Child Psychiatry

Types of Disorders of Psychological Development

• Specific developmental disorders of Speech and Language e.g. Speech articulation disorder, Acquired Aphasia with Epilepsy (Laudau-Kleffner syndrome), etc.
• Specific developmental disorders of Scholastic Skills e.g. Specific Reading Disorder (Dyslexia), etc.
• Specific developmental disorders of Motor Function (Motor Skill Disorder Or Clumsy Child Syndrome)
• Pervasive Developmental Disorders - (Autism Spectrum Disorders), etc.

Specific Disorders of Development (SDD) Types

1. SDD of Scholastic skills
   • Specific Reading Disorder
   • Specific Spelling Disorder
   • Specific Arithmetic Disorder
2. SDD of Speech & Language (Communication Disorder)
3. SDD of Motor function (Motor Skill Disorder)

Specific Developmental Disorders of Scholastic Skills (Learning Disorders)

• Specific Reading Disorder – Dyslexia
• Specific Arithmetic or Mathematics Disorder - Dyscalculia
• Specific Spelling or Written Expression - Dysgraphia

Specific Reading Disorder

Also known as dyslexia

• There is impairment in the brain's ability to translate written images received from the eyes into meaningful language.
• This is the most common learning disability in children.
• Produces a gap between the child's ability & his or her performance.
• Most have average or above-average IQ but read at lower level than expected.
• Learning disabilities affect about 5% of all school-age children (in US).
• Dyslexia occurs in individuals with normal vision and normal intelligence.
• They have normal speech (difficulty interpreting spoken language and writing).
• Causes: Malfunction in areas of the brain concerned with language.
• It runs in families.

Signs and Symptoms of Specific Reading Disorder (SRD)

• Dyslexia can be difficult to recognize, but some early clues may indicate a problem, e.g.:
• Problem with new words
• Adding new words slowly
• Having difficulty rhyming
• Having an inability to recognize words and letters on a printed page
• Having a reading ability level much below the expected level for the age & IQ of the child (< 1.5-2 Standard deviation below)
• Have problems processing and understanding what they hear
• Have difficulty comprehending rapid instructions
• Have problems following more than one command at a time
• Have difficulty remembering the sequence of things
• Reversal of letters (e.g. b for d)
• Reversal of words (e.g. saw for was)
• Writing and spelling impaired
• Errors of omissions, substitutions, or distortions of words
• There is slow reading & long hesitations
• May also try to read from right to left
• May fail to see (or hear) similarities and differences in letters and words
• May not recognize the spacing that organizes letters into separate words
• May be unable to sound out the pronunciation of an unfamiliar word
• It is more common in boys than girls

Treatment

• Identify the disorder early (Very important)
• Education is the main Rx:
• Start early before child has a sense of failure
• Extra teaching & Parental interest are important
• Use several senses to learn - like listening to a taped lesson and tracing with a finger the shape of the words spoken can help process the information
• Treat any other co-morbid conditions when present
• Mild cases - Normal reading by adolescence
• Severe cases - Only few overcome the problem by adolescence

Specific Arithmetic/Mathematics Disorder

Also known as dyscalculia

Dyscalculia, a lesser-known learning disorder, affects a person’s ability to comprehend and manipulate numbers and mathematical concepts. Much like its more famous counterpart, dyslexia, which disrupts reading-related brain areas, dyscalculia targets the neural regions responsible for mathematical skills and understanding.

However, it is essential to recognize that their difficulties do not reflect diminished intelligence or capability. Dyscalculia symptoms typically emerge during childhood, especially when children begin learning basic math. Surprisingly, many adults unknowingly grapple with dyscalculia as well.

Key Differences: Dyslexia vs. Dyscalculia

While both dyslexia and dyscalculia fall under the umbrella of “Specific Learning Disorder” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), they exhibit distinct characteristics:

• Dyscalculia:
  • Impairs mathematical abilities.
  • Challenges understanding and manipulating numbers.
  • Often leads to anxiety, depression, and other emotional struggles related to math.
  • May manifest later in life (acquired dyscalculia) due to medical conditions or other factors.
• Dyslexia:
  • Affects reading abilities.
  • Involves difficulties with reading, spelling, and language comprehension.
  • Can coexist with dyscalculia.

Specific Spelling or Written Expression

Also know as dysgraphia

Dysgraphia, often overshadowed by its more prominent counterparts like dyslexia, is a specific learning disorder that profoundly impacts a person’s ability to communicate effectively through written language. Unlike mere messy handwriting, dysgraphia encompasses a broader range of challenges, including spelling, grammar, and the organization of written tasks.

Also known as Autism Spectrum Disorders (ASD)

A group of disorders characterized by abnormalities in:

• Communication
• Social Development
• Behaviors and Interests

Generally manifest before age 5 years.

Social Interaction Abnormalities (Autistic Aloneness):

1. Marked impairment in the use of multiple non-verbal behaviors such as eye to eye contact, facial expression, body postures, and gestures during social interaction
2. Failure to develop peer relationships appropriate for developmental age
3. Lack of spontaneous will to share enjoyment, interest, or activities with other people
4. Lack of social or emotional reciprocity
5. Staring into open space and not focusing on anything specific
6. The child can appear as if deaf or dumb
7. Loss of interest in the environment and surroundings
8. Social smile is usually absent in a child with Autism

Communication Abnormalities

• Delay or total lack of development of spoken language
• Misuse of pronouns
• Inappropriate repetition of words spoken by others (Echolalia)
• Some are talkative but usually in Repetitive Monologue

Restriction of Behavior & Interest

1. Stereotyped and repetitive movement (e.g. Hand or finger flapping or twisting, etc)
2. May be associated with abnormal eating habits
3. Persistent preoccupation with parts of objects
4. Love for regimented routine activities
5. Sudden show of anger
6. Little imagination/creative play
7. Some may injure themselves

Other Things to Know about ASD

1. Autism is NOT Childhood Schizophrenia
2. Autism is NOT an auto-immune condition
3. Autism is a NEURO-DEVELOPMENTAL disorder
4. Autism could be associated with Mental Retardation
5. Autism could be associated with Epilepsy
6. Onset of Autism is usually in Childhood
7. Previously known as Kanner Syndrome, described by Dr. Leo Kanner in 1943 as Infantile Autism
8. Boys are more affected than Girls, with a ratio of 4:1
9. Onset is before 30 months
10. Up to three-quarters are mentally retarded

Etiology Considerations: Multifactorial

1. Genetic: 50 times more frequent in siblings
2. Organic brain disorders:
   • Pregnancy complications increase disorder
   • Epilepsy
3. Others: fragile X syndrome, Tuberous sclerosis, etc.
4. Environmental factors: Heavy metal - Mercury

Types of ASD (DSM IV)

1. Autistic Disorder (AD): Occurs in 20/10,000 in Canada
2. Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS): Occurs in 15/10,000
3. Asperger's Syndrome (AS): Occurs in 5/10,000; Milder; Cognitive impairment not prominent
4. Rett's: 1/10,000; Almost exclusively females
5. Childhood Disintegrative Disorder (CDD): Most uncommon 0.2/10,000; Most severe type

Management of ASD:

1. Multidisciplinary; Structured & Individualized
2. Early Recognition & Management is very important
3. Behavioral/Educational/Psychological Components: Key
   • Special Education
   • Speech therapy
   • Behavioral - Applied Behavior Analysis: encourage +ve behavior & discourage -ve ones
   • Occupational Therapy
   • Psychological Therapies including exercises
   • Picture Exchange Communication system (PECS)
   • Social Skills Training: Improves Social interactions
4. Pharmacologic Treatment: If Indicated e.g. Antidepressants in Adolescent group
5. Complimentary & Alternative Medicine: e.g. Diet - Gluten & Casein free Diets; Substitute with vitamins & Minerals supplemented food could be helpful in some cases (Anecdotal report)
6. Support groups if Available: Parental Education & Support, etc.

ADVOCACY IN NIGERIA: Based on the fact that Facilities and Law caring for the needs and rights of Children with Childhood Autism and other Developmental Disorders are unavailable

ADHD begins in childhood and may last into adult life.

Problems include:

• Inattention, hyperactivity, and impulsive behavior

They can affect nearly every aspect of life.

Children with ADHD often struggle with low self-esteem, troubled personal relationships, and poor performance in school or at work.

Symptoms of Inattention

• Having difficulty focusing on tasks at school or work
• Not paying close attention to detail, which can result in careless mistakes in schoolwork or work assignments
• Being disorganized, resulting in missed appointments and deadlines
• Getting distracted easily
• Leaving tasks such as assignments, chores, or other activities incomplete
• Frequently losing personal belongings and valuables
• Forgetting things often
• Failing to follow through on instructions and appearing not to listen when spoken to directly
• Avoiding tasks that require sustained focus for longer periods of time

Hyperactivity-impulsive behavior

• Often fidgets with hands or feet or fidgets in seat
• Cannot sit for long
• Runs or climbs excessively when it's not appropriate (an adolescent might constantly feel restless)
• Have difficulty playing quietly
• Often "on the go" or acts as if "driven by a motor"
• Talks excessively
• Blurts out answers before questions have been completely asked
• Have difficulty waiting his or her turn
• Interrupts or intrudes on others by butting into conversations or games

They have a short attention span.

NOTE: Every child is unique, with a distinct personality and temperament. Children should never be classified as having ADHD just because they're different from their friends or siblings.

Symptoms may be different in boys & girls:

• Boys are more likely hyperactive. Inattentive boys are more likely to play or fiddle aimlessly. Boys are less compliant with teachers & other adults, so their behavior is often more obvious.
• Girls tend to be inattentive.

Common finding in ADHD: They are sensitive to stimuli like sights, sounds, and touch.

When over-stimulated, they get out of control (sometimes aggressive or even physically or verbally abusive).

Inattentive form of ADHD:

• Drift away into their own thoughts
• Lose track of what's going on around them

Treatment involves medication, psychotherapy, or both.

