Child psychiatry

Psychiatry department
Beni Suef University

cdepression,
 phobia,
 anxiety and
 psychoses
 pervasive developmental disorders
 attention deficit/hyperactivity disorder,
 conduct disorder and
 mental retardation.
 functional enuresis,
 functional encopresis, and
 separation anxiety.




This is a form of disruptive behavior in which
the basic rights of others and age appropriate
societal norms or rules are violated.

 Epidemiology
 It

usually starts before the age of 18 years
 male: female ratio 10:1.
 6-16 % of boys and 2-9 % of girls below 18y have
conduct disorder.

 The

disorder is either conducted solitary or
in a group (gang).
 Aggression may be either direct (overt) or
indirect.
 A-

Overt aggression is directed to people,
animals or property with the aim of
deliberate injury or destruction.

 B-

Indirect aggression as shoplifting, lying,
and staying out late at night despite of
parental prohibition.

 It

 1.

is a multifactorial disorder:

Genetic factors
 2. Organic factors
 3. Environmental factors
 4. Family factors
 5. Social Modeling

Family factors
• Neglecting unavailable mother with absence of
support
 • drug abuse or antisocial father

• Higher psychiatric morbidity among parents
with personality deviation

•Frequent inconsistent punishment

• Increased marital discord
 • Disturbed family structure, increased marital
conflicts, divorce and parental violence.


1-For the Child
 • Behavioral therapy
 • Group therapy
 • Pharmacotherapy (to control aggression &
impulsivity)
 a. Lithium carbonate
 b. Clonidine
 c. Anticonvulsants
2- Family therapy
3- Parental training
4- Institutionalization

 Epidemiology
 This

disorder is more common in males than
in females in the ratio 3-5 : l.
 In the United States, its incidence is 3-5 % of
primary school children.
 In Britain, it is less than 1 %.

It includes three main criteria:
 1-

Disturbed attention or concentration:
 2- Hyperactivity
 3- Impulsivity

 1.

Genetic factors
 2. Organic factors (frontal lobe)
 3. Environmental factors (food additives,
preservatives, toxins)

1. Pharmacotherapy:
 a. Psychostimulants, e.g.,
dextroamphetamine, methylphenidate
(Ritalin)
 b. Antidepressants
 c. Antipsychotics
 d. Lithium carbonate
2. Special education programs
3. Family therapy

 This

is a group of psychiatric conditions in
which the expected social skills, language
behavior and behavioral repertoire are
either not developed or are lost in early
childhood before the age of 3 years.
 The most common type is Autistic Disorder.

 Epidemiology
 Autistic

Disorder occurs at the rate of 2-5 per
10,000 children under the age of 12. Male to
female ratio is 3-5 to 1.

 1.

Inability to develop relationship with
people.
 2. Delayed development of language skill,
 3. Repetitive or stereotyped movements,

It is multifactorial including
 1. Psychogenic factors
 2. Genetic factors
 3. Perinatal complications, especially during
the first trimester.
 4. Biochemical factors
 5. Neurologphysiology: EEG changes in 10-85
% of autistic children

 The

goal is to decrease the behavioral
symptoms and to help the development of
the delayed functions.
 1. Supportive home environment
 2. Special educational programs
 3. Pharmacotherapy: useful in modifying and
controlling behavior
high potency neuroleptics
Selective Serotonin Reuptake Inhibitors
(SSRI)

Functional Enuresis
 Enuresis is the repeated voiding of urine into
the child's clothes or bed.
 It may be involuntary or intentional.
Nocturnal bed wetting is the most common
form.
 Daytime control usually precedes nocturnal
control by 1-2 years.


 Prevalence

of enuresis varies greatly in
different groups, in the States 7 % of 5 year
olds are enuretic.

 To
 1.

diagnose functional enuresis:

The child must be at least 5 years old
 2. Wetting is repetitive
 3. Medical causes should be ruled out
particularly in secondary enuresis.
 Most common medical causes are urinary
tract infection, diabetes, seizure disorders
and congenital abnormalities.

•

Primary: if bladder control has never been
achieved

•

Secondary: if urinary incontinence
reappearance after maintainmg competent
functions for 1 year.

 1.Restricting

fluids before bedtime
 2.Waking the child during the night.
 3. Rewarding successful dry nights.
 4. Bladder training during the day, i.e.,
delaying bladder emptying
 5. Medications: given before going to bed,
such as:
imipramine (Tofranil),
desmopressin (synthetic ADH)
anticholinergic drugs.

 It

is characterized by fecal soiling of clothes.
Medical evaluation is necessary before
labeling the disorder as functional.

 Epidemiology

After the age of four years, encopresis occurs
3-4 times more in boys than in girls. There is
a significant relation between encopresis and
enuresis.

 Diagnosis
 1.

