NCM-117-PSYCHIATRY-PEDIA-1.pptx

NCM 117 Psychiatry: Children and Adolescents Herman M. Nicolas RN, MD, MAN A 1.2 Children and Adolescents A comprehensive evaluation of a child is composed of interviews with the parents, the child, and other family members Information: current school functioning, intellectual le...

NCM 117 Psychiatry: Children and Adolescents Herman M. Nicolas RN, MD, MAN A 1.2 Children and Adolescents A comprehensive evaluation of a child is composed of interviews with the parents, the child, and other family members Information: current school functioning, intellectual level and academic achievement. 1. standardized measures of developmental level 2. neuropsychological assessments In some cases, the court or a child protective service agency may initiate a psychiatric evaluation.  Children can be excellent informants about symptoms related to mood and inner experiences, such as psychotic phenomena, sadness, fears, and anxiety. However, they often have difficulty with the chronology of symptoms and are sometimes reticent about reporting behaviors that have gotten them into trouble. Very young children often cannot articulate their experiences verbally and do better, showing their feelings and preoccupations in a play situation. In some cases, the court or a child protective  Assessment Of Infants And Young Children of infants usually begin with the parents present because very young children may be frightened by the interview situation; the interview with the parents present also allows us 1 assess the parent-infant interaction. Infants may be referred for variety of reasons, including high levels of irritability, difficult being consoled, eating disturbances, poor weight gain, sleep disturbances, withdrawn behavior, lack of engagement in play, and developmental delay. We should assess areas of functioning that include motor development, activity level, verbal communication, ability to engage in play, problem-solving skills, adaptation to daily routines relationships, and social responsiveness.  School-Age Children Some school-age children are at ease when conversing with an adult; others may show fear, anxiety, poor verbal skills, or oppositional behavior. School-age children can usually tolerate a 45-minute session. The room should be sufficiently spacious for the child to move around, but not so large as to reduce intimate contact between the examiner and the child. We may reserve part of the  Adolescents distinct ideas about why the evaluation was initiated, and can usually give a chronologic account of the recent events leading to the evaluation, although some may disagree with the need for the evaluation. We should communicate the value of hearing the story from an adolescent's point of view and must be careful to reserve judgment and not assign blame. concerned about confidentiality assure them that permission will be requested from them before we share any specific information with parents, except in situations involving danger to the adolescent or others, in which case we must sacrifice confidentiality. open-ended manner; however, when silences occur during the interview, we should attempt to reengage the patient. We can explore what the adolescent believes the outcome of the evaluation will be (change of school, hospitalization, removal from the home, removal CONFIDENTIALITY assure them that permission will be requested from them before we share any specific information with parents, except in situations involving danger to the adolescent or others, in which case we must sacrifice confidentiality. open-ended manner of questioning; however silences: attempt to reengage the patient. We can explore what the adolescent believes the outcome of the evaluation will be (change of school, hospitalization, removal from the home, removal from peers) Identifying Data Identifying data for a child includes the child's gender, age, as well as the family constellation surrounding the child. History child's current and past functioning from the child's report, from clinical and structured interviews with the parents, and information from teachers and previous treating clinicians. chief complaint and the history of the present illness from both the child and the parents. Naturally, the child will articulate the situation according to his or her developmental level. The parents are usually the best source for determining the child's developmental history. Past clinicians can help augment the psychiatric and medical histories. The child's report is critical for understanding the current situation regarding peer relationships and adjustment to school. Adolescents are the best informants regarding knowledge of safe sexual practices, drug or alcohol use, and suicidal ideation. Mental Status Examination We should obtain a detailed description of the child's current mental functioning through observation and specific questioning. Table 1-27 presents an outline of the mental status examination Physical Appearance. The examiner should document the child's: size, grooming, nutritional state, bruising, head circumference, physical signs of anxiety, facial expressions, and mannerisms. Separation and Reunion The examiner should note how the child responds to separation from a parent, and how they react to the reunion. Either lack of affect at separation and reunion or severe distress on separation or reunion can indicate problems in the