CSS Infant, Child, And Adolescent Disorders

INFANT, CHILD, AND ADOLESCENT
DISORDERS
CLINICAL SCIENCE SESSION
Preceptor:
Tatang Muchtar S., dr., Sp! "#
Pen$u%un:
Nuru& A'n ('nt' Moha)ad a)a& *+,*-*.,/-+,+0
!o%eph'ne Teoh 1u 2'n *+,*-*.,/-+,3,
Angga Herga&'anto *+,*-*.,/-,*0+
4A5IAN ILM6 EDOTERAN !I7A
FA6LTAS EDOTERAN
6NI8ERSITAS PAD!AD!ARAN
R6MAH SAIT Dr. HASAN SADIIN 4AND6N5
.,,9
I. Pr'nc'p&e% o: ch'&d and ado&e%cent d'agno%t'c a%%e%%)ent
A comprehensive evaluation is intended to develop a formulation of the child’s
overall functioning, based on genetic contributions, maturational patterns, environmental
factors, and adaptation to the environment. The following areas should be covered:
A. Supplement date from patient interviews with information from family members,
guardians, teachers, and outside agencies.
B. Understand normal development so as to understand fully what constitutes
abnormality at a given age.
. Be familiar with the current diagnostic criteria of disorder so as to guide anamnesis on
the mental status e!amination.
". Understand the family psychiatric history, which is necessary given the genetic
predispositions and environmental influences associated with many disorders.
II. Ch'&d De;e&op)ent
"evelopment results from:
i) maturation of the #S, neuromuscular apparatus, and endocrine system
ii) various environmental influences $parents, teachers%
The developmental potential is specific to each person’s given genetic
predisposition to $&% intellectual level and $'% mental disorders, temperament, and
certain personality traits.
III. Menta& Retardat'on "MR#
1. De:'n't'on
"S()*+)T,: significantly sub)average general intellectual function resulting in or
associated with concurrent impairment in adaptive behavior and manifested during the
developmental period $before &- years%
*")&.: a condition of /arrested or incomplete development of the mind0 characteri1ed
by impaired developmental s2ills that /contribute to the overall level of intelligence0
.. C&a%%':'cat'on
Based on the degrees of severity:
(ild : *3 between 4.)44 and 5.
(oderate : *3 between 64)7. and 4.)4.
Severe : *3 between '.)'4 and 64)7.
8rofound : *3 9'.)'4
+. Ep'de)'o&og$
:ccurs in &; of the population. (ale)to)female ratio is &.4:&.
3. Et'o&og$
) cause may be organic or psychosocial
) 2nown in 4.)5.; of cases
) severity of (, depends on $&% timing and duration of trauma and $'% degree of
e!posure of #S
) cause of severe (, is commonly 2nown< as compared to mild (,
i. =enetic : chromosomal, inherited
ii. "evelopmental : prenatal e!posure to infections, to!ins
iii. Ac>uired : perinatal trauma, sociocultural factors
iv. ombination
<. C&'n'ca& Feature%
=enaral features include hyperactivity, low frustration tolerance, aggression,
affective instability, repetitive or stereotypic motor beaviours, and self)in?urious
behaviours.
(ild (,:
) usually seen in school)aged children
) cognitive deficits: poor ability to abstract, egocentric thin2ing
) difficulty in social assimilation: due to communication deficits, poor self)
esteem, dependence
(oderate (,:
) seen at younger age
) social isolation in high school
) child usually aware of deficits and e!presses frustration
Severe (,:
) obvious in preschool years
) speech is minimal
) poor motor development
) poor speech development leads to non)verbal communication in adolescents
8rofound (,:
) severely limited in communication and motor function
) re>uires constant supervision
/. D'agno%'%
DSM-I8-TR DIA5NOSTIC CRITERIA FOR MENTAL RETARDATION
A. Significantly subaverage intellectual functioning: on *.3. of appro!imately 5. of
below on an individually administered *.3. test $ for infants, a clinical ?udgement
of significantly subaverage intellectual functioning%.
B. oncurrent deficits or impairments in present adaptive functioning $i.e. the
person’s effectiveness in meeting the standards e!pected for his or her age by his or
her cultural group% in at least two of the following areas: communication, self)care,
home living, social@interpersonal s2ills, use of community resources, self)direction,
functional academic s2ills, wor2, leisure, health, and safety.
C. The onset is before age &- years.
ode based on degree of severity reflecting level of intellectual impairment:
(ild mental retardation : *.3. level 4.)44 to appro!imately 5.
(oderate mental retardation : *.3. level 64)7. to 4.)44
Severe mental retardation : *.3. level '.)'4 to 64)7.
