I Gusti Ayu Endah Ardjana

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Diagnostic Criteria from DSM-IV:

 Significantly sub-average general intellectual functioning

(IQ < 70),
 Limitation in two or more adaptive skills:
- communication,
- self direction,
- self-care,
- social skills,
- health and safety,
- leisure
- and work
 Manifests before age of 18 years

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 Based on IQ test score :
- Mild : 50–55 to ± 70 (Educable)
- Moderate : 35–40 to 50-55 (Trainable)
- Severe : 20–25 to 35-40
- Profound : below 20 / 25

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 Cerebral palsy
 Vision, hearing, orthopedic, and
dysmorphisme.
 Learning problems: attention, language,
memory.
 Behavioral / emotional problems :
motivation, self – regulation, social
interaction, hyperactivity.

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 Biologic
 Genetic ( cognitive impairment )
 Socio-economic (poverty, undernutrition,
understimulation )
 Mixed

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 MR = 2.5 % of population
 Mild MR 85 % ( 2,1 % of population )
– boys : girls = 2 : 1
 Severe MR appr, 0.3 – 0.5 % of the
population,
- boys : girls = 1.5 : 1
 a consequence of X – linked disorders.

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 Newborn, we have to concern when
- dysmorphisme
- mayor organ system dysfunction ( feeding and breathing )
 Early infancy ( 2-4 mo ), we have to be suspicious when
- failure to interact with the environment,
- lack of visual or auditory responsiveness,
- unusual muscle tone or posture,
- and feeding difficulties.
 6 and 18 mo of age,
- motor delay ( lack of sitting, crawling, walking )

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 2 – 3 year : Language delay
 3 – 5 year :
- behavior problems ( including play )
- delays in fine motor skills
( cutting, coloring, drawing )
 School age :
- academic underachievement
- behaviour difficulties ( attention, anxiety, mood,
and conduct disorders )

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 Parental concerns should be listened carefully
- some of their observations as accurate as
developmental screening tests.

 Usually have others disorders :

- vision, hearing, orthopedic, behavioral /
emotional disorders, and dysmorphisme.

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 ~ Diagnostic Criteria from DSM-IV,
 Tests of intelligence and adaptive functioning
Intelligence tests :

IQ (intelligence quotient) = Mental Age X 100

Chronological Age

- Bayley Scales of infant Development (BSID)

- the Stanford – Binet Intelligence Scale,
- Wechsler Intelligence Scales,

 Adaptive test : Vineland Adaptive Behavior Scale

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15 Months … Spontaneous Scribble

18 Months … Vertical Line

3 Years … Circle

4 Years … Cross

5 Years … Square
6 Years … Triangle

7 Years … Diamond
 The role of the pediatrician
- early diagnosis,
- identification of associated deficits,
- interdisciplinary management
- provision of primary care, and advocacy for
the child and family.
 The management strategies
- multi-modal : health, education, social and
recreational activities, behavior problems, and
associated impairments.
- Support for parents and siblings

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 Family involvement
. The family should be an integral part of
the planning and direction of this process
. Care should be family centered and
culturally sensitive.
 Older child
. should be involved in planning and
decision making.

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 Not useful, to improve intellectual function,
 Helpful, in treating associated behavioral
and psychiatric disorders.
 Psychopharmacology
- at specific symptom
- ADHD, self-injurious behavior,
aggression, anxiety and depression.

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 Some families have emotional / social difficulties
 Higher risk of parental depression and child abuse and
neglect
 Factors associated
- good family coping
- good parenting skills
- stability of marriage
- self-esteem
- limited number of siblings
- higher socioeconomic status
- lower degree of disability/associated impairments.
- appropriate parental expectations and acceptance
- supportive extended family members
- and availability of community programs and care services.

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 Depends on
- underlying cause,
- degree of cognitive and adaptive deficits,
- presence of associated medical and
developmental impairments,
- capabilities of the families
- school / community supports
- services and training provided to the child and
family
 During school years
- develop sufficient adaptive behavior skills
- as the effects of maturation and plasticity of the brain.

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 DS is the trisomy of chromosome 21,
the most common trisomy among live
births.
 The syndrome was named after
Langdon Down, who first coined the
term mongolism because of the
mongoloid facial appearance of the
patients.
 Patient features also include mental
retardation and short stature.

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 In all areas of the world
 All racial groups
 the incidence rate is 1 per 600 – 700 live
births.
 Sex:
The male to female ratio is increased
(approximately 1.15 : 1) in newborns with DS.
The effect is restricted to free trisomy 21.