parent-child relationship or other psychiatric disturbances. Orientation to Time, Place, and Person Impairments in orientation can reflect neurologic damage, low intelligence, or a thought disorder. The age of the child must be kept in mind, how-ever, because very young children may not know the date, other chronologic information, or the name of the interview site. Speech and Language speech and language acquisition: Is it appropriate for the child's age? expressive language usage and receptive language The child's rate of speech, rhythm, latency to answer, the spontaneity of speech, intonation, articulation of words, and prosody. Echolalia, repetitive stereotypical phrases and unusual syntax are significant psychiatric findings. Children who do not use words by age 18 months or who do not use phrases by ages 2.5 to 3 years, but who have a history of typical babbling and responding appropriately to nonverbal cues, are probably developing typically. hearing loss is contributing to a speech and language deficit. Mood A child's sad expression, lack of appropriate smiling, tearfulness, anxiety, euphoria, and anger are valid indicators of mood, as are verbal admissions of feelings. Persistent themes in play and fantasy also reflect the child's mood. Parent-Child Interaction Before the interview, the examiner can observe the interactions between parents and the child in the waiting area. How the parents and child interact, both verbally and emotionally, are pertinent. Social Relatedness We should assess the appropriateness of the child's response to the interviewer, general level of social skills, eye contact, and degree of familiarity or withdrawal in the interview process. Overly friendly or familiar behavior may be as troublesome as extremely retiring and withdrawn responses. The examiner assesses the child's self-esteem, general and specific areas of confidence, and success with family and peer relationships. Motor Behavior The motor behavior part of the mental status examination includes observations of the child's coordination and activity level and ability to pay attention and carry out developmentally appropriate tasks. It also involves involuntary movements Cognition We also should assess the child's intellectual functioning and problem-solving abilities. We can estimate the relative level of intelligence from a child's general information, vocabulary, and comprehension. For a specific assessment of the child's cognitive abilities, we can use a standardized test. Memory School-age children should be able to remember three objects after 5 minutes and to repeat five digits forward and three digits backward. Anxiety can interfere with the child's performance, but an apparent inability to repeat digits or to add simple numbers may reflect brain damage, mental retardation, or learning disabilities. Judgment and Insight The child's view of the problems, reac-tions to them, and suggested solutions may give us a good idea of the child's judgment and insight. Also, the child's understanding of what he or she can realistically do to help and what we can do adds to the assessment of the child's judgment. Neurodevelopmental Disorders and Other Childhood Disorders Intellectual Disability Intellectual disability (ID), formerly known as MENTAL RETARDATION caused by a range of environmental and genetic factors that Iead to a combination of cognitive and social impairments. The American Association on Intellectual and Developmental Disability (AAIDD) defines intellectual disability as a disability characterized by significant limitations in both intellectual functioning (reasoning, learning, and problem-solving) and in adaptive behavior (conceptual, social, and practical skills) that emerges before the age of 18 years. GENETIC INTELLECTUAL DISABILITY AND BEHAVIORAL PHENOTYPE SPECIFIC AND PREDICTABLE BEHAVIORS genetically based cases of intellectual disability. These behavioral phenotypes occur with a significantly higher probability than expected among those individuals with a specific genetic abnormality..  High rates of aberrant interpersonal behavior and language function often meet the criteria for autistic disorder and avoidant personality disorder. Prader-Willi syndrome is almost always associated with compulsive eating disturbances, hyperphagia, and obesity. Socialization is an area of weakness, especially in coping skills. Externalizing behavior problems such as temper tantrums, irritability, and arguing seem to be heightened in adolescence.  DOWN SYNDROME English physician Langdon Down in 1866, was based on physical characteristics associated with subnormal mental functioning. Since then, Down syndrome has been the most investigated, and most discussed, syndrome in intellectual disability. amenable to postnatal interventions to address the cognitive deficits that it produces than was previously thought.  Phenotypically, children with Down syndrome have characteristic physical attributes, including slanted eyes, epicanthal folds, and a flat nose. Three types of chromosomal aberrations in Down syndrome: 1. Patients with trisomy 21 (three chromosomes 21, instead of the usual two represent the overwhelming majority; they have 47 chromosomes, with an extra chromosome 21. The mothers' karyotypes are normal. 2. Nondisjunction occurring after fertilization in any cell division results in mosaicism, a condition in which there are both normal and trisomic cells in various tissues. 