THE SOURCES OF DISTURBANCES IN CHILDHOOD AND ADOLESCENCE

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2 THE SOURCES OF DISTURBANCES IN CHILDHOOD AND ADOLESCENCE I..Evolution theories The behaviour and emotions are connected with the development stage of brain structures, as we experience in the course of filo- and ontogenesis

3 Due to Jackson s theory the youngest brain structures are the most sensitive to disruptive factors leading to dissolutionthese parts should be damaged then lower parts take control over.

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5 II. Mental Retardation [MR] A significantly sub-average general intellectual functioning resulting in or associated with concurrent impairments in adaptive behaviour and manifested during the developmental period, before the age of 18 /DSM IV, AAMD/. MR is a condition of arrested or incomplete development of the mind characterised by impaired developmental skills that contribute to the overall level of intelligence /ICD-10/

6 Causative factors in MR include: 1. genetic (chromosomal, metabolic) inherited factors 2. prenatal exposure to infections and toxins 3. mother s health during pregnancy 4. maternal infections 4. complications of pregnancy 5. perinatal factors 6. acquired childhood disorders more severe mental retardation = more likely is the cause evident for 3/4 of people with borderline intellectual functioning - no cause is known

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8 Clinical features of mental retardation I 0 mild MR IQ acquire language late, but speak well - their skills may develop at a lower rate when they learn reading and writing - they are capable of basic academic functions - they are adequate in the pre-school years and diagnosed when enter school - they are able to take care of themselves, to earn for their living, but they lack in social spontaneousness because of their shortcomings

9 II 0 moderate MR IQ may slowly gain limited language use - some learn basic school skills, do simple work, engage in social activities in supervised settings - they are impaired in caring for themselves - they are aware of their deficits and often feel alienated from their peers and frustrated by their limitations

10 III 0 severe MR IQ resembles the moderate category - limited or no language ability and marked motor or other impairments indicate CNS damage or maldevelopment - non-verbal forms of communication may be evolved - they need extensive supervision

11 IV 0 profound MR IQ below 20 - require constant supervision, are incapable of providing for their most basic needs - some speech development and simple self-help skills may be acquired - they are severely limited in cognitive abilities, immobile or restricted mobile

12 III. Pervasive Developmental Disorders They include a group of psychiatric conditions as: autistic disorder, childhood disintegrative disorder, Asperger s disorder and not specified ones, in which the following skills are impaired: 1. reciprocal social skills 2. language development 3. range of behavioural repertoire disturbances are not appropriately to mental or developmental level generally multiple areas are affected they manifest before the end of the 3 rd year they cause persistent dysfunction

13 AUTISTIC DISORDER = early infantile autism, childhood autism, Kanner s autism. It affects children with: 1. high socio-economic family status 2. psychosocial stresses 3. neurological and biological factors lesions and perinatal complications of pregnancy, high incidence of medication usage during pregnancy 4. genetic factors fragile X 5. immunological incompatibility between mother and fetus

14 Diagnostic Criteria for Autistic Disorder Social interactional deficits, such impairment in : - nonverbal communicative behaviours - poor relationships - social interactions - interpersonal reciprocity within relationships

15 Communicative deficits, such as: - impairment in language development - impairment in conversational skills - use of repetitive or idiosyncratic language - impairment in the development of imaginative or imitative play

16 Diagnostic criteria for Autistic Disorder Behavioural deficits, such as: - preoccupation with part of objects - stereotyped motor movements (e.g. rocking, hand flapping) - excessive need for routine, ritualized behaviours, resistance to changes - preoccupation with one or a few areas of interest, restricted willing to be interested in surrounding environment

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18 Clinical features of autism children fail to manifest the emotional relationships with parents and other people, they are unable to recognise and approach them; in school age they fail to play with peers and to make friends they lack a social smile abnormal eye contact they don t like being carried and hugged show no separation anxiety on being left

19 language deviance and delay: in the first year of life they emit noises clicks, sounds, screeches, nonsense syllables in stereotyped fashion without the intent of communication automatically speech peculiar voice quality and rhythm, speech contains echolalia, stereotyped phrases out of context stereotypes, mannerisms, grimacing are frequent toys are manipulated in an unintended way, have no symbolic meaning the play, if any is, has a compulsive character read without any comprehension