8rofound mental retardation : *.3. level below '. or '4
(ental retardation, severity unspecified : where there is strong presumption of mental
retardation but the person’s intelligence is untestable by standard tests.
9. Ph$%'ca& E=a)'nat'on
*nspect for signs of genetic@chromosomal disorders, e!. microcephaly,
hypertelorism, flat nasal bridge, prominent eyebrows, epicanthal folds, corneal opacities,
retinal changes< low)set, small, misshapen ears< protruding tongue, problems in dentition.
>. Neuro&og'c E=a)'nat'on
hildren with (, are four times more li2ely to have hearing disorders. They
should also be evaluated for visual problems and sei1ures, which occur in &.; of those
with (,.
0. La(orator$ E=a)'nat'on
• Aab wor2:
Blood and urine B metabolic disorders
hromosomal analysis
• C)rays B craniosynstosis, hydrocephalus, intracerebral calcifications
• #euroimaging $T)scans, (,*% B internal hydrocephalus, cortical atrophy,
porencephaly
• DD= B nonspecific changes $e!cept in sei1ures%, including slow fre>uency with
bursts of spi2es and sharp or blunt wave comple!es
) *,. D'::erent'a& D'agno%e%lac2 of
stimulation at home
) deafness@ blindness
) speech deficits
) cerebral palsy
) chronic debilitating diseases
) convulsive disorders
) learning disorders
) brain damage
) autism
schi1ophreni
a
**. Manage)ent
(anagement is based on individual social and environmental needs. Special
attention is needed for comorbid conditions.
 Pre;ent'on
8rimary:
To prevent (,
) increase public awareness about (,
) improve maternal and child healthcare
) family@ genetic counseling
) provide supplements for pregnant women
Secondary:
To shorten course of illness
Tertiery:
To minimi1e se>uelae and@or conse>uent disabilities
 Educat'on
) special schools or classes providing remediation, tutoring, vocational training, and
social s2ills training
 P%$cho&og'ca&
o Behaviour therapy
o Eamily and parental counseling
 proper care of patients
 how to fulfil needs of patients
o *ndividual supportive psychotherapy
o Activity groups
 *mproves sociali1ation
 Phar)aco&og$
Aimed at comorbid conditions:
• A"F": methylphenidate
• Agression@ self)in?urious behaviour: lithium, atypical antipsychotics,
anticonvulsants
• "epression: serotonin reupta2e inhibitors
• Stereotypical motor movements: typical antipsychotics
• :bsesive)compulsive disorders: serotonin reupta2e inhibitors
• D!plosive rage: G)adrenergic antagonists
I8. Per;a%';e De;e&op)enta& D'%order%
*. 5enera& con%'derat'on%
1) Autistic disorder
) affects 7 in &.,... persons
) male)to)female ratio 6:&
) function may be normal or poor, depending on *.3. amount, communicativeness
of language, and severity of other symptoms
) 5.; have *.3.s below 5.
) associated genetic disorders include tuberous sclerosis and Eragile C syndrome
2) Asperger’s disorder
) characteri1ed byautistic)li2e behaviour without significant delays in language or
cognitive development
) cause is un2nown
) prevalence) more common than autistic disorder
3) ,ett’s disorder
) neurodegenerative
) probable genetic basis, only seen in girls
4) hildhood disintegrative disorder $Feller’s Syndrom%
) distinguished by at least ' years of normal development before deterioration to
clinical picture of autistic disorder
) cause is un2nown
) associated with other neurological conditions
.. Treat)ent
• Special Dducation
) paramount< evidence suggests that early, intensive special educational
intervention is very beneficial
• 8harmacological
) antipsychotics, selective serotonin reupta2e inhibitors, stimulants, opioid
antagonists, lithium, and anticonvulsants $in ,ett’s disorder%
• 8sychological
) individual psychotherapy of no use
) family support and counseling crucial
) group support
8. Learn'ng d'%order%, )otor %?'&&% d'%order, and co))un'cat'on d'%order%
Aearning disorders $reading disorders, mathematics disorders, disorders or written
e!pressions%, motor s2ills disorder $developmental coordination disorders%, and
communication disorders $e!pressive language disorder, mi!ed receptive)e!pressive
language disorders, phonologic disorders, stuttering%.
