Child Psychiatry

1) Autism Spectrum Disorder

2) Attention Deficit Hyperactive Disorder (ADHD)
3) Elimination Disorder
4) School Refusal

AUTISM SPECTRUM
DISORDER (ASD)
DSM V 299.00 (F84.0)

Definition
ASD is a complex developmental disorder
that can cause problems with thinking,
feeling, language and the ability to relate to
others.
It is a neurological disorder, which means it
affects the functioning of the brain.
The effects of autism and the severity of
symptoms are different in each person.

ASD Characteristics Vary:

Social Interaction
Aloof-----------------Passive-------------Active but
odd

Communication

Nonverbal---------------------------------------------Verbal

Behaviors

Intense----------------------------------------------------Mild
Measured
Intelligence
Severe--------------------------------------------------Gifted

Adaptive Functioning

Low-------------------------Variable----------High in
areas

Pervasive Developmental Disorders (PDDs)

to Autism Spectrum Disorder (ASD)

DSM-IV,TR
1994, 2000

DSM-5

May 2013

Pervasive Developmental
Disorders:

Autistic disorder
Aspergers
PDD-NOS
Retts
CDD

Autism Spectrum
Disorder

agnostic and Statistical Manual (DSM), American Psychiatric Association

Changes from DSM-IV to DSM-5

DSMIV

DSM5

ASD Criteria

A. Persistent deficits in social communication

and interactions
1. Social-emotional reciprocity
2. Nonverbal communication behaviors used
for social interactions;
3. Developing, maintaining, and
understanding relationships

ASD Criteria (continued)

B. Restricted, repetitive patterns of behavior,
interests, and activities (at least TWO of the
following):
1. Stereotyped or repetitive motor movements, use of
objects, or speech
2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or
nonverbal behavior
3. Highly restricted, fixated interests
4. Hyper- or hypo-reactivity to sensory input or
unusual interest in sensory aspects of environment

ASD Criteria (continued)

C.Symptoms must be present in the early
developmental period (but may not become
fully recognized until social demands exceed
limited capacities)

D. Symptoms cause clinically significant

impairment in social, occupational, or other
important areas of current functioning

ASD Criteria (continued)

E.These disturbances are not better explained by
intellectual disability or global developmental
delay.
* For criteria A & B, specify current severity based on
social communication impairments and restricted,
repetitive patterns of behavior. (See table next slide)
* Specify ASD if:
With/wout accompanying intellectual impairment
With/wout accompanying language impairment
A/W known medical/genetic/environment factors
A/W another neurodevelopmental/mental/bhvr disorder
With catatonia

ASD Screening & Diagnosis

1) No medical test to diagnose ASD.
Diagnose based on observing how the child
talks and compare with children of similar age.

2) RED FLAGS by CDC:

Not responding to his/her name by 1 yo
Not pointing to object that interests 14 mo
Not playing pretend games by 18 mo
3) M CHAT SCREENING (modified checklist for
Autism in Toddlers)

ASD High Risk Factors

M CHAT

ASD CO MORBIDITIES
1) Intellectual disability
2) ADHD
3) Sleep problems
4) Epilepsy
5) GIT problems
6) Motor coordination deficits
* No substantial evidence on the
prevalence of psychosis in ASD children.

BIO PSYCHOSOCIAL TREATMENT

* Pharmacology treatment only for

ASD with co morbities.

BIO PSYCHOSOCIAL TREATMENT

Psychosocial therapy includes:

1) Speech Language Therapy
2) Occupational Therapy
3) Psychological / Behavioural Therapy
4) Education

Attention Deficit/Hyperactive
Disorder (ADHD)
Pattern of diminished sustained attention
and higher levels of impulsivity in a
child/adolescent than expected for someone
of that age and developmental level

Attention Deficit/Hyperactive
Disorder
Epidemiology
3-7% of prepubertal elementary
school children
M:F = 2:1 up to 9:1
High risk in first degree family
members

