORDER

• Most common mental disorder in children• Estimates of 3-5% of preschool and school-age

children have ADHD (2 mil. in USA)(NIMH)• 1 in a class of 25-30• Begins in preschool and elementary school• Often lasts into adulthood: 30-70% of children

with ADHD will continue to have symptoms as adults

• Boys diagnosed 3x girls--probably because boys more hyperactive and disruptive

AACAP, 2009

NORMAL BEHAVIOR Vs. ADHD

• Lasts more than six months• Occurs in more than just one setting

(typically at home and at school) • Regularly disrupts school, play, and

other daily activities• Causes problems in relationships with

adults and other children• Consider age and cognitive development

ADHD: INATTENTION SYMPTOMS

Fails to pay close attention to details or makes careless mistakes in schoolwork or other activities

Trouble sustaining attention during tasks or playSeems not to listen even when spoken to directlyDifficulty following through on instructions and often

fails to finish schoolwork, chores or other tasksHas problems organizing tasks or activitiesAvoids or dislikes tasks that require sustained mental

effort, such as schoolwork or homeworkFrequently loses needed items, such as books,

pencils, toys or toolsEasily distractedOften forgetful

ADHD: Hyperactivity symptoms Fidgets or squirms frequently Often leaves his or her seat in the classroom or in

other situations when remaining seated is expected

Often runs or climbs excessively when it's not appropriate or, if an adolescent, might constantly feel restless

Frequently has difficulty playing quietly Always seems on the go Talks excessively Blurts out the answers before questions have

been completely asked Frequently has difficulty waiting for his or her turn Often interrupts or intrudes on others'

conversations or games

ADHD: Girls vs. boys

• Boys are more likely to be hyperactive, whereas

girls tend to be inattentive.

• Girls who have trouble paying attention often

daydream, but inattentive boys are more likely to

play or fiddle aimlessly.

• Boys tend to be less compliant with teachers and

other adults, so their behavior is often more

conspicuous.

ADHD: treatment Without treatment children fall behind in school, have

social problems, higher rates of: substance abuse, conduct disorder, accidents, divorce, job loss.

Combination of behavioral and medication therapy. Behavior therapy: point systems or charts to reward

good behavior, “time out,” family time and positive attention.

Individual therapy: examine upsetting thoughts or feelings, learn alternative ways of handling emotions, change or better cope with ADHD symptoms-- organizing schoolwork or dealing with emotional experiences.

Social skills training: model social skills--waiting for a turn, sharing toys, or asking for help, reading others’ facial expression or tone; Structured play dates.

Medications: Stimulant and non-stimulant meds.

Oppositional Defiant Disorder

• Occasional oppositionality is common especially when hungry, tired, or stressed—especially age 2-3 and early adolescence.

• ODD is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with a child’s day to day functioning.

ODD: symptoms

Frequent temper tantrumsExcessive arguing with adultsOften questioning rulesActive defiance and refusal to comply with adult requests and rulesDeliberate attempts to annoy or upset peopleBlaming others for his or her mistakes or misbehaviorOften being touchy or easily annoyed by othersFrequent anger and resentmentMean and hateful talk when upsetSpiteful attitude and revenge seeking

ODD: frequency & causes

Multiple settings—home, school, after-school activities

1-16 % of all school-age children and adolescents have ODD

No clear causes, but some factors are:The child's inherent temperamentThe family's response to the child's temperamentA genetic component that when coupled with

certain environmental conditions — such as lack of supervision, poor quality child care or family instability — increases the risk of ODD

A biochemical or neurological factorThe child's perception that he or she isn't getting

enough of the parent's time and attentionMayo Clinic, 2007

ODD: risk factorsA parent with a mood or substance abuse disorderBeing abused or neglectedHarsh or inconsistent disciplineLack of supervisionPoor relationship with one or both parentsFamily instability such as occurs with divorce, multiple moves, or changing schools or child care providers frequentlyFinancial problems in the familyExposure to violenceSubstance abuse in the child or adolescent Parents with a history of ADHD, oppositional defiant disorder or conduct problems

Mayo Clinic, 2007

ODD: treatment

Parent Management Training Programs to help parents and others manage the child’s behavior. 

