طب نفسي الأطفال للأخصائيين النفسيين

Child PsyChiatry

M A D E B Y :

D r M a h m o u d H a m d y A h m e dA s s o c i a t e c o n s u l t a n t b y t h e S a u d i G e r m a n

h o s p i t a l J e d d a h E g y p t i a n f e l l o w s h i p o f p s y c h i a t r y D i p l o m a i n m a n a g e m e n t o f N G O ’ s

M a s t e r o f H o s p i t a l m a n a g e m e n t

أهداف المحاضرة

أن يتعرف المتدرب علي فلسفة اختلف الضطرابات النفسية الخاصة بالفطفال عن غيرها من •الضطرابات النفسية.

ان يتعرف المتدرب علي أمراض التأخر العقلي و انواعها واعراضها و فطرق العل ج المختلفة و •القياسات النفسية المستخدمة في التشخيص و العل ج .

ان يتعرف المتدرب علي مرض التوحد و اعراضة و فطرق العل ج المختلفة و القياسات النفسية •المستخدمة في التشخيص و العل ج .

ان يتعرف المتدرب علي مرض فرط الحركة و نقص النتباة و اعراضة و فطرق العل ج المختلفة •و القياسات النفسية المستخدمة في التشخيص و العل ج .

مقدمة و لماذا فطب نفسي الفطفال مختلف

• Apart from dementias, there are no “adult” disorder from which children are exempt. In other words, can occur in this developmental period.

• There is a group of disorders that are relatively specific to children and adolescents. In other words, arise in this developmental period.

جميع الضطرابات النفسية •بخلف الزهايمر يمكن حدوثها

في الفطفال .توجد بعض الضطرابات •

المرتبطة في بداية ظهورها و تطورها بمرحلة الطفولة ويمكن خصوصيتها في تاثيرها الشديد

علي النمو و التعليم .

المراض النفسية المتعلقة بالطفولة• Mental retardation• Learning disorders

– Reading, mathematical, written expression, NOS

• Motor skills disorder• disorderCommunication

disorders:– Expressive, mixed receptive-expressive, phonological,

stuttering,NOS.

• Pervasive developmental disorder:

– Autistic, Rett’s, childhood disintegrative, Asperger’s, NOS.

• Attention deficit and disruptive behavior disorders

– ADHD, ADHD NOS, Conduct disorder, Oppositional defiant disorder, Disruptive behavior NOS

التأخر العقلي بدرجاتة المتعددة •صعوبات التعلم •امراض الجهاز الحركي •امراض صعوبات التواصل •

امراض تأثر علي تطور و نمو •الفطفال في جميع التجاهات

مرض فرط الحركة و نقص النتباة•

Other child disorder• Feeding and eating disorders of infancy or early childhood:

Pica, Rumination, NOS• Tic disorder:

Tourette’s disorder, Chronic motor or vocal tic, transient tic, tic NOS• Elimination disorders

Encopresis, enuresis

• Separation anxiety disorder, • Selective mutism, • Reactive attachment disorder, • Stereotypic movement disorder,• Disorders of infancy, childhood or adolescence NOS

خلل المقابلة اللكلينيكية للفطفال

Special aspects in assessment:• Who is the patient?• Application of norms• Involvement of family and

significant others.• Involvement of nonphysicians

in Health Care Team• Comorbidity is the rule.• Interviewing: Use concrete level of talk, Playing: games, imaginative play, Turn taking in telling stories, Direct observation.

يجب مراعاة اليتي :•من الطفل وفي اي مرحلة عمرية ..1

ماهو المتوقع من هذا الطفل في ظل السن .2و مستوي التعليم و خلفة .

مقابلة الرسرة و الخرين الذين لهم دور .3في يتربية الطفل مثل المدررسين .

.يتكامل بين افراد الفريق العليجي للطفل .4خلل المقابلة يتم ارستخدا م لكل م واضح .5

بدون لكنايات و ارستخدا م اللعاب و الحكايات لرستخل ص و يتوصيل الررسائل

العليجية

أدوات و اختبارات في فطب نفسي الفطفال

• Testing:IntelligenceEducation & achievementAdaptive behaviorPerceptual-motor abilitiesPersonality.Other lab. or imaging tests• Physical examination

الفحص الجسدي للطفل .•

اختبارات نفسية و يتتضمن .•أختبارات الذلكاء –اختبارات الشخصية للفطفال –اختبارات التأخر الدرارسي –اختبار فرط الحرلكة و نقص النتباة –اختبار مقياس التوحد –

الفحوصات و التحاليل و العشعات •

• Subnormal intelligence, as measured by IQ tests, accompanied by deficits in adaptive functioning (at least 2 domains).

Mild: 50-55 to 70Moderate: 35-40 to 50-55Severe: 20-25 to 35-40

Profound: <20• Diagnosed before 18years.• Not due to brain insult in late

childhood (dementia)

يتعريف الذلكاء :هو القدرة علي ربط العشياء .•Epidemiology:• 1-2%• More in males 2:1• Mild is more common and more

prevalent in lower social classes. moderate and severe and profound are equally common in low and high social classes.

Etiology:• Heridity, perinatal and

environmental events during infancy or early childhood.

