i am just trying to essay child related psychiatric problems in community. At child age there have many problems and its converted into changing behavior of child towards the community. so the child problem its create the child behavior.

1. Child psychiatry
MR.VIKRANT KULTHE

2. Normal child development
• Divided into four major areas:
1. Motor behaviour
2. Adaptive behaviour
3. Language
4. Personal and social behaviour
• In addition to these milestones, other
developmental parameters are:
Height, weight, activity level and general health
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3. Intellectual development
• Acc. to Jean Piaget’s developmental theory:
Sensory-motor stage: from birth – 2 yrs of age
1. actions related to sucking, orality and
assimilation of objects
2. ability to think of only one thought at a time
3. Inanimate objects given human qualities
4. Out of sight means ceasing to exist
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4. Intellectual development
• Concrete thinking stage: 2-7 yrs
1. Egocentric thought with a unique logic of its
own, involving a limited point of view and
lacking introspection
2. Inability to generalise from specific events and
to specify from general events
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5. Intellectual development
• Abstract or conceptual thinking stage: 7-11
yrs
1. Ability to focus on several aspects of a
problem at a time
2. Thought process is flexible & reversible
3. Ability of abstraction, & to find similarities
and differences among specific objects
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6. Intellectual development
• Adolescent thinking or formal operational
stage: 11yrs and life-long
1. Ability to imagine possibilities inherent in a
situation, thus making the thought
comprehensive
2. Ability to develop complete abstract
hypotheses and test them
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7. Intellectual development
• By the end of adolescence, the individual’s
intellectual structures are completely
developed , although learning and
intellectual growth continues
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8. Classification in child psychiatry
• Mental retardation
• Specific developmental disorders
• Pervasive developmental disorders
• Hyperkinetic disorders
• Conduct disorders
• Tic disorders
• Enuresis and encopresis
• Speech disorders
• Habit disorders
• Other disorders
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9. Mental retardation
• 1-3% of general population
• Called learning disability
• Definition:
Significantly sub-average general intellectual
functioning associated with significant deficit
or impairment in adaptive functioning, which
manifests during developmental period
(before 18 years of age).
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10. Mental retardation
• On standardised intelligence tests, 2 SD’s
below mean, i.e. IQ below 70
• Adaptive behaviour is person’s ability to meet
responsibilities of social, personal,
occupational and interpersonal areas of life
acc. to his age and socio-cultural and
educational background.
• Adaptive behaviour is measured by clinical
interview and standardised assessment scales.
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11. Mental retardation
• IQ score alone cannot be taken as a measure of
one’s intelligence and there has to be deficit in
adaptive behaviour too.
• Intelligence Quotient = mental age
chronological age
Mental retardation levels:
– Mild: 50-70
– Moderate: 35-50
– Severe: 20-35
– Profound: < 20
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12. Mild mental retardation
• Commonest type, 85-90% cases, called educable
• Diagnosis made later
• Pre-school period, almost normal development,
with very little deficit
• Often progress up to 6th grade
• Can achieve vocational and social self-sufficiency
with a little support
• Supervised care needed only in stressful
conditions or in presence of an associated
disease
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13. Moderate mental retardation
• About 10 %
• Previously called trainable but can be educated to
some extent
• In the early years can learn to speak
• Drop out of school after 2nd grade
• Poor social awareness
• Can be trained to support themselves by
performing semi-skilled or unskilled work under
supervision
• Mild stress enough to destabilise them
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14. Severe mental retardation
• Often recognised early, with poor motor
development ( significantly delayed
milestones)
• Absent or markedly delayed speech and other
communication skills
• Elementary training in personal health care
possible, sometimes can be taught to talk.
• Can perform only simple tasks under
supervision, called dependent.
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15. Profound mental retardation
• About 1-2%
• Associated with physical disorders, which
contribute to the retardation
• Markedly delayed developmental milestones
• Need nursing or life-support under carefully
planned and structured environment.
