Child and Adolescent Psychiatry Notes

Posted on Aug 8, 2024 in Medicine & Health

Stages of Psycho-Social Development (E. Erikson)

5 Stages:

Stage 1: Trust vs. Mistrust (0-18 Months)

• 0-18 Months
• Most fundamental stage in life
• Infant development is based on trust, dependability, and quality of caregiver
• If a child develops trust, they will feel secure and safe in the world
• If a caregiver is unavailable or rejecting… Failure to develop trust will result in fear and a belief that the world is unpredictable

Stage 2: Autonomy vs. Shame & Doubt (18 Months – 3 Years)

• 18 Months – 3 Years
• Greater sense of personal control
• Toilet training, learning body functions
• Food choices, toy preference, clothing
• If the stage is completed = Secure + Confident
• Importance of the word “NO”

Stage 3: Initiative vs. Guilt (3-5 Years Old)

• 3-5 Years Old
• Assert power + control
• Social interaction
• Success —> Capable of leading others

Stage 4: Industry vs. Inferiority (6-11 Years Old)

• 6-11 Years Old
• Children begin to develop a sense of pride in accomplishments
• If positive, develop feelings of confidence and belief in skills
• If negative —> Doubt

Stage 6: Identity vs. Confusion (12-18 Years Old)

• 12-18 Years Old
• Children explore their independence and develop a sense of self
• Encouragement —> Sense of security + control
• Lack of encouragement —> Insecure

Specific Developmental Disorders of Scholastic Skills

• Specific learning disabilities affect language learning, math, and calculation
• Children need to hear in order to learn language

Types of Learning Disabilities:

1. Dyslexia: Problem with reading
2. Phonological Dyslexia: Problems with sound analysis and memory
3. Surface Dyslexia: Problems with visual recognition of form and word structure
4. Dysgraphia: Problem with spelling and written expression
5. Dyscalculia: Problem with math and problem-solving
6. Ageometria: Problem with disturbed mathematical reasoning
7. Anarithmia: Disturbance in basic concept formation
8. Dysnomia: Difficulty recalling words from memory

Symptoms:

• Trouble learning the alphabet
• Speech perception limited
• Language development is slower
• Problems understanding what is read

Treatment:

1. Psychological therapy
2. Specialized instructions
3. Separate and intense educational programs (for some children)

Childhood Autism: Symptoms, Correction, Pervasive Development

Treatment:

1. Behavioral therapy (psychologist + educator)
2. Speech and language therapy (should begin early via use of media, singing, picture exchange)
3. Physical and occupational therapy
4. Medication therapy: SSRIs to improve behavior

ADHD: Pathophysiology and Diagnosis

Pathophysiology:

• Loss of normal asymmetry in the brain
• Smaller brain volume of specific structures (prefrontal cortex + basal ganglia)
• Reduction of 5-10%
• Low blood flow to the striatum
• Prefrontal cortex and ganglia rich with dopamine receptors
• Dopamine hypothesis: Disturbance of dopamine systems leads to ADHD

Diagnosis: (Criteria 1 or 2)

Conduct Disorder (CD)

• Recurrent, persistent behavior that violates the rights of others
• Diagnosis is made by history
• Treatment: Needs supervision
• 10% of the population during childhood and early adolescence
• More common in boys than girls

Etiology:

• Genetic and environmental factors
• Parents engaged in substance abuse
• Parents at risk of ADHD, schizophrenia, antisocial personality disorder

Symptoms:

• Lack of sensitivity/feelings for the well-being of others
• Misperceive the behavior of others as threatening
• May be aggressive, bully, make threats
• Cruelty to animals
• In adolescents, may destroy property
• Poor tolerance of frustration
• Boys tend to fight, girls tend to lie and run away

ADHD and Hyperactivity Treatment

ADHD Treatment:

1. Behavioral therapy
2. Medication

• Behavioral therapy + medication is more successful
• Medications are used to alleviate symptoms and stop the cycle of inappropriate behavior

Medications:

• Stimulants: Methylphenidate, dextroamphetamine
  • Response is dose-dependent
• Methylphenidate:
  • Start at 0.3 mg/kg/day and then increase
• Dextroamphetamine:
  • Start at 0.15-0.2 mg/kg/day and then increase
• Atomoxetine:
  • Selective norepinephrine reuptake inhibitor
  • Side effects: Nausea, sedation, irritability, temper tantrums, liver toxicity
  • Starting dose: 0.5 mg/kg/day
• Antidepressant/Bupropion (Dopamine & Norepinephrine Reuptake Inhibitor):
• Alpha-2 agonists: Clonidine, guanfacine

Behavioral Therapy:

• Counseling
• Cognitive behavioral therapy
• Classroom behavior is improved by environmental control
• Techniques for parents
• Elimination diets
• Megavitamin therapy
• Antioxidants

Conduct Disorder Treatment:

• Medication for comorbid disorders
• Psychotherapy
• Residential treatment center (helps with self-esteem, self-control)
• Medications such as stimulants, mood stabilizers, antipsychotics

Do Not:

• Moralize or use dire admonition – not effective

Substance Use Disorder

General Information:

• Common among children and adolescents
• Substances used: Alcohol, tobacco, marijuana, amphetamines, methamphetamines, cocaine, etc.

Causes:

• Reasons for substance use: Escape pressure, challenge authority, seek novel experiences

Diagnosis:

1. Screening:
   • Screen adolescents for use of alcohol and drugs
   • Provide counseling
   • Referrals to treatment services and resources
   • CRAFFT questionnaire (2+ means further evaluation)

CRAFFT Questionnaire:

1. C: Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been drinking alcohol or using drugs?
2. R: Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
3. A: Do you ever use alcohol or drugs while you are Alone?
4. F: Do you ever Forget things you did while using alcohol or drugs?
5. F: Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
6. T: Have you ever gotten into Trouble while using alcohol or drugs?