1. D'agno%'%, %'gn%, and %$)pto)% $the criteria for the disorders are similar%.
1. Aearning disorders. The learning problems significantly interfere with
academic achievement or everyday activities. Associated with:
- "emorali1ation
- Aow self)esteem
- "eficit in social s2ills
2. (otor s2ills disorder
"iagnostic criteria for developmental coordination disorders
a. 8erformance on daily activities that re>uired motor coordination is
substantially below that e!pected given the person’s chronological age
and measured intelligence.
b. The disturbance in riterion A significantly interferes with academic
achievement or activities of daily living.
c. The disturbance is not due to a general medical condition $e.g.,
cerebral palsy, hemiplegia, or muscular dystrophy% and does not meet
criteria for a pervasive developmental disorder.
d. *f (, is present, the motor difficulties are in e!cess of those usually
associated with it.
3. ommunication disorders
&% D!pressive language disorder:
a. The child s2ills are below the e!pected level of vocabulary, use of
correct tenses, production of comple! sentences, and recall of words.
b. :ften appears in the absence of comprehension difficulties.
c. an be ac>uired at any time during childhood.
d. *t can be secondary to:
- Trauma or a neurological disorder
- "evelopmental
- ongenital
2) (i!ed receptive)e!pressive language disorders
a. hildren are impaired in both understanding and e!pressing language.
b. Aanguage difficulties must be severe enough to impair academic
achievement or daily social communication
c. 8ervasive developmental disorder $)%
d. (, $)%
2. 5enera& con%'derat'on%
Aearning, developmental coordination, and communication disorders often
coe!ist with one another and with attention)deficit and disruptive behavior disorders.
The family incidence is increased.
3. Treat)ent
1. ,emediation. ,emediation for learning disabilities is usually provided in
school and depend on the severity of the condition. (ost cases re>uire no
intervention or tutoring. ,esource rooms or special class placement may be
necessary. Speech therapy is often re>uired for patients with communication
disorders. #o intervention or tutoring is re>uired in milder cases.
2. 8sychological. Aowered self)esteem, school failure, and dropping out are
common in patients with this disorders. Therefore, psychoeducation is crucial,
and school counseling or individual, group, or family therapy may be
indicated.
3. 8harmacological. :nly for an associated psychiatric disorder, such as A"F".
#o evidence that medication directly benefits children with learning, motor
s2ills, or communication disorders.
8I. Attent'on-de:'c't and de%rupt';e (eha;'or d'%order%
A. A"F", prevalence is probably 6)4;. The male)to)female is 6:& to 4:&.
*. D'agno%'%, %'gn%, and %$)pto)%.
a. The essential features:
) inattention
) Fyperactivity
) *mpulsivity
b. Here present before age 5 years.
c. *s present two or more setting $e.g., of school Ior wor2J and at home.
d. Significant impairment in social, academic, or occupational function.
e. The symptoms are not occur e!clusive during the course of a pervasive
developmental disorder, schi1ophrenia, or other psychotic disorder and are
not better accounted for by another mental disorder $e.g., mood disorder,
an!iety disorder, dissociative disorder, or a personality disorder%.
.. 5enera& con%'derat'on%. A"F", particularly the predominantly hyperactive)
impulsive type, often coe!ists with conduct disorders or oppositional defiant
disorder. A"F" also coe!ists with learning and communication disorders.
*t is thought that A"F" reflects subtle but unclear neurological impairments.
A"F" is associated with perinatal trauma and early malnutrition. The
incidence is increased in parents and siblings, and concordance is greater in
mono1ygotic than in di1ygotic twins. hildren with A"F" are often
temperamentally difficult. *n neurotransmitter systems, the clearest evidence
is of noradrenergic and dopaminergic dysfunction. #onfocal $soft%
neurological signs are common. ,educed frontal lobe disinhibition is
supported by imaging studies< frontal lobe hypoperfusion and lower frontal
lobe metabolic rates have been noted.
A"F" is probably not related to sugar inta2e< few patients $perhaps 4;% are
affected by food additives. :f persons with A"F", '.)'4; continue to show
symptoms into adolescence, and some into adulthood. Some, especially those
with concomitant conduct disorder, become delin>uent or later develop and
social personality disorder.
+. Treat)ent.
a. 8harmacological
1) Stimulants reduced symptoms in about 54;< they improved self)
esteem by improving the patient’s rapport with parents and teachers.
Stimulants decrease hyperactivity. 8lasma level are not useful.
a) "e!troamphetamine $"e!erdine% is approved by the E"A for
children ages 6 years and older.
b) (ethylphenidate $,italin% is E"A)approved for children ages K
years and older.
c) The duration of action of amphetamine)de!troamphetamine
$Adderall% appears to be longer than that of methylphenidate.
d) (odafinil $8rovigil%, used on narcolepsy, is being tried. *t si long
acting and appears to have a small abuse potential.
e) 8emoline $ylret% is given in dosages of &-.54 to 65.4 mg@day. *ts
onset and duration of action are delayed, but the drug is of very
limited use because of associated liver to!icity.
