Childhood Psychiatry

Autism

Autism spectrum disorder (ASD) is characterized by:

• Impaired social interaction (reduced empathy, reduced interest in socialization)

• Impaired communication (inability to understand social cues and nonverbal messages)

• Repetitive/stereotyped patterns of behavior (fixated interests, inflexibility to change)

According to DSM-5, ASD symptoms must be present by "early development" (previous DSM-IV timeframe was age 3).

Some key buzzwords and phrases in recognizing autism spectrum disorder in a question stem:

• Does not play with other children

• Has a notebook filled with drawings of the same object

• Speaks in a monotone or "professorial" style

Before making diagnosis of autism based on poor language/social skills, order a hearing test to rule out deafness.

Individuals smay have increased serotonin levels.,

Neuroanatomical findings include increased cortical thickness and increased total brain volume.,

Treatment may involve remedial education and behavioral therapy.

Prognosis is best determined by language development.

In DSM-5, the following disorders were removed and instead made to fit under the umbrella of autism spectrum disorder:

• Autistic Disorder

• Asperger's Disorder

• Childhood Disintegrative Disorder

• Pervasive Developmental Disorder NOS

Patients who were previously diagnosed with these disorders fit the diagnostic criteria for autism spectrum disorder and receive the new diagnosis.

Rett syndrome is an X-linked disorder marked by regression in physical and psychomotor development after around 6 months of normal development. This is an important distinguishing factor when compared to autism spectrum disorder.

Rett syndrome is predominantly seen in girls, since affected males die in utero.

The classic description of Rett syndrome is stereotyped hand-wringing movements.

Associated with the de novo mutations of the MECP2 gene on the X chromosome.

ADHD

Attention deficit hyperactivity disorder (ADHD) is characterized by:

• Inattention: problems with listening, concentrating, paying attention to details, organizing tasks, easily distracted, or often forgetful

• Hyperactivity: blurting out answers, interrupting, fidgeting, and talking excessively

The symptoms of inattention and/or hyperactivity must be observed in multiple settings such as at home, in school, etc. and before the age of 12 years.

Two thirds of children with ADHD also have conduct disorder or oppositional defiant disorder.

Lead toxicity may produce symptoms similar to ADHD. Consider it in the differential if a patient has risk factors (e.g. living in an old house with chipping paint, using foreign pottery, etc.)

1st line treatment for ADHD is CNS stimulants (methylphenidate, dextroamphetamine, amphetamine salts). Atomoxetine is a non-stimulant that can be used if the patient cannot tolerate stimulants.

Amphetamine stimulants may have the following side effects:

• Insomnia

• Anxiety

• Decreased appetite

• Secondary hypertension

• Poor growth (growth should be regularly monitored)

Watching for the development of these side effects is important when starting a patient on these medications.

MDDD

Characterized by severe, recurrent temper outbursts that are inconsistent with the situation and the child’s developmental level. Outbursts can be verbal rages or acts of physical aggression that occur at least three times per week for at least 12 months. In between outbursts, the patient is persistently irritable. The diagnosis must be made between the ages of 6 and 18. Initial treatment generally involves psychotherapy such as cognitive behavioral therapy. If nonpharmacological treatments fail to improve symptoms, stimulants, antipsychotics, and antidepressants are the most effective medications for the treatment. Methylphenidate is a stimulant that decreases irritability in children.,

Other Disorders

Oppositional Defiant

Oppositional defiant disorder is characterized by negative, hostile, and defiant behavior. Children typically are disobedient with authority figures, and are argumentative and angry.

Treatment of oppositional defiant disorder centers on psychotherapy.

Conduct

Conduct disorder is characterized by violation of basic rights of others or social norms. Frequently used examples in question stems include:

• Torturing or killing animals

• Destruction of property

Note: Conduct disorder is more severe and serious than the disobedient behaviors of oppositional defiant disorder.

After age 18, conduct disorder is considered antisocial personality disorder.

The primary treatment of conduct disorder is psychotherapy. Pharmacotherapy can be used to manage the associated symptoms of mood instability, anger, etc.

Separation Anxiety

Separation anxiety disorder is characterized by excessive anxiety concerning separation from home or from those to whom the individual is attached. The anxiety is persistent and lasts ≥4 weeks in children and adolescents and ≥6 months in adults. It most commonly occurs at age 7-8 after a stressful life event (e.g. divorce, birth of a sibling, changing schools, etc.).

When forced to separate, children with separation anxiety disorder avoid separation by feigning physical complaints.

The differential of separation anxiety disorder includes physiological separation anxiety. Children are expected to stop experiencing separation anxiety around age 2-3.

Treatment of separation anxiety disorder includes CBT and SSRI 's.

Separation anxiety disorder is a risk factor for the development of MDD and panic disorder as an adult.

Selective Mutism

Selective mutism is characterized by refusal to speak in certain situations for at least 1 month, despite the presence of normal language ability. The classic presentation is a child with minimal verbal interaction at school, but whose parents notice no problems at home.

The treatment of selective mutism involves psychotherapy, behavior therapy, and management of anxiety.

Imaginary friends

It is normal for children to have imaginary friends from ages 2-6. In the absence of other concerning signs (e.g. violent command hallucinations, genital trauma, etc.), do not be fooled by question stems into thinking this behavior is indicative of psychosis, abuse, or other pathology.

