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CHILD PSYCHIATRYLaurence L. Garcia
• The branch of psychiatry that specializes in the study, diagnosis, treatment, and prevention of psychopathological disorders of children, adolescents, and their families
• encompasses the clinical investigation of phenomenology, biologic factors, psychosocial factors, genetic factors, demographic factors, environmental factors, history, and the response to interventions of child and adolescent psychiatric disorders
• Any nurse working with children or adolescents should be knowledgeable about “normal” stages of growth and development.
• At best, the developmental process is one that is fraught with frustrations and difficulties.
• Behavioral responses are individual and idiosyncratic. They are, indeed, human responses.
• Whether a child’s behavior indicates emotional problems is often difficult to determine.
• The DSM-IV-TR (American Psychiatric Association [APA], 2000) includes the following criteria among many of its diagnostic categories. An emotional problem exists if the behavioral manifestations:
● Are not age-appropriate.● Deviate from cultural
norms.● Create deficits or
impairments in adaptive functioning
MENTAL RETARDATION• Essential feature is below-
average intellectual functioning (IQ less than 70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self-care, home living, social or interpersonal skills, use of community resources, self direction, academic skills, work, leisure, health and safety.
MENTAL RETARDATION
MENTAL RETARDATION• The degree of retardation is
based on IQ and greatly affects the person’s ability to function:
Mild – IQ 50 to 70 Moderate – IQ 35 to 49 Severe – IQ 20 to 34 Profound – IQ less than 20
MENTAL RETARDATIONLevel (IQ) Ability to
Perform Self-Care
Activities
Cognitive/
Educational Capabilities
Social /Communicati
on Capabilities
Psychomotor
Capabilities
Mild (50–70)
Capable of independentliving, with assistanceduring times of stress.
Capable of academic skillsto sixth-grade level.
Capable of developing socialskills. Functions wellin a structured, shelteredsetting.
Psychomotor skills usuallynot affected, althoughmay have some slightproblems with coordination.
MENTAL RETARDATION
Level (IQ) Ability to Perform Self-
Care Activities
Cognitive / Educationa
l Capabilitie
s
Social / Communication Capabilities
Psychomotor
Capabilities
Moderate(35–49)
Can perform some activitiesindependently. Requiressupervision.
Capable of academic skillto second-grade level. Asadult may be able to contributeto own support insheltered workshop.
May experience some limitationin speech communication.Difficultyadhering to social conventionmay interferewith peer relationships.
Motor development is fair.Vocational capabilitiesmay be limited to unskilledgross motoractivities.
MENTAL RETARDATIONLevel (IQ) Ability to
Perform Self-Care Activities
Cognitive / Educational Capabilities
Social / Communication
Capabilities
PsychomotorCapabilities
Severe(20–34)
May be trained in elementaryhygiene skills.Requires complete supervision.
Unable to benefit from academicor vocationaltraining. Profits fromsystematic habit training.
Minimal verbal skills. Wantsand needs often communicatedby acting-out behaviors.
Poor psychomotor development.Only able to performsimple tasks underclose supervision.
MENTAL RETARDATIONLevel (IQ) Ability to Perform Self-
Care ActivitiesCognitive/
Educational Capabilities
Social/Communication
Capabilities
PsychomotorCapabilities
Profound(below 20)
No capacity for independentfunctioning.Requires constant aidand supervision.
Unable to profit from academicor vocationaltraining. May respond tominimal training in self-helpif presented in theclose context of a one-to-onerelationship.
Little, if any, speech development.No capacity forsocialization skills.
Lack of ability for both fineand gross motor movements.Requires constantsupervision and care.May be associated withother physical disorders.
MENTAL RETARDATIONCAUSES:Hereditary Conditions ( Tay-Sachs
disease or Fragile X chromosome syndrome);
early alterations in embryonic development such as trisomy 21 or maternal alcohol intake that causes fetal alcohol syndrome;
pregnancy or perinatal problems such as fetal malnutrition, hypoxia, infections, and trauma
MENTAL RETARDATIONCAUSES:Medical conditions of infancy such
as infection or lead poisoningEnvironmental influences such as
deprivation of nurturing or stimulation
MENTAL RETARDATIONSome people with mental
retardation are passive and dependent; others are aggressive and impulsive.