2) lonidine $atapres% and guanfacine $Tene!% are reported to reduce
arousal in children with the disorder.
3) Antidepressants is stimulants fail< may be best in A"F" with
comorbid depression or an!iety. Dfficacy has been reported for
imipramine $Tofranil% and desipramine $#orpramin%. Bupropion
$Hellbutrin% and venlafa!ine $Dffe!or% are also reported to be useful
for A"F" and appear to be safe.
4) Antipsychotics, lithium, or divalproe! $"epa2ote% if other medications
fail, but only for patients with severe symptoms and aggression
$concomitant disruptive behavior disorder%.
b. 8sychological. (ay include medication, behavioral techni>ue, individual
psychotherapy, family therapy, and special education. These interventions
are crucial in moderate or severe cases, given the ris2 for dele>uency.
B. onduct disorder. 8revalence range from 4)&4; in studies. Accounts for many
inpatient admissions in urban areas. The male)to)female ratio is 7:& to &':&.
1. D'agno%'%, %'gn%, and %$)pto)%. A repetitive and persistent pattern of
behavior in which the basics rights of others or ma?or age L appropriate
societal norms or rules are violated.
2. 5enera& con%'derat'on%. onduct disorder is associated with family
instability, including victimi1ation by physical or se!ual abuse. 8ropensity for
violence correlates with child abuse, family violence, alcoholism, and signs of
severe psychopathology $e.g., paranoia and cognitive or subtle neurological
deficits%.
onduct disorder often coe!ists with A"F" and learning or communication
disorders. Suicidal thoughts and acts and alcohol and drug abuse correlate
with conduct disorder.
Some children with conduct disorder have low plasma levels of dopamine and
G)hydro!ylase. Abnormal serotonin levels have been implicated.
3. Treat)ent
a. 8harmacological. Stimulants may reduce mild aggression in conduct
disorder comorbid with A"F". Aithium and haloperidol is of proven
efficacy in targeting e!plosive, aggressive behavior in children with
conduct disorder. Fowever, the atypical antipsychotics also diminish
aggression and have better side effect profile than haloperidol. M)
adrenergic agonists may help< G)adrenergic receptor antagonists deserve
study.
b. 8sychological. (ay include medication, behavioral techni>ue, individual
psychotherapy, family therapy, parenting classes, tutoring, or special class
placement $for cognitive or conduct problems%. *t is crucial to discover and
fortify any interest or talents to build resistance to the lure of crime. *f the
environmental is no!ious or if conduct disorder is severe, placement away
from home may be indicated.
. :ppositional defiant disorder
1. D'agno%'%, %'gn%, and %$)pto)%. A recurrent pattern or negativistic, defiant,
disobedient, and hostile behavior toward authority figures.
2. 5enera& con%'derat'on%. :ppositional defiant disorder can coe!ist with many
disorders, including A"F" and an!iety disorder. *t can result from parent)
child struggles over autonomy< therefore, the occurrence increase in families
with overly rigid parents and temperamentally active, moody, and intense
children.
3. Treat)ent.
a. 8harmacological)drug are used for any comorbid disorder may be
necessary, but only after careful consideration of benefits and ris2 and
failure of other interventions.
b. 8sychological)behavioral interventions and family therapy are the
interventions of choice. Behavior modification can be helpful.
8II. Feed'ng and eat'ng d'%order% o: 'n:anc$ or ear&$ ch'&dhood
A. P'ca. ,epeated ingestion of a nonnutritive substance that is inappropriate to the
developmental level, for at least & month, by infants who do not met the criteria
for autistic disorder, schi1ophrenia, or Nleine)Aevine syndrome. *t is associated
wit (,, neglect, and nutritional deficiency $e.g., iron or 1inc%. Treatment involves
testing for lead into!ication and treating if necessary.
B. Ru)'nat'on d'%order. ,epeated regurgitation, for at least & month, that follows a
period of normal eating and is not secondary anore!ia nervosa or bulimia nervosa.
Swallow food is brought bac2 into the mouth, e?ected or rechewed, and
swallowed. The child is in no distress. The condition is rare, with onset between 6
and &' month of age. Treatment involves parental guidance and behavioral
techni>ues.
C. Feed'ng and eat'ng d'%order% o: 'n:anc$ or ear&$ ch'&dhood. ategory for
children who persistently eat inade>uately for at least & month in the absence of a
general medical condition or other casual mental condition, with resultant failure
to gain weight and loss of significant weight. The onset is before K year of age.
ounseling of the caregivers is often crucial. ognitive behavior interventions can
be useful.
