1、CHILD AND ADOLESCENTS PSYCHIATRY AND MENTAL HEALTHSU Lin-yan M.D. OutlinePreface of Child and Adolescents PsychiatryMental RetardationAttention Deficit Hyperactivity DisorderDefinitionChild and Adolescents Psychiatry is the academic and clinical discipline which studying and caring for children and
2、adolescents with Emotional disordersbehavioral disordersdevelopmental disordersThe field of child and adolescent psychiatry is quite young. 1867 Maudsley H. first described insanity of early life in his book Physiolgy and pathology of mind 1950 formal training programs in child psychiatry become pop
3、ular in American 1970 quick development The social sciences (social and communal factors, family functioning, parent-child relations) Many basic science contribute to knowledge relevant child psychiatryThe biological science (brain development)The child developmental psychologyEpidemiologyChild and
4、adolescent mental health is an essential part of overall health. World-wide up to 20% of children and adolescents suffer from a disabling mental illness (WHR, 2000). World-wide suicide is the 3rd leading cause of death among adolescents (WHR 2000). Major depressive disorder (MDD) often has an onset
5、in adolescence, across diverse countries, and is associated with substantial psychosocial impairment and risk of suicide (Weissman, 1999) Epidemiology XIN RE(1992) CBCL 12.97% Li XR (1993) DSM-III-R 14.89%It means that there are 46770000 children need help in China.Poor outcomesLightandBailey(1998)r
6、eportthatlongitudinalstudiesfindthatabouthalfthechildrenwithpsychiatricdisordersexhibitthesameorsimilardisordersyearslater.Conductdisorderrelatedbehaviorstendtopersistentintoadolescenceandadultlifethroughdrugabuse,juveniledelinquency,adultcrime,antisocialbehavior,maritalproblems,pooremployeerelation
7、s,unemployment,interpersonalproblems,andpoorphysicalhealth(Patterson,DeBaryshe,&Ramsey,1989).Present states of child mental health Most Scandinavia countries, many European countries and American : about one child psychiatrist for every 50,000 people in the population In China :less than 100 child p
8、sychiatrist throughout the country0 0101020203030404050506060707080809090 Present states of child mental health 1950s-1970s, a few doctors working in the child psychiatric clinic in big cities. The first Child psychiatry clinic in China was established in Nanjing by Dr. Tao Guotai. Chinese Child Men
9、tal Health Board of Chinese Mental Health Association was established in 1989 Now, many child psychiatry research institutes have been built, including clinics, wards and caring centers for children and adolescents in Beijing, Nanjing, Shanghai, Changsha, Chengdu, Fuzhou, Jinan, and so on. Child men
10、tal health clinics have also been built in more cities. Social need is increasingEmotional quotient (EQ, Garduer H and Salovey P.) The ability to accurate appraisal and expression of emotions in oneself and others to regulate emotion in a way that enhances living to recognize the consensually agreed
11、 upon emotional qualities of objects in the environment. The achievement of one depend upon IQ 20% EQ 80% The WHO School Contest, held as part of World Health Day 2001 which had the theme “Stop Exclusion: Dare to Care” Chinese President Jiang Ze-min in his letter to Dr Blundtland, the secretary-gene
12、ral of WHO, has emphasized Chinese government will mobilize the whole society to create a suitable environment for people with mental disorders to go back society.ClassificationWHO(1992):InternationalClassificationofDisease,TenEdition(ICD-10)APA(1994):DiagnosticandStatisticalManualofMentalDisorders,
13、FourthEdition(DSM-IV)Chinese Classification of Mental Disorders-Version 3(CCMD-3) 2000 7.Mental retardation, and disorder of psychological developmental with onset usually occurring in childhood and adolescence8. Hyperkinetic, Conduct,and Emotional disorders with onset usually occurring in child and
14、 adolescenceClassification71.1 Specific speech articulation disorder71.2 Expressive language disorder71.3 Receptive language disorder71.4 Acquired aphasia with epilepsy71.9 Other or unspecified developmental disorders of speech and language 70. Mental retardation 71.Developmantal disorder of speech
15、and languageClassification72.1 Specific reading disorder 72.2 Specific spelling disorder72.3 Specific disorder of arithmetical skills 72 Specific developmental disorders of scholastic skillsClassification72.4 Mixed disorder of scholastic skills 72.9 Other or unspecified developmental disorders of sc