Children with mild to moderate MR usually receive treatment in their homes and communities and make periodic visits to physicians.
Those with severe or profound mental retardation may require residential placement or day care services.
MENTAL RETARDATIONRESPONSIBILITIESMedical strategies are focused at
correcting structural deformities and treating associated behaviors
Implement community and educational services using multidisciplinary approach
Promote care skills as much as possible
Assist with communication and socialization
Facilitate appropriate play time
MENTAL RETARDATIONRESPONSIBILITIES Initiate safe precautions as
necessaryAssist the family with decisions
regarding careProvide information regarding
support services and community agencies
LEARNING DISORDERS
LEARNING DISORDERSDiagnosed when a child’s
achievement in reading, mathematics, or written expression is below that expected for age, formal education, and intelligence
Learning problems interfere with academic achievement and life activities requiring reading, math, or writing.
Reading and written expression disorders usually are identified in the first grade; math disorder may go undetected until the child reaches fifth grade.
LEARNING DISORDERSLow self-esteem and poor social
skills are common in children with learning disorders.
As adults, some have problems with employment or social adjustment; others have minimal difficulties.
Early identification of the disorder, effective intervention, and no co-existing problems are associated with better outcomes.
LEARNING DISORDERSChildren with learning disorders
are assisted with academic achievement through special education classes in public schools.
MOTOR SKILLS DISORDERS
MOTOR SKILLS DISORDERSAlso known as Developmental
Coordination Disorder Essential feature is impaired
coordination severe enough to interfere with academic achievement or activities of daily living.
Diagnosis is not made if the problem with motor coordination is part of a general medical condition such as cerebral palsy or muscular dystrophy.
MOTOR SKILLS DISORDERSBecomes evident as a child
attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks.
Often coexists with a communication disorder
Its course is variable; sometimes lack of coordination persists into adulthood.
Schools provide adaptive physical education and sensory integration programs to treat motor skills disorder.
MOTOR SKILLS DISORDERSAdaptive physical education
programs emphasize inclusion of movement games such as kicking a football or soccer ball.
Sensory integration programs are specific physical therapies prescribed to target improvement in areas where child has difficulties
COMMUNICATION DISORDERSDiagnosed when a communication
deficit is severe enough to hinder development, academic achievement, or activities of daily living, including socialization.
EXPRESSIVE LANGUAGE DISORDER – involves impaired ability to communicate through verbal or sign language. The child has difficulty learning new words and speaking in complete and correct sentences; his or her speech is limited.
COMMUNICATION DISORDERS
MIXED RECEPTIVE – EXPRESSIVE LANGUAGE DISORDER – includes the problems of expressive language disorder along with difficulty understanding (receiving) and determining the meaning of words and sentences. Both can be present at birth (developmental) or may be acquired as a result of neurologic injury or insult to the brain.
COMMUNICATION DISORDERS
Phonologic Disorder – involves problems with articulation (forming sounds that are part of speech).
Stuttering – a disturbance of the normal fluency and time patterning of speech.
Phonologic disorder and stuttering run in families and occur more frequently in boys than girls.
COMMUNICATION DISORDERS
Maybe mild or severeDifficulties that persist into
adulthood are related most closely to the severity of the disorder.
Speech and language therapists work with children who have communication disorders to improve their communication skills and to teach parents to continue speech therapy activities at home.
PERVASIVE DEVELOPMENTAL
DISORDER• Characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavioral patterns
• Also called AUTISM SPECTRUM DISORDERS and includes autistic disorder (classic autism), Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder.
• Approx. 75% of children with PDD have MR.
AUTISTIC DISORDER
AUTISTIC DISORDER• The best known of the pervasive
developmental disorders, is more prevalent in boys than in girls and is identified no later than 3 years of age.
Characteristics:They display little eye contact with
and make few facial expressions towards others .
They use limited gestures to communicate.
They have limited capacity to relate to peers or parents.
AUTISTIC DISORDERCharacteristics:They lack spontaneous enjoyment,
express no moods or emotional affect, and cannot engage in play or make~believe with toys.
There is little intelligible speech.These children engage in
stereotyped motor behaviors such as hand flapping, body twisting, or head banging.
