Child and Adolescent Mental Health-Dr Lim Choon Guan.pdf

Overview of Child/Adolescent Psychiatry Dr Lim Choon Guan Psychiatrist, CGC, IMH 2021 Introduction: Child vs Adult     Children seldom initiate the referrals Children are developing and this must be considered Children are usually less able to express themselves Less use of medication in treatme...

Overview of Child/Adolescent Psychiatry Dr Lim Choon Guan Psychiatrist, CGC, IMH 2021 Introduction: Child vs Adult     Children seldom initiate the referrals Children are developing and this must be considered Children are usually less able to express themselves Less use of medication in treatment of children Presentation of Mental Health Problems  Emotional Problems   Behavioral Problems   Unusually shy, inhibited, solitary, withdrawn behavior, anti-social behavior, disobedient, violent, quarrelsome, destructive, lying, stealing, shoplifting, truancy, running away from home, hyperactivity, sexual misdemeanors and deviations, disruptive behavior, inattentive and poor concentration, distractibility, frequent temper tantrums, obsessive compulsive acts and bizarre irrational behavior etc. Developmental Problems   Persistent fear and anxiety, school refusal, depression, suicidal ideas and attempts, daydreaming and self-preoccupation, jealousy, sibling rivalry, anger, hostility, irritability and mood swing. Language and speech delay, stuttering, bedwetting, soiling, reading and learning problems and socialization difficulties. Other Problems  Include parent–child relationship problems, martial problems that affect their children emotionally, bodily pains and aches, child abuse and eating problems. Dimensional vs Categorical Approach to Psychiatric Disorders? Does my child have a problem?  A mother is concerned that her 3-year old is still crying and refusing to enter his nursery classroom in the morning after 2 weeks. When assessing a behaviour, consider Appropriateness  Intensity  Persistence  Pervasiveness  Impairment  Some common child psychiatric conditions REACH: Community-centric Model Counsellors School Educational Psychologists Social workers Family Social Services GPs Medical Services Child Mental Health Services DSM 5 1. Neurodevelopmental Disorders 2. Schizophrenia Spectrum and Other Psychotic Disorders 3. Bipolar and Related Disorders 4. Depressive Disorders 5. Anxiety Disorders 6. Obsessive-Compulsive and Related Disorders 7. Trauma and Stressor-Related Disorders 8. Dissociative Disorders 9. Somatic Symptom and Related Disorders 10. Feeding and Eating Disorders 11. Elimination Disorders 12. Sleep-Wake Disorders 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse Control, and Conduct Disorders 16. Substance-Related and Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders Neurodevelopmental Disorders   Intellectual disability (intellectual developmental disorder) Communication disorders  Language disorder  Speech sound disorder (phonological disorder)  Childhood-onset fluency disorder (stuttering)  Social (pragmatic) communication disorder  disorder.     Specific learning disorder Motor disorders Tic Disorders Autism spectrum disorder Autism Spectrum Disorder DSM-IV TR Pervasive Developmental Disorders – Autistic Disorder – Asperger Syndrome – Pervasive Developmental Disorder Not Otherwise Specified – Childhood Disintegrative Disorder – Rett’s Syndrome DSM 5 Neurodevelopmental Disorders Autism Spectrum Disorder Not included in DSM 5 Autism Spectrum Disorder  Prevalence of autism 4 per 10,000 for childhood autism (Lotter 1996)  Other systematic surveys  30-100 per 10,000 for autism  3-10 per 10,000 for Asperger’s Syndrome (Baird, Simonoff, Pickles 2006 , Fombonne 1999, 2003) Autism Spectrum Disorder  Prevalence of Autism  Males: Females (Fombonne 2003)  4:1  Intellectual disability  Profound ID 40%, mild to moderate 30%, normal intellectual function 30%  Risk of second child:  5% (100 times) Who picks up first?    Childhood developmental assessment by primary care doctors Opportunity for early identification, referral for assessment and early intervention Study at KK Child Development Unit  7% developmentally appropriate  Most common presenting concern speech and language delay  Most common clinical developmental diagnosis was autism spectrum disorder Lian WB, et al. Singapore Med J 2012; 53(7) : 439-445 DSM-5: ASD (A) Persistent deficits in social communication and social interaction in all areas: 1. Deficits in social-emotional reciprocity Abnormal social approach Lack of reciprocal conversation Reduced sharing of interests, emotions, and affect and response Lack of initiation of social interaction 2. Deficits in nonverbal communicative behaviours Poorly integrated- verbal and nonverbal communication Abnormalities in eye contact and body-language Deficits in nonverbal communication Lack of facial expression or gestures. 