Professional Documents
Culture Documents
SCHOOL OF NURSING
DEPATMENT OF PSYCHIATRY
Child and Adolescence psychiatry
April, 2018,
Mekelle, Ethiopia
Child and Adolescence
psychiatric
assessment
Introduction
Psychiatric assessment is the cornerstone
of Psychiatry
Assessment of children and adolescents is
difficult
Need multiple source of information
Need to use a range of techniques for
eliciting information
4
INTRODUCTION
Discuss as much as possible with child and family together,
including the diagnosis and treatment plan
12
Mental State Examination
• Intelligence and fund
Physicalappearance of knowledge
Manner of relating Attention,
with examiner and concentration and
impulsivity
parent
• Neurological
Affect function
Motor Judgement and
Quality of thinking insight
and perception Preferred modes of
Speech and language communication
13
When needed
Physical
Examination
Neuropsychiatric Examination
14
Other assessment
School
Peers
Home
Emotions
Relevant observations during interview
Classifications
&
Epidemiology
Child and adolescent psychiatric disorders
Neurodevelopmental disorders
Intellectual Disability
Communication Disorders
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder
Motor disorders
Specific Learning Disorder
Eliminationdisorders
Feeding and eating disorders
Disruptive, impulse control and conduct
disorders
17
Child and adolescent cont. . .
□ Mood disorders
Anxiety disorders
23
Psychiatric Interview
Developmental approach is very
important
Adult alone vs Child alone Vs Adult +
Child together
24
Distinctive features of Childhood
Psychopathology
Lackof developmental progress Vs specific
symptoms that are pathognomonic of adult
psychiatric disorders
Language disorder, Separation anxiety disorder
Developmental states affect presentation
Depression
Distressing
emotions and behaviors may be
normal part of development
Separation anxiety, oppositional behavior
25
Distinctive features of Childhood
Psychopathology cont’
Need for treatment
Normal development or not
Level of distress, impairment in functioning,
persistence and effect on the child and others
Comorbidity is a rule
Adult definitions of psychopathology may not
work
Childhood symptoms affect development of
skills in multiple areas
Biological and environmental interaction
26
Distinctive features of Assessment
Not there by choice
Problem may be more distressing to
others than self
They think problem has purely external
cause
Have limited capacity to reflect,
conceptualize and report
Require other modes of interaction
Interview, play, stories, drawing, observation in
multiple settings
27
Conflicting Information
Accurate picture of the child in different
settings
Lack of awareness by one party
A desire to get the interview over with
Failure to admit difficulties
Multiple perspectives rather than one
single truth
28
Issues with Adolescents
Adolescents may be seen alone first
Confidentiality
Rapport
Multiple assessments
Developmental stage
29
Issues with children's
The interviewer has to know and be familiar
with different aspects of development
Are non-verbal so direct observation is
invaluable
Cannot be evaluated separately from their
environment
Several sessions are needed before making
the diagnosis
Parent only
• Parent + child to ease the child and observe child
caregiver interaction
30
Epidemiology
Child Psychiatric Disorders
PDD 0.2 -
Schizophrenia <0.1 -
Note
1) Early-mid adolescence (13-16 years) is
commonest age of onset for MDE and Anxiety
Disorders and second most common age of onset for
schizophrenia and bipolar disorder.
Age/Sex
Boys having higher prevalence in pre-adolescence (disruptive
behavior disorders, learning and developmental disorders)
Marital discord
Low SES
Thank you!!
Intellectual Disability---DSM 5
(Mental Retardation---DSM IV)
Neuro-developmental disorders
FRAGILE X SYNDROME:-
Fragile x syndrome is the second most common single cause
of ID.
The syndrome results from a mutation on the x chromosome
at what is known as the fragile site (xq27.3).
The mental retardation ranges from mild to severe.
Fragile x syndrome is believed to occur in about 1 of every
1,000 males and 1 of every 2,000 females.
Prader-willi Syndrome
Friendships with
peers are often
affected by social or
communicative
deficits
The child generally has There are limited The child needs
little understanding of spoken language skills ongoing support
written language or with simplistic for all activities of
numbers. vocabulary and daily living: eating,
Severe grammar. dressing, bathing,
Care takers must provide elimination.
extensive support for Speech may be single
problem solving words/phrases. Caregivers must
throughout life. supervise at all
The child times.
understands simple
speech and gestures. Some youths
show challenging
Relationships are behaviors, such as
with family members self-injury.
and other familiar
people.