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Age:
Occurrence strongly depends on maternal age.
Risk for recurrence of DS in a patient’s siblings also
is inherent to maternal age.
- For young mothers, risk of a free trisomy is 1–2%
- For mothers aged 20 years or younger,
occurrence is 1 per 2000 births.
- Risk increases considerably for mothers aged 35
years  1 per 365 live births.
- in mothers aged 45 years or older, occurrence
is 1 per 30 live births.

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Eight or more of the characteristic clinical findings
lead to a definite diagnosis.
 Px have characteristic craniofacial findings, i.e.

- flat occiput and flattened facial appearance.

 Px have short limbs, short and broad hands, and
short fifth middle phalanx.
 Anteriorly and posteriorly flattened head with
dysplastic ears, small nose, depressed nasal
bridge, protruding tongue, high-arched palate,
dental abnormalities, shortened extremities,

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 Simian palmar creases, dry skin, joint
hyperextensibility or hyperflexibility, neuromuscular
hypotonia, premature aging,

 Intelligence Quatient (IQ) in patient with DS varies

from 20 to 80, being mostly between 45 and 55.

 Ocular findings in px with trisomy 21 include the

following: blepharitis, conjunctivitis, prominent
epicanthal folds, upward slanting of palpebral
fissures, nasolacrimal duct obstruction,

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Ocular
 chronic external infections,

 high refractive errors,

 strabismus (up to 20%),

 nystagmus,

 keratoconus, keratoglobus,

 Brushfield spots (up to 90%),

 cataracts,

 glaucoma and retinovascular anomalies.

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1. Genetic
2. Radiation
3. Infectious disease
4. Autoimmunity
5. Maternal age
6. Other factors, such as intragametic
accidents, factors relating to satellite
association and nucleolar organizers,
chemicals.

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 Various chromosomal abnormalities may lead to
DS, including :
- free trisomy 21 (94%)
- translocation (4%)
- mosaicism (2%)
 A free trisomy 21 results from non disjunction
during meiosis in one of the parents.
This occurrence is correlated with advanced
maternal and paternal age.

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 DS (trisomy 21) is the most commonly
recognized genetic cause of mental
retardation.
 The risk of trisomy 21 is directly related to
maternal age.
 All forms of prenatal testing for DS must be
voluntary.
 A nondirective approach should be used when
presenting patients with options for prenatal
screening and diagnostic testing.
 Patients who will be 35 years or older on their
due date should be offered chorionic villus
sampling or second – trimester amniocentesis.

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 Women younger than 35 years should be
offered maternal serum screening at 16
to 18 weeks of gestation.

 The maternal serum markers used to

screen for trisomy 21 are alpha-
fetoprotein, unconjugated estriol and
human chorionic gonadotropin.

 The use of ultrasound to estimated

gestational age improves the sensitivity
and specificity of maternal serum
screening.
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 Patients with DS have a shortened life expectancy,
- about one third of patients die within the first
year,
- and one half of patients die by 4 years.
- The remainder of patients has a reduced life
expectancy as compared to the general
population.
 Congenital heart disease is the major cause of
morbidity and early mortality.
 Recurrent respiratory infections, epilepsy, intestinal
obstruction, and leukemia may affect these
patients.

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 Because of frequent congenital heart malformation,
early cardiology consultation is needed. Early
cardiologic evaluation is crucial for diagnosing and
treating congenital heart defects, which occur in
up to 60% of these patients.
 Due to recurrent respiratory tract infections, a
pediatric pneumologist also should manage
patients with DS.
 A child Psychiatrist should lead liaison
interventions, family therapies, and psychometric
evaluations.
 Up to 10% of patients with DS have epilepsy:
therefore, neurological evaluation is needs.
 Genetic counseling is indicated.

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 Patients have a shortened life expectancy.
Early evaluation, diagnosis, and intervention
may prevent deaths due to congenital heart
defects.

 Mental Retardation is common in patients

with trisomy 21; however, patients with
mosaicism have higher IQ.

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 Early stimulation therapy may benefit patients
with DS.
 Patients may benefit from education programs.
Psychometric studies and social worker
intervention are needed for special education
planning.
 Risk of recurrence for the patient’s child is
50%.
 The advocacy efforts of patients with DS and
their families have resulted in huge
improvements in life quality and expectancy.