3. In translocation, a fusion occurs of two chromosomes, usually 21 and 15, resulting in a total of 46 chromosomes, despite the presence of an extra chromosome 21.  FRAGILE X SYNDROME Fragile X syndrome is the second most common single cause of intellectual disability. The syndrome results from a mutation on the X chromosome at what is known as the fragile site (Xq27.3). The fragile site occurs in only some cells, and it may be absent in asymptomatic males and female carriers. Much variability is present in both genetic and phenotypic expression. Fragile X syndrome occurs in about 1 of every 1,000 males and 1 of every 2,000 females.  The typical phenotype includes a large, long head and ears, short stature, hyper extensible joints, and post pubertal macroorchidism Associated intellectual disability ranges from mild to severe. The behavioral profile of persons with the syndrome includes a high rate of ADHD, learning disorders, and autism spectrum disorder. Deficits in language function include rapid perseverative speech with abnormalities in combining words into phrases and sentences. Persons with fragile X syndrome seem to have relatively strong skills in communication and socialization; their intellectual functions seem to decline in the pubertal period.  Prader-Willi Syndrome Prader-Willi syndrome likely results from a small deletion involving chromosome 15, occurring sporadically. Its prevalence is less than 1 in 10,000. Persons with the syndrome exhibit compulsive eating behavior and often obesity, intellectual disability, hypogonadism, small stature, hypotonia, and small hands and feet.  CAT'S CRY (CRI-DU-CHAT) SYNDROME. Children with cat's cry syndrome have a deletion in chromosome 5. They are typically severely intellectually disabled and show many signs often associated with chromosomal aberrations, such as microcephaly, low-set ears, oblique palpebral fissures, hypertelorism, and micrognathia. The characteristic cat-like cry that gave the syndrome its name is caused by laryngeal abnormalities that gradually change and disappear with increasing age.  PHENYLKETONURIA (PKU). Ivar Asbjörn Fölling first described PKU in 1934 as an inborn error of metabolism. PKU is transmitted as a recessive autosomal Mendelian trait and occurs in about 1 of every 10,000 to 15,000 live births. For parents who have already had a child with PKU, the chance of having another child with PKU is 20 to 25 percent of successive pregnancies. PKU is reported predominantly in persons of North European origin; a few cases may occur in African Americans, Yemenite Jews, and Asians. The underlying metabolic defect in PKU is an inability to convert phenylalanine, an essential amino acid, to paratyrosine because of the absence or inactivity of the liver enzyme phenylalanine hydroxylase, which catalyzes the conversion. Therefore, PKU is mostly preventable with a screening for it, which, if positive, should be followed with a low phenylalanine diet.  RETT SYNDROME Rett syndrome, now diagnosed in the DSM-S as a form of autism spectrum disorder, is believed to be caused by a dominant X-linked gene. It is degenerative and affects only females. In 1966, Andreas Rett reported on 22 girls with a severe progressive neurologic disability. Deterioration in communications skills, motor behavior, and social functioning starts at about 1 year of age. Symptoms include ataxia, facial grimacing, teeth-grinding, and loss of speech. Intermittent hyperventilation and a disorganized breathing pattern are characteristic while the child is awake. Stereotypical hand movements, including hand-wringing, are typical. Progressive gait disturbance, scoliosis, and seizures occur. Severe spasticity is usually present in middle childhood. Cerebral atrophy occurs with decreased pigmentation of the substantia nigra, which suggests abnormalities of the dopaminergic nigrostriatal system. Associated features include seizures in up to 75 percent  NEUROFIBROMATOSIS. Also called von Recklinghausen's disease neurofibromatosis is the most common of the neurocutaneous. syndromes caused by a single dominant gene, which may be inher ited or occur as a new mutation. The disorder occurs in about 1 o 5,000 births and is characterized by café-au-lait spots on the ski and by neurofibromas, including optic gliomas and acoustic neuromas, caused by abnormal cell migration. Mild intellectual disability occurs in up to one-third of those with the disease.  TUBEROUS SCLEROSIS. Tuberous sclerosis is the second most common of the neurocutaneous syndromes; a progressive intellectual disability occurs in up to two-thirds of all affected persons. It occurs in about 1 of 15,000 persons who inherit it through autosomal dominant transmission. Seizures are present in all those with intellectual disability, and in two-thirds of those without. Infantile spasms may occur as early as 6 months of age. The phenotypic presentation includes adenoma sebaceum and ash-leaf spots, identifiable with a slit lamp.  LESCH-NYHAN SYNDROME Lesch-Nyhan syndrome is a rare disorder caused by a deficiency of an enzyme involved in purine metabolism. The disorder is X-linked; patients have intellectual disability, microcephaly, seizures, choreoathetosis, and spasticity. The syndrome is also associated with severe compulsive self-mutilation by biting the mouth and fingers. Lesch-Nyhan syndrome is another example of a genetically determined syndrome with a specific, predictable behavioral pattern.  