1、精神病学,CHILD AND ADOLESCENTS PSYCHIATRY AND MENTAL HEALTH,SU Lin-yan M.D.,Outline,Preface of Child and Adolescents PsychiatryMental RetardationAttention Deficit Hyperactivity Disorder,Definition,Child and Adolescents Psychiatry is the academic and clinical discipline which studying and caring for chil
2、dren and adolescents with Emotional disordersbehavioral disordersdevelopmental disorders,The field of child and adolescent psychiatry is quite young. 1867 Maudsley H. first described insanity of early life in his book Physiolgy and pathology of mind 1950 formal training programs in child psychiatry
3、become popular in American 1970 quick development,The social sciences (social and communal factors, family functioning, parent-child relations),Many basic science contribute to knowledge relevant child psychiatry,The biological science (brain development),The child developmental psychology,Epidemiol
4、ogy,Child and adolescent mental health is an essential part of overall health. World-wide up to 20% of children and adolescents suffer from a disabling mental illness (WHR, 2000). World-wide suicide is the 3rd leading cause of death among adolescents (WHR 2000). Major depressive disorder (MDD) often
5、 has an onset in adolescence, across diverse countries, and is associated with substantial psychosocial impairment and risk of suicide (Weissman, 1999),Epidemiology,XIN RE(1992) CBCL 12.97% Li XR (1993) DSM-III-R 14.89%It means that there are 46770000 children need help in China.,Poor outcomes,Light
6、 and Bailey (1998) report that longitudinal studies find that about half the children with psychiatric disorders exhibit the same or similar disorders years later. Conduct disorder related behaviors tend to persistent into adolescence and adult life through drug abuse, juvenile delinquency, adult cr
7、ime, antisocial behavior, marital problems, poor employee relations, unemployment, interpersonal problems, and poor physical health (Patterson, DeBaryshe, & Ramsey, 1989).,Present states of child mental health,Most Scandinavia countries, many European countries and American : about one child psychia
8、trist for every 50,000 people in the population In China :less than 100 child psychiatrist throughout the country,Present states of child mental health,1950s-1970s, a few doctors working in the child psychiatric clinic in big cities. The first Child psychiatry clinic in China was established in Nanj
9、ing by Dr. Tao Guotai. Chinese Child Mental Health Board of Chinese Mental Health Association was established in 1989,Now, many child psychiatry research institutes have been built, including clinics, wards and caring centers for children and adolescents in Beijing, Nanjing, Shanghai, Changsha, Chen
10、gdu, Fuzhou, Jinan, and so on. Child mental health clinics have also been built in more cities.,Social need is increasing,Emotional quotient (EQ, Garduer H and Salovey P.) The ability to accurate appraisal and expression of emotions in oneself and others to regulate emotion in a way that enhances li
11、ving to recognize the consensually agreed upon emotional qualities of objects in the environment. The achievement of one depend upon IQ 20% EQ 80%,The WHO School Contest, held as part of World Health Day 2001 which had the theme “Stop Exclusion: Dare to Care” Chinese President Jiang Ze-min in his le
12、tter to Dr Blundtland, the secretary-general of WHO, has emphasized Chinese government will mobilize the whole society to create a suitable environment for people with mental disorders to go back society.,Classification,WHO(1992) : International Classification of Disease, Ten Edition(ICD-10)APA(1994
13、):Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition (DSM-IV),Chinese Classification of Mental Disorders-Version 3(CCMD-3) 2000,7.Mental retardation, and disorder of psychological developmental with onset usually occurring in childhood and adolescence,8. Hyperkinetic, Conduct,and E
14、motional disorders with onset usually occurring in child and adolescence,Classification,71.1 Specific speech articulation disorder71.2 Expressive language disorder71.3 Receptive language disorder71.4 Acquired aphasia with epilepsy71.9 Other or unspecified developmental disorders of speech and langua
15、ge,70. Mental retardation,71.Developmantal disorder of speech and language,Classification,72.1 Specific reading disorder 72.2 Specific spelling disorder72.3 Specific disorder of arithmetical skills,72 Specific developmental disorders of scholastic skills,Classification,72.4 Mixed disorder of scholas
16、tic skills 72.9 Other or unspecified developmental disorders of scholastic skills,73 Specific developmental disorder of motor skills,74 Mixed specified developmental disorders,Classification,75.1 Childhood autism75.2 Atypical autism75.3 Retts syndrome75.4 Childhood disintegrative disorder75.5 Asperg
17、ers syndrome75.9 Other or unspecified Pervasive developmental disorders,75 Pervasive developmental disorders,Classification,80. 1 Attention deficit and hyperactivity disorder80.2 Hyperkinetic conduct disorder80.9 Other or unspecified hyperkinetic disorder,80. Hyperkinetic disorder,Classification,81.
