Embed Size (px)
Citation preview
PSYCHIATRIC DISORDERS in CHILDHOOD and ADOLESCENCE
Dr Wendy Duncan Senior Specialist – Child Psychiatry Child, Adolescent & Family Unit CharloFe Maxekhe Johannesburg Academic Hospital
OUTLINE
• Making a ‘Diagnosis’ • Epidemiology in Child Psychiatry • Mental Illness in Context • Epidemiology of Specific Psychiatric Disorders • AeQological ConsideraQons • IntervenQons
MAKING A ‘DIAGNOSIS’ • ICD-‐10 and DSM-‐IV TR -‐ “woefully inadequate” • Categorical vs Dimensional approaches • The impact of cultural factors • Tendency to idenQfy co-‐morbidity • Trend towards earlier diagnosis • ‘PromoQonal’ impact of pharmaceuQcal industry ?
• “Diagnosis Shi^ing” – “Epidemic of AuQsm” (Belfer & Nurcombe, The Epidemiology & Burden
of Child and Adol Mental Dis, 2007)
EPIDEMIOLOGY in CHILD PSYCHIATRY
• BriQsh Isle of Wight Surveys – mid 1960s
• Sir Michael RuFer et al • MulQple data sources • 2 phase design • Direct quesQons -‐
children • DefiniQon of ‘Caseness’
– Behavioural paFern – Evidence of impairment
• Longitudinal surveys
EPIDEMIOLOGY in CHILD PSYCHIATRY • ISLE of WIGHT STUDIES – Poor peer relaQons -‐ significant correlate of impairment – Depression more common with increasing age – Anxiety & depressive symptoms needed to be disQnguished
– DifferenQaQon between pervasive and situaQon-‐specific presentaQons
– PaFerns of co-‐morbidity and their associaQons – The combinaQon of emoQonal and conduct problems – Varying correlates of adolescent-‐onset disorders
(RuFer, J Am Acad Child Adol Psych, 1989)
EPIDEMIOLOGY in CHILD PSYCHIATRY
CULTURAL CONTEXT
NO DEFINITIVE STUDY/IES
INADEQUATE REPORTING
EPIDEMIOLOGY in CHILD PSYCHIATRY
• Nonetheless in a Nigerian study…. – 62.2% new referrals experienced significant psychosocial stressors in preceding year
– DisrupQon of primary support – DisrupQon of family – Maternal abandonment – Parental psychiatric illness – Sexual and physical abuse
• Significant numbers of suicidal behaviours, externalizing and internalizing disorders (Omigbodum, Soc Psych Psychiatric Epidem, 2004)
EPIDEMIOLOGY in CHILD PSYCHIATRY
• PREVALENCE: – India = 10% <14 years (7 -‐10%) – Sudan, Phillipines, Colombia, India = 12 -‐29% <15y – Gaza strip : Anxiety Disorders = 21% – Western Ethiopia : Severe behaviour disorders = 17,7%. Boys > Girls
– Shi^ in trends due to globalizaQon e.g. EaQng Disorders, AuQsm, ADHD
OUTLINE
• Making a ‘Diagnosis’ • Epidemiology in Child Psychiatry • Mental Illness in Context • Epidemiology of Specific Psychiatric Disorders • AeQological ConsideraQons • IntervenQons
CONTEXTUAL CONCERNS
• Violence and Abuse • HIV/AIDS • Substance Abuse • ExploitaQon • Exposure to Conflict • Displacement • Child Soldiers and ProsQtuQon
The Global Picture • United NaQon’s Secretary General’s Study on Violence against Children -‐ 11 Oct 2006 – 53 000 -‐ died as a result of homicide (2002) – 80-‐98% -‐ suffer physical punishment in their home – 150 million girls & 73 million boys have forced sexual experiences before 18 years of age
– 3 million girls in sub-‐Saharan Africa, Egypt & Sudan subjected to genital muQlaQon
– 218 million – child labour (2004) – 1,8 million – prosQtuQon or pornography (2000)
Social
EmoQonal
Intellectual
Physical
CONTEXTUAL CONCERNS
CONTEXTUAL CONCERNS
• SUBSTANCE ABUSE -‐ THE SOUTH AFRICAN PICTURE – SACENDU surveys trends in all 9 provinces -‐ May 2009
– Alcohol most common, then THC – Treatment admissions in <20 years from 3% in W.C. -‐ 20% in KZN
– Decrease in cocaine uQlizaQon – Heroin use stable, spike in KZN “sugars” – “Tik” in 35% admissions in W.C.
