CHILD PSYCHIATRY

Dr.Howaida Abbas

Pervasive Developmental Disorders

Attention Deficit Hyperactivity

Disorder(ADHD)
Nocturnal Enuresis

Pervasive Developmental Disoreders

A group of disorders in understanding and

expressing language and the production of

speech. These disorders affect multiple areas
of development, are manifested early in life,
and cause persistent dysfunction.

There are five pervasive developmental

disorders:
a.Autistic Disorder
b.Rett,s Disorder
c.Childhood Disintegrative Disorder

d.Asperger,s Disorder
e. Pervasive Disorder not otherwise specified.

Autistic Disorder
Autistic disorder is characterized by

qualitative deficits in reciprocal social

interaction and communication skills and
restricted patterns of behaviors.

Diagnosis:
Among the principal criteria for diagnosis

autism are deficits in language development

and difficulty using language to communicate.
Autistic children do not demonstrate special
attention to important people in their lives
and have impaired eye contact and
attachment behaviors to family members and
notable deficits in interacting with peers.
Activities and play are often rigid, repetitive,
and monotonous.

Common behavior problems include hyper

kinesis, hypo kinesis, aggression, head

banging, biting, scratching, hair pulling, and
resistance to routine.
Prodigious cognitive or visuomotor capabilities
may occur in a small subgroup (idiot or
autistic savants).

Epidemiology
Occurs in 0.05% of children.
Four to five times more common in males,
females with the disorder or more likely to
have more severe mental retardation.
Onset before age 3 years.

Etiology
Genetic factors:
Higher concordance rate in monozygotic than
dizygotic twins, at least 2-4% of siblings are
affected.
Biologic factors:
Implicated due to high rates of seizure
disorder and mental retardation.

Immunologic factors:
Incompatibility and prenatal and perinatal
insults might be contributory factors.
Magnetic resonance imaging (MRI):
MRI studies have demonstrated increased
brain volume in occipital, parietal, and
temporal lobes.
Subgroups have abnormal levels of dopamine
and serotonin metabolites in cerebrospinal
fluid (CSF).

Course and prognosis:

Autistic disorder is generally a lifelong disorder
with a guarded prognosis. Two thirds remain
severely handicapped and dependent.
Improved prognosis if IQ >70 and
communication skills are seen by age 5 to 7
years.

Treatment
The goals of treatment for children with autism
spectrum disorder are:
To target core behaviors
To improve social interactions, communication
Broaden strategies to integrate into schools
Develop meaningful peer relationships
To increase long-term skills in independent
living.

Remediation:
Structured classroom training in a
combination with behavioral methods is the
most effective treatment method. Language
and academic remediation are often required.

Psychotherapy:
Parents are often struggle and need support

and counseling.
Social Skills Approaches
Social Skills Training.
Behavioral Interventions (BIs) and CognitiveBehavioral Therapy (CBT) for repetitive
behaviors and associated symptoms.

Psychopharmacological Interventions
Psychopharmacological interventions in

autism spectrum disorder are mainly directed

at ameliorating impairing associated
behavioral symptoms rather than core
features of autism spectrum disorder. Target
symptoms include irritability, broadly
including aggression, temper tantrums and
self-injurious behaviors, hyperactivity,
impulsivity, and inattention.

Rett Syndrome
Rett syndrome is a progressive condition that
has its onset after some months of what
appears to be normal development. Head
circumference is normal at birth and
developmental milestones are unremarkable in
early life. Between 5 and 48 months of age,
generally between 6 months and 1 year, head
growth begins to decelerate.

Epidemiology
Available data indicate a prevalence of 6 to 7

cases of Rett syndrome per 100,000 girls.

Originally, it was believed that Rett syndrome
occurred only in females, but males with the
disorder or syndromes that are very close to
this disorder have now been described.

Etiology.
The cause of Rett syndrome is unknown,
although the progressive deteriorating course
after an initial normal period is compatible with
a metabolic disorder. It is likely that Rett
syndrome has a genetic basis. It has been seen
primarily in girls, and case reports so far
indicate complete concordance in monozygotic
twins.

Diagnosis and Clinical Features.

During the first 5 months after birth, infants

have age-appropriate motor skills, normal

head circumference, and normal growth.
Social interactions show the expected
reciprocal quality. At 6 months to 2 years of
age, however, these children develop
progressive encephalopathy with a number of
characteristic features.

The signs often include the loss of purposeful

hand movements, which are replaced by

stereotypic motions, such as hand-wringing;
the loss of previously acquired speech;
psychomotor retardation; and ataxia.

The head circumference growth decelerates

and produces microcephaly. All language skills

are lost, and both receptive and expressive
communicative and social skills seem to
plateau at developmental levels between 6
months and 1 year.

. Poor muscle coordination and an apraxic gait

with an unsteady and stiff quality develop.

Associated features include seizures in up to
75 percent of affected children and
disorganized EEG findings with some
epileptiform discharges in almost all young
children with Rett syndrome, even in the
absence of clinical seizures.