Course and outcome:• Reduced life expectancy.• Progress at a slower rate.• Maturational spurts.Clinical management:• Thorough investigations.• Comprehensive program• Management of medical comorbidities

• Inability to achieve at a level consistent with the person’s overall IQ, in a specific area of learning.

Epidemiology: • Relatively common (reading disability:2-8% of school aged children). • More in males.• High comorbidity with ADHDEtiology: • neurodevelopmental defectComplications: • psychologicalManagement: • Educational interventions (remedial and compensatory).• Treatment of comorbidities.

Autistic disorder is the most important among them. Characterised by:

• Impaired social interactions.• Impaired ability to communicate.• Restricted repertoire of activities and

interests.

Epidemiology:• 10-15 per 10,000• More in males (4:1)

Etiology: neurodevelopmental. • Large brain size, wide ventricles, failure to

achieve normal cerebral asymmetry (defective pruning)

• cerebellum (vermis), temporal lobes (hypoperfusion),Anterior cingulategyrus (decreased metabolic activity) hippocampal complex.

• Immature cells in limbic structures in the cerebellum.

DSM-IV-TR ( at least 6 of 12) onset before 3 years• Impaired social interactions. (at least 2)

1. Nonverbal behaviors to regulate social interactions2. Peer relations3. Spontaneous sharing of interest, enjoyment.4. Emotional reciprocity

• Impaired ability to communicate. (at least 1)1. Develop language2. Initiate or sustain speech3. Stereotypic or idiosyncratic language.4. Make-belief play

• Restricted repertoire of activities and interests (at least 1)1. Stereotyped preoccupation with interests or activities2. Adherence to non functional routine.3. Stereotyped motor mannerisms4. persistent preoccupation with parts of objects.

Investigations:• Audiometry & visual

examination: rule out sensory defects as a cause.

• IQ: co-morbid MR (70%).• EEG: co-morbid changes in

(50%)• Kariotyping, metabolic

disorders screening, heavy metal toxicity screening.

• Psychmetry (cars).

Course: • chronic, lifelong disorder, • severe morbidity. Only (2-3%) may

be able to progress normally in school and live independently.

• Good prognostic factors include higher IQ and milder forms.

Differential diagnosis: MR, severe sensory defects,

language disorders, childhood schizophrenia.

Clinical management:• Parent education• Parent support• Special education• Speech therapy• Behavioral modification• Medical treatment: adjuvent to

behavioral approaches. They include: antiepileptics, antipsychotics, fluoxetine, naltrexone, clomipramine.

• Rett’s syndrome:Severe form of autism strictly in

females, characterized by: epilepsy, microcephaly, cerebellar involvement symptoms.

• Asperger’s syndrome:Milder form of autism??,

characterized by normal language and normal intelligence.

• DSM-IV-TR: (at least 12 from 18)persisting for at least 6 months and are maladaptive.

A) Inattention: – Fails to pay close attention to details and

makes careless mistakes.– Difficult to sustain attention in tasks or play.– Easily distracted by external stimuli– Dislikes tasks that require sustained mental

effort.– Does not seem to listen when spoken to

directly.– Does not follow instructions and fails to finish

tasks– Difficulty organising tasks or activities– Forgetful in daily activities.

B) Hyperactivity-– Often fidgets– Leaves seat– Runs and climbs– Difficult to play quietly– On the go– Excessive talking

c) Impulsivity:.– Blurts out answers– Difficulty waiting turns– interrupts or intrudes

Epidemiology: • 3-10% in school aged children. More in

males (3:1)Etiology: • Genetics (gene for D4 receptor or

dopamine transporter gene)• Perinatal problems.• Neuroimaging studies showed reduced

size of the prefrontal cortex (executive functions and response inhibition), basal ganglia and cerebellum (timing)

• Psychosocial: parental anxiety, inexperience

Course: • 50% remit• 25% antisocial, substance abuse,• depression

Differential Diagnosis:1. Normal2. Conduct disorder3. Learning disorders4. Mood disorders5. Adjustment disorder6. Thyroid disorderClinical management:• Combination of somatic and

behavioral management1) Psychostimulants (1st. Line):• DA reuptake inhibitorsShort acting: methylphenidate: 0.5-

1mgmg/dLong acting: methylphenidate, concerta• NA reuptake inhibitor: atomoxetine

(strattera): 1.2mg/kg/d.2) antidepressant: clomipramin, bupropion

Conduct DisorderDSM-IV-TR: (3 or more for 12 months).

Aggression to people and animals: 1. Bullies, threats or intimidates.2. Initiates fights3. Used weapon4. Physically cruel to people5. Physically cruel to animals6. Stolen while confronting victim7. Forced someone into sexual act

Destruction of property:1. Fire setting intending serious damage2. Deliberate destruction of other’s propertyDeceitfulness:1. Broken into someoneelse’s house, car2. Lies to obtain good or favors3. Theft without confrontationSerious violation of rules:1. Stays out at nightdespite prohibition before 132. Run away from home at least twice3. Truancy from school before 13

Conduct DisorderEpidemiology: • 10% of males, 2% femalesEtiology: • Genetics• PsychosocialCourse:• 40% antisocialDifferential diagnosis: • ADHD, Learning disability, mood disorder, oppositional defiant disorder.Clinical management: • Parental training• Anti epileptic drugs• SSRIs• Treatment of comorbidies