Conceptual skills generally The child has limited The child is
involve the physical world understanding of dependent on
rather than symbols (e.g., symbolic others for all
Profound letters, numbers). communication. aspects of physical
care, health, and
Some visual spatial skills, The child may safety, although he
such as matching and understand some or she may
sorting, may be acquired simple instructions participate in
with practice. and gestures. some aspects of
self care.
Co-occurring physical Communication is
problems may greatly limit usually through Some youths show
functioning. nonverbal, non- challenging
symbolic means. behaviors, such as
self-injury.
Relationships are
usually with family Co-occurring
members and other physical problems
familiar people. may greatly limit
functioning
Co-occurring physical
problems may greatly
limit functioning.
Comorbidity
Psychiatric disorders among persons with
intellectual disability are varied, and include
o Mood disorders, Epilepsy
o Schizophrenia,
o Attention-deficit/hyperactivity disorder (ADHD), and
o Conduct disorder.
Frequent psychiatric symptoms that occur in
children with intellectual disability include
o Hyperactivity and short attention span,
o Self-injurious behaviours (e.g., head-banging and
self-biting), and
In children and adults with milder forms of intellectual
disability
o Negative self-image,
o Low self-esteem,
o Poor frustration tolerance, Interpersonal dependence,
and
o A rigid problem-solving style are frequent.
Treatment I
Primary prevention:
◦ Special education , language therapists, behavioral
therapists, occupational therapists, and community
resources that are all vital in the management of this
disorder
◦ Improved medical care & infection prevention
Secondary/tertiary prevention:
◦ Correct diagnosis
◦ Symptom relief/treatment of co morbidity
◦ Optimal education/training
◦ Psychosocial support for affected individual and careers
Treatment II
Family support:
◦ Parental reactions to diagnosis may include grief,
anger, guilt, denial, overprotection, rejection
(negative response), social isolation or abuse
◦ Education around appropriate expectations
◦ Emotional support and chance to ventilate
◦ Support groups
◦ Assistance with home programms
Medications based on the clinical presentation
different drugs could be prescribed
Case Scenario - A
- A 23 years old unmarried woman has
been present to psychiatry clinic
- Since childhood she is unable to
communicate
- She did not yet develop self care practice,
and
- She has been cared by her mother for
dressing, eating, bathing, etc
- She spends her time by playing with 3-5 yrs
old children
- When given different trainings, her progress
80
Case scenario-B
A 17 yrs old boy has been unable to
pass from grade 7th repetitively, with
this complaint the client was brought
to you
He has Downs syndrome on medical
evaluation
With moderate level of training he can
accomplish certain activities,
He can practice self care;
communicates effectively 81
Next
DEVELOPMENTAL MILE STONES
April, 2018,
Mekelle, Ethiopia
83
DEVELOPMENTAL MILESTONES
At 2 Months:
- Begin to smile
- Turns towards sound
- Follow things with eyes
At 6 months:
- Knows familiar faces
- Plays with parents
- Responds to own name
- Sit without support
84
Developmental…
At 9 months:
- Say a two word sentence; like ‘mamma’, ‘babaa’
- Point to things with fingers
- Can stand and sit without support
At 12 months:
- Responds to simple questions
- Points to the right picture when named
- Follows simple directions
85
Developmental…
At 18 months:
- Shows affection to familiar people
- Plays simple games
- Walks alone
- May run
- Drinks from a cup
- Eats with spoon
86
Developmental…
At 24 months:
- Names pictures in a book
- Follows 2 step instructions, e.g. “pick up your
shoes and give them to me”
- Kicks a ball
At 5 years:
- Can use toilet by his/her own
- Tells a simple story with sentences
- Likes singing, dancing and acting
87
Next
AUTISM SPECTRUM DISORDERS
April, 2018,
Mekelle, Ethiopia
89
Learning objectives
After completion of this chapter, the students should
be able to:
Describe what Autism is
Discuss common features of ASD
Elaborate DSM – 5 diagnostic criteria
Clarify management of ASD
90
Introduction
Previously called ‘Pervasive Developmental disorders’
Deficits in social communication and
restricted/repetitive behavior/interest are main
features
One-third had co-morbid intellectual deficit
Prevalence: 0.08%
Boys: Girls => 4: 1
91
Introduction…
Etiology
◦ Genetic factors
◦ Immunological factors
◦ Prenatal & per natal factors
◦ Co-morbid neurological factors
92
Geneti c Fa cto rs
Up to 15 percent of cases of autism spectrum disorder
appear to be associated with a known genetic
mutation,
The most common of these inherited disorders is :-
*. fragile X syndrome,
*. X-linked recessive disorder
*. Tuberous sclerosis.