Individual Psychotherapy to develop more effective anger management. 

Family Psychotherapy to improve communication and mutual understanding. 

Cognitive Problem-Solving Skills Training Therapies to assist with problem solving and

decrease negativity.  Social Skills Training to increase flexibility and

improve social skills and frustration tolerance with peers. 

Medication for ADHD, anxiety, mood disordersAACAP

DepressionSadness over loss, disappointments, or stress is normal Depression is an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function.About 5 percent of children and adolescents in the general population suffer from depression at any given point in time.Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders are at a higher risk for depression. Depression also tends to run in families.

Depression: symptoms

Frequent sadness, tearfulness, crying

Decreased interest in activities; or inability to

enjoy previously favorite activities

Hopelessness

Persistent boredom; low energy

Social isolation, poor communication

Low self esteem and guilt

Extreme sensitivity to rejection or failure

Increased irritability, anger, or hostility

Difficulty with relationships

Frequent complaints of physical illnesses such as

headaches and stomachaches

Frequent absences from school or poor performance

in school

Poor concentration

A major change in eating and/or sleeping patterns

Talk of or efforts to run away from home

Thoughts or expressions of suicide or self destructive

behavior

Depression: treatment Individual Therapy

• Cognitive Behavior Therapy (CBT): changing unhealthy patterns of thinking. The therapist then helps the child replace this thinking with thoughts that result in better feelings and behaviors.

• Interpersonal Therapy (IPT) helps improve mood by improving interpersonal relationships.

Family Therapy focuses on helping the family function in more positive and constructive ways by looking at patterns of communication and providing support and education.

Group Therapy

Medications Antidepressants, mood stabilizers

Bipolar Disorder

Manic +/- depressive symptoms. Some may have mostly depression and others a

combination of manic and depressive symptoms. Highs may alternate with lows.

Bipolar disorder can begin in childhood and during the teenage years, although it is usually diagnosed in adult life.

The illness can affect anyone. However, if one or both parents have Bipolar Disorder, the chances are greater that their children may develop the disorder. Family history of drug or alcohol abuse also may be associated with greater risk for Bipolar Disorder.

Bipolar disorder: symptoms

• Severe changes in mood-either unusually happy or silly, or very irritable, angry, agitated, or aggressive

• Unrealistic highs in self-esteem – e.g., a teenager who feels all powerful or like a superhero with special powers

• Great increase in energy and the ability to go with little or no sleep for days without feeling tired

• Increase in talking - the adolescent talks too much, too fast, changes topics too quickly, and cannot be interrupted

• Distractibility - the teen's attention moves constantly from one thing to the next

• Repeated high risk-taking behavior; such as, abusing alcohol and drugs, reckless driving, or sexual promiscuity

• Overlaps with symptoms of: drug abuse, delinquency, ADHD, or even schizophrenia.

Bipolar Disorder: treatment

• Education of the patient and the family about the illness

• Psychotherapy helps the child understand himself or herself, adapt to stresses, rebuild self-esteem and improve relationships.

• Medications: Mood stabilizing medications such as lithium, valproic acid, or “atypical antipsychotic”, and psychotherapy.

Mood stabilizing medications often reduce the number and severity of manic episodes, and also help to prevent depression.

ANXIETY DISORDERS

Separation anxiety

• Constant thoughts and intense fears about the safety of parents and caretakers

• Refusing to go to school• Frequent stomachaches and other physical

complaints• Extreme worries about sleeping away from home• Being overly clingy• Panic or tantrums at times of separation from

parents• Trouble sleeping or nightmares

Phobias

• Extreme fear about a specific thing or situation (ex. dogs, insects, or needles)

• Fears cause significant distress and interfere with usual activities 

Social anxiety

• Fears of meeting or talking to people

• Avoidance of social situations

• Few friends outside the family

Obsessive-compulsive disorder• Obsessions: undesirable,

unpleasant, intrusive thoughts, images, or impulses that reoccur uncontrollably; over and over again and feel out of your control. Contamination, illness, harm, sexual ideas, order.