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16. aetiology
• Genetic ( probably in 5% cases)
i. Chromosomal abnormalities:
down’s syndrome, fragile X syndrome, Turner’s
syndrome, Klinefelter’s syndrome
ii. Inborn errors of metabolism: involving
a. a.: phenylketoneuria, homocystinuria,
lipids: Tay-Sachs disease, Gaucher’s disease
purines: Lesch Nyhan Syndrome
iii. Single gene disorders:
tuberous sclerosis, neurofibromatosis
iv. Cranial anomalies: microcephaly
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17. Aetiology
• Peri-natal causes: probably 10% of cases
i. Infections- rubella, syphilis, toxoplasmosis,
CMV, herpes
ii. Prematurity
iii. Birth trauma
iv. Hypoxia
v. IUGR
vi. Kernicterus
vii. Placental abnormalities
viii.Drugs during 1st trimester
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18. Aetiology
• Acquired physical disorders in childhood: 2-5 %
i. Infections, esp. Encephelopathies
ii. Cretinism
iii. Trauma
iv. Lead poisoning
v. Cerebral palsy
• Socio-cultural causes: probably in 15%
deprivation of socio-cultural stimulation
• Psychiatric disorders: 1-2 %
PDD- infantile autism, childhood onset
schizophrenia
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19. Diagnosis
• History
• General physical examination
• Detailed neurological examination
• Mental status examination
• Investigations:
i. Routine investigations
ii. Urine test for phenylketonuria, maple syrup
urine disease
iii. EEG, esp. In presence of seizures
iv. Blood levels, for inborn errors of metabolism
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20. Diagnosis
v. Chromosomal studies, e.g. In Down’s syndrome,
prenatal and post-natal
vi. CT scan or MRI scan, e.g. In tuberous sclerosis,
focal seizures, anomalies of skull configuration,
severe or profound MR without apparent cause,
toxoplasmosis
vii. TFT’s
viii.LFT’s
ix. Psychological tests: Seguin form board test,
Stanford- Binet test, WISC, Raven’s progressive
matrices, VSMS for adaptive behaviour4/21/2020 MR. VIKRANT KULTHE 20

21. Differential diagnosis
• Deaf and dumb
• Deprived children with inadequate social
stimulation
• Isolated speech defects
• Psychiatric disorders
• Systemic disorders- with physical debilitation
• epilepsy
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22. Management
Primary prevention:
– improvement of socio-economic conditions,
prevent malnutrition
– Education of lay people about individuals with
MR
– Medical measures to prevent perinatal
infections, trauma, excessive use of medicines,
diseases of pregnancy
– Universal immunisation of children
– Facilitating research to study causes of MR
– Genetic counselling of at-risk parents
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23. Management
• Secondary prevention:
– Early detection and treatment of preventable
causes e.g. Phenylketonuria, hypothyroidism
– Early detection of handicaps in sensory, motor or
behavioural areas with early remedial measures
and treatment
– Early treatment of correctable disorders, e.g.
Infections, skull configuration anomalies
– Early diagnosis
– Avoid segregation or discrimination
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24. Management
• Tertiary prevention
– Adequate treatment of psychological and
behavioural problems
– Behaviour modification using positive and
negative reinforcement
– Rehabilitation in vocational, physical, and social
areas
– Parental counselling to lessen levels of stress,
increasing adaptational skills
– Institutionalisation or residential care
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25. Management
• Legislation: persons with disability act 1995
envisages mandatory support for prevention,
early detection, education, employment, and
other facilities for the welfare of people with
disabilities and esp. MR
this act provides for affirmative action and
non-discrimination of persons with disabilities
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26. Specific developmental disorder
• Ch/b inadequate development in usually one
specific area of functioning
• May be scholastic skills, speech and language,
and motor skills
• May include reading, language, arithmetic or
mathematics, articulation or co-ordination
• Sometimes more than one disorder is present
• Either cause impairment in academic
functioning or in daily activities
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27. Specific reading disorder
• Called “dyslexia” or developmental reading
disorder
• Serious delay in learning to read
• May include omissions, distortions, or
substitutions of words, long hesitations,
reversal of words, or simply slow reading
• Writing and spelling are also affected
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28. Specific arithmetic disorder
• Called developmental arithmetic disorder or “
dyscalculia”
• May include failure to understand simple
mathematical concepts, recognise