Psychotherapy:

• Talk about issues that bother them
• Explore negative behavioral patterns and learn ways to deal with the symptoms

Behavior therapy:

• Helps teachers and parents learn strategies for dealing with the child's behavior
• Strategies may include: Token reward systems, timeouts, and behavior modification

Others

• Family therapy: Help parents & siblings deal with the stress of living with the patient.
• Social skills training: Help children learn appropriate social behaviors.
• Support groups: Offer a network of social support, information, and education.
• Parenting skills training: Help parents develop ways to understand and guide their child's behavior.
• Academics and work intervention

For best results: Use a team approach with teachers, parents, and therapists or physicians working together.

Medications:

1. Psychostimulants

   The most commonly prescribed & used, e.g. Methylphenidate (Ritalin, Concerta). These medications increase brain dopamine by blocking the activity of dopamine transporters, which remove dopamine after it has been released.

2. Antidepressants — especially for children who don't respond to stimulants or who are depressed or have other problems.

3. Other medications:

   • D & L-amphetamine racemic mixture (Adderall)
   • Dextroamphetamine (Dexedrine)
   • Atomoxetine (Strattera), etc.

Beware of side effects.

Repetitive and persistent pattern of dissocial, aggressive, or deviant conduct amounts to major violations of age-appropriate social expectations (more severe than ordinary childish mischief or adolescent rebelliousness).

CD - Conduct Disorder (DSM IV)

A chronic pattern of behavior that causes harm to others or violates societal rules.

Antisocial behavior in children includes:

• Actions and attitudes that are age inappropriate
• Violations of expectations of family & society
• Damage to others or personal property

Repetitive or persistent pattern of behavior where the rights of others or societal norms are violated. Three or more of the following features must have occurred in the past year, or at least 1 in the past 6 months:

1. Aggression to people and animals:
   • Often bullies, threatens, or intimidates others
   • Initiates fights, uses a weapon that can cause serious physical harm
   • Physically cruel to people and animals
   • Steals while confronting the victim
   • Forced sexual activity

Types of Conduct Disorders (ICD 10)

1. CD confined to the family context: Abnormal behavior entirely or almost entirely confined to the house and/or interactions with members of the nuclear family or immediate household.

2. Unsocialized CD:

   • Significant pervasive abnormality in their relationship with other children
   • Lacks effective integration into a peer group and is unpopular with other children
   • Lacks close friends or lasting empathic reciprocal relationships with others in the same age group
   • Relationships with adults involve hostility and resentment

3. Socialized CD:

   • Well integrated into their peer group
   • Presence of adequate, lasting relationships with others of roughly the same age
   • Often, but not always, the peer group is involved in delinquent or dissocial activities
   • Relationships with adults in authority tend to be poor, but there may be good relationships with others
4. Oppositional Deviant Disorder (ODD): Seen usually in children below the age of 9 or 10 years. Persistently negativistic, hostile, defiant, provocative, and disruptive behavior. Deliberately annoys others, is angry, and readily loses temper, etc.

Oppositional Defiant Disorder (ODD) DSM IV

A. For at least 6 months, and at least 4 of the following must be present (considered against what is normal for age level):

• Often loses temper
• Argues with adults
• Actively defies or refuses adult requests or rules
• Deliberately annoys people
• Blames others for own mistakes
• Easily annoyed by others
• Angry and resentful
• Spiteful or vindictive

B. Does not meet criteria for Conduct Disorder, and does not occur exclusively during psychosis or depression.

Two Subtypes of CD

• Childhood-Onset type: One criterion of CD present before age 10 years old
• Adolescent-Onset type: No evidence prior to age 10 years

Severity: Mild, moderate, severe

Associations with CD & ODD

• Intelligence and underachievement in school
• Lack of emotional intelligence
• Personality factors: impulsive, callous, unemotional
• Multiple problems in relationships: peers, family, teachers, authority figures
• Co-occurring Disorders: ADHD, Anxiety, Depression, Substance abuse, etc.

Epidemiology:

• Prevalence: 5-8% for CD. 10.2% for ODD.
• Gender differences: Ratio of boys to girls 10 to 1 in childhood; 1.5 to 1 in adolescence. Gender differences in symptom expression.
• Developmental pathways: Early onset versus later onset, Peer aggression, Fire setting, and cruelty to animals.

Etiological (Risk) factors:

• CD is associated with the person's environment (adverse psychosocial environments) - Child/Family/School/Neighborhood
• Poverty / Disorganized neighborhood
• Violence within the home/Neighborhood
• Abuse/Neglect/Inadequate supervision/Ineffective parenting
• Poor quality schools / Failure at school
• Abnormal temperament
• Problematic peers, etc.

Treatments:

• Working with Parents
• Problem-solving/Social skills training
• Family Therapy

Prevention Issues: Targets multiple systems with a treatment "team"

• Family, including siblings
• School Personnel
• Peers & Juvenile Justice
• Others: Prevention / Institutionalization / Medication