18、1 Dissocial conduct disorder81.2 Oppositional defiant disorder81.9 Other or unspecified conduct disorder,81 Conduct disorders,82 Mixed disorders of conduct and emotions,83.1 Separation anxiety disorder of childhood,83.Emotional disorders with onset specific to childhood,83.2 Phobia anxiety disorder
19、of childhood,83.3 Social anxiety disorder of childhood,83.Emotional disorders with onset specific to childhood,83.91 General anxiety with onset specific to childhood,Classification,84.1 Elective mutism84.2 Reactive attachment disorder of childhood84.9 Other or unspecified childhood disorders of soci
20、al functioning,84.Disorders of social functioning with onset specific to childhood and adolescence,Classification,85.1 Transient tic disorder85.2 Chronic motor or vocal tic disorder85.3 Tourettes syndrome85.9 Other or unspecified tic disorder,85.Tic disorders,Classification,86.1 Nonorganic enuresis8
21、6.2 Nonorganic encopresis86.3 Feeding disorder of infancy and childhood86.4 Pica of infancy and childhood86.6 Stuttering,86 Other behavioral disorders with onset usually occurring in childhood and adolescence,89 Other or unspecified childhood disorders of social functioning,Mental Retardation (MR),D
22、efinition,Mental retardation is a condition of arrested or incomplete development of the mind, which is characterized by deficits in intelligence and social adjustment. The disorder emerges before 18 years old. The level of intelligence as shown in standardized psychometric test is defined as below
23、70, while the scores from 70-85 are defined as borderline intelligence,Epidemiology,WHO(1985):The prevalence of MR in the general population is 4 of mild and severe MR 30 (include mild MR); Li XR (1993) DSM-III-R 22.2 More common in rural than in city population,Clinical Description,(1) The range of
24、 IQ is from 50 to 69 and the psychological age lies between 9 and 12 years old;(2) Poor academic performance with specific difficulties in reading and writing, while at work these patients are only capable of unskilled manual jobs;(3) Independence in self-care;(4) Intact ability to communicate at or
25、dinary level in daily life despite difficulty in communicating difficult information in reading and writing,Mild mental retardation,Clinical Description,(1) The range of IQ is from 35 to 49 and psychological age is about 6 to 9 years old;(2) Capability in simple arithmetic but not up to primary scho
26、ol level. These patients can cope simple laboring jobs with simple work output and efficiency;(3) Capability of self-care;(4) Capability in daily life communication at ordinary level despite limited range of vocabulary,Moderate mental retardation,Clinical Description,mental retardation (1) The range
27、 of IQ is from 20 to 34, and psychological age is approximately between 3 and 6 years old;(2) Presence of marked motor impairment and other associated deficits in task performance;(3) Incapability of self-care;(4) Marked deficits in language development and incapability in communicating in daily lif
28、e,Severe mental retardation,Clinical Description,Profound mental retardation(1) The range of IQ is under 20 and psychological age is below 3 years old;(2) Complete social disability with lack of awareness of dangerous situation;(3) Incapability in self-care and bladder or bowel control;(4) Absence o
29、f communicable speech.,Profound mental retardation,Etiology,Chromosomal aberrationsDown syndrome,Genetic disorders,Etiology,Single-gene mutations:Tuberous sclerosis, phenylketonuria and other metabolic disorders,Genetic disorders,Etiology,Fragile X syndrome,Genetic disorders,Etiology,Malformation sy
30、ndromes Prader-Willi, Williams, and Angelman due to microdeletions syndromes,Genetic disorders,Etiology,Maternal infections:Congenital rubella, HIVTeratogens:Fetal alcohol syndromeToxemia: placentalprematurity insufficiencyOther:radiation, trauma,Exposure,Etiology,EncephalitisToxins:Lead poisoningOt
31、her postnatal causesTraumas brain tumors,Postnatal Infections,Etiology,PovertyEducation,Psychosocial problems,Unknown,Diagnosis and differential diagnosis,Psychometric tests of IntelligenceGesell :03 years oldBayley:230 month PPVT:morn than 2 yearsWISC-RC :616 years old C- WYCSI :46.5 years old,Soci