mathematical signs or numerical symbols,
difficulty in carrying out mathematical
manipulations and difficulty in learning
mathematical tables
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29. Specific developmental disorder of speech and language
• Called communication disorder or dysphasia
• 3 main types:
– Phonological disorder: dyslalia
includes severe articulation errors, speech
sounds or phonemes are omitted, distorted or
substituted
– Expressive language disorder: below par ability
to use expressive language
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30. Specific developmental disorder of speech and language
restricted vocabulary, difficulty in selecting words
and immature grammatical usage. Cluttering of
speech may also be present
– Receptive language disorder; often presents as a
receptive- expressive disorder
ch/by below par understanding of language,
failure to respond to simple instructions
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31. Specific developmental disorder of motor function
• Called motor skills disorder, developmental
co-ordination disorder, clumsy child syndrome
or motor dyspraxia
• Ch/by poor co-ordination in daily activities of
life like dressing, walking, feeding, playing
• Inability to perform fine or gross motor skills
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32. Treatment
• Based on learning theory principles and
behaviour therapy
- use of special remedial teaching focussing on
underlying deficit
• Treatment of co-morbid emotional problems
• Parental education and counselling
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33. Pervasive developmental disorder
• Infantile autism 1st described by Leo Kanner in
1943
• Described as autistic disorder, childhood
autism, childhood psychosis, pseudo- defective
psychosis
• M > F, 3-4 : 1
• Prevalence- 0.4- 0.5 / 1000
• Onset before 2 ½ yrs.
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34. Pervasive developmental disorder
• Clinical features:
• Autism- marked impairment in reciprocal
social and interpersonal interaction
- absent social smile
- lack of eye-to-eye contact
- lack of awareness of others’ existence or
feelings, treats people as furniture
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35. Pervasive developmental disorder
– lack of attachment to parents and absence of
separation anxiety
– no or abnormal social play, solitary games
– marked impairment in making friends
– lack of imitative behaviour
– absence of fear in presence of danger
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36. Pervasive developmental disorder
• Marked impairment in language and non-verbal
communication:
- lack of verbal or facial response to sounds or
voices
- absence of communicating sounds e.g. Babbling
- absent or delayed speech
- abnormal speech patterns and content.
Presence of echolalia, perseveration, poor
articulation, pro-nominal reversal (I-you)
- rote memory is usually good
- impaired abstract thinking4/21/2020 MR. VIKRANT KULTHE 36

37. Pervasive developmental disorder
• Abnormal behavioural characteristics:
- mannerisms
- stereotyped behaviours like head-banging,
body spinning, rocking, clapping etc.
- Ritualistic and compulsive behaviour
- resistance to even slightest change in
environment
- attachment to inanimate objects
- hyperkinesis4/21/2020 MR. VIKRANT KULTHE 37

38. Pervasive developmental disorder
• Mental retardation:
- only 25% have IQ >70
- about 50% have moderate to profound MR
• Other features:
- Many children enjoy music
- Idiot savant syndrome: certain islets of
precocity or splinter function may remain. E.g.
Prodigious rote memory or calculating ability
and musical ability
- Epilepsy common in children with IQ < 50
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39. Aetiology
• Predominantly biological
• h/o perinatal CNS insult, EEG abnormalities,
epilepsy, ventricular dilatation, increased
serotonin levels in brain
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40. Treatment
• Behaviour therapy: regular routine, classroom
teaching, self-care skills training, speech
therapy, encouragement of interpersonal
interactions
• Pharmacotherapy: antipsychotics, SSRI’s,
multivitamins, T3, T4, antiepileptics
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41. Other Pervasive developmental disorders
• Childhood psychosis- includes autism,
schizophrenia, mood disorders, organic
psychiatric disorders
• Asperger’s syndrome: autism without any
delay in language or cognitive development,
high functioning autism. M > F, 8:1
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42. Other Pervasive developmental disorders
• Rett’s syndrome: reported only in girls.
Apparently normal growth f/by deceleration
of head growth between 5- 30 months. Loss of
purposive hand movements and acquired fine
motor skills, subsequent stereotypic hand
movements. Severe mental handicap follows.