CONTEXTUAL CONCERNS
OUTLINE
• Making a ‘Diagnosis’ • Epidemiology in Child Psychiatry • Contextual Concerns w.r.t. Mental Illness • Epidemiology of Specific Psychiatric Disorders • AeQological ConsideraQons • IntervenQons
EPIDEMIOLOGY – SPECIFIC PSYCHIATRIC DISORDERS
• PSYCHIATRIC DISORDERS – Major Depression – Bipolar Disorder – Schizophrenia and other psychoQc disorders…….
• BEHAVIOURAL and EMOTIONAL DISORDERS – Conduct Disorder & OpposiQonal Defiant – ADHD – EmoQonally unstable personality and adjustment………
• NEURODEVELOPMENTAL DISORDERS – AuQsm and Pervasive Developmental Disorders – Epilepsy – Mental RetardaQon and Learning Disorders……….
MAJOR DEPRESSIVE DISORDER
• Point prevalence = 1 -‐2% pre-‐pubertal • Point prevalence = 3 -‐8% adolescence • At end of adolescence = 20% • Prior to puberty gender distribuQon is equal, therea^er F:M = 3:1
MAJOR DEPRESSIVE DISORDER
• ASSOCIATED FACTORS: – Premature puberty in girls – Death of a parent before 12 years – In pre-‐pubertal child
• Family adversity • Parental psychopathology, criminality and/or substance abuse • Familial loading (less common)
– In adolescence • High rates of anxiety • Increased interpersonal conflict • Substance abuse • Disrupted sleeping paFerns • Recurrent episodes in adulthood
MAJOR DEPRESSIVE DISORDER
• COMORBIDITY (40 -‐90%) – Anxiety disorders – ADHD – Substance Use Disorders – DisrupQve Behaviour Disorders
• DURATION – 3 -‐6 months community samples
– 6 -‐9 months referred samples – Recurrence – 40% in 2 years (Birmaher et al, JAACAP, 2007)
SUICIDE
• USA (2003) – 9.5 PER 100 000, 15 -‐24 yrs • Third leading cause of death in this age group • Males > Females. But more girls will aFempt • Firearms > Hanging > Poisoning • 34% adolescents admiFed to MHC for suicide aFempts. 9 x higher than community samples
• ‘Copycat’ suicides • In SA – rising, associated with stressors and family conflict (Pillay & Wassenaar, J Adoles, 1997
• African picture – 20% (RudaQkira et al, BMC Psych, 2007)
SUICIDE
Pfeffer, Suicidal Behaviour in Childrean & Adol, Lewis 4th Ed. 2007)
BIPOLAR DISORDER
• MulQple controversies making this diagnosis • World-‐wide = 1 -‐2% • “So^” sub-‐clinical presentaQons = 6% • RetrospecQve adult studies – 60% report symptoms with onset prior to 20 years
BIPOLAR DISORDER • COMORBIDITY:
– ADHD : 60 -‐80% – DBDs : 20 -‐60% – Anxiety : 30 -‐70%
• OUTCOME: – 80% recurrence in 5 yrs – Psychosis – HospitalizaQon – Suicide – Substance use – Poor academic & social funcQoning
BIPOLAR DISORDER
SCHIZOPHRENIA
• Transient ‘psychoQc phenomena’ – common
• EOS -‐ <18 years • VEOS -‐ <13 years RARE • Males, 5 years earlier than females
• About 1% by mid-‐adolescence
• Prodrome (McClellan et al, JAACAP, 2001)
SCHIZOPHRENIA
• COMORBIDITY: – Depression (54%) – OCD (21%) – GAD (15%) – ADHD (15%)
• COURSE: – Phasic, individual variability
– Recovery incomplete in 80% youth
ANXIETY DISORDERS
• INCLUDE: – SeparaQon Anxiety Disorder * – Generalized Anxiety Disorder – Social Anxiety Disorder – Obsessive Compulsive Disorder – Post TraumaQc Stress Disorder – SelecQve MuQsm – Panic Disorder
ANXIETY DISORDERS
• Most common condiQons – 4 -‐20% – Girls > Boys – SAD early onset: infancy, toddlers – Social anxiety onsets: adolescence
• Strong predictors of anxiety in adulthood and risk for other psychopathology
• Strong associaQon with somaQc presentaQons • NB. impairment criteria • High rates parental psychopathology esp. ANXIETY
ANXIETY DISORDERS
• CORRELATES: – Highly co-‐morbid with one another
– High rates of depression – Significant risk for substance misuse