ADRENOLEUKODYSTROPHY The most common of several disorders of sudanophilic cerebral sclerosis, adrenoleukodystrophy is characterized by diffuse demyelination of the cerebral white matter resulting in visual and intellectual impairment, seizures, spasticity, and progression to death. Adrenocortical insufficiency accompanies the cerebral degeneration. A sex-linked gene located on the distal end of the long arm of the X chromosome transmits the disorder. The clinical onset is generally between 5 and 8 years of age, with early seizures, disturbances in gait, and mild intellectual impairment. Abnormal pigmentation reflecting adrenal insufficiency sometimes precedes the neurologic symptoms, and attacks of crying are frequent. Spastic contractures, ataxia, and swallowing disturbances are also frequent. Although the course is often rapidly progressive, some patients may have a relapsing and remitting course.  Childhood Disintegrative Disorder The previous diagnosis of childhood disintegrative disorder, now included in autism spectrum disorder, is characterized by marked regression in several areas of functioning after at least 2 years of apparently normal development. Childhood disintegrative disorder, also called Heller syndrome and disintegrative psychosis, was described in 1908 as a deterioration over several months of intellectual, social, and language function occurring in 3- and 4-year-olds with previously normal function. After the deterioration, the children closely resembled children with autistic disorder.  Acquired Childhood Disorders Infection. The most severe infections affecting cerebral integrity are encephalitis and meningitis. The universal use of the measles vaccine had virtually eliminated measles encephalitis. However, a recent refusal by some individuals and communities to vaccinate their children has increased the risk of this as well as subacute sclerosing panencephalitis, a rare and usually fatal degenerative disease that can occur years after the infection. Antibacterial agents have reduced the incidence of other bacterial infections, at least in the developed world. Viruses now cause most episodes of encephalitis. Sometimes a clinician must retrospectively consider a probable encephalitic component in a previously unknown illness with a high fever. A delayed diagnosis of meningitis, even when followed by antibiotic treatment, can seriously affect a child's cognitive development. Thrombotic and purulent intracranial phenomena secondary to septicemia are rarely seen today except in small infants. Head Trauma. The best-known causes of head injury in children that produce developmental handicaps, including seizures, are motor vehicle accidents (household accidents are the most common cause of head injuries, such as falls from tables, open windows, and on stairways). Child maltreatment is a frequent cause of head traumas or intracranial trauma such as bleeding due to "shaken baby" syndrome. Asphyxia. Brain damage due to asphyxia associated with near-drowning is not an uncommon cause of intellectual disability. Long-Term Exposures. Long-term exposure to lead is a well- established cause of compromised intelligence and learning skills. A 2.3 Autism Spectrum Disorder Autism spectrum disorder (previously known as pervasive developmental disorders), describes a wide range of impairments in social communication and restricted and repetitive behaviors. It is a phenotypically heterogeneous group of neurodevelopmen-tal syndromes, with polygenic heritability. Before DSM-5, five overlapping disorders captured the spectrum: autistic disorder, Asperger disorder, childhood disintegrative disorder, Rett syn-drome, and pervasive developmental disorder not otherwise speci-fied. These differed by the level of severity, specific syndrome, and in some cases underlying pathology. ICD-10 continues to follow this approach to a degree. However, the recent clinical consensus has shifted the conceptualization of autism spectrum disorder toward a continuum model in which heterogeneity of symptoms is inherent in the disorder. DSM-5 collapses the core diagnostic impairments into two domains: deficits in social communication, and restricted and repetitive behaviors. Aberrant language development and usage are no longer considered a core feature of autism spectrum disorder. This diagnostic change, is based, in part, on recent studies in siblings with diagnoses of autistic disorder, suggesting that symptom domains may be transmitted separately and that aberrant language development and usage is not a defining feature, but an associated feature in some individuals with autism 2.2 Communication Disorders 2.2 Communication Disorders Communication disorders range from mild delays in acquiring language to expressive or mixed receptive-expressive disorders, phonologic disorders, and stuttering, which may remit spontaneously or persist into adolescence or even adulthood. Language delay is one of the most common very early childhood developmental delays, affecting up to approximately 7 percent of 5-year-olds. The rates of language disorders are understandably higher in preschoolers than in school- age children; rates were close to 20 percent of 4-year-olds in the Early Language in Victoria Study (ELVS). To communicate effectively, children must have a mastery of multiple aspects of