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43. Hyperkinetic disorder
• Attention deficit disorder
• 3% school children
• Occurs before the age of 7yrs.
• Four types- ADD with hyperactivity,
ADD without hyperactivity
residual type
with conduct disorder
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44. Diagnosis
• Teacher’s school report (often most reliable)
• Parent’s report
• Clinical examination
• Mental retardation should be excluded
Aetiology:
Cause not known but supposedly minimal brain
damage
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45. Course:
• Majority (80%) improve by puberty
• 20% persistent symptoms in adulthood
• Impulsivity and inattention likely to remain
Treatment:
Pharmacotherapy: stimulant medication, clonidine,
venlafaxine, lithium, imipramine, chlorpromazine
etc. Barbiturates contraindicated
Behaviour modification
Counselling and supportive psychotherapy
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46. Conduct disorder
• Ch/by persistent and significant pattern of
conduct in which the basic rights of others are
violated or rules of society are not followed
• Diagnosis is made when conduct is far in
excess of the routine mischief of children an d
adolescents
• onset usually before puberty
• 5-10 times common in males
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47. Clinical features
1. Frequent lying
2. Stealing or robbery
3. Running away from home and school
4. Physical violence like rape, fire- setting, assault,
use of weapons
5. Cruelty towards other people and animals
• Earlier called juvenile delinquents
• Unsocialised type more severe
• Chronic course, may progress to ASPD
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48. Clinical features
• High co-morbidity – secondary complications like
drug abuse, dependence, unwanted pregnancy,
syphilis, AIDS, criminal records, suicidal and homicidal
behaviour
• Treatment: usually difficult
placement in corrective institution
behavioural, educational and psychotherapeutic
medicines- anticonvulsants, stimulant medication (
for hyperactivity),antipsychotics
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49. Non-organic enuresis
• enuresis is repetitive voiding of urine, either
during the day or night, at inappropriate
places.
• Technically diagnosed only after 5 years of age
and at least after 4 years of mental age.
• Types: primary
secondary
• Majority are nocturnal bed-wetting only
• M > F, 2:14/21/2020 MR. VIKRANT KULTHE 49

50. Non-organic enuresis
• Aetiology: exact cause unknown
– 75% have 1st degree relative
– Psychosocial: emotional disturbances,
insecurity, sibling rivalry, death of a parent
– Organic cause, esp. In diurnal enuresis and
adolescent enuresis- worm infestation, spina
bifida, UTI, neurogenic bladder, DM, seizure
disorder
– Secondary enuresis- age of onset, 5-8 years.
Tends to remit spontaneously. 1% continues in
adulthood
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51. Non-organic enuresis
• Treatment:
– Restriction of fluid intake after 8 PM
– Bladder training during daytime, progressive
– Interruption of sleep before expected time of bed-
wetting. Child should be woken up and made
aware of passing of urine
– Conditioning devices like alarm setting off as soon
as urine touches the bed-sheet
– Supportive psychotherapy for the child and the
whole family
– Pharmacotherapy: TCA- imipramine
intranasal desmopressin
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52. Non-organic encopresis
• Repetitive passage of faeces at inappropriate
time and/or place, after bowel control is
physiologically possible.
• Normal toilet training between 2-3 yrs. of age
• Diagnosed after the age of 4 years.
• Types: primary
secondary- 4-8 years of age
• M > F , 3-4 : 1
• Bye 5 years, 1- 1.5% children encopretic
• Tends to remit spontaneously with age.
• 25% are also enuretic
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53. Non-organic encopresis
• Aetiology: factors implicated are-
– Inadequate, inconsistent toilet training
– Sibling rivalry
– Maturational lag
– Underlying hyperkinetic disorder
– Emotional disturbances
– Mental retardation
– Childhood schizophrenia
– Autistic disorder
• Organic cause should be ruled out.
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54. Non-organic encopresis
• Treatment:
– Best treatment is preventive
– Family environment should be warm and
understanding
– Emotional disturbances should be dealt with as
soon as noticed
– Behaviour therapy
– Psychotherapy, biofeedback and imipramine
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55. Thank you
4/21/2020
MR. VIKRANT KULTHE 55