PEDIATRIC MENTAL

HEALTH
 DISRUPTIVE, IMPULSE
CONTROL AND CONDUCT
DISORDERS
• Oppositional Defiant Disorder
• Conduct Disorder
 Oppositional Defiant Disorder (ODD)
• Pattern of negative, hostile, and defiant behavior and angry mood that
lasts at least 6 months

• Begins at early age with excessive temper tantrums, argumentativeness

and defying rules, refusal to comply with rules, anger & resentment

• Developmental level, gender and culture must be considered before

making the diagnosis

• These behaviors cause impairments in social, educational, and vocational

activities and may occur in one or multiple settings
 Conduct Disorder (CD)
• A repetitive & persistent pattern for at least 12 months, of disregard for the
rights of others, ignoring norms, breaking rules.
• Four main problem areas are:
• Aggression toward people and animals
• Some examples: _Bullying and threatening, staring physical fights, using weapons in fight________
• Destruction of property
• Examples: _deliberate fire setting, vandalism__________________________________
• Deceitfulness or theft
• Examples: _breaking into a house or car, shoplifting, lying to obtain goods___________________
• Serious violation of rules
• ODD may develop into CD at later ages
• If onset occurs in adolescence without prior history it may be transient
 ODD & CD: Treatment
• Behavioral techniques:
• ___Setting consistent limits____________________________________________
• ___Behavioral expectations and consequences_______________________________
• ___Behavioral contract_____________________________________________
• ___Positive reinforcements, tokens_____________________________________

• Medications: antidepressants, mood stabilizers, antipsychotics

• Development & improvement of self-esteem & self-efficacy

• Development of skills for competence in ADL, school & leisure may

improve emotional adjustment
ANXIETY DISORDERS
• Generalized anxiety disorder
• Panic disorder
• Social anxiety disorder
• Obsessive Compulsive Disorder
(OCD)
• Post-traumatic stress disorder
 Generalized anxiety disorder
• The diagnosis requires at least 3 months of excessive anxiety and worry on most days,
about two or more areas (family, health, finances, school or work).

• Child has difficulty controlling the worry and has accompanying symptoms such as
• restlessness, feeling keyed up,
• Quick fatigue
• Problems concentrating,
• Irritability
• Muscle tension
• Disturbed sleep

• Child requires frequent reassurances

• Treatment includes cognitive behavioral therapy, and at times medications such as SSRIs
 Panic Disorder
• Panic attacks recur, are unexpected and combine with
consequences of the attacks.

• May cause change in body functions: fast heartbeat, rapid

breathing, sweating

• Usually do not begin until puberty

• Treatment includes cognitive behavioral therapy and medications

(benzodiazepines)
 Social anxiety disorder
• Intense fear of acting in a way that will be negatively evaluated

• The fear is out of proportion to the actual danger posed by the social
situation

• Extreme cases may cause selective mutism

• Social phobia includes marked and persistent fear of one or more social
situations in which a person is exposed to strangers or scrutiny

• This fear impairs social functioning and sometimes school performance

• Treatment includes cognitive behavioral therapy, speech making and

acting classes, and medications (SSRIs)
 Post traumatic stress disorder
• PTSD is anxiety disorder that occurs after exposure to a traumatic event in which the person
experiences or witnesses an actual or threatened death, serious injury or loss of a parent or
other attachment figure.

• In children with developmental disabilities, PTSD may occur after physical abuse, or injury
that caused the disability

• Children with ID may be at risk for PTSD due to limited coping skills.

• Common in children with severe medical conditions and in refugee children

• Symptoms include:
• Re-experiencing trauma,

• avoidance and numbing, and

• increased arousal

• Treatment includes psychotherapy, play therapy, and SSRIs

 Obsessive Compulsive Disorder (OCD)
• Characterized by obsessive thoughts and compulsive activities

• Obsessions- recurrent thoughts, images, or impulses that are experienced as

disturbing, intrusive, & inappropriate and cause anxiety or distress

• Compulsions- repetitive behaviors or mental acts that are done to neutralize

obsessions, reduce anxiety/distress or as a part of following rigid rules.