language that is, the ability to understand and express ideas- using words and speech to express themselves in vernacular language. In DSM-5, Language Disorder includes both expressive and mixed receptive-expressive problems. DSM-5 speech disorders include Speech Sound Disorder (formerly known as Phonologic Disorder) and Childhood-Onset Fluency Disorder (Stuttering). Children with expressive language deficits have difficulties expressing their thoughts with words and sentences at a level of sophistication expected for their age and developmental level in other areas. These children may struggle with  SPEECH SOUND DISORDER Children with speech sound disorder have difficulty pronouncing speech sounds correctly due to omissions of sounds, distortions of sounds, or atypical pronunciation. Formerly called phonologic disorder, typical speech disturbances in speech sound disorder include omitting the last sounds of the word (e.g., saying mou for mouse or drin for drink), or substituting one sound for another (saying wu instead of blue or tup for cup). Distortions in sounds can occur when children allow too much air to escape from the side of their mouths while saying sounds like sh or producing sounds like s or z with their tongue protruded. Speech sound errors can also occur in patterns because a child has an interrupted airflow instead of a steady airflow preventing their pronouncing  A 2.3 Autism Spectrum Disorder Autism spectrum disorder (previously known as pervasive developmental disorders), describes a wide range of impairments in social communication and restricted and repetitive behaviors. It is a phenotypically heterogeneous group of neurodevelopmen-tal syndromes, with polygenic heritability. Before DSM-5, five overlapping disorders captured the spectrum: autistic disorder, Asperger disorder, childhood disintegrative disorder, Rett syn-drome, and pervasive developmental disorder not otherwise speci-fied. These differed by the level of severity, specific syndrome, and in some cases underlying pathology. ICD-10 continues to follow this approach to a degree. However, the recent clinical consensus has shifted the conceptualization of autism spectrum disorder toward a continuum model in which heterogeneity of symptoms is inherent in the disorder. DSM-5 collapses the core diagnostic impairments into two domains: deficits in social communication, and restricted and repetitive behaviors. Aberrant language development and usage are no longer considered a core feature of autism spectrum disorder. This diagnostic change, is based, in part, on recent studies in siblings with diagnoses of autistic disorder, suggesting that symptom domains may be transmitted separately and that aberrant language development and usage is not a defining feature, but an associated feature in some individuals with autism  Associated Behavioral Symptoms that May Occur in Autism Spectrum Disorder Disturbances in Language Development and Usage. Deficits in language development and difficulty using language lo communicate ideas are not among the core criteria for diagnosing autism spectrum disorder; however, they occur in a subset of those individuals with autism spectrum disorder. Some children with autism spectrum disorder are not merely reluctant to speak, and their speech abnormalities do not result from a lack of motivation. Language deviance, as much as language delay, is characteristic of more severe subtypes of autism spectrum disorder. Children with severe autism spectrum disorder have significant difficulty putting meaningful sentences together, even when they have extensive vocabularies. When children with autism spectrum disorder with delayed language learn to converse fluently, their conversations may impart information without typical prosody or inflection. In the first year of life, a typical pattern of babbling may You sent Intellectual Disability. About 30 percent of children with autism spectrum disorder are intellectually disabled. Of those, about 30 percent of children function in the mild to moderate range, and about 45 to 50 percent are severe to profoundly intellectually disabled. The IQ scores of autism spectrum disorder children  CLINICAL FEATURES ADHD can have its onset in infancy, although it is rarely recognized until a child is at least toddler age. More commonly, infants with ADHD are active in the crib, sleep little, and cry a great deal. In school, children with ADHD may attack a test rapidly but may answer only the first two questions. They may be unable to wait to be called on in school and may respond before everyone else. At home, caregivers cannot put them off for even a minute. Impulsiveness and an inability to delay gratification are characteristic. Children with ADHD are often susceptible to accidents. The most cited characteristics of children with ADHD, in order of frequency, are hyperactivity, attention deficit (short attention span, distractibility, perseveration, failure to finish tasks, inat- tention, poor concentration), impulsivity (action before thought, abrupt shifts in activity, lack of organization, jumping up in class), memory and thinking deficits, specific learning disabilities, and speech and hearing deficits. Associated features often include perceptual-motor impairment, emotional lability, and developmental coordination disorder. A significant percentage of children with ADHD show behavioral symptoms of aggression