8III. T'c d'%order%
A. Tourette@% d'%order $Gilles de la Tourette’s syndrome%. The prevalence is about 7
in &..... to 4 in &.....< the mean age of onset is 5 years. The male)to)female
ratio is 6:&.
1. D'agno%'%, %'gn%, and %$)pto)%. (otor and vocal tics can be simple or
comple!. Simple tics generally are the first to appear, e!ample:
Simple motor tics: eye blin2ing, head ?er2ing, facial grimacing.
Simple vocal tics: coughing, grunting, sniffing.
omple! motor tics: hitting self, ?umping
omple! vocal tics: coprolalia $use of vulgar words%, palilalia $repeating own
words%, echolalia $repeating another’s words%.
2. 5enera& con%'derat'on%. Dvidence suggests a genetic transmissions)familial
increases in tic disorder, significantly greater concordance in mono1ygotic
twins than in di1ygotic twins. Dvidence of neurobiological substrate)
nonspecific DD= abnormalities and abnormal T findings in many patients.
*mplication of dopamine abnormality< abnormal levels of homovanillic acid
$dopamine metabolite% in SE< stimulants, which are dopamine antagonist,
can worsen tics or precipitate their occurrence< dopamine antagonists
generally cause tics to diminish. Tourette’s disorder and other tic disorders
must be differentiated from a multitude of other disorders and diseases $e.g.,
dis2inesias, Sydenham’s chorea, Funtington’s disease%. Associated with
tourette’s disorder: A"F", learning problems, and obsessive)compulsive
symptoms, of which the prevalence is increased in first)degree relatives.
Social ostracism is fre>uent. *f the condition is untreated, the course is usually
chronic, with periods in which tics wa! and wane.
3. Treat)ent
a. 8harmacological
1) Faloperidol
2) 8imo1ide $:rap%
3) lonidine)M')adrenergic agonist
b. 8sychological)counseling or therapy is often necessary for child, family,
or both. The nature of tourette’s disorder, coping with it, and ostracism
must be addressed. =roup therapy may reduce social isolation.
B. Chron'c )otor or ;oca& t'c d'%order. Similar to Tourette’s disorder< diagnostic
criteria are the same, e!cept the patient has either single or multiple motor tics or
vocal tics, not both. The condition is much more prevalent than Tourette’s
disorder, but it is less severe and generally causes less social impairment than
Tourette’s disorder. =enetically, chronic motor or vocal tic disorder and Tourette’s
disorder fre>uently occur in the same families. The neurobiology appears to be
same, and the treatment is identical to that for Tourette’s disorder.
C. Tran%'ent t'c d'%order. 8revalence is about 4)'7; of school children have some
sort of tic. The male)to)female ratio is 6:&.
1. D'agno%'%, %'gn%, and %$)pto)%
a. Single or multiple motor and@or vocal tics
b. The tics occur many times a day, nearly every day for 7 wee2s, but no
longer than &'consecutive month
c. The onset is before age &- years
d. The disturbance is not due to the direct psychological effects of a
substance or a general medical condition.
e. riteria have never been met for Tourette’s disorder or chronic motor or
vocal tic disorder.
2. 5enera& con%'derat'on%. *n most case, the tics are psychogenic, increasing
during stress and tending to remit spontaneously.
3. Treat)ent. *n mild case, treatment may not be needed. *n severe cases,
behavioral techni>ues or psychotherapy is indicated. (edication used for
other tics disorders is tried only in severe cases.
IX. E&')'nat'on d'%order%
A. Encopre%'%. The prevalence is about &; of 4)year)old children< more common in
boys than in girls.
1. D'agno%'%, %'gn% and %$)pto)%
DSM-I8-TR DIA5NOSTIC CRITERIA FOR ENCOPRESIS
A. ,epeated passage of feces into inappropriate places $e.g., clothing of floor%
whether involuntary or intentional
B. At least one such event a month for at least 6 months
C. hronological age is at least 7 years $or e>uivalent developmental level%
D. The behavior is not due to the direct physiological effects of a substance $e.g.,
la!atives% or a general medical condition e!cept through a mechanism involving
constipation
ode as follows:
7'th con%t'pat'on and o;er:&oA 'ncont'nence
7'thout con%t'pat'on and o;er:&oA 'ncont'nence
2. 5enera& con%'derat'on%
,ule out a physical disorder, such as aganglionic megacolon $Firschsprung’s
disease%. *nade>uate toilet training can result in child)parent power struggles and
functional encopresis. Some children appear to have abnormal anal sphincter
contractions, which contribute to the condition. Some fear using the toilet. *mpaction
can develop in children with constipation and overflow incontinence, causing pain on
defecation and anal fissures. Aea2age is persistent. Those without constipation and
overflow often have oppositional defiant or conduct disorders. Dncopresis usually
brings embarrassment and social ostracism. Hhen encopresis is deliberate, the
associated psychopathology is usually severe. About '4; of patients also have
enuresis. Dncopresis can last for years but usually resolves.