An additional associated feature is irregular

respiration, with episodes of hyperventilation,

apnea, and breath holding. The disorganized
breathing occurs in most patients while they
are awake; during sleep, the breathing usually
normalizes. Many patients with Rett syndrome
also have scoliosis. As the disorder
progresses, muscle tone seems to change
from an initial hypotonic condition to
spasticity to rigidity.

Although children with Rett syndrome may

live for well over a decade after the onset of

the disorder, after 10 years, many patients are
wheelchair-bound, with muscle wasting,
rigidity, and virtually no language ability.
Long-term receptive and expressive
communication and socialization abilities
remain at a developmental level of less than 1
year.

Course and Prognosis

Rett syndrome is progressive, and those
individuals who live into adolescence and
adulthood function at a cognitive and social
level equivalent to that in the first year of life.

Treatment.
Treatment is symptomatic.
Physiotherapy has been beneficial for the
muscular dysfunction
Anticonvulsant treatment is usually necessary
to control the seizures.

Behavior therapy, along with medication, may

help control self-injurious behaviors, as it does

in the treatment of autistic disorder, and it
may help regulate the breathing
disorganization.

Childhood Disintegrative Disorder

Childhood disintegrative 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 Hellers
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-yearolds with previously normal function. After the
deterioration, the children closely resembled
children with autistic disorder.

Epidemiology
Epidemiological data have been complicated

by the variable diagnostic criteria used, but

childhood disintegrative disorder is estimated
to be much less common than the formerly
diagnosed autistic disorder. The prevalence
has been estimated to occur in about 1 in
100,000 boys. The ratio of boys to girls is
estimated to be between 4 and 8 boys to 1
girl.

Etiology
The cause of childhood disintegrative disorder
is unknown, but it has been associated with
other neurological conditions, including seizure
disorders, tuberous sclerosis, and various
metabolic disorders.

Diagnosis and Clinical

Features
Cases reported have ranged in onset from

ages 1 to 9 years, but in most, the onset is

between 3 and 4 years. The onset may be
insidious over several months or relatively
abrupt, with abilities diminishing in days or
weeks. In some cases, a child displays
restlessness, increased activity level, and
anxiety before the loss of function.

The core features of the disorder include loss

of communication skills, marked regression of

reciprocal interactions, and the onset of
stereotyped movements and compulsive
behavior. Affective symptoms are common,
particularly anxiety, as is the regression of
self-help skills, such as bowel and bladder
control.

To receive the diagnosis, a child must exhibit

loss of skills in two of the following areas:

language, social or adaptive behavior; bowel
or bladder control; play; and motor skills.
Abnormalities must be present in both of the
following categories: reciprocal social
communication skills, and restricted and
repetitive behavior. The main neurological
associated feature is seizure disorder.

Course and Prognosis

The course of childhood disintegrative disorder
is variable, with a plateau reached in most
cases, a progressive deteriorating course in rare
cases, and some improvement in occasional
cases to the point of regaining the ability to
speak in sentences. Most patients are left with
at least moderate mental retardation.

Aspergers Disorder
The former diagnosis of Aspergers disorder is
characterized by impairment and oddity of
social interaction and restricted interest and
behavior. Unlike the former autistic disorder, in
Aspergers disorder there are no significant
delays in language or cognitive development.

In 1944, Hans Asperger, an Austrian

physician, described a syndrome that he

named autistic psychopathy. His original
description of the syndrome described
individuals with normal intelligence who
exhibits a qualitative impairment in reciprocal
social interaction and behavioral oddities
without delays in language development.

. Aspergers disorder occurs in a wide variety

of severities, including cases in which very

subtle social cues are missed, but overall
social interactions are mastered.

Etiology
Aspergers disorder, a version of autism
spectrum disorder, has a complex etiology
including genetic contribution and potentially
environmental and perinatal contributing
factors.

Diagnosis and Clinical Features

The clinical features include at least two of

the following indications of qualitative social

impairment: Markedly abnormal nonverbal
communicative gestures, the failure to
develop peer relationships at the expected
level.

Restricted interests and patterns of behavior

are present, but when they are subtle, they

may not be immediately identified or singled
out as different from those of other children.
According to DSM-IV-TR, individuals with
Aspergers disorder exhibit no language delay,
clinically significant cognitive delay, or
adaptive impairment.

Course and Prognosis

The factors associated with a good prognosis

in this subgroup within autism spectrum

disorder are a normal IQ and more
competencies in social skills. Reports of some
adults diagnosed with Aspergers disorder
indicate that their social and communication
deficits remain and they continue to relate in
an awkward way and appear socially
uncomfortable.

Treatment
Treatment of individuals who meet the criteria

for the previous Aspergers disorder diagnosis

aims to promote social communication and
peer relationships. Interventions are initiated
with the goal of shaping interactions so that
they better match those of peers.

Pervasive Developmental Disorder Not

Otherwise Specified

Whereas the DSM-IV-TR defines pervasive

disorder not otherwise specified as a condition

with severe, pervasive impairment in
communication skills or the presence of
restricted and repetitive activities and
associated impairment in social interactions.

Treatment
The treatment approach is identical to that of

other autism spectrum disorder.

Mainstreaming in school may be possible

ATTENTIONDEFICIT/HYPERACTIVITY DISORDER
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.

