Classification of childhood psychiatric disorders. special focus on ADHD, clinical picture and management

1. Dr. Shewikar El Bakry
Ass. Prof. of Psychiatry

2.  Why childhood mental disorders
 What is mental disorder and warning signs
 Why early intervention
 DSM V classification
 ADHD

3.  Why is it important for parents, caregivers &
professionals to know about children’s mental
health?
 One in five (21%) of children have a
diagnosable mental, emotional, or behavioral
disorder.
 One in 10 suffer from a serious emotional
disturbance.
 70% of children, however, do not receive
mental health services

4.  “The prevalence of mental disorders among
children is predicted to rise in the next 15
years by 50%, becoming a major cause of
morbidity, mortality and disability.”
 Suicide is already:
 4th leading cause of death between ages 10-14
years
 3rd leading cause of death between ages 15-24
years

5.  All children pass through a rough time at
school, with friends or with their families.
 Children can be stressed too.
 Development and life incidents

6.  Brain development depends on interaction
between the brain cells and their immediate
environment.
 Both biological and psychosocial factors
influence the development of the brain and
brain disorders.
 Stressful life events, injury, infection,
malnutrition, exposure to toxins. childhood
maltreatment may lead to mental health
disorders.

7.  Negative attitudes and beliefs
 Fear, rejection, avoidance
 Disrespect and discrimination
 Discourages individuals and families from
getting the help they need

8. A mental disorder is a syndrome
characterized by clinically significant
disturbance in an individual’s
cognition, emotion regulation, or behavior that
reflects a dysfunction in the
psychological, biological, or developmental
processes underlying mental functioning.
There is usually significant distress or
disability in social or occupational activities.

9.  Consider three things if you suspect a child
may be experiencing an emotional problem:
 Frequency: How often does the child
exhibit the symptoms?
 Duration: How long do they last?
 Intensity: How severe are the symptoms?

10.  Can reduce the effects an emotional or mental
health disorder may have on children and their
families.
 Can lessen the duration and severity of the
disorder.
 Can help children learn positive coping
strategies and prevent academic and social
failure.

11.  Neurodevelopmental Disorders
 Bipolar Disorders
 Anxiety Disorders
 Obsessive compulsive related disorders
 Trauma and stress related disorders
 Feeding and eating disorders
 Elimination disorders
 Sleep disorders
 Disruptive, Impulse control and conduct
disorders
 Others

12.  Most common pediatric mental health
disorders include:
 Anxiety disorders (most common)
 Mood disorders
 Attention Deficit Hyperactivity Disorders
 Autism Spectrum Disorders
 Conduct Disorders
 Eating Disorders
 Substance abuse

13.  Axis I Clinical syndromes. (All mental disorders & criteria for
rating them except personality disorders/mental
retardation, also abuse/neglect)
 Axis II Personality disorders, Mental retardation. (Life long
deeply ingrained, inflexible & maladaptive)
 Axis III General medical condition. (Any medical condition
that could effect the patients mental state.)
 Axis IV Psychosocial & environmental problems. (Stressful
events that have occurred within the previous year)
 Axis V global assessment functioning. (How well the patient
performed during the previous year)

14.  Symptoms affect all areas of life – academic, social,
cognitive and behavioral performance.
 Symptoms persist to adulthood in 60-70%
 Children, adolescents, and adults with ADHD are at
greater risk for experimentation with and abuse of
alcohol and drugs, school and job failure, and
accidental injuries.
 Effective treatment is indirect & adult dependent

15.  ♦ADHD is a common neurobehavioral disorder
of childhood.
 ♦Symptoms persist into adolescence and
adulthood for majority of patients.
 ♦Hyperactivity and impulsivity may diminish
at a higher rate than inattention.

16.  •Must have symptoms for at least 6-Months
 •Symptoms must be present prior to age 7
 •Impairment Across Settings (2 or more)
 •Evidence of significant functional impairment
 •Symptoms are extremes of normal behavior

17.  fidgets or squirms
 can’t stay seated
 restless
 loud, noisy
 always “on the go”
 talks excessively
 blurts out
 impatient
 intrusive
Often…

18.  Appears to not be listening
 Follows through poorly on obligations
 Disorganized
 Dislikes sustained mental effort
 Loses needed objects
 Easily distracted
 Forgetful
 Careless errors, inattentive to detail
 Sustains attention poorly
Often…

19.  Low self esteem
 Humiliation
 Feeling “dumb”
 Always “in trouble”
 Quick to lie about behavior
 Become defensive
 Feel defeated

20.  Sometimes work harder at avoiding work than
actually doing it
 Academic progress is often a roller coaster – up
and down all year
 Moody
 Really do want to do well
 Frustration

21.  Creative
 Charming
 Funny
 Social
 Sensitive and caring
 Hyperfocus
 Enthusiasm

24.  5% (one out of twenty) children.
 30% to 70% of these cases persist into
adulthood. Often have ADHD children.
 Most common psychiatric disorder of
childhood.
 Often misdiagnosed as an anxiety
disorder, manic state, or personality disorder.