93
Immunological Factors:- immunological incompatibility
(i.e., maternal antibodies directed at the fetus)
Prenatal and Perinatal Factors:-
prenatal factors:- advanced maternal and paternal age at birth,
maternal gestational bleeding, gestational diabetes, and firstborn
baby.
Perinatal risk factors:- umbilical cord complications, birth
trauma, fetal distress, small for gestational age, low birth weight,
94
Coo morbid Neurological
Disorders
Electroencephalography (EEG)
abnormalities and seizure disorders occur
with greater than expected frequency in
individuals with autism spectrum disorder.
Four percent to 32 percent of individuals
with autism spectrum disorder have grand
mal seizures at some time, and about 20
to 25 percent show ventricular
enlargement on computed tomography
(CT) scans.
95
Introduction…
Clinical features
I . Persistent Deficits In Social Communication and
Interaction
Poor reciprocal (give--and–take) social skills and
spontaneous nonverbal social interactions
Infants may not develop a social smile, and as older babies
may lack the anticipatory posture for being picked up by a
caretaker
Less frequent and poor eye contact is common during
childhood and adolescence
A child may not differentiate the most important persons
in their lives—parents, siblings, and teachers
May not react as strongly to being left with a stranger
compared to others their age.
96
Introduction…/Clinical Features/
98
Introduction…/Clinical Features/
Insistence on sameness,
inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior
◦ e.g., extreme distress at small changes,
◦ difficulties with transitions,
◦ rigid thinking patterns,
◦ greeting rituals,
◦ need to take same route or eat same food every
day 99
Introduction…/Clinical Features/
100
Introduction…/Clinical Features/
104
DSM-5 Autism…
B. Restricted, repetitive behavior as
manifested by > 2 of the following:
currently or by history
1. Stereotyped or repetitive motor
movements, use of objects, or
2. Insistence on sameness, inflexible
adherence to routines, or ritualized
patterns of verbal or nonverbal
behavior
105
DSM-5 Autism…
106
DSM-5 Autism…
107
Severity level of Autism spectrum disorder
Severity Level Social Communication Restricted behavior
108
Differential Diagnosis
Social communication disorder
Early onset schizophrenia
Intellectual disability
Social phobia( social anxiety disorder)
109
Social communication disorder
Social communication disorder is
diagnosed for children with difficulty in
the social uses of verbal and nonverbal
communication but who do not have
restricted repetitive behavior or
activities.
Social communication disorder is
described as an impairment of
pragmatics.
Intellectual disability
There must also be impaired
adaptive functioning in
communication, social participation,
school or work, or personal
independence at home or in
community settings.
Sensory processing disorder
Sensory processing disorders refer to
individuals who perceive, process, and
respond to sensory information with
difficulty.
This processing difficulty can lead to severe
sensitivity to sensory input (input from
inside the body, and input from the external
world), leading to traumatically anxious over
stimulation.
social anxiety disorder
When shy children fail to develop peer
relations and
stop trying to share their interests with
others, these two symptoms are enough to
achieve the autism spectrum diagnosis'
criterion for qualitative impairment in social
interaction, even though the symptoms may
reflect shyness or social anxiety rather than
an autistic problem.
Obsessive-compulsive disorder
The diagnoses of OCD and autism both
require the presence of recurrent and
persistent thoughts or behaviors.
Yet in OCD the recurrent thoughts cause
anxiety, and in autism this is not necessarily
the case, or it is hard to know if this is the
case.
Further, in autism there must also be
impairment in socialization and
communication, whereas this is not required
for the OCD diagnosis.