Attention Deficit/Hyperactive
Disorder

DSM V
A.
Persistent pattern of inattention/hyperactivity-impulsivity that interferes
with functioning/development, as characterized by (1) or (2):
1)
Inattention 6 of the following symptoms ( 5 symptoms in 17 years
old) have persisted for 6 months to a degree that is inconsistent with
developmental level and negatively impacts directly on social and
academic/occupational activities
Often fails to give close attention to details/make careless mistakes in
schoolwork/work/during other activities
Often has difficulty sustaining attention in tasks/play activities
Often does not seem to listen when spoken to directly (mind seems
elsewhere, even in the absence of any obvious distraction)
Often does not follow through on instructions and fails to finish
schoolwork/chores/duties in the workplace (start tasks but quickly loses
focus and easily side-tracked)
Often has difficulty organizing tasks and activities
Often avoids/dislikes/reluctant to engage in tasks that require
sustained mental effort
Often loses things necessary for tasks/activities
Often easily distracted by extraneous stimuli (unrelated thought in
adult)

Cont.
2) Hyperactivity and impulsivity - 6 of the following
symptoms ( 5 symptoms in 17 years old) have persisted
for 6 months to a degree that is inconsistent with
developmental level and negatively impacts directly on
social and academic/occupational activities

Often
Often
Often
Often
Often
Often
Often
Often
Often

fidgets with/taps hand or feet or squirms in seat

leaves seat in situations when remaining seated is expected
runs about/climbs in situations where it is inappropriate
unable to play/engage in leisure activities quietly
on the go, acting as if drive by motor
talks excessively
blurts out an answer before a question has been completeled
has difficulty waiting his/her turn
interrupts/intrude on others

Cont.
B. Several inattentive/hyperactive-impulsive symptoms
were present prior to age 12 years
C. Several inattentive/hyperactive-impulsive symptoms
are present in 2 settings (home/work/school; with
friends/relatives; in other activities)
D. Clear evidence that symptoms interfere with/reduce
quality of social/academic/occupational functioning
E. Symptoms do not occur exclusively during course of
schizophrenia/another psychotic disorders and are
not better explained by another mental disorder

Attention Deficit/Hyperactive
Disorder
Types
Inattentive (Only A1 are met for past
6 months)
Hyperactive/impulse (Only A2 are
met for past 6 months)
Combined (Both A1 and A2 are met
for the past 6 months)

Attention Deficit/Hyperactive
Disorder

Etiology
1. Genetic factors
a. Greater concordance in monozygotic than in dizygotic
twins
b. Siblings have 2x risk
c. Parents with ADHD will have 2-8x to have child with
ADHD
2.

Developmental factors
a. September is the peak month for births of children
with ADHD due to winter infections during first
trimester
b. Subtle damage to CNS and brain development during
fetal & perinatal periods
c. Preterm birth, low birth weight and neonatal
complications

Cont.
3.

Neurochemical factors
a. Many neurotransmitters maybe involved in process,
mainly noradrenergic and dopaminergic system
b. Evidenced by stimulants and some tricyclic drug,
desipramine reduce level of urinary norepinephrine
metabolite or Clonidine, a norepinephrine agonist
successful in treating ADHD

4.

Neurophysiological factors
a. Human brain normally undergoes major growth spurts
at 3-10 months, 2-4 years, 6-8 years 10-12 years and
14-16 years.
b. Some may have maturational delay and manifest
symptoms of ADHD that appear to normalise by about
5 years old

Cont.
5. Psychosocial factors
a. Children in institutions are frequently
overactive and have poor attention spans due
to prolonged emotional deprivation
Disappear when the stressors are removed
like adoption/placement in foster home
b. Also in malnutrition & abuse

Attention Deficit/Hyperactive
Disorder
Tests
1.
Screening
a.
Following two questions sensitivity is 91% and specificity 82%
Is the child unable to pay attention?
Is the child extremely active?
b.
Few rating scales, however not validated in Malaysian setting
The Conners Rating Scales-Revised
ADHD Rating Scale-IV ADHD RS-IV
Vanderblit ADHD Diagnostic Parent and Teacher Scales
Brown ADD Rating Scales for Children, Adolescents and Adults
2.
EEG disorganised, immature result on EEG
3.
PET decreased cerebral blood flow in frontal regions
4.
Cognitive testing
a.
Continuous performance task
i.
Asked to press button each time a particular sequence of
letters/numbers is flashed on screen
. Inattention -> fail to press button even after sequence has flashed
. Impulsivity -> continuously pressing the button before desired
sequence appeared

Attention Deficit/Hyperactive
Disorder
Treatment
Principle
Need combination of biological &
psychosocial
Treat the underlying mood/anxiety
disorder first if they are causing
ADHD

Attention Deficit/Hyperactive
Disorder

1. Biological/Pharmacological (first line)

. Divided into CNS stimulants and non-stimulants

a. CNS stimulants
i.

ii.
iii.

iv.
v.

