Care Of Individuals With Childhood Mental Disorders PDF

CARE OF INDIVIDUALS WITH CHILDHOOD MENTAL DISORDERS Ms. Mimi Cheung Learning outcome ◦Identify the common mental disorders diagnosed in children & adolescents ◦Understand the causes of mental disorders in children & adolescents ◦Describe the therapeutic management related to childhood...

CARE OF INDIVIDUALS WITH CHILDHOOD MENTAL DISORDERS Ms. Mimi Cheung Learning outcome ◦Identify the common mental disorders diagnosed in children & adolescents ◦Understand the causes of mental disorders in children & adolescents ◦Describe the therapeutic management related to childhood mental disorders MC Which of the following is a common symptom of Attention-Deficit/Hyperactivity Disorder (ADHD) in children? A) Excessive sleeping B) Inattention and distractibility C) Consistent mood swings D) Difficulty with speech MC Which of the following is a common characteristic of Autism Spectrum Disorder (ASD) in children? A) Consistent eye contact B) Strong verbal communication skills C) Difficulty with social interactions D) Preference for large group activities MC Which of the following behaviors is commonly associated with Oppositional Defiant Disorder (ODD) in children? A) Frequent compliance with rules B) Persistent argumentative behavior C) Excessive shyness D) Lack of interest in activities MC Which of the following is a common behavior associated with Conduct Disorder in children? A) Frequent daydreaming B) Aggressive behavior towards people or animals C) Excessive fear of new situations D) Difficulty with fine motor skills Overviews of Child & Adolescent Psychiatric Disorders ◦Worldwide, 10- 20% of children and adolescents have a diagnosable mental disorder. ◦With increasing age, more children develop one or more disorders. ◦The persistence of psychiatric disorder into adult life with impact in various areas of functioning. Overviews of Child & Adolescent Psychiatric Disorders Child & Adolescent Psychiatric disorders cover broad range of mental health domains ◦Cognitive & Learning ◦Social & Communication ◦Emotional & Behavioral ◦Neurological & Physical ◦ Attachment disorder: infants and young children are notable difficulty in bonding with parents, under regulation of emotions and poorly coordinated social development that is insensitive to others. ◦ Pervasive developmental disorder: Autism ◦ Hyperkinetic disorder and conduct disorder: four and six years. impact on social development. If untreated, adolescence: antisocial behavior and dropping out of school ◦ Examples of emotional disorders are mood and neurotic disorders: easily identifiable by staff trained to treat mental disorders in children ◦ 12 and 18:Substance abuse. children are particularly impressionable and extremely eager to conform to the social norms defined by their immediate peers ◦ psychotic disorders such as schizophrenia in later adolescence ◦ Figures of child & adolescents rose from 18 900 in 2011-2012 to 28 800 in 2015-2016 ◦ increase by >50% ◦ The major disorders present in children are Autism Spectrum Disorder (ASD) and ADHD, which make up over half of the caseload of the C & A psychiatric team within the HA Causes of mental disorders in children & adolescents ◦Biological Risk Factors ◦Psychosocial Risk Factors ◦Psychological and Cultural Risk Factors Biological Risk Factors ◦Genetic : associated with the etiology of autism, conduct disorder, attention deficit/ hyperactivity disorders ◦Biochemical : decreases in norepinephrine & serotonin levels are related to depression; elevated plasma level of testosterone has possible correlation with aggressive behavior ◦Prenatal & postnatal : disordered brain function in child can result from mother’s exposure to drugs, infections, fetal malnutrition, birth hypoxia, lead poisoning, brain injuries due to accidents or abuse Psychosocial Risk Factors ◦Familial risk factors : associated with childhood psychiatric disorders and the risk factors are discordant family relationships, lack of emotional warmth in family relationships, psychiatric disorder in a parent, criminality in a parent , and large family size ◦Parenting : Authoritarian parenting (autocratic, unaffectionate) is associated with over-compliance, dependency and withdrawal in the child. Permissive parenting (laissez-faire, indulgent and affectionate) is associated with immaturity, lack of purpose and lack of self-control in child. https://www.youtube.com/watch?v=WjOowWxOXCg attachment theory Psychological and Cultural Risk Factors ◦Family adversity, life events & adverse experience : loss of a parent by divorce or death, acute life events and child abuse are associated with childhood psychiatric disorder ◦Attachment : long separation from attachment figures in the early life of a child can affect the child’s future relationships, social and cognitive development ◦Culture shock and culture conflicts : could have a profound effect on immigrant children’s development and the risk of mental and emotional problems Protective factors for mental health of children and adolescents ◦Biological factors Age-appropriate physical development Good physical health Good intellectual functioning ◦Psychological factors Ability to learn from experience Good self-esteem High level of problem solving ability Social skills Protective factors for mental health of children and adolescents ◦Social factors Family attachment Opportunities for positive involvement in family Rewards for involvement in family Opportunities for involvement in school life Positive reinforcement from academic achievement Identity with school or need for educational attainment Adverse Childhood Experiences (ACE) ACE : Intensive and frequent sources of stress that children may suffer early in life Common mental disorders of childhood and adolescence ◦ Neurodevelopment Disorders ◦ Mood disorders - Autism Spectrum Disorder (ASD) - Anxiety Disorders - Attention Deficit Hyperactivity Disorder - Depression (ADHD) - Borderline Personality Disorder ◦ Disruptive behavior disorders ◦ Eating Disorders - Conduct Disorder (CD) ◦ Substance Abuse Disorders -Oppositional Defiant Disorder (ODD) ◦ Psychosis Neurodevelopment disorders - Autism Spectrum Disorder (ASD) - Attention Deficit Hyperactivity Disorder (ADHD) https://www.youtube.com/watch?v=aNagOL99OI0  Autism Spectrum Disorder (ASD) ◦ Autism Spectrum Disorder is a neurodevelopment disorder that causes a wide range of impairments in social communication and restricted and repetitive behaviors. ◦ It is a lifelong, developmental condition that affects the way a person communicates, interacts and processes information. A. Deficits in Social Communication B. Restricted/ Repetitive Interests and Behaviors DSM-5-TR Criteria for Autism Spectrum Disorder A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive): -Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. -Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. -Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. DSM-5-TR Criteria for Autism Spectrum Disorder B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive): ◦ Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). ◦ Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day). ◦ Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest). ◦ Hyper-or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). DSM-5-TR Criteria for Autism Spectrum Disorder C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and Autism spectrum disorder frequently co-occur; to make comorbid diagnoses of Autism spectrum disorder and intellectual disability, social communication should be below that expected for general development level Autism Spectrum Disorder (ASD) Autism Spectrum Disorder (ASD) ◦The worldwide prevalence of ASD is 1% ◦Girls and boys presentation of ASD may different ◦Most diagnostic tools and research predominantly on male presentation of ASD (Most studies quote a ratio of 4-5:1) ◦Increased incidence among siblings (19%) and twins ◦More than half have normal intelligence (FSIQ above 90) Why are girls with ASD under- diagnosed? ◦ Traditional view of ASD occurring much more exclusively in males ◦ Researchers identified that in particular, higher-functioning girls with ASD are underdiagnosed For both male and females with ASD, higher intellectual abilities help mask social difficulties; they are able to learn ◦ Girls with less impaired nonverbal behaviors (able to use nonverbal gestures better) ◦ Girls can hold reciprocal conversations and initiate friendships better Assessment of ASD ◦Multidisciplinary Team Assessment ◦Developmental History (consider using an autism- specific tool, e.g. ADI-R) ◦Assessment of social and communication skills and behaviours (consider using an autism-specific tool, e.g. ADOS-2) ◦Medical history, physical examination ◦Consideration of differential diagnoses  Training for ASD Behavioural based Interventions ◦ proven effectiveness in building behavioural repertoires, reducing maladaptive behaviours, and improving functional communication skills in young children with ASD (Dawson and Burner, 2011). ◦ usually more suitable for children who are younger (under ages of 5) and with more severe behavioural and learning deficits Social Skills Training ◦ teaching specific skills in social communication through behavioural and social learning techniques, such that desired social skills are explicitly taught and reinforced through positive reinforcement strategies, or direct feedback ◦ target specific social challenges such as understanding perspectives, social pragmatic difficulties ◦ can span from young children (4 and above) through adulthood ◦ social Skills Training, Social Thinking Model (iLaugh) ILAUGH 社交思考模式  Broad Principles When Interacting with ASD 1.Difficulties with language