• Obsessions & compulsions must last for more that 1 hour/day and interfere
with functioning

• Treatment includes cognitive behavioral therapy, SSRIs. Antianxiety &

antidepressant medications may also help.
• http://www.youtube.com/watch?v=OcXn3m3M-U0
 Comorbidity

• ADHD, Tourette Syndrome, Obsessive-compulsive disorder

and oppositional- defiant disorder are distinct categories of
behavioral disorders that have a high co-morbidity rate
MOOD DISORDERS
• Major Depression
• Bipolar disorder
 Depression
• About 5 % children and adolescents in the general population suffer from
depression at any given point in time

• Children under stress, who experience loss, or who have attention,

learning, conduct or anxiety disorders are at a higher risk

• Symptoms of depression due to bereavement should not be the cause of

the diagnosis

• The symptoms should cause impairment in the child’s daily function

• http://www.5min.com/Video/Childhood-Depression-175539380
 Depression - Symptoms
• Depressed mood by subjective report or as observed by others (children and
adolescents may have irritable mood)

• Decreased interest or pleasure in most activities

• Significant change in weight or appetite

• Insomnia or hypersomnia

• Psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness or guilt

• Decreased concentration or indecisiveness

• Recurrent thoughts of death and dying.

 Depression: Treatment
• Comprehensive treatment often includes both individual and family
therapy
• Cognitive behavioral therapy (CBT)

• Antidepressant medication
• Most commonly used are SSRIs, which block the reuptake of serotonin in the
neural synapse
• Monoamine Oxidase Inhibitors (MAOIs)– older class of drugs with slightly
more side effects, but are still used by some individuals
 Bipolar Disorder
• Bipolar disorder (also known as manic-depression) is a serious but treatable
medical illness

• Disorder of the brain marked by extreme changes in mood, energy, thinking

and behavior

• Symptoms may be present since infancy or early childhood, or may suddenly

emerge in adolescence or adulthood

• Until recently, a diagnosis of the disorder was rarely made in childhood

 Bipolar disorder
• According to DSM-V, there are four basic types of bipolar disorder:
1. Bipolar I: Defined by manic or mixed episodes that last atleast 7 days, or
manic symptoms that are so severe that the individual needs immediate
hospital care. Usually the person also has depressive episodes typically lasting
atleast 2 weeks
2. Bipolar II: Pattern of depressive episodes shifting back and forth with
hypomanic episodes
3. Bipolar Disorder – NOS: Person has symptoms of illness that do not meet the
diagnostic criteria for either bipolar I or II.
4. Cyclothymic: Mild form of Bipolar disorder. People who have cyclothymia
have episodes of hypomania that shift back and forth with mild depression for
at least a year (for an adult, 2 years).

http://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml
 Bipolar disorder
• A manic episode consists of abnormally and persistently elevated, expansive or
irritable mood lasting at least 1 week.
• The mood disturbance must have at least three of the following symptoms if
happy and four if irritable:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative, pressured speech, vocalization
4. Flight of ideas or racing thoughts
5. Distractibility
6. Psychomotor agitation
7. Excessive involvement in pleasurable activities that have high potential for
painful consequences.
• Hypomania is ___________________ severe symptoms than mania
 Bipolar Disorder: Treatment
• Medications – Mood stabilizers, antipsychotics

• Education about the illness

• Counseling or psychotherapy for the individual and family

• Stress reduction

• Good nutrition

• Regular sleep and exercise

• Participation in a network of support

PSYCHOSES
• Juvenile schizophrenia
• Schizoaffective disorder
 Juvenile Schizophrenia
• Schizophrenia is associated with deficits in cognition, affect and social
functioning
• Onset of the illness occurs rarely before the age of 13 years, but then
increases steadily during adolescence
• Early Onset (EOS) as onset before age 18 years, with very-early-onset
schizophrenia (VEOS) developing before age 13 years
• EOS, especially VEOS, occurs predominantly in males, with ratios of
approximately 2:1
• As age increases, this ratio tends to even out
• The average age of onset in males in 5 years earlier than that in females
(Loranger, 1984)
 Juvenile Schizophrenia: Phases
• Prodrome: Prior to developing overt psychotic symptoms
• Period of deteriorating function
• May include social isolation, idiosyncratic or bizarre preoccupations,
unusual behaviors, academic problems and/or deteriorating self-care skills
• While the presence of these problems should raise concerns, psychotic
symptoms must be present before a diagnosis of schizophrenia can be made