Increases dopamines and norepinephrines

concentrations by promoting their release and
blocking their uptake
Baseline of BP, PR and BMI should be checked prior
initiation
Mild growth suppression over 2 years plot series
height and weight on growth char should be
considered once to twice a year
Drug holidays or switch to other medication if
height/weight crosses two percentile lines
Drug holidays refer to periods when patients are
allowed to temporarily stop medications due to side
effects, initiated in low stress times such as

Cont.
Generic Name

Time to maximum effect

Duration of Action

Methylphenidate preparation (first line)

Short acting
Ritalin

2 hrs

3-5 hrs

Intermediate-acting
Ritalin SR

3 hrs

3-8 hrs

4-7 hrs
5 hrs

8-12 hrs
8-12 hrs

Short-acting
Dexedrine
(Dextroamphetamine)
Adderall

1-4 hrs
3 hrs

9 hrs
6-8 hrs

Long-acting
Dexedrine Spansule
Adderall X

1-2 hrs
7 hrs

8-10 hrs
12 hrs

Extended release
Concerta
Ritalin LA

Amphetamine preparation

Cont.
Methylphenidate also indicated for ADHD with comorbid conduct disorder
Short and sustained released prepared is safe, but
currently using once a day sustained release for
convenience and diminished rebound side effects
Dextroamphetamine indicated also for refractory
hyperkinetic state
Dexmethylphenidate for patient obtain partial
response from methyphenidate or due to side effects
from methylphenidate
Dextroamphetamine in 3 years old,
methylphenidate 6 years old

Cont.
Side effect (Due to increased adrenergic activity)
1. Anorexia
2. weight loss
3. Stomach-ache
4. Insomnia
. Insomnia can be treated by diphenhydramine/low dose of
trazodone/-2 agonists (guanfacine or clonidine)
. Some cases insomnia gone on its own after several months
of treatment
5. Rebound irritability/moodiness (usually 4-5 hours after last
dose)
6. Linear growth impairment
7. Tics, headache, generalised irritability, dysphoria, agitation

Cont.
b. Non-stimulants
i. Atomoxetine
Noradrenergic reuptake inhibitor
Indicated for ADHD with tics, high risk of
misuse of methyphenidate, poor
response to methylphenidate
Fewer side effects on appetite and sleep
but may cause more nausea and
sedation, agitation, irritability.
Need to monitor height, weight, cardiac
function, BP and seizure
Cautious about suicidal thinking during
first few months of treatment

Cont.
2. Psychosocial
a. Social skills groups
Refining social skills and increase
self-esteem -> create sense of
success
b. Training for parents of children with
ADHD/Parent psychoeducation
c. Behavioural interventions
Occupational therapy
Positive re-inforcement
Environmental modifications aim

Attention Deficit/Hyperactive
Disorder
Prognosis
1. Children with predominantly
hyperactive-impulsive type
More likely to have stable diagnosis
Concurrent conduct disorder

2. 50% may persists into adolescence

or adult -> conduct disorder ->
substance abuse
a.

Factors
Family history of disorder
Negative life events
Comorbidity with conduct symptoms

Cont.
3. Some cases hyperactivity will disappear
but not inattention and impulsivity
a. Hyperactivity is the first symptoms to remit
and inattention is last
b. Remission between age 12-20 years
Partial remission full criteria previously
met, fever than full criteria met for past 6
months, still result in impairment of function
in school/work/home

4. High incidence of comorbid mood

disorders, anxiety disorders, personality
disorders, conduct disorder (30-50%) and

Eliminati
on
disorders

Enuresis
Refers to a repeated inability to
control urination.
Urinary continence is normally
established by the age of 4.
Approximately 5 percent of five-yearold children.
More common in boys.
Prevalence decreases with age.