Course and Prognosis of ASD
It is a lifelong, disorder with a highly variable
severity and prognosis
Children with IQs above 70 with average
adaptive skills, have the best prognoses
Positive changes in communication and social
domains over time are possible with higher
IQ
Repetitive behavioral symptoms have poor
progress over time
115
Management of ASD
Target core behaviors:
to improve
social interactions,
communication,
to integrate into schools,
develop meaningful peer relationships,
and increase long-term skills in independent
living
116
Management of ASD…
Psychosocial treatment interventions
◦ To develop skills in social conventions,
◦ To increase socially acceptable and pro social
behavior with peers, and
◦ To decrease odd behavioral symptoms
language and academic remediation
reduction of irritable and disruptive
behaviors
117
Management of ASD…
For parents
◦ Psycho education,
◦ support, and counseling
In order to optimize their relationships
and effectiveness with their children
118
Management of ASD…
Comprehensive treatment plans
Intensive behavioral programs,
Parent training and participation, and
Academic/educational interventions
119
Management of ASD…
Common interventions
expanding social skills, communication,
and language,
through
◦ practicing imitation,
◦ Joint attention,
◦ social reciprocity, and
◦ play in a directed but child-centered manner
120
Famous people with Autism
Leonardo Da Vinci
Mahtma Gandhi
Cleopatra
Princess Diana
Adolf Hitler
?Einstein
121
ATTENTION DEFICIT
HYPERACTIVITY
DISORDER
/ADHD/
April, 2018,
Mekelle, Ethiopia
123
Learning Objectives
After completion of this course, the students
should be able:
To define what ADHD is
To describe epidemiology and etiology of ADHD
To list out clinical features of ADHD
To explain DSM diagnostic criteria for ADHD
To deal with management of ADHD
124
ADHD
ADHD is characterized by diminished
sustained attention and higher levels of
impulsivity than expected to the child’s
age level
It is generally categorized as
Inattentive type,
Hyperactive type, and
Combined type
The symptoms should start before
the age of 12 years
125
ADHD…
Not diagnosed before the age of 12 years
until their behaviors cause problems in
school and other places
Impairment must be observable in at least
two settings and interfere with appropriate
functioning socially, academically, or in other
areas
ADHD is not diagnosed when symptoms
occur in autistic spectrem disorder,
schizophrenia, or other psychotic disorder
126
ADHD Epidemiology
Prevalence:Varied figure (1% - 20%) in
school children [western countries]
Male to female ratio= 2 – 9: 1
Girls are often inattentive/ boys are
hyperactive
1st degree biological relatives are at higher
risk
Symptoms start at the age of 3 years
127
Etiology of ADHD
Genetics
High risk among monozygotic twins if one
develops the disorder
Biological parents have higher risk than
adoption parents
Children with ADHD are at risk of developing
conduct disorder, alcohol use disorder and
antisocial personality disorder
Developmental factors
prenatal infection during 1st trimester
pregnancy 128
Etiology of ADHD…
Brain damage
Physical damage to the brain during early
infancy by infection, inflammation and trauma
Neuro chemical factors
Possible dysfunction in both adrenergic and
dopaminergic systems
Not accounted to a single neuro transmitter
129
Diagnosis of ADHD
Detailed history of child development is
crucial
Direct observation of the child in situations
that require attention
Hyperactivity may be severe at school; less
in sports and games
Persistent, impairing symptoms of either
hyperactivity/impulsivity or inattention that
cause impairment in at least two different
settings
130
Dx of ADHD…
Inattentiveness
At school, a child cannot follow instructions and
often demand extra attention from their
teachers.
At home, they often do not comply with their
parents' requests; act impulsively; show
emotional lability, and are explosive and irritable
Hyperactive children are referred more
frequently than inattentive children
131
Dx of ADHD…
Hyperactive children are more exposed to
conduct disorder than inattentive
School history and teachers' reports in
evaluating a child's difficulties in learning and
school behavior
are primarily caused by the child's inability to
sustain attention or compromised understanding
of the academic material
Additional school difficulties can result from
attitudinal or maturational problems, social
rejection, and poor self-image because of felt
inadequacies
132
Dx of ADHD…
How the child has related to siblings, to peers,
to adults, and to free and structured activities
It also helps to identify the complications of the
disorder
MSE
Secondarily depressed mood, but no thought
disturbance, impaired reality testing, or inappropriate
affect
A child may show great distractibility, perseveration,
and a concrete and literal mode of thinking
133
Dx of ADHD…
134
Clinical features
Infants with the disorder are overly
sensitive to stimuli and are easily upset by
noise, light, temperature, and
environmental changes
138
ADHD
HYPERACTIVITY
DSM 5 Diagnostic criteria for ADHD
A. A persistent pattern of
1. Inattention and/or
2. Hyperactivity-- Impulsivity that interferes
with functioning or development.