– School refusal – Adult depression and anxiety
POST TRAUMATIC STRESS DISORDER
• Exposure to a traumaQc event in which there was real or threatened injury/ to physical integrity. Intense fear, horror, helplessness
• In SA most studies look at poliQcal violence in 1980s • Youth in W.Cape – most common condiQon (Traut et al, CuraQonis, 2002)
• High rates in South Africa – 20% – Witnessing/Exposure to violence – Assault by a family member – Sexual Assault (Seedat et al, Br J Psych, 2004)
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• Worldwide : 5 -‐12% • Over-‐esQmated if don’t
consider impairment • Boys > Girls
– 2:1 community samples – 3-‐5:1 referred samples
• Girls less disrupQve • Highest levels
– Male, low SECs – Young age
• HyperacQve Pre-‐schoolers – 2%
• HyperacQvity reduces with age
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• COMORBIDITY: – ODD and Conduct Disorder, up to 50%
– Anxiety Disorders, 25-‐30% – Learning Disorder, 20-‐25% – Higher risk of depression – Risk of adolescent substance abuse very HIGH
– Associated with ToureFes’s and OCD
• CORRELATES: – 60% conQnue symptoms into adulthood
– “outgrow” hyperacQvity – Polysubstance abuse and adult anQsocial behaviour
– Difficulty sustaining employment
– Unwanted pregnancy – Driving accidents – Divorce
AUTISM and PDDs • Previously equated with
“Childhood Psychosis” • Kanner – Early InfanQle
AuQsm (Kanner, Nervous Child, 1943) • 11.3 per 10 000 • M:F = 4.3:1 • Female tend to be MR • Increase in prevalence (Fombonne, Handbook of AuQsm & PDDs, 2005)
• PDD NOS and ASDs • High associaQon with Mental
Handicap, 30 -‐60%
AUTISM and PDDs
• ASPERGER’S DISORDER: – “Higher funcQoning AuQsts” – Fewer language delays, preoccupaQons, more social capable BUT sQll parQcularly inept
– 2.5 per 10 000 – Strong associaQon with seizure disorder and psychoQc episodes
CONDUCT DISORDER and other DBDs
• ? ODD developmental precursor to CD
• Childhood-‐onset < 10yrs • Adolescent-‐ onset • “Hot-‐headed” vs “Cold-‐hearted”
• Overall CD -‐ 5% and ODD – 5 -‐7%
• Boys 2 -‐3x higher • Community dependent
CONDUCT DISORDER and other DBDs
• Plethora of associated risk factors – Biological – Individual – Family – Social and School
• PotenQal opportuniQes for intervenQon • High rates of Co-‐morbidity – ADHD and LDs – Mood disorders and Anxiety Disorders – Substance Use Disorders
• Childhood antecedent to adult AnQsocial Personality Disorder
SUBSTANCE USE DISORDERS
• The prevalence of substance misuse and SUDs increases linearly from early to late adolescence
• In USA, 1 in 4 older adolescence meet criteria for substance ABUSE and 1 in 5 meet criteria for substance DEPENDENCE
• Early onset strong predictor for lifeQme use • Highly associated with DBDs and delinquency • THC associated with SCHIZOPHRENIA
EATING DISORDERS
• Anorexia Nervosa • Bulimia Nervosa • EDNOS (EaQng Disorder Not Otherwise Specified)
• Obesity • (Pica) • (RuminaQon Disorders)
EATING DISORDERS
• ANOREXIA NERVOSA – In Europe and N. America: 6 fold increase over 30 years
– EsQmated 8.1 per 100 000 – Male : Female = 1: 10-‐20 consistently – Onset between 13 and 30 years, peak at 14.5 year and then a^er 18 year
– AssociaQon with dieQng in the family • BULIMIA NERVOSA – Sharp rise in prevalence, 1%
EATING DISORDERS
• Body figure preference in South African adolescent females: a cross cultural study. – relaQonship between body dissaQsfacQon and eaQng disorders
– racial homogenizaQon exists regarding body figure preference within the urban se{ng.
