THE SOURCES OF DISTURBANCES IN CHILDREN AND ADOLESCENCE

I. .Evolution theories

The behaviour and emotions are connected with the development stage of brain structures, as we repeat in the course of filo- and ontogenesis Due to Jackson’s theory the youngest brain structures are the most sensitive to disruptive factors leading to dissolution, these parts should be damaged then lower parts take control over.

II. Mental Retardation [MR]

A significantly sub-average general intellectual functioning resulting in or associated with concurrent impairments in adaptive behaviour and manifested during the developmental period, before the age of 18 /DSM – IV, AAMD/.

MR is a condition of “arrested or incomplete development of the mind” characterised by impaired developmental skills” that “contribute to the overall level of intelligence” /ICD-10/

Causative factors in MR include:

1. genetic (chromosomal, metabolic) inherited factors2. prenatal exposure to infections and toxins3. mother’s health during pregnancy 4. maternal infections 4. complications of pregnancy5. perinatal factors6. acquired childhood disorders

the more severe the mental retardation = the more likely is the cause is evident

for 3/4 of people with borderline intellectual functioning - no cause is known

Clinical features of mental retardation

I0 mild MR – IQ 50-69

- acquire language late, but speak well- their skills may develop at a lower rate when they learn reading and writing, they are capable of basic academic functions - they are adequate in the pre-school years and diagnosed when enter school- they are able to take care of themselves, to earn a living, but they lack social spontaneity because of their shortcomings

II0 moderate MR IQ 35-49

- may slowly gain limited language use- some learn basic school skills, do simple work, engage in social activities in supervised settings- they are impaired in caring for themselves- they are aware of their deficits and often feel alienated from their peers and frustrated by their limitations

III0 severe MR IQ 20-34-resembles the moderate category-limited or no language ability and marked motor or other impairments indicate CNS damage or maldevelopment-non-verbal forms of communication may be evolved-they need extensive supervision

IV0 profound MR IQ below 20-require constant supervision, are incapable of providing for their most – basic needs-some speech development and simple self-help skills may be acquired-they are severely limited in cognitive abilities, immobile or restrictedly mobile

III. Pervasive Developmental Disorders They include a group of psychiatric conditions as: autistic disorder, childhood disintegrative disorder, Asperger’s disorder and not specified ones, in which the following skills are impaired: 1. reciprocal social skills 2. language development 3. range of behavioural repertoire disturbances are not appropriately to mental or developmental level generally multiple areas are affected

they are manifested before the end of the 3rd year

they cause persistent dysfunction

AUTISTIC DISORDER

= early infantile autism, childhood autism, Kanner’s autism. It affects children with:

1. high socio-economic family status,2. psychosocial stresses3. neurological and biological factors – lesions

and perinatal complications of pregnancy, high incidence of medication usage during pregnancy4. genetic factors – fragile X5. immunological incompatibility between mother

and fetus 6. elevated plasma serotonin in 1/3 of autistic children:

increased CSF homovanilic acid and decreased 5-HIAA

Clinical features of autism

1) handedness – failure of lateralization,

2) immature or abnormal autonomic nervous system

3) behavioural impairments in social interaction: children fail to manifest the emotional relationships with parents and other people, they are unable to recognise and approach them; in school age they fail to play with peers and to make friends they lack a social smile, abnormal eye contact they don’t like being carried and hugged show no separation anxiety on being left

4) disturbances in communication and linguistic skills

language deviance and delay: in the first year of life they emit noises – clicks, sounds, screeches, nonsense syllables in stereotyped fashion without the intent of communication, read without any comprehension automatically speechpeculiar voice quality and rhythm, speech contains echolalia, stereotyped phrases out of context

5) stereotyped behaviour toys are manipulated in an unintended way, have no symbolic meaning the play, if any, is has a compulsive character stereotypes, mannerisms, grimacing are frequent

6) instability of mood and affect7) changed response to sensory stimuli: hyper-vigilance, over- or under-responsive heightened pain threshold they like vestibular stimulation (spinning, swinging) 8) a complete inability to focus on a task9) sleeplessness10) IQ scores: 50 - 55 - 40 %, 50 – 70 - 30 %, > 70 - 30 %the risk of autistic disorder increases as the IQ decreases

no drug has been found to be specific for autistic disorder; to ameliorate a variety of symptoms the following drugs are used: haloperidol, risperodone, SSRI, clomipramine, lithium

