I C

T R
IA
C H
Y
PS ES
LD S
H I ES 0
1
9

C LN 8
,
2

IL U S T
G
U
A
OVERVIEW OF COMMON PSYCHIATRIC
ILLNESSES IN CHILDREN
1) Reactive attachment disorders (RAD)
2) Disinhibited social engagement disorders (DSED)
3) Intellectual disability disorder
4) Autism spectrum disorder (ASD)
5) Attention deficit hyperactivity disorder (ADHD)
6) Specific learning disorders
7) Motor disorders
8) Disruptions and impulse-control disorders
9) Elimination disorders
REACTIVE ATTACHMENT DISORDER
• History of extreme insufficient care (at least one of the
following)
• Social neglect/deprivation
• Repeated changes in primary caregivers
• Raised in unusual settings that limit opportunities to form
attachments
• Consistent patterns of emotional withdrawal, inhibited
behavior toward adult caregivers (both of the following):
• Rarely seeks comfort when distressed
• And rarely responds to comfort when distressed
• Persistent emotional and social disturbance
• Minimal responsiveness to others
• Limited positive affect
• Episodes of unexplained sadness, irritability, fearfulness
REACTIVE ATTACHMENT DISORDER
This condition is evident prior to what age?
• Age 5
Differential diagnosis?
• Autism Spectrum Disorder (ASD)
Similarity between the two:
• Both RAD and ASD can have rocking or flapping behaviors
Treatment: will focus on psychoeducation for caregivers.
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
• History of extreme insufficient care (at least 1 of the
following):
• Social neglect/deprivation
• Repeated changes in primary caregivers
• Raised in unusual settings that limit opportunities to form
attachments
• Child actively approaches and interacts with unfamiliar
adults (2 of the following)
• Socially disinhibited behaviors, but not general impulsivity
• Developmental age?
• Age >9 months
• Differential diagnosis
• ADHD, DSED lacks attention problems and hyperactive behaviors
INTELLECTUAL DISABILITY DISORDER
• 3 criteria
1) Deficits in intellectual functions such as reasoning, planning, problem-solving
2) Problems with adaptive functioning
3) Onset during developmental period
• Clinical assessment : looks at level of functioning
• Although ID severity is no longer classified according to an IQ score, IQ
measures of intellectual impairment may be considered as being in the
following ranges:
●Mild – IQ between 50 to 55 and 70
●Moderate – IQ between 35 to 40 and 50 to 55
●Severe – IQ between 20 to 25 and 35 to 40
●Profound – IQ less than 20 to 25
• Common co-occurring disorders:
• ADHD, depression, bipolar disorder, anxiety disorders, autism spectrum disorders,
stereotypic movement disorders, and impulse control disorders.
INTELLIGENCE QUOTIENT (IQ)
• Estimate of person’s functional capacity
• Mean= 100, standard deviation=15
• Recalibrated every 10-15 years: 2 methods for generating score
• 1) MENTAL AGE METHOD
• Used for children <16 yo
• Mental age/chronological age
• An 8 year old boy scores on his IQ test about the level of the average
10 year-old boy. What is his IQ?
• MA/CA x100=IQ, 10/8 x100=125
• 2) DEVIATION FROM NORM METHOD
• Compares within same age group
• An 8 year old boy scored 1 standard deviation above the mean on the
distribution of score for 8 year olds. What is his IQ?
• Mean =100, standard deviation=15, IQ is 115
CLINICAL CASE
A 2½-year-old boy is brought to a pediatrician by his parents for his regular yearly
examination. He is the couple's only child. The parents relate a normal medical
history with a single episode of otitis media. They recently placed their son in
day care for 2 half-days a week. However, he has not adjusted well, crying and
having tantrums during the first hour of school. Then he usually quiets down,
but he does not interact with the rest of the children. The teacher cannot seem
to make him follow directions and notes that he does not look at her when she
is near him and attempting to interact with him.
On further discussion with the parents, the pediatrician finds that the patient has
only a limited vocabulary of perhaps 10 words. He does not use these words in
any greater length than two words in a row and often uses them
inappropriately. He did not speak his first clear word until 6 to 9 months. The
patient does not interact well with other children but does not seem upset by
them. His favorite toys are often used inappropriately-he performs single,
repetitive movements with them for what seems like hours on end. The
pediatrician picks the child up to help him onto the examination table and
notices that he seems quite stiff, pushing himself away from the examiner with
his hands. Although his hearing and eyesight appear to be intact, the child
does not respond to requests by the pediatrician and does not make eye
contact. All other gross neurologic and physical features are within normal
limits.
CLINICAL CASE 1 CONTINUED
What is the most likely diagnosis?
• Autism spectrum disorder (ASD).