3. Treat)ent
The child may re>uire individual psychotherapy to address the meaning of the
encopresis and any embarrassment or ostracism. Behavioral techni>ues often are
helpful. 8arental guidance and family therapy often are needed. *f conditions such as
impaction and anal fissures are present, consultation with a pediatrician is re>uired.
B. Eneure%'% "not due to genera& )ed'ca& cond't'on#. 8revalence: age 4, 5;< age
&., 6;< age &-, &;. (uch more common in boys. The diurnal subtype is the least
prevalence and is more common in girls than in boys.
1. D'agno%'%, %'gn%, and %$)pto)%
DSM-I8-TR DIA5NOSTIC CRITERIA FOR ENE6RESIS
A. ,epeated voiding of urine into bed or clothes $whether involuntary or intentional%
B. The behavior is clinically significant as manifested by either a fre>uency of twice a
wee2 for at least 6 consecutive months or the presence of clinically)significant
distress or impairment in social academic $occupational%, or other important areas
of functioning
C. hronological age is at least 4 years $or e>uivalent developmental level%
D. The behavior is not due e!clusively to the direct physiological effect of substance
$e.g., diuretic% or a general medical condition $e.g., diabetes, spina bifida, or
sei1ure disorders%
Specify type:
Nocturna& on&$
D'urna& on&$
Nocturna& and d'urna&
2. 5enera& con%'derat'on%
Dneuresis tends to run in families< concordance is greater in mono1ygotic than in
di1ygotic twins. Some patients have small bladders that re>uire fre>uent voiding. *t
does not seem to be related to a specific stage of sleep, as are sleepwal2ing and sleep
terror disorders. (any patients have no coe!isting mental disorder, and impairment
reflects only conflict with caregivers, loss of self)esteem, and social ostracism, if any.
Dneuresis is li2ely to coe!ist with other disorders and can be precipitated by such
events as birth of a sibling or parental separation. Spontaneous remissions are
fre>uent at ages K to - and at puberty.
3. Treat)ent
a. P%$cho&og'ca&
) 4eha;'ora& approache%
,ecord dry nights on a calendar and reward dry nights with a star and five
to seven consecutive dry nights with a gift. A bell $or bu11er% and pad
apparatus is a successful treatment but is cumbersome.
) P%$chotherap$
#ot recommended unless psychopathology or other problems coe!ist,
such as reduced self)esteem. The e!ploration of conflicts underlying enuresis
has met with little success. 8arental guidance related to the management if the
disorder often is necessary.
b. Phar)aco&og'ca&
,arely used, given the rate of spontaneous remissions, success of
behavioral approaches, and development of tolerance to drugs. *mipramine
often is effective in reducing or even eliminating wetting, but tolerance can
develop after about K wee2s. The mode of action is unclear< effects on bladder
or sleep cycle are considered. Some success has been achieved with
desmopressin $""A+8%.
X. Other d'%order% o: 'n:anc$, ch'&dhood, or ado&e%cence
A. Separat'on an='et$ d'%order. Dstimated prevalence is 6)7; of school age
children. &.; of adolescents. The male)to)female ratio is &:&. :nset is from
preschool to adolescence.
1. D'agno%'%, %'gn%, and %$)pto)%
DSM-I8-TR DIA5NOSTIC CRITERIA FOR SEPARATION AN1IET2
DISORDERS
A. "evelopmentally inappropriate and e!cessive an!iety concerning separation from
home or from home or from those to whom the individual is attached, as
evidenced by three $or more% of the following:
1) recurrent e!cessive distress when separation from home or ma?or attachment
figures occurs or is anticipated
2) persistent and e!cessive worry about losing, or about possible harm befalling,
ma?or attachment figures
3) persistent and e!cessive worry that an untoward event will lead to separation from
a ma?or attachment figure $e.g., getting lost or being 2idnapped%
4) persistent reluctance or refusal to go to school or elsewhere because of fear of
separation
5) persistently and e!cessively fearful or reluctance to be alone or without ma?or
attachment figures at home or without significant adults in other settings
6) persistent reluctance or refusal to go to sleep without being near a ma?or
attachment figure or to sleep away from home
7) repeated nightmares involving the theme of separation
8) repeated complaints of physical symptoms $such as headaches, stomachaches,
nausea, or vomiting% when separation from ma?or attachment figures occurs or is
anticipated
B. The duration of the disturbance is at least 7 wee2s
C. The onset is before age &- years
D. The disturbance causes clinically significant distress or impairment in social,
academic $occupational%, or other important areas of functioning
E. The disturbance does not occur e!clusively during the course of a pervasive
developmental disorder, schi1ophrenia, or other psychotic disorder and, in
adolescents and adults, is not better accounted for by panic disorder with
agoraphobia
Specify if:
Ear&$ on%et: if onset occurs before age K years
2. 5enera& con%'derat'on%
The disorder clusters in families, but genetic transmission is unclear. Some data
lin2 affected children with parents who have a history of the disorder in addition to
current panic disorder, agoraphobia, or depression. An!iety disorders are li2ely to
develop in temperamentally inhibited infants, and increased autonomic neuron system
activity has been demonstrated. Social debilitation is a ris2 in severe cases.
