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Child Psychiatry

I. Attention Deficit Hyperactivity Disorder (ADHD)

A behavioral disorder marked by inattention, impulsivity and hyperactivity.

Symptoms

A. Either (1) or (2)

(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with child psychiatry, child psyciatry, attention deficit disorder

Inattention

(a) Often fails to giver close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) Often has difficulty sustaining attention in tasks or play activities

(c) Often does not seem to listen when spoken to directly

(d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the

(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level

Hyperactivity

(a) Often fidgets with hands or feet or squirms in seat

(b) Often leaves seat in classroom or in other situations in which remaining seated in expected

(c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) Often has difficulty playing or engaging in leisure activities quietly

(e) Is often "on the go" or often acts as if "driven by a motor" often

Impulsivity

(g) often blurts out answers before questions have been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (eg, butts into conversations or 

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years

C. Some impairment from the symptoms is present in two or more settings (eg, at school (or work) and at home)

D. There must be clear evidence of clinically significant impairment in social, academic, or 

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (eg, Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a 

Clinical Concerns

1. boys > girls

(Inattentive - more unrecognized girls

hyper-imp - smaller %, more boys, more persistent}

2. Age of onset before age 3

3. Family history patterns

4. Connors, Child Behavior Checklist

5. ADHD vs Bipolar - Family history, multiple comorbidities (anxiety, aggressive, depressed)

Chronic irritability

6. 24-hour illness; structuring techniques, ongoing counseling; ? therapy for self-image, re-evaluation, coordination with schools

7. Diet

Medications for ADHD

1. Stimulants - problems of dosage, half-life, effect on achievement, growth, tics, dysphoria

2. Antidepressants - introductory phase; cardiac toxicity, 24 hour length of action, monitoring

Treatment Issues

Impact on self-esteem

Working with schools

Case management

Prognosis

1. Sample selection - SES, LD, conduct, depression, adolescent ADHD

2. Remission, SES, Genetics neg, less aggressive

Learning Disabilities

Increasingly common diagnosis seen in children with ADHD, conduct disorders, seizures, ? after chemotherapy

Many subtypes, including reading, arithmetic and language

Language can be expressive and receptive. Presentation can be at a variety of ages and grades

Examples: 1. Can decode words in reading without comprehension

2. "Organizational skills" essays, taking notes

3. Short-term memory deficits

II. Conduct Disorder

A. "A repetitive and persistent pattern in which the basic rights of others are major age appropriate societal norms or rules are violated as manifested by the presence of 3 or more criteria such as aggression to people or animals, destruction of property, deceitfulness or

B. Problems of Differentiation: Shoplifting, lying, staying out late versus serious criminal activity or aggression.

C. Early Onset (prior to age 10) versus adolescent onset.

D. More common in boys than girls.

E. Most conduct disordered children and adolescents do not grow up to be anti-social or criminal. Wide variety of outcomes including psychosis, character disorders, poor work history, divorce, etc.

F. Most serious prognosis - early onset, neuropsychiatric impairment, a violent and abusive upbringing.

III. Anxiety Disorders

Separation Anxiety

A. Symptoms ranging from anticipatory uneasiness to panic about separation from parents or other loved ones. Frequently includes physical symptoms such as abdominal pain, palpitations, and

B. Normal to severe impairment especially in kindergarten or first grade.

C. Higher risk after serious illness or death, family history of panic or agoraphobia, depression or somatization disorders.

Generalized Anxiety Disorder

A. Excessive and unrealistic worries about competent approval, appropriateness of past behavior (can include separation anxiety types of concerns).

B. Similar pattern of multiple somatic complaints.

Phobias

A. Common, up to 10% of children have a specific phobia(s) concerning a specific situation or object

Post Traumatic Stress Disorder

A. Incident depends on circumstances. Examples: Chowchilla School Bus kidnapping, Challenger disaster, hurricanes, etc.

B. Early response - silence, funny feelings in their stomachs, dizziness.

C. Causal attribution, traumatic imagery, fears.

D. Play

E. Dreams, sleeplessness, irritability, recollections

F. Anniversary reaction

IV. Divorce: Impact on Children

Statistics:

1.2 million divorces (? financial issues)

1.2 million children

6.8 average age

Parent of custody 90% mother (joint custody ?)

Clinical Reactions

1. Infants and young toddlers - irritable, regressive; maternal depression

2. Early school age - guilt

3. School age - school performance

boys - aggressiveness

adolescent - pseudomature, withdrawal, individuation

Clinical Issues

1. Parental status - depression, other psychiatric disorder

2. Social economic shading

3. Ongoing discor

4. Need for F/U 1-2 years; 10-20% may require more intensive treatment

5. Joint custody

6. Young adult programs

V. Adolescent Suicide and Depression

A. Impact of puberty, identity (body image), separation/autonomy

Suicide: 13/100,000

Other Death Rate: 15-24 y.o.

Heart 3

Malignant Neoplasm 8

Accidents 100

Accidents vs. Attempts, Age and Under-reporting

B. Methods: Availability

Poisoning/Overdose -25% of death

-24% hospitalized

-220 attempts/1 suicide (intoxication vs. O.D.)

Firearms - fewer attempts to completions

Hanging - 1:10-15

One Quarter (1/4) had previous attempt (unknown # secret)

One Quarter (1/4) plus previous referral

C. Development Context

1. How much of "self" is vulnerable to defect - school, sexual relationships, peers, family

2. Under current issues of loss and separation from family

3. Impulsivity

4. Concept of death, regression, under stress

a. Being alone and separation as temporary

b. Personification of death

c. Quasi-ability to observe after death

d. Permanent, mature

D. Suicidal Adolescent Risk Factors

Psychological

1. Vulnerability to loss - previous real losses, inability to invest world with meaning, no self (memory, value, interests, old pleasure) to fall back on

2. No way out - parental expectations, hopeless

3. Angry, tense

4. Resentful

5. Socially isolated, lonely, helpless