What is the most likely prognosis for this condition?

• The child will likely experience a number of developmental
delays, but with intensive treatment at home and at school,
he could achieve near-normal or normal development.
Language development is the most important indicator of
future developmental potential in ASD children.
AUTISM SPECTRUM DISORDER
• Male to Female ratio 4:1
• 80% have IQ < 70
• Some have deficits in chromosome 11 or 15
• Higher rates with:
• Prenatal injury
• Maternal Rubella in 1st trimester
• Mother has asthma, allergies, or psoriasis while pregnant
• Father older than 40
• Likely exposure
• Exposure to environmental toxins (mercury, pesticides)
• Failure of apoptosis
• Neurological findings: lack of mirror neurons
• Treatments
• Behavioral techniques: shaping
• Respiration to reduce agitation and aggression
CLINICAL CASE
A 7 year old girl is brought to her pediatrician on the
suggestion of her 2nd grade school teacher. The patient has
been back in school for 3 weeks following summer break.
According to the teacher, the patient has found it very
difficult to complete her classroom tasks since returning to
school. The child is seldom disruptive but cannot finish
assignments in the allotted time although her classmates do
so without difficulty. She also makes careless mistakes in
her work. Although she is still passing her class, her grades
have dropped, and she seems to daydream a great deal in
class. The teacher reports that it takes several repetitions
of instructions for the patient to complete a task. The
patient enjoys physical education and does well in that
class. The child indicats that when it appears to others that
she is not paying attention she is thinking about other
things. Teachers report that her attention wanders
constantly and they have to call her name or wave to get
her immediate attention. There have been no episodes
where she stares blankly or is briefly non-responsive
CLINICAL CASE CONTINUED
Although her parents have noticed some of the same behaviors at home, they
have not been particularly concerned because they have found ways to work
around them. If they monitor the child and her work directly, she can
complete her homework, but they must continually check her work for
careless mistakes. She does seem to know the right answer when it is pointed
out. The parents also report that the patient does not get ready for school in
the mornings without moment-by-moment monitoring. Her bedroom is in
shambles, and she loses things all the time. The parents describe their
daughter as a happy child who enjoys playing with her siblings and friends.
They note that she does not like school, except for physical education classes.

What is the most likely diagnosis?