3. Treat)ent
a. Phar)aco&og'ca&
) An='o&$t'c% B little research in childhood an!iety disorders. Alpra1olam
$Cana!% has shown some efficacy.
) Ant'depre%%ant% B tricyclics $e.g., imipramine% can be tried.
) Ant'p%$chot'c% B not useful in an!iety disorders. The ris2 for side effects
outweighs potential benefits.
) Ant'h'%ta)'ne% B diphenhydramine $Benadryl% is sometimes used to relieve
childhood an!iety. *ts usefulness is limited, and some children can have a
parado!ical reaction of e!citement.
b. P%$cho&og'ca& B multimodal treatment is recommended.
) Ind';'dua& p%$chotherap$ B children with separation an!iety disorder
e!aggerate environmental dangers so that they fear their safety and that of
their parents. Their feelings and attitudes are addressed in insight)oriented or
cognitive)behavioral therapy.
) Fa)'&$ therap$ or parent gu'dance B if parents are fostering separation
an!iety.
) 4eha;'or )od':'cat'on B may be helpful to achieve separation from parents
and a return to school.
B. Se&ect';e )ut'%).
,are, more common in girls. "iagnostically, a child which both spea2s and
comprehends refuses to tal2 for at least & month $but this period is not limited to the
first month of school% in social situations. Begins between ages 7 and -, usually
resolves in wee2s to months. Associated with parental overprotection, parental
ambivalence, communication disorders, shyness, and oppositional behavior.
Treatment can include individual psychotherapy and parent counseling. SS,*s may be
helpful.
C. React';e attach)ent d'%order o: 'n:anc$ or ear&$ ch'&dhood. 8revalence and
se! ratio are un2nown. :ften diagnosed and treated by pediatricians.
1. D'agno%'%, %'gn%, and %$)pto)%
=rossly inade>uate care $persistent disregard of physical or emotional needs or
repeated change of careta2er% results in mar2edly disturbed social relatedness in a
child younger than 4 years. *nhibited type is characteri1ed by a failure to initiate or
respond to interactions that is accompanied by apathy, passivity, and lac2 of visual
trac2ing. "isinhibited type is characteri1ed by indiscriminate and shallow sociability.
These failure)to)thrive children are apathetic and passive, and do not trac2 visually.
The disturbance is not secondary to (, or autistic disorder.

2. 5enera& con%'derat'on%
8hysically, head circumference is generally normal< weight, very low< height,
somewhat short. 8ituitary functioning is normal. Associated with low socioeconomic
status and mothers who are depressed and isolated and have e!perienced abuse.
ourse L the earlier the intervention, the more reversible the disorder. Affectionless
character can develop. "eath can occur.
3. Treat)ent
*n many cases, removal of child may be necessary. Severe malnourishment and
other medical problems may re>uire hospitali1ation. Some homes become ade>uate
following parent education, the provision of a homema2er or financial aid, or
treatment of mental disorders in family members.
D. Stereot$p'c )o;e)ent d'%order.
"iagnostically, a repetitive, seemingly nonfunctional behavior lasts for at least 7
wee2s $e.g., hand sha2ing, roc2ing, head banging, nail biting, nose pic2ing, and hair
pulling% and mar2edly interfere with normal activities or cause physical in?ury. The
disorder is common in (,. *t is not diagnosed for behaviors associated with
obsessive)compulsive disorder, pervasive developmental disorders, or chotillomania.
An increase in dopamine activity seems to be associated with an increase in
stereotypic movements. 8ervasive developmental disorder and tic disorder must be
absent. ommon in (, and blindness. Treatment varies. *f movement increase with
frustration, boredom, or tension, these conditions are addressed. ,epetitive behavior
may respond to an SS,*. Self)abusive behaviors may re>uire antipsychotics or opioid
antagonists $which are currently under study%.
