Gangguan Psikologis Pada Anak

Fitrie Desbassarie WJeevanisha Patmanathan

I. Attention Deficit and Hiperactivity Disorder

Attention Deficit and Hiperactivity Disorder (ADHD) dalam disebut juga sebagai

Gangguan Hiperaktivitas dan Defisit Perhatian (GHDP). Gejala GHDP sering muncul

pada usia tiga tahun, namun diagnosis umumnya baru dapat ditegakkan setelah anak

masuk sekolah (TK atau Play group), berdasarkan hasil dari pengamatan oleh guru di

sekolah yang membandingkan atensi dan impuls anak dengan teman sebayanya.

1. Definisi

Adalah gangguan perilaku yang paling sering ditemukan pada anak. GHDP ditandai

dengan berkurangya kemampuan untuk mempertahankan perhatian, walaupun tidak ada

stimulus pengalihan perhatian dari luar.

Anak dengan gangguan GHDP mengalami hiperaktivitas (karena adanya impulsivitas

yang tinggi), dan sering tampak resah dan gelisah.

2. Epidemiologi

Sedikitnya sekitar 3-7% dari anak-anak sekolah dasar di dunia menderita ADHD.

Prevalensi GHDP lebih besar pada anak laki-laki dibandingkan dengan anak perempuan

dengan rasio dari 2:1 sampai dengan 9:1.

3. Etiologi

Penyebab pasti hiperaktivitas pada anak tidak dapat disebutkan dengan pasti,pada

beberapa referensi penyebab terjadinya hiperaktivitas dikatakan bersifat multifaktorial.

Dari faktor genetik, perkembangan otak saat kehamilan, perkembangan otak saat

perinatal, tingkat kecerdasan (IQ), terjadinya disfungsi metabolisme, ketidakteraturan

hormonal, lingkungan fisik, sosial dan pola pengasuhan anak oleh orang tua, guru dan

orang-orang yang berpengaruh di sekitamya.

4. Diagnosis, signs, and symptoms.

Menurut Diagnostic and Statistical Manual of Mental Disorder edisi keempat (DSM

IV), diagnosis dibuat dengan menegakkan sejumlah gejala dalam bidang inatensi atau

bidang hiperaktifitas-impulsifitas atau keduanya :

Untuk memenuhi kriteria diagnostik, gangguan harus terjadi sekurang – kurangnya

selama 6 bulan, menyebabkan gangguan dalam fungsi akademik atau sosial, dan terjadi

sebelum usia 7 tahun.

Table 43-1 DSM-IV-TR Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2): 1. six (or more) of the following symptoms of inattention have persisted for at

least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention a. often fails to give close attention to details or makes careless mistakes in

schoolwork, work, or other activities b. often has difficulty sustaining attention in tasks or play activities c. often does not seem to listen when spoken to directly d. often does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

e. often has difficulty organizing tasks and activities f. often avoids, dislikes, or is reluctant to engage in tasks that require

sustained mental effort (such as schoolwork or homework) g. often loses things necessary for tasks or activities (e.g., toys, school

assignments, pencils, books, or tools) h. is often easily distracted by extraneous stimuli i. is often forgetful in daily activities

2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

a. often fidgets with hands or feet or squirms in seat b. often leaves seat in classroom or in other situations in which remaining

seated is expected c. often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

d. often has difficulty playing or engaging in leisure activities quietly e. is often “on the go” or often acts as if “driven by a motor”

f. often talks excessively

Impulsivity

a. often blurts out answers before questions have been completed b. often has difficulty awaiting turn c. often interrupts or intrudes on others (e.g., butts into conversations or

games)H. Some hyperactive-impulsive or inattentive symptoms that caused impairment were

present before age 7 years. I. Some impairment from the symptoms is present in two or more settings (e.g., at

school [or work] and at home). J. There must be clear evidence of clinically significant impairment in social,

academic, or occupational functioning. K. The symptoms do not occur exclusively during the course of a pervasive

developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Code based on type:   Attention-deficit/hyperactivity disorder, combined type: if both Criteria A1 and A2 are met for the past 6 months

   Attention-deficit/hyperactivity disorder, predominantly inattentive type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

   Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

   Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “œin partial remission” should be specified.

(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

5. Differensial Diagnosis

Anak dengan tingkat aktifitas yang tinggi dan rentang perhatian yang pendek harus

dicurigai menderita GHDP. Membedakannya GHDP dengan gejala gangguan deficit

atensi-hiperaktifitas sebelum usia 3 tahun sulit. Diferensial diagnosisnya antara lain :

Kecemasan mungkin menyertai gangguan defisit atensi-hiperaktifitas sebagai ciri

sekunder dan dimanifestasikan oleh overaktifitas dan distrakbilitas.

Depresi sekunder pada anak dengan gangguan defisit atensi-hiperaktifitas harus

dibedakan dari gangguan depresi primer yang kemungkinan dibedakan oleh

hipoaktivitas dan menarik diri.

Gangguan konduksi dimana anak-anak tidak mampu membaca atau mengerjakan

matematika karena gangguan belajar bukan inatensi. Akan tetapi, gangguan defisit

atensi-hiperaktifitas juga sering ditemukan bersamaan gangguan konduksi ini.

Stres yang dialami anak dalam keluarga seperti kematian anggota keluarga, perceraian

orangtua, ketidakharmonisan dalam keluarga, penggunaan obat-obatan terlarang oleh

orangtua ataupun hubungan anak-orangtua yang buruk dapat menimbulkan gejala yang

mirip dengan gangguan GHDP.

6. Manajemen

Penatalaksanaan bergantung terhadap orang tua dan guru sebagai agent of change. Penting

untuk menolong anak terutama dalam fungsi sosial dan fungsi akademis serta

mengutamakan pentingnya harga diri (self esteem), oleh karena itu usaha yang dilakukan

pertama-tama adalah menyediakan intervensi secara psikologis dan sosial sebelum

menggunakan obat-obatan. Intervensi yang terbukti berguna antara lain:

CBT (Cognitive and Behavioral Therapy) methods, terutama terapi tingkah laku,

ditemukan cukup efektif.

Pelatihan keterampilan sosial (social skills training)

Pelatihan penatalaksanaan orang tua (parent management training)

Terapi individu/keluarga/kelompok

Intervensi pendidikan.

Terapi tingkah laku dapat juga diberikan. Tujuan dari terapi tingkah laku adalah untuk

mengurangi tingkah laku yang bermasalah dan menambah tingkah laku yang diinginkan.

Parent management training, adalah metode yang paling sering digunakan agar orang tua

dapat menjadi agent of change. Orang tua sebaiknya dapat menemukan sesuatu yang

positif daripada menggunakan kalimat negatif (positive reinforcement) untuk dapat

mengontrol anak, contoh “Ini akan lebih baik jika...” dibandingkan dengan “ini akan jadi

jelek jika…”.

Selain itu, sebaiknya hindari hukuman atau membuat urutan hukuman dan hadiah

(hierarchy of rewards and punishments), dan diterapkan secara nyata.

Contoh CBT antara lain self monitoring, anger control dan self-reinforcement. Selain

intervensi di rumah, intervensi juga dilakukan di sekolah, dan konsisten dengan yang

dilakukan di rumah.

Terapi yang selanjutnya adalah dengan menggunakan obat-obatan. Pengobatan terbukti

efektif untuk 70% kasus. Pengobatan tidak menyembuhkan secara keseluruhan.

Sampai saat ini obat pilihan untuk GHDP adalah stimulan, contoh Methylphenidate

(Ritalin; dextroamphetamine; pemoline), karena efikasi yang tinggi dan morbiditasnya

yang rendah. Stimulan dapat meningkatkan jumlah reseptor adrenergik yang menstimulus

attention and inhibitory centre. Stimulants mengurangi symptoms sekitar 75% , juga

meningkatkan self-esteem, karena dapat memperbaiki rapport pasien dengan orangtua dan

guru.

Table 43-3 Nonstimulant Medications for Attention-Deficit/Hyperactivity Disorder (ADHD)

MedicationPreparation (mg) Recommended Dose

Atomoxetine HCLStrattera 10, 18, 25, 40 (0.5 to 1.8 mg/kg) 40 to 80 mg/d, may use b.i.d.

dosingBupropion preparationsWellbutrin 75, 100 (3 to 6 mg/kg) 150 to 300 mg/d; up to 150 mg/dose

b.i.d.Wellbutrin SR 100, 150 (3 to 6 mg/kg) 150 to 300 mg/d; up to 150 mg q AM;

>150 mg/d, use b.i.d. dosingVenlafaxineEffexor 25, 37.5, 50, 75,

10025 to 150 mg/d; use b.i.d. dosing

Effexor XR 37.5, 75, 150 37.5 to 150 mg q AMα-Adrenergic agonistsClonidine (Catapres)0.1, 0.2, 0.3 3 to 10 µg/kg/d divided t.i.d.; up to 0.1 mg t.i.d.

Table 43-2 Stimulant Medications in the Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

MedicationPreparation (mg)

Approx. Duration (hr) Recommended Dose

Methylphenidate preparationsRitalin 5, 10, 15, 20 3 to 4 0.3“1 mg/kg t.i.d; up to 60

mg/d

Ritalin-SR 20 8 Up to 60 mg/dConcerta 18, 36, 54 12 Up to 54 mg/q AMMetadate ER 10, 20 8 Up to 60 mg/dMetadate CD 20 12 Up to 60 mg/qRitalin LA 5, 10, 15, 20 8  Dexmethylphenidate preparationFocalin 2.5, 5, 10 3 to 4 Up to 10 mgFocalin XR 5, 10, 20 6 to 8 Up to 20 mgDextroamphetamine preparationsDexedrine 5, 10 3 to 4 0.15 to 0.5 mg/kg b.i.d.; up to

40 mg/d

Dexedrine Spansule

5, 10, 15 8 Up to 40 mg/d

Dextroamphetamine and amphetamine salt preparationsAdderall 5, 10, 20, 30 4 to 6 0.15 to 0.5 mg/kg b.i.d.; up to

40 mg/d

Adderall XR 10, 20, 30 12 Up to 40 mg q AM

t.i.d., three times daily; q, every; b.i.d., twice daily.

Guanfacine (Tenex) 1, 2 0.5 to 1.5 mg/d

b.i.d, twice daily; q, every; t.i.d., three times daily.

7. PROGNOSIS OF GHDP

Sekitar 80% pasien GHDP mengalami perbaikan bila mendapat penanganan yang tepat.

Umumnya, pada saat menjelang dewasa gejala inattention (kurang perhatian) cenderung

lebih menetap, sementara gejala hiperaktivitas-impulsif semakin lama cenderung menurun.

Pada pasien GHDP yang menetap hingga dewasa, dapat muncul beberapa gejala :

Tingginya perilaku “deliquent” (25-50%)

Rendahnya pertahanan diri

Rendahnya tingkat pendidikan

Meningkatnya penyalahgunaan obat atau zat lain

Pada sekitar 60-80% anak dengan GHDP gejala akan membaik saat dewasa.

GHDP menetap pada 10-50% pasien dewasa muda, namun sebagian besar hanya berupa

satu gejala minimal.

Pada anak yang tidak agresif, IQ tinggi, kalangan ekonomi menengah ke atas biasanya

prognosisnya baik.

II. Conduct disorder.

1. Definisi

Suatu pola perilaku yang berulang dan menetap, yang melanggar norma sosial serta

hak-hak orang lain.

Berdasarkan DSM IV-TR, diperlukan 3 (tiga) dari 15 kriteria, yaitu antara lain :

bullying, mengancam atau mengintimidasi orang lain, dan pulang larut malam atau

bahkan tidak pulang ke rumah tanpa ijin dari orangtua, yang bermula sejak <13

tahun. Terjadi dalam 12 bulan terakhir, dengan minimal 1 kriteria dalam 6 bulan

terakhir.

2. Epidemiologi

Prevalennsi 5-15% di dunia, lebih sering terjadi di daerah perkotaan, dan lebih sering

pada anak laki-laki, dengan rasio 4:1 - 12:1.

3. Etiologi

Biopsikososial faktor yang berperan, antara lain :- Parental Factors

Orangtua yg kasar dan suka menghukum, serta perceraian orangtua

- Sociocultural Factors, Sosioekonomi rendah, konsumsialkohol atau narkoba

- Psychological Factors, Anak yg tumbuh dalam suasana rumah yang chaotic, dan negligent conditions biasanya memiliki lebih banyk emosi anger, frustration, and sadness.

- Child Abuse and Maltreatment Anak yang terekspose pada kekerasan dalam waktu lama baik sebagai korban maupun saksi dari kekerasan dalam rumah tangga.

- Neurobiological dan Neurologic Factors

4. Diagnosis, signs, and symptoms.

Table 44-2 DSM-IV-TR Diagnostic Criteria for Conduct DisorderA. A repetitive and persistent pattern of behavior in which the basic rights of others or

major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Aggression to people and animals

1. often bullies, threatens, or intimidates others 2. often initiates physical fights 3. has used a weapon that can cause serious physical harm to others (e.g., a

bat, brick, broken bottle, knife, gun) 4. has been physically cruel to people 5. has been physically cruel to animals 6. has stolen while confronting a victim (e.g., mugging, purse snatching,

extortion, armed robbery) 7. has forced someone into sexual activity

Destruction of property

1. has deliberately engaged in fire setting with the intention of causing serious damage

2. has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft

1. has broken into someone else's house, building, or car 2. often lies to obtain goods or favors or to avoid obligations (i.e., “cons†�

others) 3. has stolen items of nontrivial value without confronting a victim (e.g.,

shoplifting, but without breaking and entering; forgery)

Serious violations of rules

1. often stays out at night despite parental prohibitions, beginning before age 13 years

2. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)

3. is often truant from school, beginning before age 13 years

N. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

O. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Code based on age at onset:   Conduct disorder, childhood-onset type: onset of at least one criterion characteristic of conduct disorder prior to age 10 years    Conduct disorder, adolescent-onset type: absence of any criteria characteristic of conduct disorder prior to age 10 years    Conduct disorder, unspecified onset: age at onset is not known

Specify severity:   Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others   Moderate: number of conduct problems and effect on others intermediate between mild and severe   Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others

(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)5. Differe

Table 44-4 ICD-10 Diagnostic Criteria for Conduct Disorders

G1. There is a repetitive and persistent pattern of behavior, in which either the basic rights of others or major age-appropriate societal norms or rules are violated, lasting at least 6 months, during which some of the following symptoms are present (see individual subcategories for rules or numbers of symptoms).Note: The symptoms in 11, 13, 15, 16, 20, 21, and 23 need only have occurred once for the criterion to be fulfilled.The individual:

1. has unusually frequent or severe temper tantrums for his or her developmental level; 2. often argues with adults; 3. often actively refuses adults' requests or defies rules; 4. often, apparently deliberately, does things that annoy other people; 5. often blames others for his or her own mistakes or misbehavior; 6. is often “touchy†or easily annoyed by others; �7. is often angry or resentful; 8. is often spiteful or vindictive; 9. often lies or breaks promises to obtain goods or favors or to avoid obligations; 10. frequently initiates physical fights (this does not include fights with siblings); 11. has used a weapon that can cause serious physical harm to others (e.g., bat, brick,

broken bottle, knife, gun); 12. often stays out after dark despite parental prohibition (beginning before 13 years of

age); 13. exhibits physical cruelty to other people (e.g., ties up, cuts, or burns a victim); 14. exhibits physical cruelty to animals; 15. deliberately destroys the property of others (other than by fire-setting);

16. deliberately sets fires with a risk or intention of causing serious damage; 17. steals objects of nontrivial value without confronting the victim, either within the

home or outside (e.g., shoplifting, burglary, forgery); 18. is frequently truant from school, beginning before 13 years of age; 19. has run away from parental or parental surrogate home at least twice or has run away

once for more than a single night (this does not include leaving to avoid physical or sexual abuse);

20. commits a crime involving confrontation with the victim (including purse-snatching, extortion, mugging);

21. forces another person into sexual activity; 22. frequently bullies others (e.g., deliberate infliction of pain or hurt, including

persistent intimidation, tormenting, or molestation);

23. breaks into someone else's house, building, or car.

5. Differensial Diagnosis

6. Manajemen

a. Pharmacological.

Stimulants dapat mengurangi perilaku aggresif pada conduct disorder (comorbid with

ADHD). Lithium dan haloperidol terbukti efektif dalam menangani explosive,

aggressive behavior pada anak dengan conduct disorder. However, the atypical

antipsychotics also diminish aggression and have better side effect profile than

haloperidol. α-adrenergic agonists may help; β-adrenergic receptor antagonists

deserve study.

b. Psychological.

Meditasi, behavioral technique, psikoterapi individu, terapi keluarga, parenting

classes, tutoring. Jika lingkungan tempat tinggal anak bermasalah, namun tidak dapat

diintervensi, sementara conduct disorder yang terjadi sudah parah, maka placement

away from home mengeluarkan anak dari rumah mungkin diperlukan.

Pharmacotherapy for Conduct Disorder

Medication Dosage rangeCommon adverse effects

Monitoring/special considerations

Stimulants

Methylphenidate (Ritalin)

For children six years and older: 2.5 to 5.0 mg per dose given before breakfast and lunch to maximum dosage of 2 mg per kg per day or 60 mg per day

Anorexia, nervousness, sleep delay, restlessness, dysrhythmias, palpitations, tachycardia, anemia, leukopenia

Periodic CBC with differential and platelet count, blood pressure, height, weight, heart rate Tolerance or dependence can occur. Drug holidays should be considered.

Additional dose of 2.5 mg may be required, not to be given after 4 p.m.

Dextroamphetamine (Dexedrine)

Amphetamine therapy is not recommended for children younger than three years. 3 to 5 years: 2.5 mg per day; increased by 2.5 mg at weekly intervals (not to exceed 0.5 mg per kg per day) > 6 years: 5 mg three times daily; increase by 5 mg at weekly intervals; maximum dosage of 40 mg per day

Anorexia, dependence, hyperactivity, sleep delay, restlessness, talkativeness, palpitations, tachycardia

CNS activity, height, weight, blood pressure Tolerance or dependence can occur. Do not discontinue abruptly.

Antidepressants

Bupropion (Wellbutrin)*

50 to 150 mg every day Adolescents and children older than six years: 1.4 to 6.0 mg per kg per day in divided doses

Agitation, anxiety, confusion, headache/migraine, insomnia, seizures, arrhythmias, nausea, vomiting

Fluoxetine (Prozac) 5 to 20 mg per day: dose should be titrated slowly; maximum dosage in adults is 80 mg per day; no dosage information in children < 5 years

Anxiety, dizziness, drowsiness, fatigue, headache, insomnia, nervousness, tremor, anorexia, diarrhea, dyspepsia

Drug interactions (metabolized by the CYP450 pathway)

Medication Dosage rangeCommon adverse effects

Monitoring/special considerations

Anticonvulsants

Phenytoin (Dilantin) 5 mg per kg per day in 2 to 3 divided doses to a maximum of 300 mg per day

Dizziness, psychiatric changes, slurred speech, gingival hyperplasia, constipation, nausea, vomiting

Serum concentrations, CBC with differential, liver enzymes Drug interactions

Carbamazepine (Tegretol)

< 6 years: 10 to 20 mg per kg per day in 2 to 3 divided doses; maximum dosage of 35 mg per kg per day 6 to 12 years: 100 mg twice daily; increase by 100 mg at weekly intervals; maximum dosage of 1,000 mg per day

Ataxia, drowsiness, constipation, diarrhea, nausea

CBC with platelet count, liver function tests

Valproic acid (Depakene)

10 to 15 mg per kg per day in 1 to 3 divided doses; increase by 5 to 10 mg per kg per day at weekly intervals

Drowsiness, sedation, constipation, diarrhea, heartburn, nausea, vomiting, rash

Liver function tests, bilirubin, CBC with platelet count

Other

Lithium Children: 15 to 60 mg per kg per day in 3 to 4 divided doses Adolescents: 600 to 1,800 mg per day in 3 to 4 divided doses

Dizziness, drowsiness, fine hand tremor, headache, hypotension, anorexia, diarrhea, dry mouth, nausea, vomiting, polyurea

Drug interactions Serum lithium concentrations prior to next dose, monitor biweekly until stable then every 2 to 3 months; serum creatinine, CBC, urinalysis, serum electrolyte, fasting glucose, echocardiogram, TSH

Clonidine (Catapres) 0.05 mg per day; increase every 3 to 7 days by 0.05 mg per day to 3 to 5 μg per kg per day in 3 to 4 divided doses

Dizziness, drowsiness, sedation, constipation, dry mouth

Blood pressure, heart rate Do not discontinue abruptly or withdrawal symptoms may occur.

Maximum dose: 0.3 to

Medication Dosage rangeCommon adverse effects

Monitoring/special considerations

0.4 mg per day

CBC = complete blood count; CNS = central nervous system; TSH = thyroid-stimulating hormone.

*—Data on pediatric safety are not extensive.

Referensi :

1. Kaplan&Sadock's Synopsis of Psychiatry 10th Ed.

2. http://www.aafp.org/afp/2001/0415/p1579.html