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dr. I G.A. Endah Ardjana, Sp. KJ (K)
 Definition
 pervasive developmental disorder which affects
(1) social and communication skills and, to a
greater or lesser degree,
(2) motor and language skills.
 a broad diagnosis that it can include people with high IQs
and mental retardation (3/4)
 can be chatty or silent, affectionate or cold, methodical or
disorganized.
Pervasive Developmental Disorder (PDD), includes
 299.00 Autistic disorder
 299.80 Rett’s disorder
 299.10 Childhood Disintegrative disorder
 299.80 Asperger’s Disorder
 299.80 Pervasive Developmental Disorder Not
Otherwise Specified (Including Atypical Autism)
 3 cardinal features:
 Qualitative impairment in social interactions
 Qualitative impaired communication(verbal & non-verbal)
 Restricted, stereotyped,repetitive repertoire of interests &
activities.
Do symptoms of autism change over
time?
• For many children, autism symptoms improve with
treatment and with age.
• Some children with autism grow up to lead normal or
near-normal lives.
• Children whose language skills regress early in life,
usually before the age of 3, appear to be at risk of
developing epilepsy or seizure-like brain activity.
• During adolescence, some children with autism may
become depressed or experience behavioral problems.
Parents of these children should be ready to adjust
treatment for their child as needed.
Diagnosis
 Impaired ability to make friends with peers impaired ability
to initiate or sustain a conversation with others
 Absence or impairment of imaginative and social play
 Stereotyped, repetitive, or unusual use of language
 Restricted patterns of interest that are abnormal in intensity
or focus
 preoccupation with certain objects or subjects
 Inflexible adherence to specific routines or rituals
 Treatment
• no cure for autism
• the earlier the intervention, the better
1) Educational/behavioral interventions:
-use highly structured and intensive skill-oriented training
sessions to help children develop social and language skills.
-Family counseling for the parents and siblings of children
with autism often helps families cope with the particular
challenges of living with an autistic child.
2) Medications:
-antidepressant medication to handle symptoms of
anxiety, depression, or obsessive compulsive
disorder
-Anti-psychotic medications are used to treat severe
behavioral problems.
-Seizures can be treated with one or more of the
anticonvulsant drugs.
-Stimulant drugs, such as those used for children
with attention deficit disorder (ADD), are
sometimes used effectively to help decrease
impulsivity and hyperactivity.
3) Other therapies:
- There are a number of controversial therapies or
interventions available for autistic children, but
few, if any, are supported by scientific studies.
- Parents should use caution before adopting any of
these treatments.
 Treatment Planning
1)Screening
 Postpartus Newborn Screening
-if suspicious of autism, ASD, or mental retardation
-Metabolic defects associated with autism, but not covered in
routine newborn screening tests include :
(a) histidinemia
(b) adenylosuccinate lyase deficiency
(c) dihydropyrimidine dehydrogenase deficiency
(d) 5’-nucleotidase superactivity
(e) phosphoribosylpyrophosphate synthetase deficiency
 Children with prolonged history of pica or high
environmental risk
-lead level
 Children newly diagnosed with ASDs
- Genetic testing
(a) Clinical criteria for disorder such as fragile X syndrome, is not an
adequate substitute for genetic testing.
(b) Testing should include DNA testing for William’s syndrome, high
resolution chromosome testing, and fluorescent in situ
hybridization testing for Williams syndrome and subtelomeric
deletions
 The following are not recommended:
- fMRI, allergy testing, hair analysis, chelation challenge testing, gut
permeability studies, and stool analysis.
 Indications for screening
- Failure of responding to name, joing attention, babbling, single words,
pretend play, and imitation to emerge in a timely fashion.
- Loss of language or social skills
2) Treatment
• Intensive early intervention
- Extensive step-by-step curiculum targets language, daily living, and social skills
- Usually for 25 or more hours per week
- Employs ABA principles
- Commenced shortly after diagnosis and continued up to kindergarten or
primary school, depending upon the child’s progress and areas of handicap
- 6 important elements
(1) provision at the earliest possible age
(2) intensity (at least 20 hours per week)
(3) parent involvement, training, and support
(4) curricula focused on social and communication functioning
(5) systematic instruction with individual goals
(6) attention to generalisation so that acquired skills are employed in all
settings
- Parents benefit from periodic training aimed at skills building and reduction of
problematic behavior.
• Transition training
- Important whenever patient must make a major adaptation to a new setting
(new home,workplace) or new routine,or both
- 3 simple principles for successful transition planning:
(a) start early
(b) involve all service agencies and funding agencies
(c) try to have work secured before graduation or identity postsecondary
education options before graduation actually occurs
- Some of the key issues include housing/residential care, job training and
placement, social skill training, and estate planning.
- Employment options for adults with ASDs:
(a) sheltered workshops (most restrictive)
(b) secure employment
(c) supported employment
(d) full independence
- Predictors of successful employment:
(a) employment readiness
(b) adequacy of job match
(c) higher degree of social competence by the individual concerned
(d) provision and success of behavior management
Treatments
• Facilitated communication(FC)
- Information is trapped within the individual without the intervention of a
passive facilitator, who helps to tap out messages via keyboards.
• Scretin
- After a mother of a boy with autism reported very dramatic improvements in
autism symptomatology that followed diagnostic testing with secretin.
- Secretin infusions are expensive and cannot be justified for other than
gastrointestinal diagnostic purposes at this time.
• Auditory integration training (AIT)
- Identification of sound frequencies to which the patient is hypersensitive
- Music is then delivered by headphones to patient, and filtering is used to
dampen frequencies to which the individual is hypersensitive.
- Usual course: 10 days of treatment with modulated music presented in 2-half-
hour sessions per day.
- Another AIT: electronically altered music and human voice for 150-200hours
over 6-12 months.
 B6 and magnesium treatment
- Megadoses
- Pyridoxine has adverse physical effects; especially reported in children
with Down Syndrome (photosensitive blisters, GI symptoms, motor and
sensory polyneuropathy)
 Gluten- and casein-free diets
- Casein(in dairy products) forms an endogenous opiate called
casomorphine
- Gluten(found in wheat, oats, barley, and rye) breaks down to a peptide
(gliadomorphine-acts as an opiate)
- These opiates find ways into CNS of vulnerable childrenautism
(a) insufficient enzyme activity in gut
(b) an abnormally permeable gut
(c) an abnormally permeable blood-brain barrier
 Other unproven treatments
- dimethylglycine, essential fatty acids, famotidine, vit. A, nonspecific
chelation therapy
- fMRI, allergy testing, hair analysis, chelation challenge testing, gut
permeability studies, and stool analysis.
- Sensorimotor integration
(a) to improve vestibular, cerebellar, and other sensory functions
(b) probably improves motor coordination(esp gross motor)
(c) no evidence of significant effect on core symptoms of autism
dr. IGA Endah Ardjana, SpKJ (K)
● ADHD
- Chronic neurobehavioral disorders that can
interfere with an individual’s ability to inhibit
behavior (impulsivity), function efficiently in
goal-oriented activities (inattention), or
regulate the activity level (hyperactivity) in
developmentally appropriate ways
Miller KJ, Castellanos FX. AD/HDs. Ped in Rev 1998; 19 (11)