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers) Difficulties in sharing, imaginative play, making friends Lack of interest in people (B) Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least 2/4 of the following: 1. Stereotyped or repetitive speech, motor movements Simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases 2. Excessive adherence to routines or rituals or resistance to change Motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes 3. Highly restricted, fixated interests that are abnormal in intensity or focus Preoccupation with unusual objects, excessively circumscribed interests 4. Hyper-or hypo-reactivity to sensory input or unusual interest Indifference, adverse response to specific sounds or textures Excessive smelling or touching of objects, fascination with lights or spinning objects Early Signs of Autism Interaction Communication Behavioural Infants (birth – 12 months) Limited eye contact Does not smile Makes no meaningful gestures Does not babble Is difficult to by 12 months console Seems to not hear Toddlers (1 to 3 years) Likes to be alone Tunes out a lot Not interested in other children Does not point or show me things Does not turn when I call his/her name No single words by 16 months Does not wave good bye Lines up toys Throw tantrums Cannot stand changes Is “clumsy” (Filipek et al., 2000; Volkmar et al., 2005) Etiology  Genetic factors  Multiple genes identified  Risk factors: advanced paternal/maternal age, extreme prematurity  Neurobiological factors  Increased incidence of epilepsy  Neuro-imaging: structural findings  ?Environmental Diagnostic Assessments 1. Interview with parents  2. Assessment of child   3. 4. ASD specific developmental history Direct observations Cognitive/ Developmental assessments Observation in relevant environments Other relevant assessments   Audiological assessment Speech/ Language assessment Examples of Diagnostic Assessment Tools  Structured Interview with Parents  Autism Diagnostic Interview- Revised (ADI-R) (Le Couteur, Lord)  Diagnostic Interview for Social and Communication Disorders (DISCO) (Wing and Gould)  Assessment of Child  Autism Diagnostic Observation Schedule (ADOS) (Lord) Autism and Mental Health Percentage of Children with DSM-oriented scale of clinical concern N=71, 6-18 years (Mage= 10.24 years) Prevalence of Emotional and Behavioural Problems in Children with High-Functioning Autism Spectrum Disorders. YP Ooi, ZJ Tan, CX Lim, TJ Goh, M Sung. Aust NZ J Psychiatry, , 2010; May 44(5) ):410-28. Autism and Mental Health N=71, 6-18 years (Mage= 10.24 years) 40 35 30 25 20 15 10 5 0 Affective Anxiety Somatic ADHD ODD Conduct Percentage Prevalence of Emotional and Behavioural Problems in Children with High-Functioning Autism Spectrum Disorders. YP Ooi, ZJ Tan, CX Lim, TJ Goh, M Sung. Aust NZ J Psychiatry, , 2010; May 44(5) ):410-28. Management  Educational/Vocational  Behavioural Intervention  Family Support  Psychotherapy  Pharmacotherapy Prognosis Children with intervention before 3 years have a significantly better outcome than those beginning after 5 years Lord, 2001. Woods 2003. Important components: Earliest possible age High intensity Parent involvement Various modules to stimulate social and communicative functioning Systemic instruction with individual goals Generalize skills to daily life Kabot 2003 Medications by Target Symptoms Anxiety and Repetitive Behaviours Aggression, Irritability and Self-Injurious Behaviour ADHD Symptoms 1. Selective Serotonin Reuptake Inhibitors 1. Typical Antipsychotics 1.Stimiulants -Eg: Haloperidol -Eg: Methylphenidate -Eg: Fluoxetine, Fluvoxamine 2. Tricyclic Antidepressants -Eg: Clomipramine -2. Atypical Antipsychotics -Eg: Risperidone, Olanzapine 2. Selective Norepinephrine Reuptake Inhibitors -Eg: Atomoxetine 3. Mood Stabilizers -Eg: Sodium Valproate, Carbamazepine Sung, Fung, Cai, Ooi. (2010) Attention Deficit Hyperactivity Disorder (ADHD)  Symptoms of Inattention  Symptoms of Hyperactivity- Impulsivity Before 7 years of age (12 for DSM-5) Impairment in two or more settings Significant impairment in social, academic or occupational functioning    ADHD: DSM-IV TR vs DSM-5 DSM-IV TR DSM V Symptom criteria Same Same except for adults: 5/9 symptoms Onset Before age 7 Before age 12 Specifier Subtypes: -Combined -Inattentive -Hyperactiveimpulsive Current Presentation: -Combined -Inattentive -Hyperactive-impulsive Classification Disruptive Behavioural Disorder Neurodevelopmental disorder ASD Exclusion Co-morbid Criteria: Inattention Criterion Examples Careless mistakes Overlooks or misses details, work is inaccurate Can’t sustain attention Can’t remain focused during lectures, conversations or lengthy reading Doesn’t listen Mind seems elsewhere when no obvious distraction Can’t complete task Starts tasks but quickly loses focus and easily sidetracked Can’t organize Difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines Doesn’t like effortful task Preparing reports, completing forms, reviewing lengthy papers Loses things Tools, wallets, keys, paperwork, eyeglasses, mobile phones Distractible By unrelated thoughts Forgetful Returning calls, paying bills, keeping appointments Criteria: Hyperactive-Impulsive Criterion Examples Fidgets in seat Leaves seat Office or other workplace, or situations that require remaining in place Runs around May be limited to feeling restless Do things quietly On the go; energetic Unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with Talkative Blurts answers Completes other people’s sentences; cannot wait for turn in conversation Can’t wait for turn While waiting in line Interrupts or intrudes May intrude into or take over what others are doing ADHD  Prevalence 5-7% (Guilherme et al 2007; Willcutt 2012)  Significant proportion have residual symptoms in adulthood  Faraone SV, Biederman J, Mick E. Psychol Med 2006 Diagnostic level Subthreshold but impairing levels Normal levels childhood adolescence adulthood 50-75% cases What causes ADHD? Neuroanatomic Neurochemical1 Genetic origins 2-4 ADHD Environmental factors3,5 1. Swanson J, et al. Curr Opin Neurobiol 1998; 8:263-271. 2. Hauser P, et al. N Engl J Med 1993; 328:997-1001. 3. Swanson JM, et al. Mol Psychiatry 1998; 3:38-41. CNS insults5,6 4.Swanson JM, et al. Lancet 1998; 351:429-433. 5. Milberger S, et al. Biol Psychiatry 1997; 41:65-75. 6. Castellanos FX, et al. Arch Gen Psychiatry 1996; 53:607-616. Neurobiology of ADHD Genetic factors Insufficient neurotransmitter Insufficient neuronal function Inefficient & effortful brain function ADHD: Delayed cortical maturation Shaw et al. Proc Natl Acad Sci U S A. 2007 Dec 4;104(49):19649-54. Consequences of Untreated ADHD 1. Academic underachievement 2. Relationship difficulties 3. Low self-esteem 4. Social-occupational impairment 5. Motor accidents Attention Deficit Hyperactivity Disorder (continued)  Treatment  Reduction of symptoms    Behavioural/Env. Modification: Home, School Medication Treatment of associated disorders  Promotion of learning  Relieving Family Distress Tic Disorders  Types:  Tourette’s Disorder  Chronic Motor or Vocal Tic Disorder  Transient Tic Disorder  Tic Disorder NOS Tic Disorder (continued)  Definition of a Tic:  Sudden, repetitive  Movement, gesture or utterance  Typically mimics some aspect of normal behaviour Tic Disorder (continued)  Tourette’s Syndrome      Combined vocal and motor tic disorder Many times a day, nearly every day for 1 year. Marked distress or significant impairment in functioning Main focus: overall level of functioning Treatment     Educational and supportive interventions Pharmacological Treatment of associated disorders Behavioural and cognitive techniques Intellectual disability  Specific Learning Disorder  With impairment in:  Reading  Mathematics  Written Expression  Definition:   ( ) ability is substantially below that expected Interferes with academic achievement or activities of daily living that require ( ) ability Discrepancy Model  Identify a child as having a specific learning disorder if their attainment was below that to be expected compared to their peers  Discrepancy between intelligence and attainment   correlation between IQ and reading skill is modest unclear what exactly a discrepancy index based on IQ can say about the nature of a learning difficulty Response To Instruction  Diagnosis of specific learning disorder  Continue to struggle even after substantial individualized help  Continuous monitoring of their response to the intervention  Postponement of diagnosis till after intervention offered Learning Disorders (continued)  Associated with:      Attention Deficit Hyperactivity Disorder Conduct Disorder/ Oppositional Defiant Disorder Mood Disorders Self-esteem Intervention    Remediation Treat co-morbid psychiatric condition Role of parents Oppositional Defiant Disorder  A pattern of negativistic, hostile and defiant behaviour         Loses temper Argues with adults Defies requests and rules Deliberately annoys people Blames others Touchy, easily annoyed Angry and resentful vindictive Conduct Disorder  Pattern of behaviour:  Aggression to people and animals  Destruction of property  Deceitfulness or theft  Serious Violation of rules Treatment (Conduct and Oppositional Defiant Disorder)  Community based programs      Multi-systemic therapy Family Therapy Parent training Child Medication Others  Separation Anxiety Disorder  Anxiety concerning separation from home or those to whom the individual is attached  Impairment in functioning Others  Selective mutism  Consistent failure to speak up in specific social situations (eg school), despite speaking in other situations (eg home)  At least one month’s duration, often before age 5  Affects education, social interactions  To exclude ASD, psychosis, social anxiety disorder Others  School Refusal  Fear of going to school  Somatic symptoms  3 possible “mechanisms”    Separation Anxiety Specific Phobia More general psychiatric disturbance such as depression Others  School Refusal (management)  Early return to school with firm support / graded return to school  Investigation and management of comorbid conditions  Family work References  http://iacapap.org/iacapap-textbook-ofchild-and-adolescent-mental-health