147
AUTISM ADHD
Both exhibit social dysfunction and difficult to manage behavior.
149
ADHD is a deficit in self-control-in what
some professionals call the executive functions
critical to planning, organization, and carrying
out complex human behavior over long
periods of time.
That is, in a child with ADHD, the
“executive” in the brain that is supposed to
be organizing and controlling behavior,
helping the child plan for the future and
follow through on those plans, is doing a
very poor job.
ADHD drugs primarily target the prefrontal
cortex (PFC), a region of the brain that is
associated with attention, decision-making
and an individual's expression of personality.
ADHD drugs fall into a class of medications
known as stimulants. ADHD stimulants
boost levels of two neurotransmitters, or
chemical messengers in the brain, known as
dopamine and norepinephrine.
A Possible Developmental Pathway for ADHD
PATHOGENESIS
Lower activity in brain regions associated with
executive function (particularly abnormalities in
Frontostriatal circuit):
Prefrontal cortex
Basal ganglia
Cerebellum(vermis)
These areas of the brain are associated with
executive function abilities:
Attention, spatial working memory, and
short-term memory.
Management of ADHD
Pharmacotherapy
- Is first line management of ADHD
- CNS stimulants are first choices
- Methylphenidate (Ritalin)
- Dextroamphetamine (Dexedrine)
- Dextroamphetamine and amphetamine salt
combinations
- 2nd line choices include anti depressants like
Imipramine, Bupropion,Venlafaxine
- Should be used cautiously because of their effect of
impairing liver activity
154
STIMULANTS:
1. Methylphenidate:
• Available in immediate and sustained release.
• Absorption: From the GI tract, slow and
incomplete
• Dose(Ritalin): 5mg (0.3mg/kg/dose) PO BID
before breakfast and lunch.
– Increase by 5-10mg/day (0.2mg/kg/day) at
weekly intervals.
– Max = 60mg/day (2mg/kg/day).
2. Dexmethylphenidate
• Better absorbed.
• Initial Dose: 2.5mg PO BID OR 10mg PO
(XR).
Side effect of stimulant
• Common: Anorexia, Sleep disturbance,
Weight loss, Nervousness/ Restlessness,
Growth retardation Increased blood
pressure.
• Severe: Tics, Arrhythmia, Psychosis, Sudden
cardiac death, drug abuse potential.
3. Amphetamines:
Dextroamphetamine
- 5mg PO once or twice daily
- MAX: 40mg/day.
NON-STIMULANTS
• Usually second-line treatments
– If stimulants are poorly tolerated or ineffective
– As mono therapy or adjunct to stimulants
Atomoxetine:-
-- selective nor epinephrine reuptake inhibitor.
• Second-line treatment or alternative for patients with
history of drug abuse.
• Dose: 0.5mg/kg,
• Max = 1.4mg/kg
Side Effects: -
– Common: weight loss, abdominal pain, appetite
suppression, sleep disturbance
Alpha-2 adrenergic agonist:-
-Clonidine and Guanfacine
Clonidine at 3-10 mg/kg/day used as alternative
or adjunctive to Methylphenidate.
162
Guiding Principles for Raising a Child with
ADHD (Barkley, 1995)
1. Give your child more immediate
feedback and consequences
2. Give more frequent feedback
3. Use incentives before punishment
4. Strive for consistency
163
Guiding Principles for Raising a Child with
ADHD (cont’d)
6. Act, don’t yak (talk)!
7. Plan ahead for problem situations
8. Don’t personalize your child’s problems
or the disorder
9. Practice forgiveness
164
Additional Tips for Managing ADHD Behaviors
166
Tips for Managing ADHD (Cont’d)
Be patient
Be persistent
Be understanding
*Most importantly, remember to
differentiate the behaviors from the child
◦ Bad behaviors are not synonymous with a
bad child
167
CONDUCT DISORDER
Conduct disorder,
◦ male predominance
◦ more physical aggression
◦ impaired peer-relationships
◦ co morbid ADHD
Intro…
Adolescent-onset have
◦ few symptoms before puberty
◦ less likely to be aggressive
◦ more likely to be females.