• Acute Phase: Phase in which patients often present

• Dominated by positive psychotic symptoms (delusions, hallucinations,
formal thought disorder, bizarre psychotic behavior) and functional
deterioration
 Juvenile Schizophrenia: Phases
• Recovery Phase: Active psychosis begins to remit
• Some ongoing psychotic symptoms are present
• May also be associated with confusion, disorganization &/or dysphoria

• Residual Phase: Positive psychotic symptoms are minimal

• Patients will still generally have ongoing problems with “negative
symptoms” - social withdrawal, apathy, lack of motivation, &/or flat affect

• Chronic Impairment: Some patients remain chronically impaired by

persistent psychotic symptoms that have not responded adequately to
treatment
 Schizophrenia: DSM classification
(children & adults)
Psychotic Symptoms
At least two of the following are Only one symptom is needed if
needed, each present for a (1) the delusions are bizarre,
significant period of time during a
1-month period: (2) the hallucinations include a voice
providing a running commentary on
(1) delusions, the person’s behavior or thinking, or
(2) hallucinations, (3) two or more voices are conversing
(3) disorganized speech, with each other.
(4) grossly disorganized or catatonic
behavior, and/or • The duration of symptoms may be
(5) negative symptoms (apathy, less if the symptoms resolved with
affective flattening, paucity of treatment.
thought or speech)
 Schizophrenia: DSM classification
(children & adults)
Social/Occupational Dysfunction
• For a significant portion of the time since onset of the disorder, the level of
social, occupational, and self-care functioning has markedly deteriorated below
the level achieved before onset
• In children and adolescents, this may include the failure to achieve age-
appropriate levels of interpersonal, academic, or occupational development
Duration
• The disturbances must be present for a period of at least 6 months. If the
duration criterion of 6 months is not met, a diagnosis of schizophreniform
disorder is made
• The period of illness includes an active phase of overt psychotic symptoms
(criterion A) with or without a prodromal or residual phase
 Juvenile Schizophrenia: Treatment
• Combination of psychopharmacologic agents (antipsychotic medications) &
psychosocial interventions
• Treatment strategies may vary depending on the phase of illness
• Therapeutic recommendations are primarily based on the adult literature, since
there is a lack of treatment research for youth with schizophrenia
• Intervention during acute hospitalization: Stabilization of behavior, engagement in
the treatment process
• Long-term hospitalization: Provide a normalizing environment, skill development
to function in after discharge
• Intervention in community settings: Services to maintain existing skills,
monitoring for changing clinical & social needs
• Communicate simply, clearly & concretely
• External structure to environment & ADL
 Schizoaffective Disorder
http://www.youtube.com/watch?v=dXomTwod_Rg

• Combined loss of contact with reality (psychosis) and a mood disorder

• Often, people with schizoaffective disorder seek treatment for problems with mood, daily function, or abnormal
thoughts.
• Psychosis and mood problems may occur at the same time or by themselves. The disorder may involve cycles of
severe symptoms followed by improvement.
• The symptoms of schizoaffective disorder can include:
• Changes in appetite and energy
• Disorganized speech that is not logical
• False beliefs (delusions), such as thinking someone is trying to harm you (paranoia) or thinking that special messages are
hidden in common places (delusions of reference)
• Lack of concern with hygiene or grooming
• Mood that is either too good, or depressed or irritable
• Problems sleeping
• Problems with concentration
• Sadness or hopelessness
• Seeing or hearing things that are not there (hallucinations)
• Social isolation
• Speaking so quickly that others cannot interrupt you
 Schizoaffective disorder
• To be diagnosed with schizoaffective disorder, you must have psychotic
symptoms during a period of normal mood for at least 2 weeks.
• The combination of psychotic and mood symptoms in schizoaffective disorder
can be seen in other illnesses, such as bipolar disorder. Extreme disturbance in
mood is an important part of schizoaffective disorder.
• Before diagnosing schizoaffective disorder, the health care provider will rule out
medical and drug-related conditions and other mental disorders that cause
psychotic or mood symptoms. For example, psychotic or mood disorder
symptoms can occur in people who:
• Abuse cocaine, amphetamines, or phencyclidine (PCP)
• Have seizure disorders
• Take steroid medications