Enuresis

Enuresis is involuntary voiding of urine (bed-wetting) in children ≥5 years of age.

To diagnose enuresis, urinary problems must occur 2x/week for 3 months.

First line pharmacologic interventions include desmopressin and behavioral modification with enuresis alarms. Tricyclic antidepressants, most commonly imipramine, are a second-line treatment.

Organic causes of enuresis, such as UTI, diabetes, or seizures should be ruled out.

Encopresis

Encopresis is involuntary or intentional passage of feces in inappropriate places by children ≥4 years of age.

To diagnose encopresis, involuntary stool passage must occur at least 1x/month for at least 3 months.

Treatment involves psychotherapy. Address constipation if it is contributing to etiology.

Rule out organic causes of abnormal defecation before diagnosing encopresis, such as constipation, hypothyroidism, and anal fissures.

Infant Deprivation and Childhood Regression

Children can regress to younger behavior under conditions including:

• Punishment

• Physical illness

• Birth of a new sibling

• Divorce

Example: A toilet-trained child suddenly experiencing encopresis or enuresis after her parents get a divorce.

Long term deprivation of affection in infants results in crying or Wah, Wah, Wah, Wah

The 4 W’s:

• Weak → decreased muscle tone, weight loss, and physical illness

• Wordless → poor language skills and anaclitic depression

• Wanting → poor socialization skills

• Wary → lack of basic trust

Deprivation for >6 months can lead to irreversible changes or even death.

Anaclitic depression

Hospitalism is depression in an infant attributable to continued separation from a caregiver resulting in withdrawn and unresponsive infants.,

Disinhibited social engagement disorder

Disinhibited social engagement disorder presents as a young child (>9 months) who is overly familiar with and interactive with unfamiliar adults.

Additionally, these patients feel no need to check in with their adult caregiver, even in unfamiliar settings. No separation anxiety.

In contrast, reactive attachment disorder presents as a young child who is emotionally withdrawn and with a flat affect when with caregivers. Both of these “pathological relationship” childhood disorders are seen in patients with a history of social neglect/deprivation.

Intellectual Disability

Intellectual Disability is a disorder of cognitive, social, and practical functioning. Patients are deficient in multiple domains of everyday living. Specific learning disorders must be evaluated when working up this disorder, as an apparent deficit in functioning may be most accurately due to a learning disorder, intellectual disability, or both (learning disorders may be co-morbid with intellectual disability and may be concurrently diagnosed).

In order to diagnose intellectual disability, three criteria must be met:

• Intellectual deficits (verified by standardized testing)

• Adaptive functioning deficits (activities of daily life, social communication, etc.)

• Onset during developmental period

Severity of intellectual disability is no longer determined by IQ ranges, as of the DSM-5. Instead, the qualifiers of mild, moderate, or severe intellectual disability are determined by adaptive functioning deficits.

Learning Disorder

Learning disorders refer to achievement in reading, math, or writing that is significantly lower than expected age and intelligence. Reading disorder is the most common learning disorder.

Sensory deficits should be ruled out prior to diagnosing learning disorder.

Around 50% of cases of intellectual disability are idiopathic. Defined causes of intellectual disability range from genetic, prenatal, perinatal, and postnatal.

The most common chromosomal cause of intellectual disability is Down syndrome.

The most common preventable cause of intellectual disability is fetal alcohol syndrome.

The most common inherited form of intellectual disability is fragile X syndrome.

Prader-Willi syndrome is a cause of intellectual disability, with characteristic physical appearances. Suspect this disorder in a patient with obesity, hypogonadism, and almond-shaped eyes.

Prader-Willi syndrome can be caused by either:

• Sporadic deletion of paternal 15q11.2-13 (65-75% of cases)

• Maternal uniparental disomy of chromosome 15 (20-30% of cases)

Tourette

Tourette’s disorder is a disorder characterized by both motor and vocal tics. In order to diagnose Tourette's disorder, there must be the following:

• Multiple motor tic events

• One or more vocal/phonic tic events

• Tics must be present for >1 year

• Tics must take place multiple times a day and/or nearly every day

Tics must be present for >1 year to diagnose Tourette's disorder.

Types of vocal tics include:

• Coprolalia: Repetition of curse words (uncommon)

• Echolalia: Repetition of words made by another person

Tourette's disorder shares a genetic relationship to attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD).

Neuroanatomical findings include caudate nucleus atrophy and decreased frontal lobe mass.,

PANDAS

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) is group of tic and obsessive-compulsive disorders linked to Group A streptococcal infection and subsequent autoimmune damage. Classically, a patient would present with tics that are worse in winter and spring.

Treatment

Two 1st line treatments of Tourette's disorder are:

• α2 agonists (e.g. clonidine, guanfacine)

• A ntipsychotics (e.g. haloperidol, risperidone)

α2 agonists are often tried first due to the side effects and morbidities of antipsychotics.

Stimulants used to treat ADHD may exacerbate comorbid Tourette's disorder. However, atomoxetine is a non-stimulant that does not exacerbate tics.

Note: While this relationship has been contested in recent studies, it is still an important concept to be aware of.