Attention deficit hyperactivity disorder (ADHD), predominantly inattentive
presentation
What are the recommended treatments for this disorder
Use of psychostimuant or atomoxetine along with behavioral parenting
training and classroom behavioral modification programs
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• Criteria
• Inattention (6 months of 6 or more symptoms)
• Hyperactivity (6 months of 6 or more symptoms)
• Across multiple settings (home, school, play)
• Impairs functioning and relationship with others
• Symptoms must be present prior to age 12
• Clinical issues:
• 10x more in males than females
• Lower dopamine levels
• >70% of children with ADHD have sleep disorders
• 10x higher rate of depression during adolescence
• Some have developmental delays in frontal lobes and anterior
cingulate gyruus
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• Likely over-diagnosed, must differentiate from:
• Obsessive compulsive disorder (OCD)
• Tourette syndrome
• “high energy” child
• Observe response to pharmacology
• Treatment
• All pharmacological treatments must be accompanied by behavioral
therapy
• 1st line: methylphenidate, dextroamphetamine
• 2nd line: atomoxetine (NERI), extended release guanfacine (age 16-17,
selective alpha 2 a agonist), modafinil
• Key differentials
• Oppositional defiant disorder
• Intermittent explosive disorder
• Tourette
SPECIFIC LEARNING DISORDERS
• Difficulties in learning or using academic skills (for at least 6
months)
• Skills substantially and measurably below others of same age
• Difficulties begin during school years
• Impaired reading
• Impaired writing
• Mathematics
• Children with these deficits may say school is hard and seek to
avoid it
• Key differentials:
• Intellectual disability
• Uncorrected visual or auditory problems: test for problems
• Lacks of education: examine education history
MOTOR DISORDERS
Stereotypic Movement Disorder
• Repetitive, purposeless motor behaviors
• Interferes with academic, social functioning
• Onset, < age 3
• This problem in 1 to 3 year olds suggests a neurodevelopmental
problem
• Found in approximately 15% of patient with intellectual
disability
• Key differentials:
• ASD: SMD lacks communication issues
• Tic disorders: SMD has earlier onset (before age 3)
• OCD: SMD has no obsessions and behaviors more purposeful in
OCD
MOTOR DISORDER
Tic Disorder
• Tourette syndrome
• Both multiple motor and vocal tics
• Tics persist over 1 year
• Onset prior to age 18
• Peak severity of symptoms from age 10-12
• Persistent Motor or Vocal Tic Disorder
• Single motor or vocal tics (not both)
• Tics persistent over 1 year
• Onset prior to age 18 (usually before age 7)
• Rule out Tourette
MOTOR DISORDER
Tourette Syndrome
• Treatment?
• Antidopaminergic drugs (Haloperidol, Pimozide, and Aripripazole)
• Alpha-adrenergic agonists (Clonidine, Guanfacine)
• Topiramate
• Botulinum Toxin Injection
• Habit reversal training
• Deep brain stimulation (refractory)
DISRUPTIVE AND IMPULSE-CONTROL
DISORDERS
Disruptive Mood Dysregulation (DMD)
• Severe recurrent temper outbursts
• Inconsistent with developmental level
• Frequency: 3 or more times per week for over a year
• Initial diagnosis is from age 6-18
• Key differentials:
• Oppositional defiant disorder
• Intermittent explosive disorder
DISRUPTIVE AND IMPULSE-CONTROL
DISORDERS
Oppositional Defiant Disorder (ODD)
• A disorder in a child marked by defiant and disobedient behavior to
authority figures.
• Persistently angry, irritable, argumentative, defiant, vindictive
• For at least 6 months
• At least 4 symptoms of any of the 3 categories
• Angry/irritable mood
• Argumentative/defiant behavior
• Vindictiveness
• Key differentials
• Conduct disorder: ODD lacks cruelty to animals, theft, or deceit
• Disruptive mood Dysregulation: more severe and more frequent temper
outbursts
DISRUPTIVE AND IMPULSE-CONTROL
DISORDERS
Intermittent explosive Disorder (IED)
• Recurrent failure to gain control of aggressive impulses
• Verbal outbursts 2 x weekly over 3 months
• Behavior outburst involving damage to property or physical aggression 3x within
1 year
• Expressed aggression greatly out of proportion to any precipitating stressor
• Angry outbursts not premeditated
• No negative mood between outbursts
• Dx >6 years old, usually begins before adulthood
• Differentials:
• Substance abuse
• Disruptive mood Dysregulation: persistent negative mood state between outbursts
• Antisocial or borderline personality disorders: have lower levels of aggression than
IED
DISRUPTIVE AND IMPULSE-CONTROL
DISORDERS
Conduct Disorder
• Repetitive disregard of others
• Violates age related norms of behavior
• Little regard for the feelings of others
• At least 3 of the following in the past 12 months
• Aggression/cruelty to others (people or animals)
• Bullies, intimidates, threatens
• Initiates fights
• Uses weapons to cause harm
• Theft while victim is present
• Destruction of property
• Runs away form home 2 times, at least 1 long period
• Dx <18 years old
• Differentials:
• Oppositional defiant disorder
• Intermittent explosive disorder
 OVERVIEW
Disruptive OF DISRUPTIVE
Disruptive BEHAVIORS
Opposition Intermitten Conduct
Behaviors mood al defiant t explosive disorder
Dysregulati disorder disorder
on disorder
MAIN ISSUE Severe Angry, Verbal and Aggression,
outbursts, defiant of behavioral destruction
with angry authority, outbursts, of property,
in between vindictive impulsive criminal acts
aggression
PREMEDITATI no no no Yes
ON
TIME FRAME >12 months >6 months Verbal: 3 >12 mon
mon
Behavioral:
12 mo
MOOD Irritable, Angry Normal Normal
angry
DOES NOT Aggression, Aggression Negative Empathy,
HAVE defiance toward mood guilt,
others, between concern
severe outbursts, about own
outbursts seeking behavior
money/powe
ELIMINATION DISORDER
Enuresis
• Repetitive wetting of bed or clothing
• At least 2x per week for 3 months
• At least 5 years old
• Usually occurs in delta sleep (nocturnal variety)
• Daytime wetting may be linked to social anxiety, reluctance to stop
playing
• Often history of same sex parent
• First check for life stressors
• Treatment:
• Desmopressin
• Imipramine
• Oxybutynin
ELIMINATION DISORDER
Encopresis
• Repetitive passing of feces in inappropriate places (bed,
clothing, floor)
• At least 1x per month for 3 months
• At least 4 years old
• Not due to laxative use
• If involuntarily, may be linked to constipation
• Anticonvulsants and cough suppressants may increase
constipation and make encopresis more likely
Thank you