Diagnosis
A. Repeated voiding of urine into bed or clothes,
whether involuntary or intentional.
B. clinically significant as manifested
I. At least twice a week for at least 3 consecutive
months or the
II. presence of clinically significant distress or
impairment in social, academic (occupation) or
other important areas of functioning.
C. Chronological age is at least 5 years
D. not attributable to
I. the psychological effects of substance (diuretic,
antipsychotic medication)
II. another medical condition (diabetes, spina bifida,
seizure disorder).

Specify whether:
Nocturnal only : During nighttime
Diurnal only : During waking hours
Both : Combination of both subtypes

Can be divided into

I. Primary a child who never been
continent
II. Secondary - a child who has been
continent for at least 6 months
before the onset of the bedwetting.

Etiology
Primary

Secondary

Idiopathic

Idiopathic

Cystitis

Cystitis

Constipation

Constipation

Neurogenic bladder

Psychological

Urethral obstruction

Acquired neurogenic bladder

Management
Investigation rarely indicated unless
medical condition is suspected
1. Pharmacotherapy
Analogue of ADH
(desmopression acetate)
Tricyclic antidepressants
(imipramine)

Behavioral therapy
Motivational therapy reward the
child for every agreed-upon behavior.
Eg:
I. going to the toilet before bedtime
II. longer periods of dryness
III. dry at night

Alarm therapy
An alarm will be attached
at bedtime to the
underwear or pajamas.
to permit prompt sensing
of wetness
most children with enuresis
do not awaken to the
alarm, they often stop
emptying the bladder.
When the alarm sounds, a
parent must help wake the
child to the bathroom to
finish voiding.

Encopresis
involuntary discharge of feces
1% of children of 5 year old children
By the age of 4, most children can
control
their bowels and are toilet trained
Boy > Girl

Diagnosis
A. Repeated passage of feces into inappropriate
places (e.g. clothing, floor), whether
involuntary or intentional.
B. At least 1 such event occurs each month for at
least 3 months.
C. Chronological age is at least 4 years (or
equivalent developmental level).
D. not attributable to the psychological effects of
a substance (e.g. laxatives) or another medical
condition except through a mechanism
involving constipation

Specify whether:
With constipation and overflow
incontinence:
There is evidence of constipation on
PE or by
history
W/o constipation and overflow
incontinence:
There is no evidence of constipation
on PE or

Management
Diagnosis can be establish
clinically
1. Pharmacotherapy
-. Stool softener or
laxatives (in constipation)
-. High fibre diet
2. Bowel training
-. Encourage children to sit
on the toilet for 10
minutes twice a day to try
to have bowel movement

School Refusal

Introduction
Repeated absence from school
Not a psychiatric d/o but a
pattern of behavior
Associates with anxiety and
depressive d/o
Usually occur during major
changes in childrens lives (e.g.
entrance to kindergarten,
change from primary to secondary school)

Etiology
Separation anxiety worried about
safety of caregiver
Performance anxiety taking tests,
giving speeches embarrassed in front
of peers
Social anxiety worried about social
interactions with peers, teachers
Generalized anxiety perceive world as
threatening, general worries something
bad happening

 Depression lack of interest in

activities, sleep difficulties, poor
weight gain, feeling
tired/guilty/worthless, suicidal
ideation
Bullying physically threatened,
teased or left out by other children
Health-related concerns
develop after a student
has been home sick with
an actual illness

Clinical Features
Frequent complaints about attending
school
Frequent tardiness or unexcused
absences
Absence on significant days (tests,
speeches, physical education class)
Frequent requests to call or go home
Excessive worrying about a parent
when in school

 Frequent requests to go to nurses

office because of physical complaints
Crying about wanting to go home

Prognosis
Most younger children eventually
return to school
Some severely affected adolescents
do not return before time of
compulsory of school attendance
ceases
Some suffered from emotional or
social difficulties or received further
psychiatric care

Treatment
Gives psychoeducation to the family
members and teachers in the school
Provide attention to positive behaviors
and ignore negative behaviors and
physical complaints that have no
medical basis
Help child to cope with school
environment
Adjust assignment to childs level
Ensure child feel safe at school
Assign peer buddy at recess or

 Cognitive-behavior therapy
Relaxation technique
Social skills training
Set up rewards based school attendance

Supportive counselling
Antidepressant
Re-entry strategies
Gradual school re-entry for
children who extremely
anxious about attending school

E.N.D