◦ Most adolescents with this sub-type have friends but with
the context of gang or other delinquent group.
The prognosis for adolescent onset is better than the
childhood onset
Prevalence approximately 5 %
Intro…
The average age of onset of conduct
disorder is younger in boys than in girls.
Boys most commonly meet the diagnostic
criteria by 10 to 12 years of age,
whereas girls often reach 14 to 16 years of
age before the criteria are met.
DSM-5 Diagnostic Criteria for CD
◦ Destroy property
◦ Set fires.
Etiology…
Abuses
Child abuse and maltreatment
Maternal abuse
Caregiver’s physical / or sexual abuse
Differential Diagnosis
Mood disorder
◦ Bipolar Disorder
Psychotic Disorder
ADHD
Course and prognosis
CD remits in many youths, but some lead
lives of delinquency or develop antisocial
personality disorder.
Low IQ, parental antisocial personality,
early age of onset, greater number of
symptoms exhibited predict persistence
of CD.
Successful interventions of the pre morbid
conditions also predict the outcome of CD
Course and prognosis
191
Treatment
Psychotherapy mostly cognitive-Behavioral
Parent management training
Group therapy
Pharmacotherapy
OPPOSITIONAL
DEFIANT
DISORDER (ODD)
March, 2018,
Mekelle, Ethiopia
OPPOSITIONAL DEFIANT DISORDER
Learning Objectives:
After finishing this chapter, you should be
able:
- To discuss what ODD is,
- To describe common features of ODD,
- To explain etiology and epidemiology of
ODD,
- To clarify DSM diagnostic criteria for
ODD,
- To deal with management of ODD
ODD…
It is Characterized by enduring patterns of
negativistic, disobedient, and hostile
behavior toward authority figures,
Inability to take responsibility for mistakes,
leading to placing blame on others
Children with ODD frequently argue with
adults and become easily annoyed by
others, leading to a state of anger and
anger
ODD…
may have difficulty in the classroom and with
peer relationships,
but generally do not choose to physical
aggression or significantly destructive behavior
a child's temper outbursts, active refusal to
comply with rules, and annoying behaviors
exceed
The disorder is an enduring pattern of
negativistic, hostile, and defiant behaviors in the
absence of serious violations of social norms or
of the rights of others.
Epidemiology of ODD
Prevalence rates for this disorder range from
2 to 16%
Although it can begin as early as 3 years of
age, it typically is noted by 8 years of age and
usually not later than adolescence
16 to 22% of school-age children
Common in boys than girls (3:1)
Etiology of ODD
Several psychosocial mechanisms have been
hypothesized:
Parents use inconsistent methods of
disciplining, structuring and limit-setting
1. Angry/Irritable
◦ children often lose their tempers, are easily
annoyed, and feel irritable much of the time
Clinical presentation…
2. Argumentative/Defiant
- a pattern of arguing with authority figures, and
adults such as parents, teachers, and relatives
- actively refuse to comply with requests,
deliberately break rules, and purposely annoy
others
- often do not take responsibility for their actions,
and often blame others for their misbehavior
3. Vindictive type
- children are spiteful, and have shown vindictive
or spiteful actions at least twice in 6 months
to meet diagnostic criteria
ODD: DSM-5 Diagnostic criteria
A. A pattern of angry/irritable mood,
argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as
evidenced by at least four symptoms
Angry/Irritable Mood
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful
DSM-5 criteria…
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for
children and adolescents, with adults.
5. Often actively defies or refuses to comply with
requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or
misbehavior.