• Compulsions: acts performed

repeatedly (often according to "rules”) to reduce anxiety of obsessions; not pleasurable. Hand washing, checking locks, excessive & useless orderlines.

PTSD• Children usually quite resilient and recover from

stressful events• Catastrophic, life-threatening, or repeated trauma may

lead to PTSD in vulnerable individuals• Initially show agitated or confused behavior; intense

fear, helplessness, anger, sadness, horror or denial.  • Repeated trauma may produce emotional numbing that

deaden or block the pain and trauma: dissociation. • May become less responsive emotionally, depressed,

withdrawn, and more detached from their feelings• Avoid situations or places that remind them of the

trauma. • Symptoms last months to years

AACAP, 1999

PTSD: symptoms

• Frequent memories of the event, or in young children,  play in which  some or all of the trauma is repeated

• Upsetting and frightening dreams• Acting or feeling like the experience is happening

again• Repeated physical or emotional symptoms when

the child is reminded of the event

Other symptoms of anxious children

• Many worries about things before they happen• Constant worries or concerns about family,

school, friends, or activities• Repetitive, unwanted thoughts (obsessions) or

actions (compulsions)• Fears of embarrassment or making mistakes• Low self esteem and lack of self-confidence

Anxiety disorders: treatment

• Cognitive Behavioral Therapy (CBT)• Exposure and response prevention (ERP)• Medications: antidepressants (SSRIs), anti-

anxiety meds

Schizophrenia

• A serious psychiatric illness that causes strange thinking, strange feelings, and unusual behavior. 

• Uncommon in children and is hard to recognize in its early phases.

• Cause of schizophrenia is not known. Current research suggests a combination of brain changes, bio-chemical, genetic and environmental factors may be involved.

• Early diagnosis and medical treatment are important.

• Schizophrenia is a life-long disease that can be controlled but not cured.

Schizophrenia: symptoms

• Seeing things and hearing voices which are not real (hallucinations)

• Odd and eccentric behavior, and/or speech• Unusual or bizarre thoughts and

ideas                                  • Confusing television and dreams from reality• Confused thinking• Extreme moodiness• Ideas that people are out to get them or talking

about them (paranoia)• Severe anxiety and fearfulness• Difficulty relating to peers, and keeping

friends        • Withdrawn and increased isolation• Decline in personal hygiene

Schizophrenia

• The behavior of children with schizophrenia may change slowly over time. 

• Children who used to enjoy relationships with others may start to become more shy or withdrawn and seem to be in their own world.

• Talking about strange fears and ideas.  • Cling to parents or say things which do not

make sense.  • May first be noticed by the child's school

teachers.

Schizophrenia: treatment

• Need a comprehensive treatment plan. • Combination of medication, individual

therapy, family therapy, and specialized programs (school, activities, etc.) is often necessary. 

• Anti-psychotic medication can be helpful for many of the symptoms and problems identified. 

Alcohol and substance abuse

• Use is common in teens: 50-80% have used some drug recreationally

• For many this is short lived• For some leads it to abuse (maladaptive pattern of

use) or dependence (physiological tolerance and withdrawal)

• Average age of first marijuana use is 14 (26% HS seniors have used)

• Alcohol use can start before age 12 (88% seniors have used)

• Annually, 10,000 young people in the United States are killed and 40,000 injured in alcohol-related automobile accidents.

AACAP 2009

Substance abuse: risk factors

• Family history of substance abuse • Depression • Low self-esteem• More anxious, less assertive, more impulsive • Feel like they don't fit in or are out of the

mainstream• Vulnerable to peer pressure • Associated with ADHD and conduct disorder• Stimulant treatment for ADHD not associated

with adult drug use

Substance abuse: consequences

• Increased risk of serious drug use later in life

• Truancy, school failure• Antisocial behavior, conduct disorder• Poor judgment which may put teens at

risk for accidents, violence, unplanned and unsafe sex, and suicide.