Three basic form of ADHD

- Attention
- Hyperactive
- Combine (most frequent)
● ADHD  significant functional problems

- school difficulties
- academic underachievement
- troublesome interpersonal relationships with
family members and peers
- low esteem

● Untreated childhood ADHD

More likely to experience conduct disorder,

substance abuse, antisocial behavior and
injuries later in life

EARLY RECOGNITION, ASSESSMENT & MANAGEMENT

● Prevalence rates  vary substantially (changing
diagnostic criteria overtime; variations depend on
different settings sample estimation

- Varying from 4% to 12%

- Males 9.2% (5.8%-13.6%)
- Female 2.9% (1.9%-4.5%)
- School samples 6.9% (5.5%-8.5%)
- Community samples 10.3% (8.2%-12.7%)
AAP. Clinical Practice Guideline ADHD. Pediatrics 2000; 105 (5)

- Indriyani, dkk (2007)  RSUP Sanglah (2005-

2006)
(≥ 3 yo - <7 yo)  45.9%
● The causes of ADHD are unknown

● GENETIC FACTORS
● DEVELOPMENTAL FACTORS
● NEUROCHEMICAL FACTORS
● NEUROPHYSIOLOGICAL FACTORS
● PSYCHOSOCIAL FACTORS

Anonym. Attention-Deficit Disorders. In: Kaplan & Sadock’s.

Synopsis of Psychiatry. Ninth Ed. USA: Lippincott; 2003
● First degree biological relatives, e.g siblings of
probands with ADHD are at high risk to develop it as
well as to develop other disorders (disruptive behavior
disorder; anxiety disorder & depressive disorders)

● Siblings of children with ADHD are also at higher risk

than the general population to have learning disorders
and academic difficulties

● The parents of children with ADHD show an increased

incidence of hyperkinesis, sociopathy, alcohol use
disorders and conversion disorder
DSM -IV-TR (Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision)

A. Either 1 or 2
- Inattention: 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:
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
 …..Inattention
c. Often does not seem to listen when spoken to directly
d. Often does not follow through with instructions and
does not 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 requires sustained mental effort (such as
schoolwork or home work)
g. Often loses things necessary for tasks or activities (eg.
toys, school assignments, pencils, books or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
- Hyperactivity/Impulsivity: Six (or more) of the following
symptoms of hyperactivity and 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 situation
in which this behavior inappropriate
(in adolescents or adults may be limited to
subjective feelings of restlessness)
 ….Hyperactivity/Impulsivity