25. ADHD is a heterogeneous behavioral
disorder with multiple possible etiologies
CNS = Central Nervous System
Neuroanatomic
Neurochemical
Genetic
Origins
Environmental
Factors
CNS
Insults
ADHD

26. What we do know
 It is a “brain-based” disorder the basis of which is
largely genetic – likely due to multiple interacting
genes
 Some cases may be caused by external factors such
as prenatal or perinatal complications or exposures
 Dietary factors – continuing area of research
 Several differences in structure and function of
prefrontal and frontal cortices and basal ganglia have
been shown.
 Possible increase of norepinephrine with
decrease of inhibition by dopamine

27. Symptoms of ADHD are caused by abnormality
in the Executive Function of the brain.

28. Prefrontal Cortex
Frontal Lobes
Limbic System
Basal Ganglia
Caudate nucleus
Cerebellum

30.  1. Compliant: onset course duration
 2. History : Developmental
 Medical
 Family
 Social
 3. Rating scales: Conner’s BASC CBC
 Vanderbilt SNAP
 Re evaluate with no improvement or
worsening

31. Preschool
 The Early Childhood Attention Deficit Disorder Evaluation Scale
(ECADDES)
Elementary School
 Child Behavioral Checklist (CBCL) - Parent, Teacher, or Youth
forms
 Conners Parent and Teacher Rating Scales (CPRS and CTRS)
Adolescent
 Conners/Wells Adolescent Self Report of Symptoms (CAAS)
 Adolescent Symptom Inventory-4 (ASI-4)
Adults
 Conners Adult Attention-Deficit Rating Scale (CAARS)

32. Education
Medical Interventions
Psychosocial Interventions

33.  Behavioral Management: helps patients change or
control their ADHD behaviors. Identifies unwanted
behaviors and helps to replace them.
 Counseling: Helps patients and families identify
unwanted behaviors and teaches how to cope with and
change them. Can also help with low-self
esteem, depression and stubborn behaviors.
 Medication: different medications help to improve
symptoms so your child can manage better at home, at
school, and with friends. Is most helpful when
combined with behavioral management and counseling.

34.  Stimulants
 Stimulants are the best studied medications in child
& adolescent psychiatry
 Antidepressants
 Antihypertensives
 Wake-promoting agent used in narcolepsy

35.  First line medication treatment of ADHD
 Approximately 70% of children will respond to the
first stimulant prescribed
 Up to 90% respond to the first or second stimulant
attempted
 Do NOT “make” children perform better –
he/she has to do the work themselves
 Helps improve executive functioning so they can
successfully complete work

36.  Work by “stimulating” the brain to make more
of the neurotransmitters (brain chemical) that
help focus attention, control impulses, organize
and plan, keep with routines
 Increase dopaminergic and noradrenergic
activity in frontal cortex (responsible for
executive functioning)
 Research shows other treatments are more
likely to work if the child is taking a stimulant

37. Ritalin: (Methylphenidate):
 helps increase attention span during the day,
 helps with staying on task, and
 helps with rapid ADHD morning symptom control so it is easier to
start the day
Dexedrine (Dextroamphetamine):
 Stimulant
 Also helps with attention, disruptive behavior and relationship
problems
*other medications include Adderall, Straterra, Concerta and
Wellbutrin

38. A noradrenergic reuptake inhibiter that appears
to have relatively good effectiveness in
decreasing levels of hyperactivity and in
helping with increasing attention,
concentration, and organization. It has been
approved for use in children as young as 6
years old weighing above forty pounds. It
generally has lasting effects throughout the day
and into the evening. Problems have included
changes in appetite and also nausea along with
some sleep problems

39.  Good points
 24 hour coverage, once a day
 Not abusable
 May help co morbid anxiety
 Maintains a blood level and dosing can be
adjusted
 Side effects limited with slower titration

40.  Advantages
 may decrease
hyperactivity and
aggression
 may improve cognitive
performance
 Double-blind, placebo-
controlled studies
demonstrate
effectiveness
 Disadvantages
 Not as effective as
stimulants for cognitive
symptoms
 Available dosage forms
inappropriate for younger
children
 may decrease seizure
threshold
 may exacerbate tics
4.