16、holastic skills 73 Specific developmental disorder of motor skills 74 Mixed specified developmental disordersClassification75.1 Childhood autism75.2 Atypical autism75.3 Retts syndrome75.4 Childhood disintegrative disorder75.5 Aspergers syndrome75.9 Other or unspecified Pervasive developmental disord
17、ers75 Pervasive developmental disorders Classification80. 1 Attention deficit and hyperactivity disorder80.2 Hyperkinetic conduct disorder8 0 . 9 O t h e r o r u n s p e c i f i e d hyperkinetic disorder 80. Hyperkinetic disorderClassification81.1 Dissocial conduct disorder81.2 Oppositional defiant
18、disorder81.9 Other or unspecified conduct disorder 81 Conduct disorders 82 Mixed disorders of conduct and emotions83.1 Separation anxiety disorder of childhood 83.Emotional disorders with onset specific to childhood 83.2 Phobia anxiety disorder of childhood 83.3 Social anxiety disorder of childhood
19、83.Emotional disorders with onset specific to childhood 83.91 General anxiety with onset specific to childhood Classification84.1 Elective mutism84.2 Reactive attachment disorder of childhood84.9 Other or unspecified childhood disorders of social functioning 84.Disorders of social functioning with o
20、nset specific to childhood and adolescence Classification85.1 Transient tic disorder85.2 Chronic motor or vocal tic disorder85.3 Tourettes syndrome85.9 Other or unspecified tic disorder 85.Tic disordersClassification86.1 Nonorganic enuresis86.2 Nonorganic encopresis86.3 Feeding disorder of infancy a
21、nd childhood86.4 Pica of infancy and childhood86.6 Stuttering86 Other behavioral disorders with onset usually occurring in childhood and adolescence 89 Other or unspecified childhood disorders of social functioning Mental Retardation (MR) Definition Mentalretardationisaconditionofarrestedorincomplet
22、edevelopmentofthemind,whichischaracterizedbydeficitsinintelligenceandsocialadjustment.Thedisorderemergesbefore18yearsold.Thelevelofintelligenceasshowninstandardizedpsychometrictestisdefinedasbelow70,whilethescoresfrom70-85aredefinedasborderlineintelligence Epidemiology WHO(1985):The prevalence of MR
23、 in the general population is 4 of mild and severe MR 30 (include mild MR); Li XR (1993) DSM-III-R 22.2 More common in rural than in city population Clinical Description(1) The range of IQ is from 50 to 69 and the psychological age lies between 9 and 12 years old;(2) Poor academic performance with s
24、pecific difficulties in reading and writing, while at work these patients are only capable of unskilled manual jobs;(3) Independence in self-care;(4) Intact ability to communicate at ordinary level in daily life despite difficulty in communicating difficult information in reading and writing Mild me
25、ntal retardation Clinical Description(1) The range of IQ is from 35 to 49 and psychological age is about 6 to 9 years old;(2) Capability in simple arithmetic but not up to primary school level. These patients can cope simple laboring jobs with simple work output and efficiency;(3) Capability of self
26、-care;(4) Capability in daily life communication at ordinary level despite limited range of vocabulary Moderate mental retardation Clinical Descriptionmental retardation (1) The range of IQ is from 20 to 34, and psychological age is approximately between 3 and 6 years old;(2) Presence of marked moto
27、r impairment and other associated deficits in task performance;(3) Incapability of self-care;(4) Marked deficits in language development and incapability in communicating in daily life Severe mental retardation Clinical Description Profound mental retardation(1) The range of IQ is under 20 and psych
28、ological age is below 3 years old;(2) Complete social disability with lack of awareness of dangerous situation;(3) Incapability in self-care and bladder or bowel control;(4) Absence of communicable speech.Profound mental retardation Etiology oChromosomal aberrations Down syndrome Genetic disordersEt
29、iology Single-gene mutations:Tuberous sclerosis, phenylketonuria and other metabolic disorders Genetic disordersEtiology o Fragile X syndrome Genetic disordersEtiology o Malformation syndromeso Prader-Willi, Williams, and Angelman due to microdeletions syndromes Genetic disorders Etiology oMaternal