20 hyper-vigilance, over- or under-responsive instability of mood and affect changed response to sensory stimuli: - hyper-vigilance, over- or under-responsive - heightened pain threshold - they like vestibular stimulation (spinning, swinging)

21 a complete inability to focus on a task sleeplessness IQ scores: %, %, > % the risk of autistic disorder increases as the IQ decreases No drug has been found to be specific for autistic disorder; to ameliorate a variety of symptoms the following drugs are used: > haloperidol, > risperodone, > SSRI, > clomipramine, > lithium

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24 IV. Non pervasive developmental disorders ATTENTION-DEFICIT/HYPERACTIVITY DISORDER /ADHD/

25 Developmentally age-inappropriate poor attention span, easy distractibility and features of hyperactivity, impulsivity or both. The symptoms of ADHD: must be present for at least 6 months cause impairment in academic or social functioning occur before the age of 3, usually diagnose by 7 years no single factor is believed to cause the disorder- the most important are minimal brain damage, child s temperament, genetic-familiar factors, prolonged emotional deprivation and stressful psychic events

26 The main cause of ADHD is probably connected with dysfunction (immaturity) in both the adrenergic and the dopaminergic systems (affect both norepinephrine and dopamine), and this is why in treatment this syndrome - CNS stimulants are used: - dextroamphetamine - methylphenidate - pemoline - tricyclic antidepressants - clonidine - SSRI - bupropion

27 DIAGNOSTIC CRITERIA FOR ADHD Symptoms of inattention, such as: - lack of attention to details - difficulties in sustaining attention for longer time - not listening - disorganisation - difficulties in following through or completing tasks - tendency to loss personal belongings - distractibility - forgetfulness - avoidance of activities that require sustained attention

28 DIAGNOSTIC CRITERIA FOR ADHD 2. Symptoms of hyperactivity, such as: - talking excessively - fidgetiness - difficulties in engaging in nonaction activities - developmentally excessive activity level - difficulties in remaining in seat, or sitting quietly 3. Symptoms of impulsivity, such as: - frequent interruptions into other's conversation or activity - difficulty with turn-take activities - quick answers without waiting for the end of the question or without raising hands * Presence of some symptoms before 7 years of age * Functional impairment as a result of those symptoms

29 Possible results: school difficulties negative self concept, low self esteem, depressed mood, reactive hostility, acting out antisocial behaviour, self defeating and self punitive behaviour ADHD may remit at puberty - usually between the age of 12 and 20 years. In % cases, symptoms persist into adulthood they may turn into conduct disorder or substance abuses.

30 V. Disruptive behaviour disorders Children and teenagers are usual used to resolving their inner conflicts and problems through behaviour disturbances unlike adults who experience and analyse them. These disturbances are seen in young people s behaviour in the form of: Oppositional Defiant Disorder [ODD] Conduct Disorders [CD]

31 OPPOSITIONAL DEFIANT DISORDER [ODD] Recurrent pattern of negativistic, defiant, disobedient, hostile behaviour toward authority figures naughty children when the patterns of abnormal behaviour exceed the expectations for their peers, they are significantly impaired in social or academic life, work settings

32 it may be a physiological developmental phase while forming the identity, to set inner standards and may be more intensive in two periods: between months in adolescence as an expression of the need to separate from parents and establish an autonomous identity

33 environmental trauma (illness or chronic incapacity) may release oppositionalism as a defence against helplessness, anxiety, loss of self-esteem features: loss of temper, arguments with adults, defiance of or refusal to comply with adults request or rules, deliberately doing things that annoy people, blaming others

34 In treatment of ODD it is effective to reinforce and praise appropriate behaviour and ignore undesired behaviour. Eliminating punitive parenting is necessary to avoid the emergence of aggression and deviance in children

35 CONDUCT DISORDERS [CD] Repetitive and persistent pattern of behaviour in which basic rights of others, social norms or rules are violated aggressive and dis-social children groups of characteristics: 1. aggressive, assaultive and cruel behaviour with physical aggression towards other people and animals 2. demolishing other's property, vandalism 3. deceit or theft 4. serious violations of rules

36 er abnormal behaviour which occur in CD: staying out at night despite prohibitions before 13 yrs, truancy from school, persistent lying, frequent suicidal thoughts and acts, seldom exhibiting guilty or feelings of remorse, callous behaviour and blaming others, failing to develop social attachments, may display antisocial behaviour in gang groups