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:
g. Often blurts out answers before questions have been
completed
h. Often has difficulty awaiting turns
i. Often interrupts or intrudes on others (eg. Butts into
conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms
that caused impairment were present before age 7 years
C. Some impairment from the symptoms is present in two
or more setting (eg. at school (or work) and at home)
D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational
functioning
E. The symptoms do not occur exclusively during the
course of Pervasive Developmental Disorders,
Schizoprenia or other Psychotic Disorder and are not
better accounted for by another mental disorder (eg.
Mood Disorder, Anxiety Disorder, Dissociative Disorder,
or a Personality Disorder)
The DSM-IV-TR notes that the designation of “not
otherwise specified” (NOS) may be used for
disorders with prominent symptoms of inattention
or hyperactivity-impulsivity that do not meet ADHD
criteria
SUBTYPE OF ADHD

1. INATTENTIVE TYPE (ADHD/I)

meeting at least 6 of 9 inattention behaviors
2. HYPERACTIVE-IMPULSIVE TYPE (ADHD/HI)
meeting at least 6 of 9 hyperactive-impulsive
behaviors
3. COMBINED TYPE (ADHD/C)
meeting at least 6 of 9 behaviors in both the
inattention and hyperactive-impulsive list
● Anxiety disorder
● Conduct disorder
● Eating disorder
● Learning disorder
● Mood disorder
● Oppositional Defiant Disorder
● Pervasive Developmental Disorder
● Sleep disorder
Mental Health Conditions That Mimic or Coexist with ADHD

Disorder Symptoms overlapping Features Not Diagnostic

with ADHD Characteristic of problem
ADHD
Learning Underachievement in Underachievement It can be difficult to
disorder school and disruptive determine which to
Disruptive behavior behavior in evaluate first-a
during academic activity academic work, learning disorder
Refusal to engage in rather than in or ADHD (follow
academic tasks and use multiple settings the preponderance
academic materials and activities of symptoms)

Oppositional Disruptive behavior, Defiance, rather Defiant behavior is

defiant especially regarding than unsuccessful often associated
disorder rules attempts to with a high level of
Failure to follow cooperate activity
directions It is difficult to
determine the
child’s effort to
comply in
instances of
negative parent-
child or teacher-
child relationship
Mental Health Conditions That Mimic or Coexist with ADHD

Disorder Symptoms overlapping Features Not Diagnostic

with ADHD Characteristic of problem
ADHD
Conduct Disruptive behavior Lack of remorse Fighting or
disorder Encounters with law- Intent to harm or running away may
enforcement and legal do wrong be reasonable
systems Aggression & reactions to
hostility adverse social
circumstances
Antisocial
behavior
Anxiety, Poor attention Excessive worries Anxiety may be a
obsessive- Fidgetiness Fearfulness source of high
compulsive Difficulty with transitions Obsessions or activity and
disorder, or compulsions inattention
post- Physical reactivity to
traumatic stimuli Nightmares
stress Re experience of
disorder trauma
Mental Health Conditions That Mimic or Coexist with ADHD

Disorder Symptoms overlapping Features Not Diagnostic

with ADHD Characteristic of problem
ADHD
Depression Irritability Pervasive and It may be difficult
Reactive impulsivity persistent feelings to distinguish
Demoralization or irritability or depression from a
sadness reaction to
repeated failure,
which is
associated with
ADHD
Bipolar Poor attention Expansive mood It is difficult to
disorder Hyperactivity Grandiosity distinguish severe
Impulsivity Manic quality ADHD from early-
onset bipolar
Irritability disorder
Tic disorder Poor attention Repetitive vocal or Tics may not be
Impulsive verbal or motor movement apparent to the
motor actions patient, the family,
Disruptive activity or a casual
observer
Mental Health Conditions That Mimic or Coexist with ADHD

Disorder Symptoms overlapping Features Not Diagnostic

with ADHD Characteristic of problem
ADHD
Adjustment Poor attention Recent onset Chronic stressors,
disorder Hyperactivity Precipitating event such as having a
Disruptive behavior sibling with mental
illness, or
Impulsivity attachment-and-
Poor academic loss issues may
performance produce symptoms
of anxiety and
depression

AD-HD. N Engl J Med 2005; 352 (2)

● BEHAVIORAL
- Presentation of educational material for the
patient, parents and school personnel
- Behavior-modification techniques (daily
report card)
- Educational Interventions and
Accommodations for Patients with Learning
Disabilities (preferential seat placement,
more intensive accommodation)
- Social skill training (improve interactions
with peers)
- Individual counseling ( to alleviate secondary
symptoms such as low self-esteem, oppositional defiant
behavior and conduct disorder ; to control their own
behavior)
● PHARMACEUTICAL / MEDICATION
 When impulsive behavior places the child at
physical or psychological risk (table)
 Treatment
* Stimulants are first-line therapy.
Caution should be used in children with history
of seizures, Tourette’s disease, PDD, substance
abusers in the house hold, and age younger
than 6 years.
* Atomoxetine are is an alternate first-line choice
in school-aged children.
Second-line treatments include tricyclic anti
depressants, antipsychotics-risperidone
 STIMULANT MEDICATIONS

