Problematic behavior in a child

Basic Child Psychiatry for the Pediatricians

1. Psychiatric disorders of children and adolescents: Relevance in Pediatrics Dr.Sujit Kumar Kar , MD ( Psy ) Assistant Professor Department of Psychiatry King George’s Medical University, Lucknow, U.P

2. Outlines Psychiatric disorders in Pediatric populations Case vignettes Parenting issues Early life adversities Symptoms that mimic physical illnesses Choosing appropriate medications Questions & Feedback

3. CASE : Ten years old Ravi is very good in playing cricket . He is also very good in painting . His English is not bad. He performs well in Hindi and Science. He used to score highest in social studies in his class , however just manage to score minimum marks in mathematics to qualify the examination. His parents are very much worried about his mathematics . He is attending extra classes for mathematics. He is frequently scolded ( Stupid fellow…..) by his math's teacher for doing careless mistakes. Last month, he had a very bad performance in exam. He had managed to score 16 out of 100 marks, in mathematics. His parents were not talking to him for a couple of days due to his poor performance in exam. He was quite depressed and was feeling worthless.

4. Some one suggested to consult a psychiatrist and said……. He might be having dyslexia. His IQ assessed by a psychologist was in normal range (IQ ~110). Psychiatrist had made a diagnosis of – Specific Developmental Disorders of Scholastic Skills – Specific disorder of arithmetic skills with adjustment disorder (As per ICD-10 diagnostic criteria)

5. Specific issues in this patient

6. Combined type ADHD is most common in children

7. CORE SYMPTOMS OF ADHD AS PER DSM-IV-TR

8. Autism

9. DSM-IV-TR As per DSM-5, all these disorders are under same umbrella

10. Conduct Disorder

11. Case Vignettes

12. A 15 yr old boy reading in 10 th standard presented with episodes of severe headache followed by abnormal body movements and unresponsiveness . Episodes last 20-30mins, sometimes even a hour or long & present for approximately 1 year. Associated with withdrawn behavior*, school refusal, poor scholastic performance, occasional irritability*, fearfulness*, apprehension*, hopelessness, crying spells, sadness of mood *. * These symptoms were present for more than 2 years

13. Neuro -imaging, EEG, Routine hemogram , Thyroid function test, ECG – WNL Treated with antiepileptics ( Valproate , Carbamazepine, Clobazam , Levetiracetam - alone as well as in combination) Treated with antipsychotics ( Trifluoperazine , Risperidone+ THP, Quetiapine- alone & in combination), Antidepressants (Sertraline 50mg/day, Imipramine 25mg/d, Dothepin25mg/d, Amitryptyline ), Benzodiazepines ( Clonazepam , Lorazepam ), Anti-migraine drugs ( flunarizine , propranolol ) Analgesics, PPIs, Multivitamins. Also visited several traditional healers and physicians of alternative medicine

14. Reviewing the diagnosis – For more than 2 years, he had recurrent thoughts of- Door is not locked properly, thieves will enter the house The cooking gas is left open, gas will leak Also h/o repeated thoughts of contamination followed by compulsive washing behavior Always preoccupied by these thoughts In school- Unable to concentrate on studies Always stays at home, to keep a watch on these things with an apprehension, something wrong may happen at home Symptoms worsened since last one year

15. Diagnosis – OCD with Moderate Depressive Episode With Mixed Dissociative Disorder Treated with Fluoxetine alone (increased upto 60mg/day, Clobazam 10mg/d in divided doses), all other medications were stopped. In 2 months, depressive symptoms, dissociative symptoms, headache resolved completely. OCD symptoms improved significantly.

16. OCD in pediatric population Varied presentation ( eg.Withdrawn behavior to marked irritability) PANDAS (Pediatric Autoimmune Neuropsychiatic Disorders Associated with Streptococcal infections) US FDA approved medications Role of CBT

17. Dissociation A stress response Varied clinical presentations True seizure Vs Pseudo-seizures Relevance of pharmacological management

18. A 14 year boy was complaining of weakness, lethargy, reduced sleep, reduced appetite, inability to concentrate on studies, disturbed sleep & withdrawn behavior for 6 months. Since last 2 months, he reported about sadness of mood, hopelessness, feeling of guilt, suicidal thoughts (twice attempted suicide during that time). He lost 10 kg weight in last 6 months.

19. In the initial period, he was treated with Syrup. Cyproheptidine , Multivitamins & Benzodiazepine ( Clonazepam ) for sleep. Sleep improved. Due to two suicidal attempts and worsening of symptoms, he was referred for psychiatric consultation

20. History reviewed He expressed his worries related to semen loss by nocturnal emission and masturbation Extreme guilt feeling was present He attributes all his symptoms to semen loss He was prescribe Escitalopram 10mg/day and Psychosocial intervention has been done. Sexual myths were addressed. His symptoms resolved in 2 weeks. Diagnosis: Dhat Syndrome with Severe Depressive Episode

21. Dhat Syndrome Culture bound syndrome Psychosomatic features Common in late adolescence to young adults

22. Depression Normal emotional response Vs Depression as a pathological entity FDA black box warnings Association with physical illnesses

23. A 14 year girl had brought for psychiatric consultation for frequent aggressive and hostile behavior for past 2 years, which has been significantly impairing since past 4 months. Her mother reports about delayed developmental milestones, Poor scholastic performance and need of assistance in doing activities of daily living. She had history of seizure for which she was on Phenobarbitone for last 10 years.

24. On IQ assessment – IQ ~ 45 (moderate MR) Diagnosis – Moderate MR with Behavioral Problems with Seizure disorder Treatment – Valproate was added and Phenobarbitone was gradually tapered off. Behavioral symptoms improved. No relapse of seizure. Family member were psycho-educated .

25. Behavioral problems Impulsive, disruptive behavior Pharmacological options Behavioral measures

26. A primary school going child with poor scholastic performance was found persistently withdrawn, decreased interest in study, decreased interaction after being shifted to a boarding school. He always remembers about her mother, brother and had frequent crying spells . He had specific learning disability involving reading, writing and mathematics.

27. Adjustment disorders Stress related disorders Common in children and adolescents Persistence of stressor leads to persistence of symptoms Chronic maladjustment leads to failure to thrive

28. Parenting styles The ways of rearing children A difficult task Seldom taught or trained

29. Types of Parenting Style

30. Neglectful Parenting Style

31. Permissive Parenting Style

32. Authoritarian Parenting Style

33. Authoritative Parenting Style

34. Parental Loss Abuse Neglect Chronic illness

35. Child’s perception about Death

36. Death & Grief

37. Death & Grief

38. Physical Failure to thrive, Malnutrition Psychological Internalizing behaviors Externalizing behaviors

39. Look for Intellectual disability ADHD Learning disorder Several other psychiatric disorders and medical conditions cause decline in scholastic performance

40. Symptoms that mimic physical illnesses Panic attack Hyperventilation Dissociative stupor/amnesia/seizure/ sensory or motor disorder/Possession Anorexia nervosa Somatoform disorder

41. Choosing appropriate medications Antidepressants Antipsychotics Benzodiazepines Mood stabilizers Stimulants Other medications – Propranolol , THP, Promethazine

42. Target To promote desired behavior Reinforcement (Positive & Negative) Modeling To reduce undesired behavior Punishment Time out

43. Summary

44. Questions & Feedback

45. Thank you Write to me at – [email protected]