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Child psychiatry prof. fareed minhas

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Child psychiatry prof. fareed minhas

  1. 1. CLASSIFICATION: WHO/Rutter et al. 1975 1. Clinical Psychiatric Syndrome. 2. Specific delays in development. 3. Intellectual level. 4. Physical condition e.g. cerebral palsy. 5. Psychosocial problems e.g. divorce.
  2. 2.  Emotional Disorders: Anxiety. Depression. OCD. Hysteria, Phobia  Conduct Disorder: A persistent pattern of conduct, in which the basic rights of the others or major age appropriate norms or rules are violated.  Juvenile Delinquency: A behavior leading to convection of a young person of criminal offence, or am offence which would be criminal in an adult.
  3. 3. EPIDEMIOLOGY: Isle of Wight Physical health, including education, Psychological difficulties. 10-11 years old. Parents and Teachers questionnaires: Screened children → Ψ. Psychological tests and parents interviewed.  1 year prevalence: 7%  Rate in boys twice as high as girls.  No correlation with Social Class.  Increase prevalence with decrease I.Q.  Association with physical handicap
  4. 4. No illness 6.8% General 10.4% CNS 34% CNS and fits. 58%  Psychiatric illness was related to the severity of brain damage and not site.  Association Mental retardation and conduct disorders.
  5. 5. CAUSES OF PSYCHIATRIC DISORDERS 1.     2. 3. 4. CONSTITUTINAL FACTORS. Genetic Factors The effects of chromosomes abnormalities. The consequences of intrauterine damage. The result of birth injury. Physical disease and injury. Temperamental factors.
  6. 6. Easy children:  Regularity in biological functions. Positive approach to new stimuli. High adaptability to change. Mild or moderate mood intensity which is predominantly positive. 40% Difficult children:  Irregularity in biological functions. Negative withdrawal response to new stimuli. Non or slow adaptability to change. Intense mood expressions which are frequently negative. 10%. Slow to warm-up:  Negative responses of mild intensity to new stimuli, with slow adaptability after repeated contact. Mild intensity of reactions generally. Less irregularity of biological functioning than the difficult children. 15%
  7. 7. 4. ENVIRONMENTAL FACTORS Family. Wider social setting, sheltered ground, miniature society where learns to live as a member of the Group, facilitate development.  Attitudes are formed.  Disagreements/Arguments/Angry with each other.  Repression by parents of negative emotions—poor preparation for realities of life.  Stability of family group.  General Systems theory– family is a unit. Its own unwritten rules and ways of functioning. Its parts are members which are dynamically interrelated and interdependent.  Boundary—rigid, well defined DISENGAGEMENT or weak/blurred ENMESHMENT.
  9. 9. Goodness of fit.  Chess and Thomas emphasize the importance of the goodness, or poorness of fit between children and environment.  They make it clear that there is no “optimal” temperamental style that ideally all children should display, nor is there one ideal environment for children’s development.
  10. 10. Self-esteem.  Acquiring sense of self worth is a major developmental task of childhood.  Starts in infancy and continues throughout childhood and adolescence.  Good feelings of self worth is one of the major developmental tasks.  Developments depends on:  Parents child relationship.  Temperament of the parents and child. Parental attitudes, opinions and behavior.  Value the child gives to the significant others e.g. mother vs. strangers. 
  11. 11. High Self esteem:    Total acceptance of children by their parents. Clearly defined and enforced limits. Respect for individuals actions within limits. Positive Self esteem requires the experience of mastering the environment, in ways which provides feelings of satisfaction and appropriate affirming feedback from the environment.
  12. 12. NORMAL DEVELOPMENT: Smiling 3 weeks. Social Smile. 6-12 weeks Smile regularly at any one. 12-20 weeks Selective smiling.