AUTISTIC DISORDER80% of cases of autism are early
onset, with developmental delays starting in infancy
The other 20% have seemingly normal growth and developmental until 2 or 3 years of age, when developmental regression or loss of abilities begins.
It does have a genetic link; many children with autism have a relative with autism or autistic traits.
MMR Vaccine is safe and not related to autism.
AUTISTIC DISORDERThey tend to improve, in some cases
substantially, as children start to acquire and to use language to communicate with others.
If behavior deteriorates in adolescence, it may reflect the effects of hormonal changes or the difficulty meeting increasingly complex social demands.
Autistic traits persist into adulthood, and most people with autism remain dependent to some degree on others.
AUTISTIC DISORDERManifestations vary from little
speech and poor daily living skills throughout life to adequate social skills that allow relatively independent functioning.
Social skills rarely improve enough to permit marriage and child rearing.
Adults with autism may be viewed as merely odd or reclusive, or they may be given a diagnosis of OCD, Schizoid PD,or MR.
AUTISTIC DISORDERChildren with autism are being
“mainstreamed” into local school programs whenever possible.
Short-term inpatient treatment is used when behaviors such as headbanging or tantrums are out of control.
When the crisis is over, community agencies support the child and family.
AUTISTIC DISORDERThe goals of treatment of children
with autism are to reduce behavioral symptoms and to promote learning and development particularly the acquisition of language skills.
Comprehensive and individualized treatment, including special education and language therapy, is associated with more favorable outcomes.
AUTISTIC DISORDER Pharmacologic treatment with
antipsychotics such as haloperidol (Haldol) or risperidone (Risperdal) may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors.
Other medications such as naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres), and stimulants to diminish self – injury and hyperactive and obsessive behaviors have had varied but unremarkable results.
RETT’S DISORDER
RETT’S DISORDER Characterized by the development of
multiple deficits after a period of normal functioning.
It occurs exclusively in girls, is rare, and persists throughout life.
Develops between birth and 5 months of age
The child loses motor skills and begins showing stereotyped movements instead.
RETT’S DISORDER She loses interest in the social
environment, and severe impairment of expressive and receptive language becomes evident as she grows older.
Treatment is similar to that of autism.
CHILDHOOD DISINTEGRATIVE DISORDER
CHILDHOOD DISINTEGRTIVE DISORDER
Characterized by marked regression in multiple areas of functioning after at least 2 years of apparently normal growth and development
Typical age at onset is between 3 and 4 years.
Children with childhood disintegrative disorder have the same social and communication deficits and behavioral patterns seen with autistic disorder.
This rare disorder occurs slightly more often in boys than in girls.
ASPERGER’S DISORDER
ASPERGER’S DISORDER• Characterized by the same
impairments of social interaction and restricted stereotyped behaviors seen in autistic disorders, but there are NO language or cognitive delays.
• This rare disorder occurs more often in boys than in girls, and the effects are generally lifelong.
ADHD
ADHD• ATTENTION DEFICIT
HYPERACTIVITY DISORDER is characterized by inattentiveness, overactivity, and impulsiveness.
• A common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder.
ADHD• The essential feature is a
persistent pattern of inattention and/or hyperactivity and impulsivity more common than generally observed in children of the same age.
• Affects an estimated 3% to 5% of all school-aged children.
• The ratio of boys to girls ranges from 3:1 in non-clinical settings to 9:1 in clinical settings.
ADHD• To avoid overdiagnosis of ADHD, a
qualified specialist must conduct the evaluation for ADHD.
• Children who are very active or hard to handle in the classroom can be diagnosed and treated mistakenly for ADHD.
• Some of these overly active children may suffer from psychosocial stressors at home, inadequate parenting, or other psychiatric disorders.
ADHDONSET AND CLINICAL COURSE• ADHD is usually identified and
diagnosed when the child begins preschool or school, although many parents report problems from a much younger age.
• As infants, children with ADHD are often fussy and temperamental and have poor sleeping patterns.
• Toddlers may be described as “always on the go” and “into everything”, at times dismantling toys and cribs.
ADHDONSET AND CLINICAL COURSE• Forming positive peer relationships
is difficult because the child cannot play cooperatively or take turns and constantly interrupts others.
