Child Psychiatry

85% of cases of mental retardation are mild (IQ range: 55-70) and are usually idiopathic. Patients often have a reasonable level of independence with assistance or guidance during periods of stress. Fetal alcohol syndrome is the number-one preventable cause, whereas Down syndrome is the number-one overall cause. Fragile X syndrome (in males) is another common cause of mental retardation.

Autism: usually starts at a very young age. Look for impaired social interaction (isolative, unaware of surroundings), impaired verbal/nonverbal communication (strange words, babbling, repetition), and restricted activities and interests (head banging, strange movements). Autism is usually idiopathic, but look for congenital rubella as a potential cause. See Dustin Hoffman in the movie Rain Man.

Learning disorder: impairment in math, reading, writing, speech, language, or coordination, but everything else is normal and no mental retardation is present ("Johnny just can't do math").

Conduct disorder: pediatric form of antisocial disorder. Look for lire setting, cruelty to animals, lying, stealing, and/or fighting. As adults, patients often have antisocial disorder. Note: Conduct disorder is required to make a diagnosis of antisocial personality disorder in adults.

Attention-deficit hyperactivity disorder (ADHD): as the name implies, affected children are hyperactive and have short attention spans. Males are affected more often than females. Look for a fidgety child who is impulsive and cannot pay attention but is not cruel. Treat with stimulants (paradoxical calming effect) such as methylphenidate (Ritalin) and dextroamphetamine, both of which may cause insomnia, abdominal pain, anorexia, and weight loss or growth suppression.

Oppositional - defiant disorder: negative, hostile, and defiant behavior toward authority figures (parents, teachers).The child misbehaves around adults but behaves normally around peers and is not a cruel, lying criminal.

Separation anxiety disorder: look for a child who refuses to go to school. Basically, affected children think that something will happen to them or their parents if they separate; thus, they will do anything to avoid separation (stomachache, headache, temper tantrums).

Anorexia: look for a female adolescent who is a good athlete and/or student with a perfec-liomstie personality. Patients have body weight at least 15% below normal, intense fear of gaining weight ( or "feel fat" even though emaciated), and amenorrhea (all three are required for diagnosis). Death occurs in roughly 10-15% of patients as a result of complications of starvation and/or bulimia (electrolyte imbalances, cardiac arrhythmias, infections). Some patients are hospitalized against their will for IV nutrition. Roughly one-half of anorexics also have bulimia.

Bulimia: look for a female adolescent who is of normal wei ght or overweight (unless anorexia coexist s). Patients have binge -eating episodes during which they feel a lack of control and then engage in purging behavior (vomiting, laxatives, exercise, fasting). Patients may require hospitalization for electrolyte disturbances. In the classic patient tooth enamel has been eroded because of frequent vomi ting; skin may be eroded over the knuckles from putting fingers into the throat.

Tourette's disorder: only 10-30% of patients utter obscenities. Look for males with motor tics (eye™blinking, grunting, throat-clearing, grimacing, barking, or shoulder shrugging) that are exacerbated by stress and remit during activity or sleep. Of interest, Tourette's disorder can be caused or unmasked by use of stimulants (e.g., for presumed ADHD). Antipsychotics (haloperi-dol) are used if symptoms are severe. Iburette's disorder tends to be a life-long problem.

Eucoprcsis/enuresis: not a disorder until after age 4 (encopresis) or 5 (enuresis). This is obviously an important diagnostic point, to remember when the mother complains (normal finding if the child is 3 years old). Rule out physical problem (e.g., Hirschsprung's disease, urinary tract infection), then treat with behavioral therapy ("gold star for being good" charts, alarms, biofeedback), Imipramine is used only for refractory cases of enuresis; it is not a first-line agent.

Important points:

1. Depression in children often presents as irritable instead of depressed mood. Depression in the elderly may present as pseudodementia (cognitive decline), which is reversible with treatment.

2. The top three causes of adolescent deaths in order are accidents, homicide, and suicide. Together they account for about 75% of teenage deaths.

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