Medication Initial Range (R) & Common dose Available tablets/

dose (CD) Spansules
Methylphenid 2.5-5 mg R: 0.1-0.8 mg/kg/dose PO qd 5-,10- and 20 mg
ate (Ritalin, to 5 times/d scored tablets
generic) CD: 0.3-0.5 mg/kg/dose PO
tid/qid
Methylphenid Convert R: 0.2-1.4 mg/kg/dose PO 20 mg spansules
ate slow from qd/tid do not cut, crush,
release regular CD: 0.6-1 mg/kg/dose PO or chew
(Ritalin SR, qd/bid
generic SR)
Methylphenid Convert R: 0.3-2 mg/kg PO qd 18- and 36 mg
ate from CD: 0.8-1.6 mg/kg PO qd tablets
prolonged regular or Do not cut, crush,
release use 18 mg or chew
(Concerta,
Metadate CD)
 STIMULANT MEDICATIONS

Medication Initial Range (R) & Common dose Available tablets/

dose (CD) Spansules
Dextroamphe 2.5-5 mg R: 0.1-0.7 mg/kg/dose PO Dexedrine 5 mg
tamine qd/qid scored tablets
(Dexedrine, CD: 0.3-0.5 mg/kg/dose PO Dextrostat 5-, 10-
Dextrostat) qd/tid and 15-mg scored
tablets
Dextroamphe 5 mg R: 0.1-0.75 mg/kg/dose PO 5-, 10- and 15-mg
tamine qd/bid spansules
spansules CD 0.3-0.6 mg/kg/dose PO Do not cut, crush,
(Dexedrine qd/bid or chew
CR)
Dextroamphe 2.5-5 mg R: 0.1-0.7 mg/kg/dose PO 5-, 7.5-,10-,12.5-,
tamine and qd/qid 15-,20-, and 30-
amphetamine CD: 0.3-0.5 mg/kg/dose PO mg scored tablets
4-salt tid/qid
combination
EFFECTS OF STIMULANTS
Cognitive - Increased attention to assigned task
- Decreased response to irrelevant stimuli
- Improved speed and accuracy of performance
- Improved short-term memory
- Improved short-term academic performance
Motor - Reduced activity level (often normalizes)
- Decreased off-task motor behavior
- Decreased excessive talking or noise
- Increased independent play and work
- Improved fine motor control/handwriting
Social - Decreased anger and aggression
- Decreased emotional and behavioral intensity
- Increased sensitivity to reinforcement
- Increased compliance with adult requests
- Decreased negative interactions with peers
- Improved mother-child & family interaction
- Improved teacher-student relations
SIDE EFFECTS OF STIMULANTS

Common side - Appetite suppression, Weight loss, Delay in

effect sleep onset, Abdominal discomfort, Headache,
Dizziness, Minor increases in pulse & blood
pressure, Behavioral rebound
Infrequent side - Withdrawal hyperactivity (rebound),
effect Agitation/jitteriness, Moodiness/sadness,
Social withdrawal, Tics/dyskinesias, Weight
loss/reduced growth velocity, Liver toxicity
(pemoline only)
Overmedication - Irritability / weepiness (at peak), Over focusing,
/Toxic effect Dazed appearance, Fatigue, Psychosis

Miller KJ, Castellanos FX. ADHD. Ped in Rev 1998; 19 (11)

● Outcome is significantly affected by persistence of
AD/HD symptoms, comorbid condition and
psychosocial factors

● 30%-70% of children continue to be symptomatic as

adults

● Adults who have AD/HDs achieve lower academic

levels, socioeconomic status, less vocational stability,
increased marital problems
Medication continues to be effective for adults, but
response rate may be lower
● Primary symptom include inattention and/or
hyperactivity/impulsivity
● Clear interference with developmentally appropriate
social, academic, or occupational functioning
● Precise neural and pathophysiologic substrate of ADHD
remain unknown
● Frontostriatal regions, rich in noreepinephrine,
epinephrine and dopamine neurotransmitters, are
consistently implicated
● Early recognition, assessment and management of
ADHD can redirect educational and psychosocial
development
 ANOREXIA NERVOSA
BULIMIA NERVOSA
PICA

dr. I Gusti Ayu Endah Ardjana, SpKJ (K)

Bag/SMF Psikiatri FK UNUD-RSUP Sanglah Denpasar
Kuliah tanggal 30 Mei 2012
ANOREXIA NERVOSA
Anorexia ---> ( from Greek ) ---> loss of appetite
Nervosa ---> ( Latin word ) ---> nervous origin

