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Child Psychiatry The Basics

Dr. M.Nasar Sayeed Khan13-B, Aibak Block, garden town

03328440242nasarsayeed@yahoo.com

Is Infant &Toddler Mental Health Really a Problem?

• Yes!• Young children do experience

problems in social emotional competency and even psychopathology

• We are better able to understand and measure these problems

Why we resist this…

• We are too worried about cognitive skills (“ready to learn”)

• Stigma associated with mental health issues

• Myth of childhood• Our own discomfort with the idea

Prevalence

• Best estimates of serious behavior concerns in children 2 to 3 years fall between 10 to 15%

• Parent and pediatrician report behavior problems in 10% of 1 to 2 year olds

But won’t these problems go away?

• No!• 37% of 18 mos with extreme

behavior/emotional problems continue to have problems at 30 mos

• Over ½ of 2-3 with psychiatric d/o still have symptoms 2 years out

Long Term Effects

• Exposure to poor caregiving, abuse, or domestic violence can lead to developmental and mental health problems in young children

• Babies, toddlers, and preschoolers can demonstrate depression, PTSD, and disruptive behaviors

The Science of Early Childhood Development

• Babies brains are growing at a phenomenal rate

• The infant brain is “experience expectant”

• Both positive and negative experiences have significant and long lasting effects

The Science of Early Childhood Development

• Experience, especially social experiences, change the way the brain is shaped and functions

• Babies who experience or witness violence have behavioral and physiological changes

MH Challenges in Young Children

• Are real• Involve a substantial number of

babies• Can be assessed and treated

Areas to Consider When Assessing Young Children

• Developmental Levels of Infant or Child

• Quality of Important Relationships• Parent Status (Capacity for

Relationship)• Family Situations

Infant & Child Development

• A good working knowledge of typical development is needed when you assess young children

• You can’t tell what is atypical if you don’t know what is typical

Infant & Child Development

• Expected order of milestones is knownSkills are traditionally divided into 5 areasThere is much overlap between the areasUneven development across areas is concerning

Infant & Child Development

Ways to learn about development• Have a great memory from

college• Get a child development text• Watch some babies• Review some developmental

checklists online

Infant & Child Development

• Cognitive• Receptive, Expressive, and

Pragmatic Communication• Fine & Gross Motor• Social-emotional and behavior• Adaptive Skills (Self Help)

Cognitive Skills

• Thinking• Problem Solving• Memory• Attention• Imitation

Communication

• Use of gestures and facial expressions

• Understanding speech• Expressive language• Social or pragmatic aspects of

communication

Fine & Gross Motor Skills

• Use of hands and arms to manipulate objects

• Balance• Strength and tone• Walking, running, jumping

Social-emotional and behavior

• Eye contact• Social smile• Relationships/

attachment• Regulation

• Sleep • Feeding• Aggression• Compliance

Self-Help/Adaptive

• Eating• Dressing• Participation in grooming• Toileting

Ways development can be atypical

• Global delays in development

• Inconsistent development

• Atypical, unusual behaviors—red flags

Red Flags in 6 Month Olds:

• Inability to Read Signals

• Persistent Sleep Problems

• Lack of Predictability

• Failure to Imitate Sounds and Gestures

• No Affect, Range of Feelings

• Lack of Stranger Anxiety (8 months)

Red Flags 12-18 Month Olds:• No Words

• Persistent Sleep Problems

• Withdrawn

• Excessive Rocking

• Prolonged Fears

• No Separation Distress

• Immobile, Low Activity

• No Social Engagement

• Predominant Anger and Outbursts

Red Flags in 18 Months to 3 Year olds

• Eating Problems

• Non Speaking

• Extreme Shyness

• Lack Autonomy

• Failure in Gender Identification

• No Enjoyment in Play

• Poor Problem Solving

• Total Lack of Self Control

• Chaotic Behavior

Screening & Referral

• Screening methods tell you if the child needs further assessment in a given developmental area

• Many screening tools use caregiver report

• Do not use social-emotional screener for CPS population

Do’s and Don’ts

• Infants and Toddlers must be evaluated within the context of relationships with their primary caregivers

• Assessment should always include collaboration with parents and caregivers

• Multiple assessments over time are recommended

• Information from Multiple sources is recommended

Do’s and Don’ts

•Standardized Instruments May be used but not be the sole basis of the Evaluation

•Young Children Should Never be Challenged by Separation from Primary Caregivers

•Evaluation should utilize the DSM V

Etiology

• Brain damage• Lead intoxication• Family• Divorce• Death

Problems with preschoolers

• Bed wetting• Over activity• Difficulty in settling at night• Fears• Disobedience• Attention Seeking• Temper tantrums

Poor prognosis if persists beyond 3 and require

intervention

• over-activity• conduct disorder• speech difficulty• effeminacy• autism

Pica

• Is the eating of items considered as inedible

Common causes include:• brain damage• autism• mental retardation• emotional distress• usually diminishes as the child grows

Hyperkinetic and Attention Deficit disorders

Classification

• F90 Hyperkinetic disorders• F90.0 Disturbance of activity and

attention• F90.1 Hyperkinetic conduct

disorder• F90.8 Other hyperkinetic disorders• F90.9 Hyperkinetic disorder,

unspecified

Conduct and Oppositional disorders

Classification• Conduct disorder confined to the

family• Unsocial zed conduct disorder• Socialized conduct disorder• Oppositional defiant disorder• Other conduct disorders• Conduct disorder, unspecified

F84 Pervasive Developmental

Disorders• F84.0 Childhood Autism (Kanner, 1943)• Epidemiology• prevalence of 2 per 10,000• M:F=3:1• Clinical features• Kanner described four main features of

autism:• autistic aloneness• delayed or abnormal speech• an obsessive desire for sameness• onset in the first two years of life 

F93 Emotional Disorders with specific

onset in childhood• Maternal overprotection (Levy, 1943)

– excessive contact– prolongation of infantile care– prevention of independence– fathers were generally submissive– overprotected children had three times as many

operations

• Separation Anxiety Disorder– onset is before the age of six– diagnosis is not made when there is a generalized

disturbance of personality development

School refusal• Clinical features:

– there are often somatic symptoms - complaints occur on school days but not at other times

– the final refusal may occur after several events:– following a period of increasing difficulty– after an enforced absence such as respiratory infection– after an event at school such as change of class– following a problem in the family such as illness of another family

member

• Treatment– an early return to school is important (The Kennedy Approach)– discussion with teachers is needed– depressive disorder should be treated– it has been reported that antidepressants are effective for school refusal,

even when there is no depression

• Prognosis

Elective Mutism• The child refuses to speak in certain circumstances, although he

does so normally in others• usually, speech is normal in the home but lacking in school• often associated with other negative behaviours such as refusing

to sit down or play when invited to do so• Epidemiology• usually begins between 3 and 5 years, after normal speech has

been acquired• prevalence of approx. 1 in 1000• Treatment• no evidence that treatment is effective• Prognosis• can persist for months or years• a five- to ten-year follow-up showed that only 50% had improved

Stammering

Disturbance of the rhythm and fluency of speech

• Epidemiology• M:F = 4:1• affects about 1% of children• Treatment• speech therapy• Prognosis• most children improved whether treated

or not

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Mujtaba Nasar