• Sexual violence and victimization

Substance abuse: warning signs• Physical:  Fatigue, repeated health complaints, red and

glazed eyes, and a lasting cough.

• Emotional:  Personality change, sudden mood

changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest.

• Family:  Starting arguments, breaking rules,

or withdrawing from the family.

• School:  Decreased interest, negative attitude,

drop in grades, many absences, truancy, and discipline problems.

• Social problems:  New friends who are less

interested in standard home and school activities, problems with the law, and changes to less conventional styles in dress and music.

Autism & PDD

• A neurodevelopmental condition usually diagnosed in the first 3 years of life.

• Delays in speech development, limited social relatedness, and restricted interests and activities.

• Child may avoid direct eye contact and exhibit odd behaviors such as focusing on parts of objects (e.g. the spinning wheel of a toy car).

• Unusual motor movements such as hand flapping, self stimulation, or walking on toes.

• Cause is unknown, but believed due to genetic, environmental, metabolic and neurological conditions

AACAP 2009

Autism & PDD: diagnosis

3 domains

1.Social relatedness includes marked impairment in non-verbal communication, peer relationships and social-emotional reciprocity.

2.Communication/play includes either a delay or total lack of spoken language and lack of developmentally-appropriate make-believe or social play.

3.Restricted/stereotyped interests and activities includes encompassing preoccupations, adherence to non-functional routines or rituals, stereotypies and motor mannerisms.

AACAP 2009

Autism & PDD: social communication deficits

• Laughing (and/or crying) for no apparent reason;

showing distress for reasons not apparent to

others

• Prefers to be alone; aloof manner evident to

strangers and family members

• Tantrums and low frustration tolerance

• Difficulty in initiating social contact with others

• Uncomfortable with physical contact even when

given with affection such as a hug AACAP 2009

• Little or no eye contact even when spoken to directly

• Unresponsive to normal teaching methods (S)• Apparent over-sensitivity or under-sensitivity

to pain• No real fears of danger despite obvious risks

of harm.• Noticeable physical over-activity or extreme

under-activity• Impaired fine motor and gross motor skills

Autism & PDD: communication deficits

• Difficulty in expressing needs verbally, using gestures or pointing instead of words

• Repeating words or phrases in place of normal, responsive language

• Non-responsive to verbal instructions; often appears as if child is deaf although hearing tests in normal range (C)

• May not have mental retardation

AACAP 2009

Autism & PDD: Stereotypies

• Insistence on sameness in routines • Focus on spinning objects such as a fan or

the propeller of a toy helicopter• Obsessive attachment to particular objects • Rocking, flapping hands• Repetitive use of language

AACAP 2009

Autism vs. Asperger Syndrome

• Children with Asperger disorder do not present with delays in language acquisition or with marked unusual behaviors and environmental responsiveness during the first years of life.

• May achieve developmental milestones in first 3 years

• Speech patterns may be unusual and lack inflection or may be formal, but excessively loud or high pitched

• Conversation is one way, self-centered, unresponsive to others

• Restricted and obsessive interestsAACAP 2009

Autism & PDD: treatment

• No cure• Behavioral & educational interventions to

address specific cognitive, linguistic, & social deficits

• Medication to treat symptoms• Aggression, self-injurious behavior --

Risperidone• ADHD• Anxiety, OCD• Mood disorder and mood lability

AACAP 2009

Cutting & self-injurious behavior• Self-injury is the act of deliberately destroying body

tissue, at times to change a way of feeling or relieve painful feelings.

• Carving, scratching, branding, marking, picking and pulling skin and hair, burning/abrasions, cutting, biting, head banging, bruising, hitting

• To take risks, rebel, reject their parents' values, state their individuality or merely be accepted. 

• Desperation or anger to seek attention, to show their hopelessness and worthlessness, or because they have suicidal thoughts. 

• Associated with: depression, psychosis, PTSD and bipolar disorder. 

• Some may develop Borderline Personality Disorder as adults.  AACAP, 1999