(Szabo & Allwood, Afr Health Sci, 2006)
•
OUTLINE
• Making a ‘Diagnosis’ • Epidemiology in Child Psychiatry • Contextual Concerns w.r.t. Mental Illness • Epidemiology of Specific Psychiatric Disorders • AeQological ConsideraQons • IntervenQons
AETIOLOGICAL CONSIDERATIONS
• Neurobiological and psychopharmacological advances
• ConQnued expansion of our understanding of the brain
• ElucidaQon of geneQc and molecular substrates
• Endophenotypes -‐ (intermediate phenotypes) heritable traits related to biology of disorder
AETIOLOGICAL CONSIDERATIONS
AETIOLOGICAL CONSIDERATIONS
Integrated Model for Transmission of Risk
Heritability
Innate dysfuncQonal neuroregulatory mechanisms
Exposure to -‐ve affects, maladapQve
cogniQons and behaviours
Stressful environment
• Psychobiological dysfuncQon • Skills deficits • MaladapQve strategies
• CogniQve • AffecQve • Behavioural • Interpersonal
Childhood or Adolescent psycho
pathology
Adapted from Goodman & Gotlieb, Psychol Review, 1999
AETIOLOGICAL CONSIDERATIONS
RISK BEGINS IN THE WOMB
TOTAL GENES IN TOTAL ENVIRONMENT
Understanding the burden associated with childhood onset mental illness….
• The context of the child
• The developmental trajectory of the child
• The economic costs of psychiatric disorders
• The potenQal compromise to society
OUTLINE
• Making a ‘Diagnosis’ • Epidemiology in Child Psychiatry • Contextual Concerns w.r.t. Mental Illness • Epidemiology of Specific Psychiatric Disorders • AeQological ConsideraQons • IntervenQons
INTERVENTIONS
• Strategies need to incorporate – PrevenQon – EducaQon – Treatment
• Acute • StabilizaQon • Maintenance – relapse prevenQon
– ReducQon of impairment – ReducQon of mortality
INTERVENTIONS • Strategies need to incorporate – Child-‐centered approach – A “family-‐inclusive” approach – Community-‐based approach – Global health priority
• With collaboraQon from – Health – EducaQon – Social Development – JusQce – Non-‐Profit OrganisaQons and Advocacy forums
INTERVENTIONS
(Mrazek & Mrazek, Preven-on of Psychiatric Disorders, 2007. Fig 2.2.2.1)
INTERVENTIONS • “Research to inform the scaling-‐up of intervenQons for mental
disorders in low-‐income and middle-‐income countries.” • “IntervenQons that rely on non-‐specialist health workers and low-‐
cost technologies and strategies can deliver equally effecQve mental health intervenQons.”
• “The need for more research must not be used as an excuse to delay scaling-‐up of mental health systems.”
• “Recommend that, at the very least, governments should consider scaling up the coverage of mental health intervenQons for which there is credible evidence of effecQveness. The process of scaling up such intervenQons in poorly resourced se{ngs will be hindered by barriers such as scarce financial, human, and technical resources and other health needs (e.g., HIV/AIDS, tuberculosis, and malaria) that compete for priority.” (Patel et al, The Lancet, 2007)
INTERVENTIONS
• THE LAWS THAT SERVE CHILDREN – Children’s Act No. 38, 2005 – Children’s Amendment Act No. 41, 2007 – Choice of TerminaQon of Pregnancy Act, No. 92 of 1996
– Mental Health Care Act, No.17 of 2002 – Criminal Law (Sexual Offences) Amendment Bill, 2003
THANK YOU