IV. Non – pervasive developmental disorders

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER /ADHD/

Developmentally age-inappropriate poor attention span, easy distractibility and features of hyperactivity, impulsivity or both. The symptoms of ADHD:

must be present for at least 6 months cause impairment in academic or social functioning occur before the age of 3, usually by 7 years no single factor is believed to cause the disorder - the most important are minimal brain damage, child’s

temperament, genetic-familiar factors, prolonged emotional deprivation and stressful psychic events

The main cause of ADHD is probably connected with dysfunction (immaturity) in both the adrenergic and the dopaminergic systems (affect both norepinephrine and dopamine),and this is why in treating this syndrome - CNS stimulants are used:

dextroamphetamine, methylphenidate, pemoline and tricyclic antidepressants, clonidine, SSRI, bupropion

Clinical features of ADHD

1) may have onset in infancy

2) in school ADHD children: may be unable to wait for their order are often emotionally unpredictable, irritable accident–prone, incautious “action before thought” have general co-ordination deficit, lack organisation, have memory, thinking, speech and hearing deficits fail to finish tasks exhibit “body anxiety”

consequently it results in: school difficulties negative self –concept, low self – esteem, depressed mood, reactive hostility, acting–out antisocial behaviour, self – defeating and self – punitive behaviour

ADHD may remit at puberty - usually between the age of 12 and 20 years. In 15-20 % cases, symptoms persist into adulthood – they may turn into conduct disorder or substance abuses.

V. Disruptive behaviour disorders

Children and teenagers are usual used to resolving their inner conflicts and problems through behaviour disturbances unlike adults who experience and analyse them. These disturbances are seen in young people’s behaviour in the form of:

Oppositional Defiant Disorder [ODD]Conduct Disorders [CD]

OPPOSITIONAL DEFIANT DISORDER [ODD]

Recurrent pattern of negativistic, defiant, disobedient, hostile behaviour toward authority figures naughty children

when the patterns of abnormal behaviour exceed the expectations for their peers, they are significantly impaired in social, academic, work settings

it may be a physiological developmental phase to form identity, to set inner standards and may be more intensive in two periods:• between 18-24 months• in adolescence as an expression of the need to separate from parents and establish an autonomous identity

environmental trauma (illness or chronic incapacity) may trigger oppositionalism as a defence against helplessness, anxiety, loss of self-esteem

features: loss of temper, arguments with adults, defiance of or refusal to comply with adults request or rules, deliberately doing things that annoy people, blaming others

In treatment of ODD it is effective to reinforce and praise appropriate behaviour and ignore undesired behaviour.

It is desirable to eliminate punitive parenting to avoid the emergence of aggression and deviance in children

CONDUCT DISORDERS [CD]

Repetitive and persistent pattern of behaviour in which basic rights of others, social norms or rules are violated

aggressive and dis-social children

groups of characteristics:

1. aggressive, assaultive and cruel behaviour with physical harm of people and animals

2. destruction of property, vandalism

3. deceit or theft

4. serious violations of rules

other abnormal behaviour which occur in CD:

staying out at night despite prohibitions before 13 yrs,

truancy from school, persistent lying, frequent suicidal thoughts and acts, they seldom exhibit guilt or feelings of remorse, callous behaviour and blaming others, failing to develop social attachments,

may display antisocial behaviour in gang groups

children with CD are unable to develop the tolerance for frustration, ego-ideal and remorse

severe punishment invariably increases maladaptive expression of frustration, rather than ameliorating the problem

in treatment psychotherapy should be oriented toward improving problem-solving skills

the following medication is often used in therapy: haloperidol, lithium, carbamazepine, clonidine, SSRI

VII. SUICIDES [by Stangel]

Each act of intentional self– mutilation when individual performing it could not have been sure

of survival. It concerns about 3 % of teenagers.

the main reasons are:61 % mood disorders especially depression50 % conduct disorders and personality disturbances27 % anxiety disturbances3 % schizophrenia

VIII. Anorexia nervosa as an example of auto- destructive or aggressive behaviours due to drive

disturbancesaggression self –aggression eating disorders open suicides binge-eating= fights death by instalments self-mutilation anorexia = murders contract with death rapes destruction latentlies, perfidy, provocation, irony, sneer, stubborn silence, permanent defiance Suppressed = substitutes supplementary activitiesnails biting, trichotillomania, anorexia nervosa