Vindictiveness
8. Has been spiteful or vindictive at least twice
within the past 6 months
DSM criteria…
B. The disturbance in behavior causes
clinically significant impairment in social,
academic, or occupational functioning
Somatic complains
Psychomotor agitation
School difficulties
Unemployment
Bereavement
293
Learning Objectives
After completion of this course; the students should
be able to:
Describe what enuresis and encopresis are
Identify common diagnostic criteria (DSM-5)
Discuss management principles for children with
elimination problems
294
Normal Development
Bowel Continence
Bladder Continence
295
Introduction
All involve the inappropriate elimination of
urine or feces and are usually first diagnosed
in childhood or adolescence
This group of disorders includes
◦ enuresis, the repeated voiding of urine into
inappropriate places, and
◦ encopresis, the repeated passage of feces into
inappropriate places
296
Introduction
The normal sequence of developing control over
bowel and bladder functions is the development of:
◦ nocturnal fecal continence,
◦ diurnal fecal continence,
◦ diurnal bladder control, and
◦ nocturnal bladder control.
297
Introduction…
Bowel and bladder control develops gradually
over time
Toilet training is affected by many factors,
◦ such as a child’s intellectual capacity and social
maturity,
◦ Cultural determinants, and
◦ the psychological interactions between child and
parents
298
Introduction…
It also depends on the maturation of
neurobiological systems, so that children with
developmental delays may also display delayed
continence of bowel and bladder.
When children exhibit incontinence of urine or
feces on a regular basis, it is troubling to the child
and families, and often misunderstood as voluntary
misbehavior.
299
Introduction…
Diagnosis is not made for
300
encopresis
301
Encopresis
Encopresis is characterized by a pattern of
passing feces in inappropriate places, such as
in clothing or other places,
At least once per month for 3 consecutive
months,
whether the passage is involuntary or
intentional
302
Encopresis…
Up to about 80% of children with fecal
incontinence have associated constipation
A child with encopresis typically exhibits
dys regulated bowel function;
◦ for example, with infrequent bowel movements,
◦ constipation, or
◦ recurrent abdominal pain and
◦ sometimes pain on defecations
303
Encopresis…
Affects
◦ 3% of 4-year-olds and
◦ 1.6% of 10-year-old children
◦ 0.75% of 10-12 year old children
◦ virtually absent in youth with normal
intellectual function by the age of 16 years
◦ Male: Female = (3 - 6): 1
304
Encopresis…
It is considered interplay between
physiological and psychological factors
leading to an avoidance of defecation
Can be due to medical conditions
Parents insisting that their children attempt
to defecate before they are adequately
treated
305
Encopresis…
an expression of anger or rage in a child whose
parents have been punitive or of hostility at a
parent
can also be present on an involuntary basis in
the absence of physiological abnormalities
The feces may be of normal, near-normal, or
liquid consistency
In rare cases, the involuntary overflow of stool
results from psychological causes of diarrhea
306
Encopresis…
To receive a diagnosis of encopresis, a
child must have a developmental or
chronological level of at least 4 years
307
Encopresis: DSM-5 Diagnostic Criteria
A. Repeated passage of feces into inappropriate
places (e.g., clothing, floor), whether involuntary
or intentional
B. At least once per month for at least 3 months
C. Chronological age is at least 4 years (or
equivalent developmental level)
D. The behavior is not attributable to the
physiological effects of a substance or medical
condition except constipation
308
Encopresis: Course & Prognosis
In some cases, encopresis is self-limiting
It rarely continues beyond middle
adolescence
To family members, who may assume that the
behavior is due to “laziness,” and family
tensions are often high, the outcome is
guarded
309
Encopresis: Course & Prognosis…
It is affected by
◦ family’s willingness and ability to participate in
treatment without being overly punitive and
◦ the child’s ability and motivation to engage in
treatment
310
Encopresis: Treatment
Combination of medical and behavioral
treatment the most effective approach
Medical Treatment
◦ Clean out the bowel
◦ Enemas
◦ Laxatives
◦ Increase fiber and exercise
◦ Ensure regular bowel movements
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Encopresis: Treatment
CBT
◦ Regular attempts to have bowel movements in the
toilet, and to diminish anxiety related to bowel