• Many adolescents with ADHD have discipline problems serious enough to warrant suspension or expulsion from high school.
• The secondary complications such as low self-esteem and peer rejection continue to pose serious problems
ADHDSYMPTOMS OF ADHD
Inattentive Behaviors Hyperactive/Impulsive Behaviors
Misses detailsMakes careless mistakesHas difficulty sustaining attentionDoesn’t seem to listenDoes not follow-through on chores or homeworkHas difficulty with organizationAvoids tasks requiring mental effortOften loses necessary thingsIs easily distracted by other stimuliIs often forgetful in daily activities
FidgetsOften leaves seat (e.g. during meal)Runs or climbs excessivelyCan’t play quietlyIs always on the go; drivenTalks excessivelyBlurts out answersInterruptsCan’t wait for turnIs intrusive with siblings/playmates
ADHDETIOLOGY• The definitive cause remain unknown• A combination of factors such as
environmental toxins, prenatal influences, heredity, and damage to brain structure and functions
• Prenatal exposure to alcohol, tobacco, and lead and severe malnutrition in early childhood
• Brain images of people with ADHD have suggested decreased metabolism in frontal lobes (essential for attention, impulse control, organization, and sustained goal-directed activity)
• Decreased blood perfusion of the frontal cortex
ADHDRISK FACTOR:• Family hx of ADHD• Male relatives with antisocial PD• Female relatives with somatization
disorder• Lower socioeconomic status• Male gender• Marital or family discord (divorce,
neglect, abuse, or parental deprivation)
• Low birth weight• Various kinds of brain insult
ADHDTREATMENT• ADHD is chronic• Goals of treatment involves
managing symptoms, reducing hyperactivity and impulsivity, and increasing the child’s attention so that he/she can grow and develop normally
• The most effective treatment combines pharmacology with behavioral, psychosocial, and educational interventions
ADHDPSYCHOPHARMACOLOGY• Medications are effective in
decreasing hyperactivity and impulsiveness and improving attention; this enables the child to participate in school and family life
• The most common medications are methylphenidate (RITALIN) and an amphetamine compound (ADDERALL).
• Other stimulants: dextroamphetamine (Dexedrine) and pemoline (Cylert)
ADHDPSYCHOPHARMACOLOGY• METHYLPHENIDATE is effective
in 70% to 80% of children with ADHD; it reduces hyperactivity, impulsivity, and mood lability and helps the child to pay attention more appropriately
• Most common side effects include: insomnia, loss of appetite, and weight loss or failure to gain weight.
ADHDPSYCHOPHARMACOLOGY• They are available in
sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school.
• Pemoline can cause liver damage; it is the last of these drugs to be prescribed.
ADHDPSYCHOPHARMACOLOGY• Giving stimulants during
daytime hours usually effectively combats insomnia.
• Eating a good breakfast with the morning dose and substantial nutritious snacks late in the day and at bedtime help the child to maintain an adequate dietary intake.
ADHD• In most cases, non-stimulant medications are
considered when stimulants haven’t worked or have caused intolerable side effects.
STRATTERA• Generic name: Atomoxetine • The only non-stimulant medication approved
by the FDA for ADD/ADHD treatment. • Unlike stimulants, which affect dopamine,
Strattera boosts the levels of norepinephrine.• It is longer-acting than the stimulant drugs. • Its effects last over 24 hours—making it a good
option for those who have trouble getting going in the morning.
• Strattera doesn’t appear to be as effective as the stimulant medications for treating symptoms of hyperactivity.
ADHDCommon side effects of Strattera include:• Sleepiness• Headache• Abdominal pain or upset stomach• Nausea and vomiting• Dizziness• Mood swings• Straterra can also cause insomnia
and appetite suppression, but these side effects are more common in stimulants.
• Liver damage (liver function test periodically)
ADHDSTRATEGIES FOR HOME AND SCHOOL• Behavioral changes are
necessary to help the child to master appropriate behaviors.
• Environmental strategies can help the child to succeed in those settings.
• Educating parents & helping them with parenting strategies are crucial component of effective treatment.
ADHDSTRATEGIES FOR HOME AND SCHOOL• Providing consistent rewards
and consequences for behavior, offering consistent praise, using time-out (retreat to a neutral place so clients can regain self-control) and giving verbal reprimands.
• Issuing daily report cards for behavior and using point systems for positive and negative behavior.
ADHDSTRATEGIES FOR HOME AND SCHOOL• In therapeutic play, play
techniques are used to understand the child’s thoughts and feelings and to promote communication (not to be confused with play therapy).
• Dramatic play is acting out an anxiety-producing.
• Play techniques to release energy include pounding pegs, running, or working with modeling clay.
ADHDSTRATEGIES FOR HOME AND SCHOOL• Creative play techniques can
help children to express themselves.
• These techniques are especially useful when children are unable or unwilling to express themselves verbally.
ADHDINTERVENTIONS• Ensuring safety• Improving role performance• Simplifying instructions• Promoting a structured daily
routine• Providing client and family
education and support
CONDUCT DISORDER
CONDUCT DISORDER• Characterized by persistent
antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas
Symptoms are clustered into four areas: • aggression to people • destruction of property• deceitfulness and theft• serious violation of rules
CONDUCT DISORDER• little empathy for others• they have low self-esteem• poor frustration tolerance• temper outbursts• early onset of sexual behavior• drinking• smoking• use of illegal substances• other reckless or risky
behaviors
CONDUCT DISORDER• Occurs three times more often
in boys than in girls.• As many as 30% to 50% of
these children are diagnosed with antisocial personality disorder as adults.
CONDUCT DISORDER• Aggression to people
and animals• Bullies, threatens, or
intimidates others• Physical fights• Use of weapons• Forced sexual activity• Cruelty to people or
animals• Destruction of
property• Fire setting• Vandalism• Deliberate property
destruction• Deceitfulness and
theft• Lying• Shoplifting• Breaking into house,
building, or car• Cons other to avoid
responsibility• Serious violation of
rules• Stays out overnight
without parental consent
• Runs away from home overnight
• Truancy from school
CONDUCT DISORDER2 Subtypes:• Childhood onset – symptoms
before age 10 including physical aggression towards others and disturbed peer relationships
• Adolescent-onset – no behaviors of conduct disorder until after 10 years of age; less likely to be aggressive, more normal peer relationships
CONDUCT DISORDERClassifications:• MILD – has some conduct
problems that cause relatively minor harm to others (lying, truancy, staying out late without permission)
• MODERATE – the number of conduct problems increases as does the amount of harm to others (vandalism and theft)
CONDUCT DISORDERClassifications:• SEVERE – has many conduct
problems that cause considerable harm to others (forced sex, cruelty to animals, use of weapon, burglary, and robbery)
AOT – can achieve adequate social relationships and academic or occupational success as adults
CONDUCT DISORDERETIOLOGY• Genetic vulnerability,
environmental adversity, poor coping
RISK FACTORS• Poor parenting, low academic
achievement, poor peer relationships, low self-esteem
PROTECTIVE FACTORS• Resilience, family support,
positive peer relationships, good health
CONDUCT DISORDER• Common in children who have a
sibling with conduct disorder or a parent with antisocial PD, substance abuse, mood disorder, schizophrenia or ADHD
• Lack of reactivity of the autonomic nervous system (may cause more aggression in social relationships as a result of decreased normal avoidance or social inhibitions)
CONDUCT DISORDER• Poor family functioning, marital
discord, poor parenting and a family history of substance abuse and psychiatric problems
• Academic underachievement, learning disabilities, hyperactivity, and problems with attention span
CONDUCT DISORDERTREATMENT• For school-aged children, the
child, family, and school environment are the focus.
• Techniques include parenting education, social skills training to improve peer relationships, and attempts to improve academic performance and increase the child’s ability to comply with demands from authority figures.
CONDUCT DISORDERTREATMENT• Family Therapy is considered
to be essential for school-aged children.
• The most promising treatment approach includes keeping the client in his/her environment with family and individual therapies (conflict resolution, anger management, teaching social skills)
CONDUCT DISORDERMEDICATIONS• Antipsychotics – for clients
who present a clear danger to others
• Lithium or mood stabilizers like carbamazepine [Tegretol] or valproic acid [Depakote]– for clients with labile mood
CONDUCT DISORDERINTERVENTIONSDECREASING VIOLENCE AND INCREASING COMPLIANCE WITH TREATMENTProtect others from client’s
aggression and manipulationSet limits for unacceptable
behavior (inform of rules and limits; explain consequences if they exceed limit; state expected behavior)
CONDUCT DISORDERINTERVENTIONSProvide consistency with
client’s treatment planUse behavioral contractsInstitute time-outProvide routine schedule of
activities
CONDUCT DISORDERINTERVENTIONSIMPROVING COPING SKILLS AND SELF-ESTEEMShow acceptance of the
person, not necessarily the behavior
Encourage the client to keep a diary
Teach and practice problem skills
CONDUCT DISORDERINTERVENTIONSPROMOTING SOCIAL INTERACTIONTeach age-appropriate skillsRole model and practice social
skillsProvide positive feedback for
acceptable behaviorPROVIDING CLIENT AND FAMILY EDUCATION
OPPOSITIONAL DEFIANT DISORDER
OPPOSITIONAL DEFIANT DISORDER• Consists of an enduring
pattern of uncooperative, defiant, and hostile behavior toward authority figures without major antisocial violations
• Diagnosed only when behaviors are more frequent and intense than in unaffected peers and cause dysfunction
• About 5% of the population and occurs equally among male and female adolescents
OPPOSITIONAL DEFIANT DISORDER• Genes, temperament, and
adverse social conditions interact to create the disorder
• 25% of these clients will develop conduct disorder, 10% are diagnosed with antisocial PD as adults
• Treatment approaches are similar to those used for conduct disorder.
PICA
PICA• Persistent ingestion of
nonnutritive substances such as paint, hair, cloth, leaves, sand, clay, or soil
• Commonly seen in children with mental retardation, it occasionally occurs in pregnant women
PICA• Comes to the clinician’s
attention only if a medical complication develops such as a bowel obstruction or an infection or if a toxic condition develops such as lead poisoning.
• The behavior last for several months and then remits.
RUMINATION DISORDER
RUMINATION DISORDER• The repeated regurgitation
and rechewing of food• The child brings partially
digested food up into the mouth and usually rechews and reswallows the food.
• The regurgitation does not involve nausea, vomiting or any medical condition.
RUMINATION DISORDER• This is relatively uncommon
and occurs more often in boys than in girls; it results in malnutrition, weight loss, and even death.
FEEDING DISORDER• Characterized by persistent failure to
eat adequately, which results in significant weight loss or failure to gain weight.
• Equally common in boys and in girls and occurs most often during the first year of life
• 5% of all pediatric hospital admissions are for failure to gain weight, up to 50% of those admissions reflect a feeding disorder with no predisposing medical condition.
• Malnutrition and death can result in severe case, but most have improved growth after some time.
TIC DISORDER
TIC DISORDER• Sudden, rapid, recurrent,
nonrhythmic, stereotyped motor movement or vocalization
• Can be suppressed but not indefinitely
• Exacerbates with stress, diminishes with sleep and when the person is engaged with absorbing activities
• Common simple motor tics includes blinking, jerking the neck, shrugging the shoulders, grimacing and coughing
TIC DISORDER• Common simple vocal tics include
clearing the throat, grunting, sniffing, snorting, and barking
• Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene) palilalia (repeating one’s own sounds or words), and echolalia (repeating the last-heard sound or words)
TIC DISORDER• Complex motor tics include facial
gestures, jumping, or touching or smelling an object.
• They tend to run in families.• Abnormal transmission of dopamine
is thought to play a part in tic disorders.
• Usually treated with atypical antipsychotics risperidone (Risperdal) or olanzapine (Zyprexa).
• It is important to get plenty of rest and to manage stress, because fatigue and stress increase symptoms.
TOURETTE’S DISORDER
TOURETTE’S DISORDER• Involves multiple motor tics and
one or more vocal tics, which may occur many times a day for more than 1 year
• The complexity and severity of the tics change over time, and the person experiences almost all the possible tics described previously during the lifetime
• Has significant impairment in academic, social, or occupational areas and feels ashamed and self conscious.
TOURETTE’S DISORDER• Occurs in 4 or 5 out of 10,000• More common in boys and is
usually identified by 7 years of age
• Some have lifelong problems; others have no symptoms after early adulthood