The child is at least 4 years old.
 2. Encopresis occurs at least once a month
for at least 3 months.
 3. Medical causes should be excluded.



a. Primary or secondary: primary if no bowel
control has been achieved, and secondary if the
child has learned control for one year.

b. With constipation and overflow, or without
constipation:
 75 % of encopretic children have constipation.
 There is fecal concretion with overflow of fluid
fecal matter.
 Incontinence without constipation results in
intermittent production of formed stools.


 1.

For encopresis without constipation, a
behavioral program gives rewards for just
sitting on the toilet then later for moving
bowels appropriately.
 2. For children with severe retention or
impaction cleaning out the bowel initially (
enemas), followed by retraining the bowel
(high roughage diet, developing of a toilet
routine) are used in addition to behavioral
program
 3. In resistant cases individual and family
psychotherapeutic interventions are needed.

 These

disorders are termed academic skills
disorders.
 These children usually present with one of
the basic psychological problems involved in
understanding or in using spoken or written
language.
 They usually present with poor scholastic
achievement despite their average
intelligence as assessed by the individually
administered standardized intelligence tests.

 Impairment

in the academic areas includes
disorders in:
 • Reading
 • Mathematics
 • Written expression.
 It

might be associated with:
 1. Delayed speech
 2. Anxiety and other emotional problems.
 3. They may as well present behavioral
problems such as alienation or rebellion.

 Etiology
 It

includes a variety of neurocortical deficits
resulting in various
 disruptions of cognitive processing, e.g.
difficulty in visual spatial or linguistic
processing.

 Management
 1.

Special assessment including 1Q, EEG,
plain X ray skull, and CT scan brain
 2. Special educational programs with special
scholastic placements.
 3. Family counseling and training programs to
help in the education.
 4. Teacher's education to help in the
education progress
 5. Psychotherapy for the patient and family.

 The

diagnosis of Mental Retardation MR
requires both low intelligence (IQ less than
70) and
 deficits in adaptive functions i.e. impairment
of skills manifested during the
developmental period (before the age of 18
years)
 including cognitive, language, motor and
social abilities.

 Classification
 The

intelligence quotient was calculated
from the following formula:
 IQ= mental age/ chronological age x 100
 On basis of IQ : mental retardation is
classified into:
 Mild:
IQ 50-69
 Moderate:
IQ 35-49
 Severe:
IQ 20-34
 Profound:
IQ below 20

a. Biological Causes:
 Genetic Factors
 Prenatal Factors
 Perinatal Factors
 Causes during Infancy or childhood
b. Psychosocial Causes

Majority (85%) of those with M.R.
• Self care and living skills:
 Most have no difficulty in achieving full
independence in self-care (eating, washing,
dressing, and sphincteric control).
 They may need help with planning a budget.
• Language and communication skills:
 Most achieve the ability to use speech for
everyday purposes and can hold conversations
in normal circumstances.
• Education and occupation:
 Educable, many have difficulties reading and
writing, but can achieve an academic level of
grade 6.
 They can hold a job.


10% of those with M.R.
• Self care and living skills:
 Achievement of self care and motor skills is retarded, yet
they can be trained to attain considerable independence in
daily living but they need supervision.
 They are usually capable of managing pocket money but
find difficulty in calculating the change due.
 Slow in developing comprehension and use of language,
however they are usually able to communicate adequately.
• Education and occupation:
 Limited progress with school work, usually not beyond the
academic level of grade 2,
 They are trainable.
 Some adults can carry out simple manual work.


 4%

of those with M.R.
 • Self care and living skills: They need a
great deal of supervision as their self-care
and motor skills are markedly impaired.
 They are dependent on others for money
arrangement
 • Language and communication skills: The
development of comprehension and use of
language is very limited and communication
is often not by speech.
 • Education: Below first grade. They are not
trainable.

Profound M.R. (IQ below 20):
1% of MR
• Self care and living skills: Constant help
and supervision is needed for basic needs.
Severely limited in ability to understand
language.
They communicate in a very limited nonverbal way.
• Education: Extremely limited

 For

mental retardation at all levels of
severity, the developmental course is
SLOW but not deviant.



Although the normal sequence of
developmental stages occurs, the speed of
developmental change is slow and there is
a ceiling on ultimate achievement.

Mentally retarded children are four to five times
at a higher risk to have a psychiatric disorder
than children with normal intelligence.
 The most common constellation of symptoms
includes:
 irritability,
 hyperactivity,
 impulsivity,
 short attention span and
 language delay.
 aggressive temper outbursts.














1. Early detection of treatable causes as
hypothyroidism and malnutrition.
2. Proper comprehensive evaluation to address the
multiple disabilities and complications associated
with MR whether medical or psychiatric.
3. Parental guidance: support, education, genetic.
4. Detecting strengths and weaknesses
5. Specialists for speech therapy.
6. Behavior modification
7. Psychotherapy (mild MR) to enhance self-esteem,
social and emotional development and behavioral
control.
8. Treatment of co-morbid conditions e.g. depression
or ADHD.

Child psychiatry

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