movement
Regular, timed intervals on the toilet
Family tensions about the symptom must be
reduced, and
a non punitive atmosphere should be
established
Similar efforts should be made to reduce the
child’s embarrassment at school
312
Encopresis: Treatment…
Interactive parent–child family guidance
intervention
Supportive psychotherapy and relaxation
techniques
Laxatives for those with constipation
313
enuresis
314
Enuresis
Prevalence
◦ 5 to 10 % in 5-year-olds,
◦ 1.5 to 5 % in 9- to 10-year-olds, and
◦ 1% in adolescents 15 years and older
315
Enuresis…
Among boys
Nocturnal enuresis is about 50%more
common and
Accounts for about 80%of children with
enuresis
316
Enuresis: Diagnostic Criteria
Enuresis
◦ Repeated voiding of urine into bed or clothes
◦ Clinically significant
Twice per week for at least 3 consecutive months
Impairment in daily functioning (e.g., social academic)
◦ Chronological Age: 5 years (or developmental
equivalent)
◦ Behavior is not due exclusively to the direct
physiological effect of the following:
Substance (e.g., diuretic)
General Medical Condition (e.g., diabetes. Seizure disorder)
317
Enuresis: Definition
Enuresis Types:
◦ Diurnal
Voids occurring during the daytime
◦ Nocturnal
Voids occurring during the nighttime
318
Enuresis: Etiology
Enuresis involves complex neurobiological
systems
Excessive volumes of urine produced at night
may lead to enuresis at night in children
without any physiologic abnormalities
Nighttime enuresis often occurs in the
absence of a specific neurogenic cause
Daytime enuresis may develop based on
behavioral habits developed over time
319
Enuresis: Etiology
Daytime enuresis may occur in the absence
of neurological abnormalities
◦ resulting from habitual, voluntary tightening of
the external sphincter during urges to urinate
Genetic/familial factors
Psychosocial stressors appear to precipitate
enuresis
320
Enuresis: DSM – 5 Diagnostic
criteria
A. Repeated voiding of urine into bed or clothes,
whether involuntary or intentional
B. Either a frequency of at least twice a week for at
least 3 consecutive months or
the presence of significant distress or impairment in social,
academic or other important areas of functioning
C. Chronological age is at least 5 years (or equivalent
developmental level)
D. The behavior is not attributable to the
physiological effects of a substance or another
medical condition 321
Enuresis: Assessment
Medical Assessment
◦ Rule out significant medical condition
◦ Most often already ruled out by the time you
see the kid
Behavioral Assessment
◦ Assess general behavior using a broad-band
rating scale
322
Enuresis: Assessment
Behavioral Assessment: Interview
◦ Behavioral or developmental problems
◦ Medical conditions
◦ History and current status of problem
◦ Family history
◦ Potty training history
323
Enuresis: Assessment
Behavioral Assessment: Interview
◦ Environmental contributors (e.g., when, how
much fluid intake, proximity to b-room, sleep
routine and arrangements)
◦ Consequences (e.g., how do parents handle it,
how does the child react)
◦ Child’s feelings and motivation to treatment
324
Enuresis: Assessment
Behavioral Assessment: Recording Data
◦ Provide Chart for recording voids
◦ Assess time of night, number of voids, size of
void, reaction
325
Physical Exam
Abdominal pain/distention
Height/Weight
Neurological Exam
Skin Exam
Rectal Exam
Abdominal XRAY
Stool Collection
Blood Testing
Rectal Biopsy/Barium Enema
326
Enuresis: Treatment
Behavioral
◦ Moisture Alarm (Bell and Pad)
Classical Conditioning
Full bladder
Voids
Alarm sounds
Awakenings
Operant Conditioning
Avoid aversive conditions during night (e.g., waking up to
a wet bed, cleaning up procedures, changing bed linens)
327
Enuresis: Treatment
Moisture Alarm
◦ Generally achieve dry nights within 2- 4
months
◦ Research suggests up to 70% successful
outcomes
◦ High Response Effort
328
Enuresis: Treatment
Arousal Training –Focus on R+ getting up
◦ Awakens
◦ Turns off alarm
◦ Attends the restroom for toilet sit
◦ Reattach enuresis alarm
329
Enuresis: Treatment
Pharmacological
◦ Imipramine (Trofanil)
Tricyclic antidepressant
Once medication discontinued, bedwetting resumes
Relapse rate varies from 60% to 90%
Duration of treatment varies without consensus
330
Enuresis: Treatment
Pharmacological
◦ Desmopressin Acetate (DDAVP)
Analogue of Vasopressin (ADH)
Supports urine concentration
Decreases urine volume during nighttime
◦ Research findings yield mixed outcomes
Increased number of dry nights
Dryness may not maintain once terminate DDAVP
Relapse rate varies from 50% to 95%
331
332