Depression in Childhood (Risk Factors)

General Information:

• Persistent sadness and loss of interest + pleasure
• Decreased sleep

Prevalence:

• 2% of children
• 2-8% of adults
• Male:Female ratio 1:1

Etiology:

1. Genetics: First-level relative risk 2-4x higher
2. Environment:
   • Parental behavior
   • Substance abuse
   • Lack of family cohesion
   • Neglect

• Low functioning norepinephrine and serotonin are believed to be important markers of depression

Depression Symptoms by Age

ICD-10 Depressive Episodes:

• Depressed mood
• Loss of interest and enjoyment
• Reduced energy and increased fatigability (at least 2 of these)

Other Symptoms:

1. Decreased concentration
2. Decreased self-esteem and self-confidence
3. Ideas of guilt and unworthiness
4. Bleak and pessimistic views of the future
5. Ideas of self-harm and suicide
6. Disturbed sleep
7. Decreased appetite

• Minimum duration of the whole episode is about 2 weeks
• Not depressed: Fewer than 4 symptoms
• Mild depression: 4 symptoms
• Moderate depression: 5-6 symptoms
• Major depression: 7 or more symptoms with or without psychotic symptoms

Adolescence:

• Decreased self-confidence
• Apathy, lack of interest
• Concentration problems
• Psychomotor complaints
• Loss of weight
• Sleep disturbance
• Circadian rhythm disturbances

Suicidal Behaviors: Symptoms, Risk Factors, Treatment

Symptoms:

1. Genetics:
   • Twin studies that control for life events show suicide is more common in monozygotic twins than dizygotic twins
   • Pedigree analyses confirm genetic influence
2. Serotonin System:
   • Hereditary alterations in the serotonin system
   • Serotonin is important for the regulation of impulse, aggression, and mood
3. Gender:
   • Males > Females (overall)
   • Reverses in adolescents
   • Males are more aggressive and impulsive than females
   • Males have conduct disorder + chronic anxiety
   • In females, chronic anxiety is related to suicide
4. Psychological and Social Factors:
   • History of child mistreatment
   • Sexual assault
   • Family conflict

In Older Adolescents:

• Relationship breakups
• Homosexual behavior
• Gender dysphoria
• Hopelessness
• Psychological state

Intervention:

1st Principle:

1. Take suicidal ideation seriously (no sarcasm, joking, or belittling)
2. History of ingestion is necessary
3. Aggressive management of poisoning

2nd Principle:

• Biopsychosocial framework
• Psychiatric status is the primary concern
• Careful psychiatric history

Anorexia Nervosa

Etiology:

Psychological Predisposition:

• Perfectionism
• Low self-esteem
• Sexual/physical abuse
• Phobic food avoidance
• Alexithymia

Diagnosis:

1. History and Complaints:
   • Obtain information from 2 sources: Patient, parent/friend
   • Inquire about eating habits and physical activity
   • Somatic complaints: Arrhythmia
2. Symptoms:
   • Intense fear of becoming obese
   • Claiming to “feel fat”
   • Refusal to maintain normal weight for age and height
   • Denial of hunger
   • Bizarre eating behaviors
   • Purging (hiding food, inducing vomiting)
   • Restricting (limiting carbs)
3. Assess Height and Weight: Compare to normal growth curve
4. Tests:
   • CBC: Leukocytosis, leukopenia, thrombocytosis, anemia (result of malnutrition)
   • Serum electrolytes: Hypokalemic alkalosis
   • Glucose tolerance test: Oral glucose tolerance test to assess the body’s ability to metabolize glucose
   • Secretin-CCK test: To assess the function of the pancreas and gallbladder
   • Serum cholinesterase test: To test liver function
   • LH response to GnRH
   • CK test
   • BUN test for kidney function
   • Thyroid screen: TSH, T4, T3

Differential Diagnosis:

1. Mental Disorders: Depression, somatization, anxiety
2. Chronic Mental Illness: Irritable bowel syndrome

Treatment:

• Team of professionals
• Depends on the severity of the illness

1. Indications for Hospitalization:
   • Weight loss > 4 kg/month
   • Systolic blood pressure < 80 mmHg
   • Temperature < 36°C
   • Pulse < 40 bpm
   • Suicidal behavior
   • Severe depression
   • Ineffective outpatient treatment
2. Goals:
   • Weight restoration
   • Nutrient rehabilitation
   • Feeding 6 times per day
   • Start at 1000-1200 kcal/day then increase 200-500 kcal/week
   • Enteral and parenteral feeding (if necessary)
   • Liquids and nutritional additives
   • Normal defecation
3. Discharge Criteria:
   • Weight gain
   • No suicide risk
   • Normal weight range (90% of ideal body weight)
4. Psychiatric Treatment:
   • IV nasogastric tube (if necessary)
5. Nutritional Counseling:
   • Find target weight
   • Educational diet information
   • Levels of exercise
6. Medications:
   • Antidepressants (SSRIs)
   • Off-label: Olanzapine, clozapine, haloperidol

Bulimia Nervosa

Etiology:

• Inadequate impulse control (serotonin dysfunction)
• Strong dependency needs with feelings of loneliness and emptiness

Symptoms:

• Depression
• Anxiety
• Impaired impulse control
• Self-harm
• Decreased libido

Diagnosis:

• Episodes of binge eating (2x/week, 3000-4000 kcal/week excess for 3 months)
• Not being able to stop eating
• Self-evaluation
• Feelings of remorse and depression after episodes
• Difficult to diagnose because weight can be normal

Types:

***Somatic complication of Eating disorder Tx:

***Non organic encopeis: