Attention Deficit Hyperactive Disorder (ADHD)

What is ADHD?

Children with ADHD have one or more of the following symptoms: (1) Increased activity, also called “hyperactivity”. A child might have trouble sitting still or playing quietly (2) Impulsivity – A child might interrupt others or do things without thinking them through (3) Trouble paying attention – A child might be forgetful, lose things, or have trouble finishing a project. Symptoms often begin by the time a child is 4 years old and can change over time. Children often continue to have symptoms as teenagers or adults. These symptoms should be present in more than one setting (for eg. both school & home) and should affect child’s social, family and academic life.

How is ADHD diagnosed?

There is no specific test to diagnose ADHD but certain online tests/tools and assist in diagnosis. Collateral information obtained from teachers and parents via standardized scales also helps in making a diagnosis.

How is ADHD treated?

Children with ADHD might have 1 or more of the following treatments:

Medicines– ADHD medicines are often very effective at improving the condition, but they can cause side effects. Some children need to try more than one medicine to find the one that is right for them.
Behavior treatment– You might find that you can improve your child’s behavior by making changes at home. For instance, you can make a checklist for your child to use every morning so that he or she remembers what to do. Or you can have your child keep homework in the same place so he or she doesn’t lose it.

●Changes at school – Teachers can make changes in the classroom to help children with ADHD do better in school. For example, a teacher might write down what the homework is every day so the child does not forget. Or a teacher might allow a child to have extra time to finish school work. Parents should work with the teacher and school to create a “school plan” that is right for their child.

Anxiety Disorders

What are the symptoms of anxiety disorders in children?

Worries and fears are a natural and adaptive part of childhood development. Anxiety and fear meet the criteria for a clinical anxiety disorder when the concerns are persistent and excessive, causing notable distress or impairment in day-to-day life. Most common anxiety symptoms are avoidance of academic and social activities (such as school, parties, camp, sleepovers), somatic symptoms (for example, headaches, stomach aches), sleep problems, excessive need for reassurance, poor school performance, explosiveness and oppositional behavior, eating problems, suicidal thoughts or behavior

How many kinds of anxiety disorders are seen in kids?

The DSM-5 includes seven anxiety disorders seen in children. Anxiety symptoms may occur in some settings and situations and not others. Individual anxiety disorders can be distinguished by the nature of the stimuli that trigger anxiety, the cognitions experienced, and/or the resulting behaviors, as described below:

Generalized anxiety disorder (GAD) — Child presents with a host of worries that he or she finds difficult to stop or control. Many children with GAD discuss preoccupation with academic performance. The preoccupations often manifest in perfectionism and an “all or nothing” cognitive bias, wherein they perceive that they must perform perfectly or they are no good. These children and adolescents tend to focus on mistakes they have made, rather than successes.

Social anxiety disorder: Children and adolescents with social anxiety disorder will often describe a fear of saying or doing the wrong thing, being laughed at, or being embarrassed, resulting in avoidance of social and performance situations. Their worries focus more on what others think of them, rather than on their own perceptions of their performance.

Panic disorder: Youth with panic disorder will describe experiencing panic attacks as the primary presenting problem, and a fear of having another attack which is contributing to distress, avoidance, and/or impairment. They often focus on the uncomfortable physical symptoms and fears of what these symptoms might signify. Youth will often report avoiding a variety of different settings or situations for fear of triggering a panic attack.

Agoraphobia — Agoraphobia is marked by pronounced fear in particular environments or situations, such as large open spaces (parking lots, bridges), crowded places (shopping malls, theater, ballpark), small enclosed areas (elevator), public transportation (planes, trains, cars), or generally being outside of the home, especially alone. The focus of the fear, and subsequent avoidance, of these places or situations is related to thoughts of being unable to escape or cope with physical symptoms (such a panic) or other debilitating or potentially humiliating symptoms.

Specific phobias — Children and adolescents will often describe a number of different phobias, particularly when asked. Only some that they describe result in functional impairment. Many children display some anxiety during thunderstorms, but a child with a specific phobia of storms may describe a marked preoccupation with the weather and avoid going outside when it is raining.

Separation anxiety disorder: The child has trouble separating from their parent in order to participate in their portion of the interview. Parents may also display anxiety about being separated from their child. The child will typically report worries about something bad happening when they are separated from their parents. Families may report that the child often sleeps with their parents or requires a parent to lay down with him or her in order to fall asleep.

Selective mutism: Parents report that the child readily talks at home, and/or around select family or friends, but does not speak in school or other settings.

Are anxiety disorders treatable?

Childhood anxiety disorders are generally believed to have a good prognosis with evidence-based psychotherapy and/or medication treatment.

Psychotherapy:

Cognitive-behavioral therapy (CBT) focuses on the interplay between cognitions, behaviors and emotions, helping patients to recognize and modify maladaptive anxiety-provoking thoughts and to change patterns of avoidance. The content of CBT programs typically includes psychoeducation and exposure to anxiety producing stimuli and situations, couched within an active and collaborative patient-therapist relationship, and reinforced by the use of patient-centered homework assignments.

Medications:

Selective serotonin reuptake inhibitor (SSRI) including Escitalopram (Lexapro), Fluoxetine (Prozac), Sertraline (Zoloft) are prescribed as the first line treatment. Serotonin-norepinephrine reuptake inhibitors (SNRIs) like Venlafaxine (Effexor) and tricyclic antidepressants like Clomipramine are used as second- and third-line treatments due to their less easily tolerated side effects compared with SSRIs. Adverse effects: SSRIs have been associated with psychiatric adverse events, such as disinhibition, agitation, and worsening of anxiety symptoms. Physical side effects most commonly include headaches, gastric distress, and sleep disturbance. Antidepressant medications are associated with an increased risk of suicidality in children. Some children receiving venlafaxine have been reported to experience weight gain, elevated cholesterol, and hypertension.

Augmentation: Evidence from clinical trials suggests that augmentation of pharmacotherapy with cognitive behavioral therapy (CBT) may be effective in pediatric anxiety disorders.

Attachment Disorders

By what age babies get attached to their parents?

Attachment may be defined as the organization of behaviors in the young child that are designed to achieve physical proximity to a preferred caregiver at times when the child seeks comfort, support, nurturance, or protection. Typically, preferred attachment appears in the latter part of the first year of life as evidenced by the appearance of separation protest and stranger wariness.

What is Reactive attachment disorder (RAD)?

RAD is the clinical disorder that defines distinctive patterns of aberrant behavior in young children who have been maltreated or raised in environments that limit opportunities to form selective attachments.

How are attachment disorders diagnosed?

Attachment disorders are diagnosed with the help of a laboratory paradigm known as the Strange Situation Procedure which involves a series of interactions between a young child, an attachment figure, and an unfamiliar adult, including separations and reunions. Four patterns of attachment—secure, avoidant, resistant, and disorganized— have described individual differences in the organization of an infant’s attachment behaviors with respect to an attachment figure in this procedure.

How is an attachment disorder treated?

Child with RAD will require intensive attachment focused therapy. There are three basic psycho- therapeutic modalities to help children with RAD and their caregivers attune to each other and interact more positively: working through the caregiver, working with the caregiver–child dyad (and/or family) together, and/or working with the child alone.

Autism Spectrum Disorders (ASD)

What is Autism Spectrum Disorder?

ASD is a neurodevelopmental disorder with problems in 2 key areas:

Social interaction and social communication– Children with ASD have trouble relating to others or not have an interest in other people at all. They often don’t know how to read facial expressions, and they tend to avoid eye contact & want to be alone. They often dislike being touched. Many young children with autism spectrum disorder prefer not to play or interact with others. Children with ASD often take much longer than other children to learn to speak. Some never learn to speak. They do not seem to care whether they can communicate.
Limited interests– Children with ASD tend to show intense interest in certain things. But they show little interest in anything else. Young children might get completely focused on things that spin or shine and ignore most everything else. Older children might become preoccupied with 1 topic, such as the weather, numbers, or sports. Children with ASD also tend to have rituals that they must follow exactly. For example, they might need to eat particular foods in a specific order, or to take the same route from one place to another – every time. If these habits get disrupted, the child gets upset.

Children with ASD might also:

not point at objects to show interest (for example, not point at an airplane flying over)
not look at objects when another person points at them
have trouble understanding other people’s feelings or talking about their own feelings
appear to be unaware when people talk to them, but respond to other sounds
repeat or echo words or phrases said to them, or repeat words or phrases in place of normal language
have trouble expressing their needs using typical words or motions
not play “pretend” games (for example, not pretend to “feed” a doll)
repeat actions over and over again
have trouble adapting when a routine changes
have unusual reactions to the way things smell, taste, look, feel, or sound
lose skills they once had (for example, stop saying words they were using)

How is Autism diagnosed?

Autism is a clinical diagnosis and is diagnosed based on the collection of symptoms present. Structured and semi-structured testing to evaluate patient’s IQ, social skills, language skills, motor skills, academic achievements can assist in diagnoses. Genetic testing might be recommended to evaluate for any comorbid genetic disorder.

How is Autism treated?

Early intervention leads to a better outcome. Autism is treated by multidisciplinary team with child psychiatrist being the team lead responsible for diagnosis and setting up a treatment plan. Components of treatment plan include:

Behavior Therapy including Applied Behavior Analysis (ABA) Psychotherapist who address problematic behavior using various therapeutic modalities.
Medication management for anger episodes; temper tantrums; comorbid ADHD, depression, anxiety.
Speech therapy if speech delays or deficits present
Accommodations with learning as needed.
Services of OT to address clumsiness and sensory issue

Bipolar Disorder

What are the symptoms of Bipolar Disorder in Youth?

Bipolar disorder in children and adolescents is characterized by recurrent episodes of elevated mood (mania or hypomania) along with recurrent episodes of major depression. Mania typically manifests as a cluster of symptoms that include elation (euphoria) and/or irritability, increased energy, grandiose ideation or delusions, rapid to disorganized thinking, rapid (pressured) speech, distractibility, decreased need for sleep, and hypersexuality, as well as increased activity, agitation, impulsivity, and risky behaviors.

If my child has anger episodes or aggressive behavior, does that mean he/she has Bipolar disorder?

Mania rarely occurs without euphoria/elation. Chronic (non-episodic) irritability is usually associated with other disorders like disruptive mood dysregulation disorder, oppositional defiant disorder and attention deficit hyperactivity disorder, rather than bipolar disorder. Episodic irritability without euphoria/elation can be related to Intermittent Explosive Disorder.

What is the treatment of Bipolar Disorder?

Medications are a must and first line treatment. Psychotherapies is added onto pharmacotherapy. Initial pharmacotherapy for pediatric mania is a second-generation antipsychotic, such as aripiprazole, asenapine, olanzapine, quetiapine, risperidone, or ziprasidone. Patients that do not respond to multiple (eg, two to three) trials of second-generation antipsychotics should receive a trial of lithium. If monotherapy of Lithium does not work, a combination of second-generation antipsychotic with lithium should be tried. Other combinations that may be useful include second-generation antipsychotics plus an antiepileptic (eg, divalproex or lamotrigine), lithium plus an antiepileptic (eg, divalproex, lamotrigine, or carbamazepine), and first-generation antipsychotics plus lithium or an antiepileptic (eg, divalproex or lamotrigine).

Depressive Disorders

How do I know if my child is depressed?