ANOREXIA NERVOSA is a syndrome characterized by

1. Self-induced starvation to a significant degree
2. Relentless drive for thinness or a morbid fear of
fatness
3. Present medical signs and symptom resulting from
starvation
ANOREXIA NERVOSA
 Often associated with disturbances of body image -
the perception that one is distressingly large despite
obvious thinness.
 In DSM-IV-TR :
 Characterized as a disorder in which persons refuse to
maintain a minimally normal weight, intensely fear
gaining weight, and significantly misinterpret their
body and its shape.
ANOREXIA NERVOSA
Epidemiology
 ♂ : ♀ = 1:10
 Age onset
 ♀ : 16-17 yrs(rarely >30yrs)
 ♂ : 12 yrs
 Incidence 0.5% adolescent and young women.
 Community sample ; equal distribution social classes
 Clinic sample ; excess of upper/middle classes
 Greatest frequency among young women that require
thinness --> modeling, ballet
ANOREXIA NERVOSA
AETIOLOGY
 Genetic
 MZ : DZ = 65% : 32%
 Female siblings : 6-10%
 Adverse life events
 No excess of childhood physical or sexual abuse
 Psychodynamic models
 Family pathology; overprotective,rigidity
 Individual pathology; disturb body image
 Analytical model; regression, fixation oral stage
 Biological
 Dysfunction hypothalamic
 Neuropsychologycal deficits
ANOREXIA NERVOSA
CLINICAL FEATURES & DIAGNOSIS CRITERIA
 Low body weight :
 15% + below expected
 BMI 17.5% or less
 Self-induced weight loss ; avoidance of fattening foods,
vomiting, purging, excessive exercise, use of appetite
supressants
 Body image distortion - dread of fatness; overvalued idea,
imposed low weight threshold
 Endocrine disorders-HPA axis ; amenorrhoea, reduced
sexual interest, cortisol ⇈, abnormal secretion insulin.
 Delayed/ arrested puberty-if onset pre-pubertal
Figure 1
Physical features associated
with anorexia nervosa. (with
permission from Puri BK,
Laking PJ, Treasaden IH
2002. Textbook of psychiatry.
Churchill Livingstone,
Edinburg).
ANOREXIA NERVOSA
Comorbidity
 65% of cases Depression
 34% Social Phobia
 26% OCD
ANOREXIA NERVOSA
Differential diagnosis
 Chronic debilitating physical disease
 Brain tumours
 GI disorders (Crohn’s disease, malabsorption syndromes)
 Loss of appetite (secondary drug eg SSRIs, amphetamine)
 Depression/OCD (features of which may be associated)
ANOREXIA NERVOSA
Management (General principles)
 Most parients will be treated as outpatients
 Combined ;
 Pharmacological (fluoxetine, TCA)
 Psychological (family thy/, CBT)
 Education (Nutritional education)
 Hospitally if seriously medical problem like; extremely
weight loss, complication etc.
ANOREXIA NERVOSA
Diagnostic criteria for Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally
normal weight for age and height (e.g.• weight loss leading
to maintenance of body weight less than 85% of that
expected; Or failure to make expected weight gain during
period of growth. leading to body weight less than 85% of
that expected).
8. Intense fear of gaining weight or becoming fat. even
though underweight.
C. Disturbance in the way in which one's body weight or
shape is experienced, undue influence of body weight or
shape on self-evaluation or denial of the seriousness of the
current low body weight.
D. In post-menarcheal females, amenorrhea, i.e., the absence
of at least three consecutive menstrual cycles. (A woman is
considered to have amenorrhea if her periods occur only
following hormone. e.g., estrogen, administration.)
ANOREXIA NERVOSA
Specify type:
 Restricting Type: during the current episode of
Anorexia Nervosa, the person has not regularly
engaged in binge-eating or purging behavior (i.e., self-
induced vomiting or the misuse of laxatives, diuretics,
or enemas)
 Binge-eating/Purging Type: during the current
episode of Anorexia Nervosa, the person has regularly
engaged in binge-eating or purging behavior (i.e.• self-
induced vomiting or the misuse of laxatives, diuretics,
or enemas)
 Bulimia Nervosa
Epidemiology
 Incidence 1-1,5% of women
 Mid-adolescent onset, early 20s
Aetiology
Similar to anorexia nervosa, but associated
personal/family history of obesity, affective disoder,
substance misuse etc
 Bulimia Nervosa
Clinical features
 A syndrome characterized by repeated bouts of
overeating and excessive preoccupation with control
body weight, e.g. : throughself-induced vomiting,
purgative abuse and the abuse of appetite suppressants
 Figure 2
Complications of vomitting,
purging and diuretic abuse. (With
permission from Puri BK, Laking
PJ, Treasaden IH 2002. Textbook
of psychiatry, Churchill
Livingstone, Edinburgh)
 Bulimia Nervosa
Diagnostic criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
 (1) eating, in a discrete period of time (e.g., within any 2·hour period), an
amount of food that is definitely larger than mort people would eat during a
similar period of time and under similar circumstances
 (2) a sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent weight
gain. such as self-induced vomiting; misuse of laxatives, diuretics. enemas, or
other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on
average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of Anorexia
Nervosa.
 Bulimia Nervosa
Specify type:
 Purging Type: during the current episode of Bulimia
Nervosa, the person has regularly engaged in self-
induced vomiting or the misuse of laxatives, diuretics,
or enemas
 Non-purging Type: during the current episode of
Bulimia Nervosa, the person has used other
inappropriate compensatory behaviors, such as fasting
or excessive exercise, but has not regularly engaged in
self-induced vomiting or the misuse of laxatives,
diuretics, or enemas
 Bulimia Nervosa