and defi-ance. School difficulties, both learning and behavioral, commonly exist with ADHD. Comorbid communication disorders or learning disorders that hamper the acquisition, retention, and display of knowledge complicate the course of ADHD.  injurious behaviors, and severe temper tantrums. These peo are common in children and adolescents with autism per disorder. Severe temper tantrums may be difficull to subte self- injurious behaviors are often problematic to control. Ero situations can cause these symptoms in which one would epe youth to transition from one activity to another, sit in a day setting, or remain still when they desire to run around In dis with autism spectrum disorder who are lower functioning and h intellectual deficits, aggression may emerge unexpectedly rd an obvious trigger or purpose, and self-injurious behaviors sch head banging, skin picking, and biting oneself may also occu Instability of Mood and Affect. Some children with as spectrum disorder exhibit sudden mood changes, with burs laughing or crying without an apparent reason. It is difficult to ka more about these episodes if the child cannot express the tho related to the affect. Response to Sensory Stimuli. Children with autism spen disorder may overrespond to some stimuli and underrespl other sensory stimuli (e.g., to sound and pain). It is not unca for a child with autism spectrum disorder to appear deaf a i showing little response to a normal speaking voice; on the da hand, the same child may show intent interest in the soud di wristwatch. Some children have a heightened pain thresholdr altered response to pain. Indeed, some children with auism so trum disorder do not respond to an injury by crying or see comfort. Some youth with autism spectrum disorder persi on a sensory experience; for example, they frequenty hum or sing a song or commercial jingle before saying words ct s. speech. Some particularly enjoy vestibular stimulation-sp swinging, and up-and-down movements. Hyperactivity and Inattention. Hyperactiviy and at tion are both common behaviors in young children with e Spectrum disorder To dearerage activity You sent A 2.4 Attention-Deficit/ Hyperactivity Disorder ADHD is a neuropsychiatric condition affecting preschoolers, children, adolescents, and adults around the world, characterized by a pattern of diminished sustained attention, and increased impulsivity or hyperactivity. Based on family history, genotyping, and neuroimaging studies, there is clear evidence to support a biologic basis for ADHD. Although multiple regions of the brain and several neurotransmitters contribute to the emergence of symptoms, dopamine continues to be a focus of investigation regarding ADHD symptoms.  The prefrontal cortex of the brain is a focus of interest because of its high utilization of dopamine and its reciprocal connections with other brain regions involved in attention, inhibition, decision-making, response inhibition, working memory, and vigilance. ADHD affects up to 5 to 8 percent of school-age children, with 60 to 85 percent of those diagnosed as children continuing to meet criteria for the disorder in adolescence, and up to 60 percent continuing to be symptomatic into adulthood. Children, adolescents, and adults with ADHD often have significant impairment in academic functioning as well as in social and interpersonal situations. ADHD is frequently associated with comorbid disorders, including learning disorders, anxiety disorders, mood CLINICAL FEATURES ADHD can have its onset in infancy, although it is rarely recognized until a child is at least toddler age. More commonly, infants with ADHD are active in the crib, sleep little, and cry a great deal. In school, children with ADHD may attack a test rapidly but may answer only the first two questions. They may be unable to wait to be called on in school and may respond before everyone else. At home, caregivers cannot put them off for even a minute. Impulsiveness and an inability to delay gratification are characteristic. Children with ADHD are often susceptible to accidents. The most cited characteristics of children with ADHD, in order of frequency, are: 1. hyperactivity 2. attention deficit (short attention span, distractibility, perseveration, failure to finish tasks, inattention, poor concentration), 3. impulsivity (action before thought, abrupt shifts in activity, lack of organization, jumping up in class) 4. memory and thinking deficits 5. specific learning disabilities 6. speech and hearing deficits  Associated features often include perceptual-motor impairment, emotional lability, and developmental coordination disorder. A significant percentage of children with ADHD show behavioral symptoms of aggression and defiance. School difficulties, both learning and behavioral, commonly exist with ADHD. Comorbid communication disorders or learning disorders that hamper the acquisition, retention, and display of knowledge complicate the course of ADHD. Hyperactivity and Inattention Hyperactivity and attention are both common behaviors in young children with e spectrum disorder. Lower than average activity. when present, it often alternates with hyperactivity. & attention span, poor ability to focus on a task, may also interfer with daily functioning. Precocious Skills Some individuals with autism spectras order have precocious or splinter skills of high proficiency, ad prodigious rote memories or calculating abilities, usually behold capabilities of their conventional peers.  