37 children with CD are unable to develop the tolerance for frustration, ego-ideal and remorse severe punishment invariably increases maladaptive expression of frustration, rather than ameliorate the problem treatment : psychotherapy oriented toward improving problem-solving skills medications: haloperidol, lithium, carbamazepine, clonidine, SSRI

38 VII. SUICIDES [by Stangel] Each act of intentional self mutilation when individual performing it could not have been sure of survival concerns about 3 % of teenagers the main reasons are: 61 % mood disorders especially depression 50 % conduct disorders and personality disturbances 27 % anxiety disturbances 3 % schizophrenia

39 IX. Mood disorders Mood disorders most often occur in children and adolescents when emotional needs are not provided: parent's lack of interest, abandonment, illness or death overwork sexual abuse or maltreatment may be a consequence of: somatic diseases CNS disturbances endogenous major depressive disorder

40 expression of depression according to age: in 6 to 11 month old children as a reaction for the abandonment by mother: tearfulness timidity loosing the interest with surrounding child often is mute, rocking, vomiting losing sucking reflex and weight sleeplessness psychomotor retardation when mother comes back symptoms disappear, if not possibility of chronic developmental disturbances

41 in 2 to 3 year old children, the reaction to separation with mother/father can broken down into the following phases: the protest phase ranging from a few hours to several days child is crying, going away, defending him/herself from the foster father/mother the phase of distress and hopelessness bad sleeping, apathy, child gives up calling mother/father the phase of fixation of changed behaviour

42 young pre-pubertal depressed children show: marked irritability somatic complaints pervasive sense of boredom, lack of future orientation withdrawal sad appearance and poor self-esteem they may refer to their feelings by many names (sad, empty, down, blue, crying, unhappy) psychomotor agitation

43 in late adolescence more common are: feelings of aggression, sulkiness, reluctance to cooperate with/in family sense of hopelessness, restlessness pervasive anhedonia delusions severe psychomotor retardation negativistic, antisocial behaviour, use of alcohol, desire to leave home

44 CLINICAL FEATURES OF BIPOLAR I DISORDER Manic episodes appears in an adolescents with grandiose and paranoid delusions and hallucinatory phenomena lasting at least 1 week. In manic episodes are present: decreased need for sleep pressure to talk flight of ideas and racing thought distractibility an increase activity (pleasurable) in atypical manic episodes: extreme mood variability and aggressive behaviour

45 X. Schizophrenia with childhood onset - can occur as early as 5 or 6 years of age, 1/10000 children, in pre-pubertal children is exceedingly rare - delusions and hallucinations are less elaborate - visual hallucinations are more common - children may fail to achieve their expected levels of social and academic functioning the types of schizophrenia are the same as in the adults: paranoid hebephrenic catatonic simple

46 CLINICAL FEATURES OF SCHIZOPHRENIA insidious onset, the first symptoms may be sleeping and eating disturbances school difficulties in spite of normal intelligence, limited social skills deteriorated functions, thoughts, interests with religious and philosophy themes core features: visual hallucinations delusions age appropriate blunted or inappropriate affects formal thought disorders: losing of associations and thought blocking, illogical thinking, poverty of thought

47 XI. Neurosis psychogenic functional disturbances result of child s difficult psychosocial situation unawareness of illness more common in girls, prognosis is better in boys

48 defence mechanisms evolved with neurosis: moonshine regression projection of the anxiety on a toy generally one symptom is predominant: enuresis or getting dirty ticks vomiting sleep disturbances, especially falling asleep, nightmares mutism characteristics: egocentrism, affective lability, reactions are inadequate to impulses emotional and motor hyperactivity or inhibition

49 TOURETTE DISORDER - Recurrent, involuntary, purposeless motor movements accompanied by vocal tics (e.g. coprolalia, barking, swearing, grunting) - Tics are frequent, appear almost every day for a year or more - They cause emotional distress or functional impairment

50 EPIDEMIOLOGY: - onset before age 18 - more common in boys - the cause is still unknown, but probably organic, - stress exacerbates the symptoms TREATMENT: - psychotherapy - medications: Haloperidol, Pimozide, Risperidone

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