XI. Other d'%order% re&e;ant to ch'&dren and ado&e%cent%
A. Sch'Cophren'a A'th ch'&dhood on%et
Several studies confirm that some children have delusions or hallucinations
$auditory or visual%. #evertheless, few children or young adolescents are
schi1ophrenic, and delusions, hallucinations, and thought disorders are difficult to
diagnose in children. Some children in whom schi1ophrenia is diagnosed are given a
diagnosis of mood disorder when followed to adolescence. Treatment is with
antipsychotic medications $although studies are few%. 8sychotherapy, family therapy,
and special schooling may be necessary.
B. Mood d'%order%
Some prepubertal children meet the criteria for ma?or depressive disorder. SS,*s
may benefit some of them. 8repubertal children and adolescents with mania,
hypomania, or mania)li2e symptoms have been successfully treated with lithium.
+alproate benefits some adolescents and can be tried in prepubertal children.
,isperidone appears to be effective on targeting mania)li2e symptoms.
C. Other d'%order%
Some children meet criteria for an!iety disorders, including generali1ed an!iety
disorder, specific an!iety disorder, specific phobia, social phobia, obsessive)
compulsive disorder, posttraumatic stress disorder, and panic disorders.
lomipramine $Anafranil% and SS,*s appear to benefit children with obsessive)
compulsive disorder. 8osttraumatic stress disorder can result from physical or se!ual
abuse.
Substance)related, gender identity, eating, somatoform, sleep, and ad?ustment
disorders can also be diagnosed during childhood and adolescence.
XII. Other ch'&dhood '%%ue%
A. Ch'&d a(u%e and neg&ect
An estimated & million children are abused or neglected annually in the United
States, a problem that results in ',... to 7,... deaths per year. The abused are apt to
be of low birth weight or born prematurely, handicapped $e.g., (,, cerebral palsy%, or
troubled $e.g., defiant, hyperactive%. The abusing parent is usually the mother, who
li2ely was abused herself. Abusing parents often are impulsive, substance abusers,
depressed, antisocial, or narcissistic.
Dach year, &4.,... to '..,... new cases of se!ual abuse are reported. :f these
allegations, ')-; appear to be false, and many other allegations cannot be
substantiated. *n - of &. se!ually abused children, the perpetrator, usually male, is
2nown to the child. *n 4.;, the offender is a parent, parent surrogate, or relative.
B. Su'c'de
Serious attempted and completed suicides are rare in children younger than &6
years. Suicidal ideation, threats, and less serious gestures are much more fre>uent and
often precipitate hospitali1ation. Suicidal children ten to be depressed $and sometimes
preoccupied with death%< however, angry, impulsive children, in addition to children
suffering recent emotional trauma, can be suicidal.
Suicidal behavior is increasing in adolescents and, as with children, often
necessitates hospitali1ation. *t correlates with depression, aggressive behavior, and
alcohol abuse. Suicidal ideation is more common in girls, and girls ma2e more
suicidal gestures or attempts. Serious attempts and successful suicides correlate with
being male and the availability of alcohol, illicit drugs, or medications, which lower
impulse control and can be used to overdose.
8arents often are unaware of their children’s suicidal thoughts and behavior, so
that direct >uestioning of children and adolescents about suicide is necessary.
C. F're %ett'ng
Associated with other destruction of property, stealing, lying, self)destructive
tendencies, and cruelty to animals. The male)to)female ration is O:&.
D. 8'o&ence
Associated with conduct disorder, impulsivity, and anger. (ay result in homicide.
Eifty percent of children in first grade who are disruptive or oppositional are at ris2
for teenage delin>uency.
E. O(e%'t$
8resent in 4)'.; of children and adolescents. A small percentage present with an
obesity)hypoventilation syndrome that is similar to adult pic2wic2ian syndrome.
These children can have dyspnea, and their sleep is characteri1ed by snoring, stridor,
perhaps apnea, and hypo!ia with o!ygen desaturation. "eath can result. :ther
condition, such as hypothyroidism or 8rader)Hilli syndrome, should be ruled out.
F. AIDS
A*"S has presented in child and adolescent psychiatrists with a multitude of
difficult problem. Eor e!ample, the care of young patients from lower socioeconomic
groups, already grossly inade>uate because of insufficient resources, is further
burdened by F*+)related illness or the death of parents and relatives. Poung
psychiatric patients who have concomitant nonsymptomatic positive serology and
re>uire residential treatment are re?ected for fear of transmission of the disease. *n
adolescence, A*"S has further complicated se!uality and the problem of substance
abuse.