  13. 13. Types of Developments  Physical – Motor development  Cognitive development  Perceptual development  Social & Emotional development  Sexual development  Moral development
  14. 14. Physical Development Birth-Childhood Head lifting  Lying, roles  Sitting  Crawling  Creeping  Supported walk  Independent walk  1.5 – 2 months 2 months 3- 4 months 28 weeks 7 months 10 months 11-12 months 14 months
  15. 15. Pen and Paper 2. Can draw a line. _________ 3. Can draw a circle. Ο 4. Can draw a Square Ɗ 5. Can draw a Star. *
  16. 16. PLAY: 6-8/12 Object Centered. 2 years Plays parallel to other children. 3 years Active co-operative play. 5 years. According to rules.
  17. 17. NORMAL CHILD DEVELOPMENT First year.  Oral Stage.  Motor functioning. (3/52. Social Smile. 6-12/52. Smiles regularly at anyone. 12-20/52. Selective smiling).  Attachment and Bonding Behavior.  Features of attachment behavior: Crying, Calling, Stranger anxiety, Separation anxiety– all bringing proximity to the attachment figure. Infants attachment results primarily from the availability of a familiar figure. Increased social interaction results in increased attachment. IT DOES NOT DEPEND ON GRATIFICATION OF NEEDS.  Intellectual development. 
  18. 18. NORMAL CHILD DEVELOPMENT Second year.  Learns to walk and talk  Anal stage: Learns bladder control.  Temper Tantrums.
  19. 19. THE PRE SCHOOL PERIOD. (2-5 YEARS)  Further intellectual development e.g. language.  Increase in socialization. Sexual identity.       Identification with parents-motivation to do certain things. Beginning of conscience formation. The establishment of defense mechanism to deal with anxiety and guilt. The development of patterns of behavior towards those outside the family. Fantasy life. Transitional Objects.
  20. 20. MIDDLE CHILDHOOD. (5-10 YEARS)  Latency period. Clear conception of position in the family and well defined identity as a boy of girl.  Learns the fundamentals of technology.  Learns to cope with more complex and less supportive environments.  Learns to deal with defense mechanisms of anxiety and guilt.
  21. 21. ADOLESCENCE    Duration: Girls (12-21) Boys (14-25) Era of : Storm & Stress Changing from being nurtured and cared for to being able to nurture and care for others.  Becoming materially self-sufficient.  Accepting adult sexual role and coping with heterosexual behavior.  Moving out of the family of origin to form a new family of procreation.
  22. 22. RESOLUTION OF ADOLESCENCE  Attainment of separation and independence from parents.  Establishment of sexual identity.  Commitment to work.  Development of a personal moral system. The capacity for lasting relationships, and for both tender and genital sexual love in heterosexual relationships.   The return to the parents in a new relationship based on relative equality.
  23. 23. SCHOOLS Factors favorably influencing behavior and attainments were: A reasonable balance between intellectually able and less able children.  The ample use of rewards, praise and appreciation by teachers.  A pleasant, comfortable and attractive school environment.  Plenty of opportunity for children to be responsible for and participate in the running of the school.  An appropriate emphasis on academic matters.  Good models of behavior provided by teachers.  The use of appropriate group management skills in classrooms.   Firm leadership in the school, combined with a decision making process involving all staff and leading to a cohesive approach in which staff members support each other.
  24. 24. ATTACHMENT THEORY. J. BOWLBY.   Attachment occurs when there is a warm, intimate and continuous relationship with the mother in which both find satisfaction and enjoyment. Slow process.  The amount of time together is less important than the amount of activity between the two.  Bonding concerns the mother’s feelings towards the infant. Its not dependent on the feeling of security.  Skin to skin contact.? Critical time.? 
  25. 25. SIGNAL INDICATORS:  Signs of distress in the infant that prompt a behavioral response from the mother.  Three types of crying. 1. Hunger. 2. Anger. 3. Pain.  Smiling, Cooing and Looking.
  26. 26. Isolated Monkeys HARRY HARLOW . Demonstrated the emotional and behavioral effects in monkeys who were isolated from birth and were thereby kept from forming attachments. The isolates were  WITHDRAWN,  UNABLE TO RELATE TO PEERS,  UNABLE TO MATE AND  INCAPABLE OF CARING FOR THEIR OFFSPRING.