IX. Mood disorders

Mood disorders most often occur in children and adolescents when emotional needs are not provided:

parents’ lack of interest, abandonment, illness or death overwork sexual abuse or maltreatment

may be a consequence of: somatic diseases CNS disturbances endogenous – major depressive disorder

expression of depression according to age:

in 6 to 11 month old children as a reaction for the abandonment by mother: tearfulness timidity loosing the interest with surrounding child often is mute, rocking, vomiting losing sucking reflex and weight sleeplessness psychomotor retardationwhen mother comes back – symptoms disappear, if it doesn’t happen – possible chronic developmental disturbances

in 2 to 3 year old children, the reaction to separation with mother/father can broken down into the following phases:

the protest phase – ranging from a few hours to several days – child is crying, going away, defending him/herself from the foster – father/mother

the phase of distress and hopelessness – bad sleeping, apathy, child gives up calling mother/father the phase of fixation of changed behaviour

young pre-pubertal depressed children show:

mood – congruent auditory hallucinations, delusions are rare in pre-puberty because of cognitive immaturity

somatic complaints

withdrawal

sad appearance and poor self-esteem –they may refer to their feelings by many names (sad, empty, down, blue, crying, unhappy)

psychomotor agitation

in late adolescence more common are:

feelings of aggression, sulkiness, reluctance to co-operate with/in family

sense of hopelessness, restlessness

pervasive anhedonia

delusions

severe psychomotor retardation

negativistic, antisocial behaviour, use of alcohol, desire to leave home

regardless of age, in young depressed people are:

suicidal ideation

depressed or irritable mood which is vulnerable to influences of severe social stresses (family, school, peers)

sleeplessness

failure to make expected weight gain

diminished ability to concentrate and think – may be misdiagnosed as learning disorder

CLINICAL FEATURES OF MAJOR DEPRESSIVE DISORDER

the onset is insidious in children who have had difficulties with hyperactivity, separation

anxiety, intermittent depressive symptoms

symptoms last for at least 2 weeks

depressed or irritable mood is necessar

feelings of inappropriate guilt

delusions and hallucinations mood – congruent

CLINICAL FEATURES OF DYSTHYMIC DISORDER

Consist of a depressed or irritable mood for most of the day, for more days than not, over a period of at least 1 year and meet at least 3 criteria of the following:- poor self – esteem- pessimism or hopelessness- loss of interest- social withdrawal- chronic fatigue- feelings of guilt or brooding about the past- irritability- poor concentration or memory

CLINICAL FEATURES OF BIPOLAR I DISORDER

Manic episodes appears in an adolescents with grandiose and paranoid delusions and hallucinatory phenomena lasting at least 1 week.In manic episodes are present: decreased need for sleep pressure to talk flight of ideas and racing thought distractibility an increase activity (pleasurable) in atypical manic episodes: extreme mood variability and aggressive behaviour

X. Schizophrenia with childhood onset

- can occur as early as 5 or 6 years of age, 1/10000 children, in pre-pubertal children is exceedingly rare- delusions and hallucinations are less elaborate- visual hallucinations are more common- children may fail to achieve their expected levels of social and academic functioning

the types of schizophrenia are the same as in the adults:• paranoid • hebephrenic• catatonic• simple

CLINICAL FEATURES OF SCHIZOPHRENIA

insidious onset, the first symptoms may be sleeping and eating disturbances school difficulties in spite of normal intelligence, limited social skills deteriorated functions, thoughts, interests with religious and philosophy themes

core features: visual hallucinations delusions age appropriate blunted or inappropriate affects formal thought disorders: losing of associations and thought blocking, illogical thinking, poverty of thought

XI. Neurosis

psychogenic functional disturbances

neurosis is a result of difficult psychosocial situation the child turned in

children are not aware of illness

more often is met in girls, prognosis is better in boys

defence mechanisms evolved with neurosis: moonshine regression projection of the anxiety on a toy generally one symptom is predominant: enuresis or getting dirty ticks vomiting sleep disturbances, especially falling asleep, nightmares mutism characteristics: egocentrism, affective lability, reactions are inadequate to impulses emotional and motor hyperactivity or inhibition