30、infections :Congenital rubella, HIVoTeratogens:Fetal alcohol syndromeoToxemia: placental prematurity insufficiencyoOther:radiation, trauma Exposure EtiologyoEncephalitisoToxins:Lead poisoningoOther postnatal causesTraumas o brain tumors Postnatal Infections EtiologyPovertyEducation Psychosocial prob
31、lems UnknownDiagnosis and differential diagnosis Psychometric tests of IntelligenceGesell :03 years oldBayley:230 month PPVT:morn than 2 yearsWISC-RC :616 years old C- WYCSI :46.5 years old Social Adaptive Ability Scale existing concurrently with related limitations in two or more of the following a
32、pplicable adaptive skill arrears: communication self-care home living social skills community use self-direction health and safety functional academics leisure and work Diagnosis and differential diagnosisIn most cases there is mental retardation of varying degree while in some cases there are isola
33、ted locus of superior intellectual ability on a background of low general intelligence.differential diagnosis with Autism Qualitative impairment in reciprocal social interactions Abnormalities in language development Restricted, repetitive, and stereotyped patterns of behavior, interests, and activi
34、ties differential diagnosis with Autism Onset after a normal period hallucination paranoia behavior disturbance differential diagnosis with Schizophrenia TreatmentTraining and rehabilitationTreatment aim for cause of diseaseTreatment aim for symptomsAttention deficit hyperactivity disorder(ADHD) ADH
35、DisoneofthemostimportdisordersthatChildandadolescentspsychiatriststreat.Itishighlyprevalent,makingupasmuchas50%ofchildpsychiatryclinicpopulations.Untreated,itpredisposesachildtopsychiatricandsocialpathologyinlaterlife.ThecoresymptomsofADHDistheinabilitytofocusattention,difficultymaintainingcontrolov
36、erimpulsivebehavior,andageneralizedhyperactivityDefinitionEpidemiology The prevalence of ADHD in the general population is approximarely 3% to 10% . Li XR (1993) DSM-III-R 6.04% More common in boys than in girls at a ratio of 9:1 in clinical sample 4:1 in epidemiological samples Clinical Description
37、 distractable by enviernment stimuli while concentrating; failure to maintain persistence attention in calss; frequent omissions of homework; lack of persistence, move from one activity to another Inattention Clinical Description motor restlessness and fidgety, run, jump, climb and g o o f f s e a t
38、 s w h e n t h e situation does not permit as playing or whispering in class difficulties in abiding by rules in games and impatience to wait for ones own turn; HyperactivityClinical Description intruding on or interrupting others activities tease other children and to get in troubles being easily f
39、rustranted and impulsive with emotional display lack of awareness of risk and hazards. Impulsivity Comorbidity Learning disorders(LD): 10% to 92% Oppositional defiant disorder( ODD ) : 40 to 65% Conduct disorder(CD): 42.7% to 56% Clinical DescriptionResulted in marked impairment in social functionin
40、g in terms of a c a d e m i c p e r f o r m a n c e a n d interpersonal relationshipEarly onset usually before 7 years of ageEtiology Catecholamine bnormalities Blood,urine and CSF: low dopamine and norepinephrine turnover I n t e r a c t i o n b e t w e e n serotonin and catecholamine systems Bioch
41、emistry Etiology Heritability is estimated to between 0.55 to 0 .92 Twin study concordance 51% in monozygotic twins 33%in dizygotic twins; Genetic37 years old11 years old 8 years oldEtiology SPECT, PET, fMRI studies revealed lower cerebral glucose metabolism in the superior prefrontal cortex. Neuroi
42、magingEtiology Dysfunction of parent-child relationship and family Fighting with parents Psychosocial factorsEffectsBad relationshipPoor outcomesScott(2002)demonstratedincreasedcostsforcareandtosocietyinlateryearsfromthechildhooddiagnosisofconductdisorder.Leibson(2001)showedthatoveranineyearperiodth
43、emedianmedicalcostsforchildrenwithADHDwere$4,306.00comparedwith$1,944.00forchildrenwithoutADHD.Thecostsareduetohigherratesofadmissiontohospitalemergencyandoutpatientdepartmentsandvisitstoprimarycarephysicians.Treatment Central stimulants Meihy1phenidate( Ritalin) Pemoline Amphetamine Antidepressants Clonidine Atomoxetine Pharmacological Interventions Individual psychotherapy Educational intervention Family intervention Multi-modality treatment Psychosocial interventionsFamily therapySensatory integration therapySensatory integration therapyTraining of social skillPlay Therapy