  27. 27. ATTACHMENT PHASES 1. PREATTACHMENT STAGE. Birth – 8 or 12 weeks. Baby orientates to its mother, follows her with over 180 degrees range, turns towards and rhythmically with her voice. 2. ATTACHMENT IN THE MAKING. 8 or 12 weeks-6 months. Baby attaches to me or more persons in the environment. 3. CLEAR CUT ATTACHMENT. 6 - 24 months. Infant cries and shows other signs of distress when separated from mother.
  28. 28. Separation 1. 2. 3. PROTEST. Child protests against separation by crying, calling out and searching for the lost person. DESPAIR Child appears to lose hope that the mother will ever return. DETACHMENT Child emotionally separates itself from its mother. Child responds in an indifferent manner when the mother returns: Mother has not been forgotten, but the child is angry at her for having gone away in the first place and fears that she will go away again.
  29. 29. Piaget COGNITIVE DEVELOPMENT 1. SENSORI-MOTOR STAGE. Birth – 2 years.  Differentiates self from objects.  Recognizes self as agent of action.  Begins to act intentionally.  Achieves object permanence.  Achieves object constancy.
  30. 30. PRE OPERATIONAL STAGE.  2-7 YRS. Learns to use language.  EGOCENTRIC THINKING. Sees himself as center of the world.  ANIMISM. Objects having thought/feelings.  PRECAUSAL REASONING. Irrational explanations.  AUTHORITARIAN MORALITY. Behavior is seen as good or bad, black and white.
  31. 31. CONCRETE OPERATIONAL STAGE 8-12 YEARS.  Can think logically about objects/events.  Achieves conservation of numbers, mass and weight.  Classifies objects according to several features & can arrange them in series along single dimension e.g. size.
  32. 32. FORMAL OPERATIONAL STAGE. 12-15 YEARS  Can think logically & test hypothesis systematically.  Becomes concerned with future & ideological problems.
  33. 33. PSYCHOANALYSIS: Freud. 1916. MODEL OF MIND: 1. 2. 3. The ID which contains the instinctual or psychic energy necessary to drive the whole system. This is entirely UC and obeys the PLAESURE PRINCIPLE, BY WHICH TENSION IS REDUCED AS RAPIDLY AS POSSIBLE, WITHOUT REGARD TO CONSEQUENCES. Its mode of operation is described as PRIMARY PROCESS THINKING. The EGO, which develops from the ID, obeys the REALITY PRINCIPLE. It seeks gratification but takes SECONDARY PROCESS HINKING. The SUPEREGO is the conscious of the individual and incorporates the society’s moral standard.
  34. 34. STAGES OF PSYCHOSEXUAL DEVELOPMENT: • • • • • ORAL (0-1 YR.) child gains maximum pleasures from oral activities such as sucking and feeding. ANAL (1-2 YR.) Here the activity centers around the retention and elimination of feces. PHALLIC. (3-5 YR.) The genitalia become the focus of attention and the child enters a crisis phase described as the OEDIPAL COMPLEX. The child is attracted to the parent of the opposite sex, conflicts results because of the risk of punishment. LATENCY. (5-12 YR.) No major psychosexual development takes place in this phase. GENITAL. This is the final stage in which the individual achieves full heterosexual development.
  35. 35. MORAL REASONING: KOHLBERG. Level I Stage1 Stage2 Level II Stage 3 Pre conventional Morality: Punishment orientation. Obeys rules to avoid punish confirms to obtain rewards, to have favors returned. Reward Orientation. Conventional Morality: Good-boy/Good-girl orientation: Confirm to avoid disapproval of others. Upholds laws and social rules to award censure of authorities.
  36. 36. Stage 4 Level III Stage 5: Stage 6: Authority orientation. Post conventional morality: Social – contract orientation. Actions guided by principles commonly agreed on as essential to public welfare, respect of peers. Ethical principle. Orientation. Actions guided by self chosen ethical principles, (that usually value justice, dignity and equality), principles upheld to avoid self condemnation.
  37. 37. EMOTIONAL DISORDERS School Refusal: Child not Persistent reluctance or refusal to got school in order to sty with major attachment figure. Not at home. (truancy) domestic reasons At school Kept at home At home. Emotion dis. With pwerts School refusal Separation anxiety. Fear of travel General social with drawal specific fear at school Prevalence in general population not known. 3% I.W. Age of presentation: 5-7, 11×14. Equal sex distribution. Increase in decrease S.E. Class.