Treatment (like anorexia nervosa)

 Full assessment, usually as an outpatient, inpatient if
medical problem
 Combined ;
 Pharmacological (SSRI)
 Psychological (family thy/, CBT)
 Education
Prognosis
 Generally good
PICA
Clinical features
This is the persisten eating of substances normally
considered inedible,
e.g. :
 soil

 paint chippings and

 paper.
Feeding and Eating disorder of infancy or Early
Childhood
Diagnostic criteria for Pica
A. Persistent eating of nonnutritive substances for a period
of at least 1 month.
B. The eating of non nutritive substances is inappropriate to
the developmental level.
C. The eating behavior is not part of a culturally sanctioned
practice.
D. If the eating behavior occurs exclusively during the course
of another mental disorder (e.g., Mental Retardation,
Pervasive Developmental Disorder, Schizophrenia), it is
sufficiently severe to warrant independent clinical
attention.
Pica
Management
Brain damage and learning disabilities (mental-
retardation) should be excluded.
The child should be kept away from the inedible
substance (s).

Prognosis
Usually resolves as the child grows older
 TIC DISORDER
 Spontaneous, repetitive, stereotyped movements that
can be motor or vocal and usually involve ⇈ Dopamin
in basal ganglia most commonly ---> affect the
muscle of the face and neck, such as eye blinking,
head-jerking, mouth-grimacing or head shaking etc.
 Children and adolescents may exhibit tic behaviors
that occur after a stimulus or in response to an internal
urge.
Tic disorders
Epidemiology
 Prevalence
10 – 20% of children show transient tics at some time.
 Sex ratio
Commoner in males.
TIC DISORDER
Tic disorders
Management
 Education
Education, advice and reassurance for the child and
parents may be all that is required for simple tics.
 Behavioural
relaxation or massed practice may help.
 Medication
Antipsychotics haloperidol or pimozide may be
useful
 Tourette’s Disorder

∾ Gilles de la
 A developmental neuropsychiatric disorder by
multiple motor and one or more vocal tics, present for
at least a year---> distress and impaired function.
 Often begin ages of 3 and 8 yrs
 Related to fatique, emotional stress and excitement.
 Usually peaks in early adolescent---end of adolescent
 Tourette’s Disorder

Epidemiology
 ♂ : ♀ = 3:1
 Prevalence 4-6 /10000 in European and Asian
Aetiology
 Interaction genetic and environmental (psychosocial
stress).
 Possibilities include gestational and perinatal insults,
post-infectious autoimmune mechanism etc.
 Tourette’s Disorder

Diagnostic criteria for Tourette's Disorder

 A. Both multiple motor and one or more vocal tics have been present at
some time during the illness, although not necessarily concurrently. (A
tic is a sudden, rapid, recurrent, non-rhythmic. stereotyped motor
movement or vocalization.)
 B. The tics occur many times a day (usually in bouts) nearly every day
or intermittently throughout a period of more than 1 year, and during
this period there was never a tic-free period of more than 3 consecutive
months.
 C. The onset is before age 18 years.
 D. The disturbance is not due to the direct physiological effects of a
substance (e.g., stimulants) or a general medical condition (e.g.,
Huntington's disease or post-viral encephalitis).
 Tourette’s Disorder

Comorbidity
 OCD and ADHD commonly
 Depression, anxiety, migraine, sleep
difficulties, poor impulse control.
 Tourette’s Disorder
Management
 Psychoeducation child, family and life style
adjustment
 Close liason with school and educational intervention
 Pharmacological (antipsychotics)
 Treat comorbidity
 Behavioural interventions....relaxation