RESPONSE TO SENSORY STIMULI over respond to some stimuli and undergone other sensory stimuli (e.g., to sound and pain) autism spectrum disorder: to appear deaf, showing little response to a normal speaking voice Some children have a heightened pain or thrill on altered response to pain some children with autism spectrum disorder do not respond to an injury by crying or e comfort. Some youth with autism spectrum disorder response on a sensory experience; for example, they frequently hum in or sing a song or commercial jingle before saying words are speech. Some particularly enjoy vestibular stimulation-swinging, and up- and-down movements. 2.6 Motor Disorders DEVELOPMENTAL COORDINATION DISORDER Developmental coordination disorder is a neurodevelopmental disorder in which a child's fine or gross motor coordination is slower, less accurate, and more variable than in peers of the same age. Affecting about 5 to 6 percent of school-age children, 50 percent of children with developmental coordination disorder also have comorbid ADHD or dyslexia..A meta-analysis of recent research on developmental coordination disorder concluded that three general areas of deficits contribute to the disorder: 1) Poor predictive control of motor movements 2) deficits in rhythmic coordination and timing 3) deficits in executive functions, including working memory inhibition, and attention. Diagnosis and Clinical Features The presence of multiple repetitive stereotyped symptoms tends to occur frequently among children with autism spectrum disorder and intellectually disability STEREOTYPIC MOVEMENT DISORDER Stereotypic movements include a diverse range of repetitive behaviors that usually emerge in the early developmental period, appear to lack a clear function, and sometimes cause an interruption in daily life. These movements are typically rhythmic, such as hand flapping, body rocking, hand waving, hair- twirling, lip-licking appear to be self-soothing or self-stimulating; however, they can result in self-injury in some cases.  appear to be involuntary frequently can be suppressed with a concentrated effort. increased frequency in children with autism spectrum disorder and intellectual disability, but they also exist in typically developing children. Stereotypic movements, such as head-banging, face slapping, eye-poking, or hand-biting, can cause significant self-harm. Nail biting, thumb-sucking, and nose-picking are often not included as symptoms of stereotypic movement disorder because they rarely cause impairment. Head-Banging stereotypic movement disorder that can result in functional impairment. begins during infancy, between 6 and 12 months of age. Infants strike their heads with a definite rhythmic and monotonous continuity against the crib or another hard surface. They seem to be absorbed in the activity, which can persist until they become exhausted and fall asleep. often transitory but sometimes persists into middle childhood. component of temper tantrums differs from stereotypic head-banging and ceases after the tantrums, and controlling their secondary gains. NAIL-BITING Nail-biting begins as early as 1 year of age and increases in incidence until age 12. Most cases are not sufliciently severe to meet the DSM- 5 diagnostic criteria for stereotypic movement disorder. In rare cases, children cause physical damage to the fingers themselves, usually by associated biting of the cuticles, which leads to secondary infections of the fingers and nail beds.  TOURETTES DISORDER Tics are neuropsychiatric events characterized by brief, rapid motor movements or vocalizations in response to irresistible premonitory urges. Although frequently rapid, tics may include more complex patterns of movements and longer vocalizations. Because tic disorders are significantly more common in children than in adults, the postulated alterations in dopamine circuitry in many affected children appear to improve over time. Tics may be transient or chronic, with a waxing and waning course. Tics typically emerge at age 5 to 6 years of age and tend to reach their highest severity between 10 and 12 years. About one half to two-thirds of children with tic disorders will be much improved or in remission by adolescence or early adulthood. Depressive Disorders and Suicide in Children and Adolescents Depressive disorders in youth represent a significant public health concern they are prevalent and result in long-term adverse effects on the individual's cognitive, social, and psychological development. These disorders affect approximately 2 to 3 percent of children and up to 8 percent of adolescents need for early identification and access to evidence- based interventions such as CBTs and antidepressant agents, is essential.  The core features of major depression in children, adolescents, and adults bear a striking resemblance significant depression runs in families highest risk in children whose parents experienced early- onset depression twin studies have demonstrated that major depression is only moderately heritable 40 to 50 percent, highlighting environmental stressors and adverse events as significant contributors to major depressive disorder in youth. The core features of major depression in children, adolescents, and adults bear a striking resemblance; however, the developmental level of the child or adolescent