  38. 38. NIGHT TERRORS Repeated episodes of abrupt awakening lasting 1-10 minutes occurring between 30-180 minutes after onset of sleep. Usually begin with panicky scream. Signs of autonomic arousal – tachycardia, rapid breathing, dilated pupil etc. Relatively unresponsive to others. Confusion, disorientation and preservation of movements. Typically occurs during stages 3 & 4 sleep.
  39. 39. SLEEP WALKING Repeated episodes of arising from bed during sleep walking about for several minutes and remaining unresponsive to the efforts of others . Can be woken with great difficulty. Amnesic on waking. Usually occurs between 30-180 minutes after onset of sleep EEG – delta activity, stages 3+4. Between 1- 4% of children experience at some time. Isolated episodes even increase frequent. Usually disappears in adolescence.
  40. 40. THE CONCEPT OF INVULNERABILITY Some children survive GROSS DEPRIVATION & SEVERE PSYCHOLOGICAL STRESS, WITHOUT DEVELOPING psychiatric disorder. Vulnerable but invincible-an important study of children’s resilience and invulnerability. Longitudinal study of 698 Hawaiian island by Werner and Smith. 1982. What distinguished the resilient high-risk children? They:  Had few serious illnesses in their first 2 decades, and recovered quickly from those they had.  Were perceived to be “very active” and “socially responsive”as infants.  Showed advanced self-help, sensorimotor and language development I the 2 year of life.
  41. 41. PERVASIVE DEVELOPMENTAL DISORDERS  Childhood autism  Rett’s syndrome  Other childhood disintegrative disorder overactive disorder with mental retardation and stereotyped movements  Asperger’s syndrome  Atypical autism pervasive developmental disorder not otherwise specified.
  42. 42. CHILDHOOD AUTISM  Autistic aloness.  Speech and language disorder  Cognitive defect  Obsessive desire for sameness  Bizarre behavior and mannerisms Other features Sudden anger or fear without any reason over-active, distractible, poor sleep, soil or wet themselves. 
  43. 43. AETIOLOGY  Genetic factors  Organic brain disease  Abnormal parenting
  44. 44. PROGNOSIS  Between 10 and 20 percent of children with childhood autism begin to improve between the ages of about four and six years. And are able to attend an ordinary school.  10-20 percent can live at at home but cannot work and need to attend a special school or training centre.  60 percent improve little and are unable to lead an independent life, may need long-term residential care.
  45. 45. DIFFERENTIAL DIAGNOSIS  Childhood disintegrative disorders.  Asperger’s syndrome  Deafness  Developmental language disorder  Mental retardation
  46. 46. ASSESSMENT  Cognitive level  Language ability  Communication skills, social skills, and play, and repetitive or other abnormal behavior  Stage of social development in relation to age, mental age, and stage of language development  Associated medical conditions  Psychosocial factors
  47. 47. TREATMENT  Management of abnormal behavior  Arrangement for social and educational services  Help for the family
  48. 48. QUESTION  A ten years old boy has been brought to you by his mother complaining that he lies, steals and damages house hold items. There have been repeated complaints from the school for the last 04 years about his poor performance academically and refusal to follow rules.  The child was cooperative during the interview expressing his unhappiness with school authorities and his parents who quarrel all the time paying little attention to him.  Psychological testing showed no evidence of any abnormality.
  49. 49. WHAT IS YOUR DIAGNOSIS  Conduct disorder
  50. 50. WHAT ARE OTHER CONDITIONS WHICH CAN CO EXIST WITH THIS DISORDER?  Depressive illness  Learning disability  Attention deficit hyperactivity disorder  Specific learning disabilities.
  51. 51. WHAT ARE YOUR TREATMENT OPTIONS? Family therapy – changes in family system and setting up of ground rules.     Behavioral modifications Changes in school environment may be change of teachers/class Group therapy Residential case program. It has to be a multidisciplinary approach.