41.  Advantages
 may be useful to treat
very hyperactive or
aggressive patient
 improves ability to fall
asleep
 Disadvantages
 clinical effects may take
several weeks
 does not affect inattention
symptoms
 sedation
 risk of adverse CV
effects, depression, and
decreased glucose tolerance
Guanfacine (Tenex®) has a more favorable side-effect profile than
clonidine but has only been studied in open trials.
.

42. Stage 0: Assessment, discussion of treatment alternatives
Stage 1: Monotherapy: Amphetamine vs. Methylphenidate
Stage 2: Monotherapy: Stimulant not used in Stage 1
Stage 3: Monotherapy: Alternate class (Cylert®)-q 2 week LFT’s
Stage 4: Buproprion, Nortryptyline, Imipramine
Stage 5: Antidepressant not used in Stage 4
Stage 6: Alpha-agonists, monitoring cardiovascular status

43.  House rules
 Appropriate commands (specific, clear, positive)
 Ignore mild inappropriate behaviors and praise
positive behavior
 Contingency management with positive reinforcement
(eg, a point chart) and prudent negative consequences
(eg, privilege loss)
 Behavioral “contracting” in adolescent children
.
Parent Training

44.  Largely employ techniques taught in parent training
 Daily behavioral report cards
 serve to define target behaviors
 facilitate school-home communication and allow parents to
provide rewards for good school behavior and performance
 Special classroom accommodations
 clearly and consistently posting daily schedules
 breaking assignments into smaller chunks
 providing rewards for task completion and consequences for rule
violations
School Interventions
.

45.  Sometimes used to teach the child skills needed in peer
relationships and other settings
 Interaction skills  Conflict resolution
 Problem-solving skills  Anger management
 Results of studies of this strategy are inconsistent
 More effective when taught in group settings such as
summer camps, school-based, and after-school settings
.
Social Skills Training

46.  Basic Principles:
 – The “ABC’s” – Antecedent, Behavior,
Consequences
 – Parents and teachers can intervene in the
antecedent event and set consequences to
change behavior.
 – Baby steps: Pick one behavior or habit at a
time to work on and build up

47.  Topics addressed in Parent Training
 “Establishing house rules and structure
 Learning to praise appropriate
behaviors…and ignoring mild inappropriate
behaviors (choosing your battles)
 Using appropriate commands
 Using “when…then” contingencies
(withdrawing rewards or privileges in
response to inappropriate behavior)

48.  Planning ahead and working with children in
public places
 Time out from positive reinforcement (using
time outs as a consequence for inappropriate
behavior)
 Daily charts and point/token systems with
rewards and consequences
 School-home note system for rewarding
behavior at school and tracking homework”

49.  Create a routine
 Help your adolescent organize
 Avoid distractions
 Limit choices
 Change your interactions
 Use goals and rewards
 Help your teen discover a talent

50. DAILY GOAL
MY GOAL FOR TODAY IS:
Effective Participation in Classroom Instruction
DIRECTIONS FOR MY GOAL…. I WILL:
•Raise my hand before answering questions
•Look at my teacher when she is talking to the class
•Stay at my desk until given permission to move
•Listen without talking to others
DAILY CHECK-IN TO DESCRIBE HOW I DID……
.I think that my performance today:
NEEDS IMPROVEMENT 1 2 3 WAS THE BEST
My Teacher thinks that my performance today:
NEEDS IMPROVEMENT 1 2 3 WAS THE BEST
Tomorrow I will: ____________________________
Teacher’s Signature & Comments:___________
__________________________________

51.  ADHD is a valid disorder
 ADHD is universally found
 ADHD largely results from biological factors
 Genetics, neurology, acquired injuries and interactions
 ADHD is a disorder of inhibition and executive
functioning (self-regulation), not merely attention
 Social environment important for its impact on
creating prosthetic environments, reducing
impairment, affecting comorbidity and resource
availability
 ADHD can be successfully managed as a disorder
of EF leading to improved life course and
outcomes