32、al Adaptive Ability Scale existing concurrently with related limitations in two or more of the following applicable adaptive skill arrears: communication self-care home living social skills community use self-direction health and safety functional academics leisure and work,Diagnosis and differentia
33、l diagnosis,In most cases there is mental retardation of varying degree while in some cases there are isolated locus of superior intellectual ability on a background of low general intelligence.,differential diagnosis with Autism,Qualitative impairment in reciprocal social interactions Abnormalities
34、 in language development Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities,differential diagnosis with Autism,Onset after a normal period hallucination paranoia behavior disturbance,differential diagnosis with Schizophrenia,Treatment,Training and rehabilitationT
35、reatment aim for cause of diseaseTreatment aim for symptoms,Attention deficit hyperactivity disorder(ADHD),ADHD is one of the most import disorders that Child and adolescents psychiatrists treat. It is highly prevalent, making up as much as 50% of child psychiatry clinic populations. Untreated, it p
36、redisposes a child to psychiatric and social pathology in later life. The core symptoms of ADHD is the inability to focus attention, difficulty maintaining control over impulsive behavior, and a generalized hyperactivity,Definition,Epidemiology,The prevalence of ADHD in the general population is app
37、roximarely 3% to 10% . Li XR (1993) DSM-III-R 6.04% More common in boys than in girls at a ratio of 9:1 in clinical sample 4:1 in epidemiological samples,Clinical Description,distractable by enviernment stimuli while concentrating; failure to maintain persistence attention in calss; frequent omissio
38、ns of homework; lack of persistence, move from one activity to another,Inattention,Clinical Description,motor restlessness and fidgety, run, jump, climb and go off seats when the situation does not permit as playing or whispering in class difficulties in abiding by rules in games and impatience to w
39、ait for ones own turn;,Hyperactivity,Clinical Description,intruding on or interrupting others activities tease other children and to get in troubles being easily frustranted and impulsive with emotional display lack of awareness of risk and hazards.,Impulsivity,Comorbidity,Learning disorders(LD): 10
40、% to 92%,Oppositional defiant disorder( ODD ) : 40 to 65%,Conduct disorder(CD): 42.7% to 56%,Clinical Description,Resulted in marked impairment in social functioning in terms of academic performance and interpersonal relationship,Early onset usually before 7 years of age,Etiology,Catecholamine bnorm
41、alities Blood,urine and CSF: low dopamine and norepinephrine turnover Interactionbetween serotonin and catecholamine systems,Biochemistry,Etiology,Heritability is estimated to between 0.55 to 0 .92 Twin study concordance 51% in monozygotic twins 33%in dizygotic twins;,Genetic,37 years old,11 years o
42、ld,ADHD family,8 years old,Etiology,SPECT, PET, fMRI studies revealed lower cerebral glucose metabolism in the superior prefrontal cortex.,Neuroimaging,Etiology,Dysfunction of parent-child relationship and family Fighting with parents,Psychosocial factors,ADHD,Effects,conduct disorder,Bad relationsh
43、ip,learning disability,Bad self-esteem,Substance abuse,Antisocial personality,Poor outcomes,Scott (2002) demonstrated increased costs for care and to society in later years from the childhood diagnosis of conduct disorder. Leibson (2001) showed that over a nine year period the median medical costs f
44、or children with ADHD were $4,306.00 compared with $1,944.00 for children without ADHD. The costs are due to higher rates of admission to hospital emergency and outpatient departments and visits to primary care physicians.,Treatment,Central stimulants Meihy1phenidate( Ritalin) Pemoline Amphetamine A
45、ntidepressants Clonidine Atomoxetine,Pharmacological Interventions,Individual psychotherapy Educational intervention Family intervention,Multi-modality treatment,Psychosocial interventions,Family therapy,Sensatory integration therapy,Sensatory integration therapy,Training of social skill,Play Therapy,Thank you!,