Depressed people feel down most of the time for at least 2 weeks. They also have at least 1 of these 2 symptoms: (1) They no longer enjoy or care about doing the things they used to like to do (2) They feel sad, down, hopeless, or cranky most of the day, almost every day. Depression can also make one lose or gain weight, sleep too much or too little, feel tired or like you have no energy, feel guilty or like you are worth nothing, forget things or feel confused, move and speak more slowly than usual, act restless or have trouble staying still, think about death or suicide. Teenagers when depressed tend to get moodier and are described by family as “often cranky” and “easily annoyed”. They might even pick fights with people.

How is depression treated?

Children & Adolescents who have depression can get 1 of the following treatments:

Psychotherapy or counselling: Psychosocial treatments include, but are not limited to, cognitive-behavioral therapy (CBT), interpersonal therapy for adolescents (IPT-A), family therapy, dynamic therapy, group therapy, and supportive therapy. Among these, only CBT and IPT-A have been shown to be efficacious in controlled research within a delineated population.
Antidepressant medication
Combination of therapy and medication.

Which medications are effective for Pediatric Depression?

First Line: For children and adolescents with acute depressive disorders, first line pharmacotherapy is fluoxetine. There is more consistent, high quality evidence for the efficacy of fluoxetine than other antidepressants.

Second Line: Acute pediatric depressive episodes do not remit with fluoxetine in approximately 30 percent of patients. For these patients, sertraline, escitalopram, citalopram and venlafaxine are reasonable choices, based upon their efficacy in randomized trials. Paroxetine is not recommended for pediatric depression because of its lack of demonstrated efficacy.

Third Line: For children and adolescents with acute depressive disorders who do not respond to fluoxetine as well as a second trial with a different SSRI and a third trial with venlafaxine, bupropion or duloxetine is recommended, based upon randomized trials in adults and low quality studies in youth.

Do antidepressants increase the risk of suicide?

In 2004, the FDA directed manufacturers of all antidepressants to include a warning stating that antidepressants may increase the risk of suicidal ideation and behavior in children and adolescents.

The US FDA convened an advisory panel that combined analysis of 24 short-term (4 to 16 weeks), placebo-controlled trials of nine antidepressant medications in more than 4400 children and adolescents being treated for unipolar major depression and other psychiatric disorders and concluded that there was a small increased risk of suicidal thoughts or behavior in children taking antidepressants compared with placebo. The risk appeared to be greatest in the first few weeks after initiating therapy.

However, establishing the causal association is difficult because of the clear associations between severe depression and suicide and between severe depression and the need for antidepressant therapy. Because suicide is uncommon, it also is difficult to demonstrate the negative, which is that antidepressants do not cause suicide. Evidence for and against an association between antidepressant therapy and suicidal thoughts and/or behaviors in children, adolescents, and young adults comes from randomized trials, observational studies, and population-based studies comparing the rates of suicide and antidepressant use over time. Each of these study designs has limitations in demonstrating a causal association. Suicide is rare in randomized, controlled trials of antidepressants. Thus, individual trials typically lack the power to detect a relationship between antidepressants and suicidal ideation or behavior. Observational studies can more easily detect rare events such as suicide. However, causality is difficult to establish because of the association between severe depression and the use of antidepressants. Population-based studies have examined rates of antidepressant use and suicide over time. These studies have generally found lower rates of suicide with increasing rates of antidepressant use. Accordingly, the consensus has been that increases in prescribing likely yield lower rates of suicide. However, rare antidepressant-induced suicides could be masked by secular trends.

Eating Disorder

What is Anorexia nervosa?

It is an eating disorder that makes people want to weigh less than is healthy.

People with anorexia nervosa:

Weigh much less than they should for their age and height – To lose weight, people eat too little, exercise too much, or do other things, such as make themselves vomit.
Are very worried about gaining weight – To avoid gaining weight, they will not eat, even when they are hungry.
See their body and shape in an abnormal way – For example, they:
Think they are fat, even when they are underweight
Don’t understand that their low body weight can cause serious medical problems
Feel good about themselves when they lose weight and bad when they gain weight

It is also common for people with anorexia nervosa to:

Spend a lot of time thinking about food, meals, and calories
Create rules around food and eating
Skip meals and avoid eating in public

What can be the medical complications of Anorexia nervosa?

Anorexia nervosa can cause many problems. That’s because the body and brain don’t get the nutrition they need. Anorexia nervosa can cause:

Problems with the brain, heart, lungs, liver, kidney, and glands
Bone loss and muscle weakness
Bloating and trouble having bowel movements
Thinning hair and nails that break easily
Feeling cold all the time or tired a lot

How is anorexia nervosa treated?

Treatment for anorexia nervosa involves:

Gaining weight – You will work with your doctor and a dietitian (food expert) to gain weight. The dietitian will make meal plans that can help you gain weight safely and slowly. The doctor will follow your weight and health closely.
Psychotherapy – Psychotherapy involves meeting with a therapist to talk about your feelings, thoughts, and life. Different kinds of psychotherapy can be helpful, including:
Working one-on-one with a therapist
Family therapy – Your family can work with a therapist.
Group therapy – You can join a group for people with eating disorders.

Medicines are not usually used to treat anorexia nervosa, except in certain cases when the above treatments alone don’t help.

Learning Disorders

What are learning disabilities?

Learning disabilities are problems that cause a child to have trouble learning. For example, a child might have problems learning to read, write, or do math. Learning disabilities do not have anything to do with how smart a child is. Children with learning disabilities can be just as smart or smarter than other children of their age. But they have brain differences that make it hard for them to learn, remember, and use information.

How are learning disabilities diagnosed?

Learning Disabilities are diagnosed using structured tests like IQ tests; achievement tests in reading, writing and math; vision; hearing; speech; motor skills. The tests also include a review of the child’s school records and watching how he or she acts in a classroom.

How are learning disabilities treated?

Learning disabilities are treated with “special education.” This is when a child learns from a teacher with special training. Special education uses different ways to teach children with disabilities. The methods depend on the learning disability. Examples include using pictures along with written or spoken words to explain things. Teachers might also give the child tips on how to remember things or help them stay organized. Children with learning disabilities might be given extra time to solve problems or take tests.

Obsessive-Compulsive Disorder (OCD)

What are the symptoms of Obsessive-Compulsive Disorder (OCD)?

OCD is characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress, and by repetitive mental or behavioral acts (compulsions) that the individual feels driven to perform, either in relation to an obsession or according to rules that he or she believes must be applied rigidly or to achieve a sense of completeness. People with obsessive-compulsive disorder (OCD) experience obsessions, compulsions, or both.

What treatments are available for OCD?

Patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT) consisting of exposure and response prevention, a selective serotonin reuptake inhibitor (SSRI) medication, or both. For most patients with OCD, first-line treatment should be with exposure and response prevention (a type of CBT). SSRI medication is a reasonable alternative if CBT is unavailable, not indicated, or if the patient prefers medication. If an adequate trial of the SSRI results in no response, we suggest treatment with a different SSRI, clomipramine, or venlafaxine. If a trial of an SSRI or SNRI results in a partial response, we suggest augmenting the antidepressant with antipsychotic medication. (eg, risperidone 0.5 to 3 mg/day). Other approaches with less supporting evidence are increasing the SSRI dose above the maximum approved by the FDA or adding clomipramine (≤75 mg/day).

Post-Traumatic Stress Disorder (PTSD)

What is PTSD?

Post-traumatic stress disorder, or “PTSD,” is a condition that can happen after people see or live through a trauma. The symptoms of PTSD include:

Reliving the trauma through thoughts and feelings – People can have upsetting memories, nightmares, or flashbacks. Flashbacks are when people “see” or feel the trauma over and over again.
Feeling “numb” and avoiding certain people or places – People avoid thinking about the trauma and avoid people and places that remind them of it. Some people also feel “numb.” They might not enjoy activities they used to enjoy or feel part of the world around them.
Having intense feelings, such as anger, fear, or worry – People might frighten or startle easily. Many people have trouble sleeping.

Symptoms of PTSD can come and go. They might return when people are under stress or see or hear something that reminds them of the trauma.

How is PTSD treated?

PTSD is treated with one or both of the following:

A type of therapy called cognitive-behavioral therapy, or “CBT” – CBT involves meeting with a therapist to talk about your feelings and thoughts. Your therapist will do certain activities with you that can reduce your symptoms. Different types of therapists can do CBT, including psychologists, psychiatrists, and social workers. You can work one-on-one with a therapist to have CBT. You can also have CBT as part of group therapy.
Medicines – Doctors can use different types of medicines to treat PTSD. The right one for you will depend on your symptoms and the medicine’s side effects. People usually start feeling better after they have been on medicine for a few weeks.

Psychotic Disorders including Schizophrenia

Is childhood schizophrenia real?

Schizophrenia is a neurodevelopmental disorder that 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.

What are the symptoms of Schizophrenia?

Prior to developing overt psychotic symptoms, most individuals will experience a prodromal phase which is a period of deteriorating function, which may include social isolation, idiosyncratic or bizarre preoccupations, unusual behaviors, academic problems, and/or deteriorating self-care skills. However, while the presence of these problems should raise concerns, psychotic symptoms must be present before a diagnosis of schizophrenia can be made. During acute phase patients often present, and it is dominated by positive psychotic symptoms (i.e., hallucinations, delusions, formal thought disorder, bizarre psychotic behavior) and functional deterioration. Recovery Phase follows the acute phase and has some ongoing psychotic symptoms and may also be associated with confusion, disorganization, and/or dysphoria. Residual Phase: positive psychotic symptoms are minimal. However, patients will still generally have ongoing problems with “negative symptoms,” i.e., social withdrawal, apathy, amotivation, and/or ﬂat affect.

How is Schizophrenia treated?

Primarily with medications which include traditional neuroleptic medications (block dopamine receptors) and the atypical antipsychotic agents (that have a variety of effects, including antagonism of serotonergic receptors). Compared with traditional agents, the atypical antipsychotics are at least as effective for positive symptoms, and they may be more helpful for negative symptoms. Clozapine has documented efficacy for treatment-resistant schizophrenia in adults. However, clozapine is generally used only after failed trials of at least two other antipsychotic medications.

Tourette’s Syndrome

What are the symptoms of Tourette’s syndrome?

There is no confirmatory laboratory test for TS; the diagnosis is based on a set of clinical diagnostic criteria:

Both multiple motor tics and one or more phonic tics must be present at some time during the illness, although not necessarily concurrently
Tics must occur many times a day, nearly every day, or intermittently throughout a period of more than one year
Anatomical location, number, frequency, type, complexity, or severity of tics must change over time
Onset of tics before the age of 18 years
Involuntary movements and noises must not be explained by another medical condition (or by the physiological effects of substances as per the DSM-5)
Motor tics, phonic tics, or both must be witnessed by a reliable examiner at some point during the illness or be recorded by videotape or cinematography

How is Tourette’s syndrome treated?

Patients with TS who have tics that are mild and nondisabling should receive education, counseling, and supportive care; behavioral or pharmacologic tic suppression therapy is not clearly indicated. For patients with TS and tics that are causing psychosocial, physical, functional, or other problems, we suggest habit reversal training with Comprehensive Behavioral Intervention for Tics (CBIT). When CBIT is not an option for patients with TS and debilitating tics, we suggest medication treatment with tetrabenazine. Alternatives include fluphenazine or risperidone. For patients with TS who have only focal motor or phonic tics, we suggest treatment with botulinum toxin injections into the affected muscles.