 ADHD affects up to 5 to 8 percent of school-

aged 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
disorders, and disruptive behavior disorders.

Epidemiology
Rates of ADHD have been reported to be 7 to

8 percent in prepubertal elementary school

children. Epidemiologic studies suggest that
ADHD occurs in about 5 percent of youth
including children and adolescents, and about
2.5 percent of adults.

The rate of ADHD in parents and siblings of

children with ADHD is 2 to 8 times greater

than in the general population. ADHD is more
prevalent in boys than in girls, with the ratio
ranging from 2:1 to as high as 9:1. Firstdegree biological relatives (e.g., siblings of
probands with ADHD) are at high risk for
developing ADHD.

Siblings of children with ADHD are also at

higher risk than the general population for

learning disorders and academic difficulties.
The parents of children with ADHD show an
increased incidence of substance use
disorders.

Symptoms of ADHD are often present by age

3 years, but unless they are very severe, the

diagnosis is frequently not made until the
child is in kindergarten, or elementary school,
when teacher information is available
comparing the index child peers of the same
age.

Etiology
Data suggest that the etiology of ADHD is

largely genetic, with a heritability of

approximately 75 percent. ADHD symptoms
are the product of complex interactions of
neuroanatomical and neurochemical systems
evidenced by data from twin and adoption
family genetic studies, dopamine transport
gene studies, neuroimaging studies, and
neurotransmitter data.

In some cases, contributory factors for ADHD

may include prenatal toxic exposures,

prematurity, and prenatal mechanical insult to
the fetal nervous system. Food additives,
colorings, preservatives, and sugar have been
proposed as possible contributing causes of
hyperactive behavior.

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, they cannot be put
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, inattention, 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 liability, and

developmental coordination disorder. A
significant percent 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.

Course and Prognosis

The course of ADHD is variable. Symptoms

have been shown to persist into adolescence

in 60 to 85 percent of cases, and into adult life
in approximately 60 percent of cases.

The remaining 40 percent of cases may remit

at puberty, or in early adulthood. In some

cases, the hyperactivity may disappear, but
the decreased attention span and impulse
control problems persist. Over activity is
usually the first symptom to remit, and
distractibility is the last.

ADHD does not usually remit during middle

childhood.
Persistence is predicted by a family history of
the disorder, negative life events, and
comorbidity with conduct symptoms,
depression, and anxiety disorders.

Treatment
Pharmacotherapy. Pharmacologic treatment
is considered the first line of treatment for
ADHD. Central nervous system stimulants are
the first choice of agents in that they have been
shown to have the greatest efficacy with
generally mild tolerable side effects.

Stimulants are contraindicated in children,

adolescents, and adults with known cardiac

risks and abnormalities. Nonstimulant
medications approved by the FDA in the
treatment of ADHD include atomoxetine
(Strattera), a norepinephrine uptake inhibitor.

Unlike the stimulants, Strattera carries with it

a black box warning for potential increases in

suicidal thoughts or behaviors and requires
children with ADHD to be monitored for these
symptoms.

Psychosocial
Interventions
.Psychosocial interventions for children with

ADHD include psychoeducation, academic

organization skills remediation, parent
training, behavior modification in the
classroom and at home, cognitive behavioral
therapy (CBT), and social skills training.

Enuresis
Enuresis is characterized by repeated voiding

of urine into clothes or bed, whether the

voiding is involuntary or intentional. The
behavior must occur twice weekly for at least
3 months or must cause clinically significant
distress or impairment socially or
academically. The childs chronological or
developmental age must be at least 5 years.

EPIDEMIOLOGY
The prevalence of enuresis ranges from 5 to

10 percent in 5-year-olds, 1.5 to 5 percent in

9- to 10-year-olds and about 1 percent in
adolescents 15 years and older. The
prevalence of enuresis decreases with
increasing age.

COURSE AND PROGNOSIS

Enuresis is often self-limited, and a child with

enuresis may have a spontaneous remission.

About 80 percent of affected children have
never achieved a year-long period of dryness.

Enuresis after at least one dry year usually

begins between the ages of 5 and 8 years; if it

occurs much later, especially during
adulthood, organic causes must be
investigated.

Some evidence indicates that late onset of

enuresis in children is more frequently

associated with a concomitant psychiatric
difficulty than is enuresis without at least one
dry year.

TREATMENT
A relatively high rate of spontaneous

remission of enuresis occurs over time in

childhood; however, in many cases,
interventions are necessary because enuresis
is causing functional impairment.

A star chart may be particularly helpful. Other

useful techniques include restricting fluids

before bed and night lifting to toilet trains the
child. Interventions with alarm therapy, which
is triggered by wet underwear, has been a
mainstay of treatment for enuresis.

Behavioral Therapy
Classic conditioning with the bell (or buzzer)

and pad (alarm) apparatus, Bladder training

encouragement or reward for delaying
micturition for increasing times during waking
hours.

 Pharmacotherapy

Medication is considered when enuresis is

causing impairment in social, family, and school
function and behavioral, dietary, and fluid
restriction have not been efficacious.