pragmatics and verbal understanding ◦ Clear, succinct and explicit communication ◦ Reduce sarcasm and irony 2.Difficulties with unexpected changes ◦ Predictability and routines [importance of advanced notice] 3. Literal, black and white understanding ◦ Teaching in stepwise (breaking down steps), making things quantifiable 4. Prone to emotional arousal, weak in emotional regulation ◦ Reduce use of emotionally charged or inducing language ◦ Use positive language, reduce use of threats and negative language ◦ Keep calm, balancing kind but firm approaches Attention Deficit Hyperactivity Disorder (ADHD) Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active. https://www.youtube.com/watch?v=xAcg5_8Ef3w DSM-5-TR Criteria for ADHD Inattention ◦ Lack of attention to details, make careless mistakes ◦ Difficulty sustaining attention ◦ Does not listen when spoken to ◦ Trouble following instructions, completing or finishing jobs or tasks ◦ Problems organizing tasks / activities (time mx, keeps things in order, deadlines) ◦ Avoids or dislikes tasks requiring sustained mental effort ◦ Loses and misplaces things ◦ Easily distracted ◦ Forgetful in daily activities DSM-5-TR Criteria for ADHD Hyperactivity & Impulsivity ◦ Fidgety, squirmy ◦ Leaves seat when not supposed to ◦ Excessive run/climb ◦ Difficulty engaging in leisure activities quietly ◦ Always “on the go” ◦ Talks excessively ◦ Blurts out answers before questions have been completed ◦ Difficulty waiting in line or waiting his/her turns ◦ Interrupts or intrudes others when they are working or busy (conversations, activities, use others’ things w/o asking) 6/9 (ATT) + 6/9 (HA & IMP), onset 12 yrs; last  6 months ADHD presentation ◦ Excessive variability in task performance ◦ Situational variation of symptoms ◦ Performance is worse if: ◦ Tasks more complex demanding greater organization skill ◦ Where behavioral restraint is necessary (than free play) ◦ Longer period prior to reinforcement availability ◦ Tasks requiring more persistence ◦ Under low level of stimulation ◦ Absence of adult supervision Disruptive behavior disorders -Conduct Disorder (CD) -Oppositional Defiant Disorder (ODD)  DSM-5-TR Criteria for Oppositional Defiant Disorder (ODD) Angry / Irritable Mood ◦ often loses temper ◦ is often touchy or easily annoyed by others ◦ is often angry and resentful Argumentative / Defiant Behavior ◦ often argues with authority figures / adults ◦ often actively defies or refuses to comply with adults 'requests or rules ◦ often deliberately annoys people ◦ often blames others for his or her mistakes or misbehavior Vindictiveness ◦ is often spiteful or vindictive ◦ At least 4 symptoms,  1x/week (on most days if younger than 5 yo); last  6 months Oppositional Defiant Disorder (ODD) ◦Cause distress in child or others in the immediate social context ◦Negative impact on social, educational, or occupational or other areas of function DSM-5-TR Criteria for Conduct Disorder Aggression to people & animals Deceitfulness or theft ◦ 1. bullies, threatens or intimidates others 10. broken into a house/car 11. lies to obtain goods / avoid obligation ◦ 2. initiates physical fight 12. Stealing non-trivial valued items w/o confronting ◦ 3. use weapon that can cause serious physical harm Serious violations of rules ◦ 4. physically cruel to people 13. stay out at night beginning before ◦ 5. physically cruel to animal age despite parents’ prohibition 14. run away from home overnight ◦ 6. steal with confrontation 15. truancy beginning before age 13 ◦ 7. force someone into sexual activity Destruction of property ◦ 8. fire setting with intent to damage ◦ 9. destroy property 3 /15 criteria in past 12 months, with at least one criteria in past 6 months Overlap among ADHD, ODD & CD ◦The same child may demonstrates two, or all three disorders, either cross-sectionally or longitudinally ◦High co-occurrence (co-morbidity) ◦Familial clustering (suggesting shared genetic &/or shared environmental causes; and shared underlying psychopathological mechanism) ADHD/CD/ODD  Presenting problems : Comparison among ADHD, ODD & CD ADHD ODD CD Inattentive, distractible Angry mood Aggression to people/animals Disorganized, poor time mx Irritable mood Destruct property Careless mistakes Argumentive Deceitful / theft Poor response inhibition Defiant Serious violation of rules Overactive, impulsive Vindictiveness Emotional dysregulation Variable performance Varies with different adults Rules breaking Struggle / conflict with authority figures Annoying to others Negative affect Assessment for ADHD/ODD/CD ◦ Primarily a clinical diagnosis –No laboratory or brain scan confirmation ◦ Comprehensive history –Developmental perspective –Informants who know the child well across multiple settings –Child’s perspective ◦ Mental state examination ◦ Questionnaires / psychometric measurements may help in screening & monitor changes ◦ Co-morbidities is common ◦ Assess general development, strengths & weaknesses ◦ Assess family functioning, school and social support ◦ Child often under-estimate their symptoms or problems (esp for externalizing disorders) ◦ Informants may be biased by a number of factors e.g. own mental state, past experience ◦ Complex interplay and interaction among child’s deficits, environmental factors, and reactions from significant others ADHD treatment ◦Medication (Ritalin, Concerta, Ampetamine, Strattera) ◦ Reduce core symptoms ◦ Improve self acceptance ◦ Enhance the therapeutic effects of behavior intervention & skill training ◦ Maximize functioning ◦ Alleviate functional problems / minimize long term risks Broad Principles When Interacting with ADHD ◦ discussion Broad Principles When Interacting with ADHD ◦ Preferential seating to minimize distraction from the environment ◦ Sit near teacher so that prompting or support may be delivered more readily ◦ Provided structured environment e.g. schedule / rules posted; use color coding for notebook, folders ◦ Provide opportunity to get up and move around ◦ Increase novelty and interesting level of tasks ◦ Provide written directions on important issues on top of verbal ones ◦ Break task into smaller (more manageable) steps ◦ Give one direction at a time (avoid ‘busy’ learning environment); make eye contact (but don’t insist child look straight at you) ◦ Actively explore if child needs assistance or further explanation on what s/he is expected to do ODD treatment ◦ Parent management training  decrease +ve reinforcement of disruptive behavior  Increase +ve reinforcement of prosocial/compliant/desirable behaviour Apply consequences and/or punishment for disruptive behaviour Parental response be predictable, contingent and consistent ◦ Child-based therapy (problem solving skill, emotion regulatory skill) Role of drug treatment for ODD ◦ No specific drug treatment for ODD ◦ Indicated for co morbid conditions, e.g. ADHD, depression ◦ Mood stabilizers, antipsychotics, clonidine, psychostimulant, Atomoxetine may be helpful CD treatment ◦ Youth-based training Emotional regulation Anger management Problem solving skill Moral reasoning ◦ Parent management training ◦ Improve family interaction & communication Role of drug treatment for CD ◦Treat co-morbid conditions ◦Reduce impulsivity ◦Alleviate mood lability Mood disorders ◦Anxiety Disorders, Depression, Borderline Personality Disorder Anxiety disorders Anxiety disorders often begin in childhood or adolescence and continue into adulthood. Common anxiety disorders can include: 1. Obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder and phobias (symptoms similar to those seen in adults) 2. Separation anxiety disorder: characterized by the fear of being separated from the attachment figure. Symptoms include refusal to attend school, somatic complaints, severe anxiety about separation, and worry about harm coming to a significant caretaker Depressive disorders (DSM-5- TR) Experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure ◦ Diagnostic criteria -Pervasive low mood -Loss of interests -Weight loss -Insomnia/hypersomnia -Psychomotor agitation or retardation nearly every day -Loss of energy -Feeling worthless/guilty -Unable to concentrate -Suicidal ideation Borderline personality disorder 1. A pervasive pattern of instability of interpersonal relationships, self-image, and affects 2. Marked impulsivity; 5 of the following: -Frantic efforts to avoid real or imagined abandonment -Unstable and intense interpersonal relationships -Unstable self-image -Impulsivity -Recurrent suicidal behavior, gesture, or threats, or self-mutilating behavior -Affective instability due to marked reactivity of mood -Chronic feelings of emptiness -Inappropriate, intense anger or difficulty controlling anger -Transient, stress-related paranoid ideation or severe dissociative symptoms Self-harm Common forms of self-harm ◦Wrist cutting -Superficial VS deep -Single VS multiple ◦Drug overdose ◦Head or body banging ◦Hair pulling Functions of self-harm ◦Communication ◦Tension release ◦Addiction ◦Suicidal Risk factors of self harm ◦Personal factors -Presence of a mental health problem such as depression/PD -Previous self-harm -Poor coping skills -LGBT (lesbian, gay, bisexual, and transgender) ◦Environment factors -Family history and parental discord -Peer pressure -Social stress: Trauma, losses Treatment ◦Treat underlying mental illness ◦Remove access to tools of self-harm ◦Depends on functions of self-harm -Communication (validation) -Tension release (emotional regulation skills and distress tolerance skills) Eating disorders ◦ Anorexia nervosa -Restriction of energy intake leading to a significantly low body weight -Dread of fatness -Distorted body image Level of Severity Mild BMI >17 kg/m² Moderat BMI 16-16.99 kg/m² e Severe BMI 15-15.99 kg/m² Extrem BMI