Childhood and early-onset psychological disorders: Pathology review

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Case studies0:00–0:41

A 16 year old female, named Tayla, comes to the clinic because she’s been feeling urges to repeatedly blink her eyes, shake her head from side to side, or clear her throat.
Tayla notes that she is able to suppress the urge for a while, but she eventually loses control of her actions. This all started a little over a year ago, and Tayla is under distress because her classmates often tease her about it.
During the conversation, she suddenly utters an inappropriate curse word, and immediately goes on to say that she doesn’t know how that came out of her mouth.
Physical examination reveals no neurological deficits and she shows normal cognitive skills for her age.Okay, based on the initial presentation, Tayla seems to have some form of childhood or early-onset psychological disorder.

Pathology0:41–1:30

These include several psychological conditions that typically have their onset during childhood, although some of these disorders may last into adulthood.
As a consequence, these disorders can interfere with how the affected person functions independently in society, and impair everyday activities like working, studying, eating, and sleeping, as well as have an impact on their families.
For your exams, the most common childhood or early-onset psychological disorders are separation anxiety disorder, selective mutism, oppositional defiant disorder, conduct disorder, disruptive mood dysregulation disorder, tourette syndrome, and child abuse.
Let’s begin with separation anxiety disorder. That happens when separation from someone that the child is very attached to, like a parent, causes overwhelming or excessive fear and anxiety.

Separation anxiety disorder1:30–2:37

In some cases, this can reach the point where it may lead to factitious physical complaints so that individuals can stay home and miss school.
To be diagnosed as separation anxiety disorder, this needs to last for at least four weeks or more. Bear in mind, though, that this can be considered normal behavior until the age of 3 or 4.
Now, treatment includes cognitive behavioral therapy, or cbt for short, which is a type of talk therapy that primarily focuses on teaching the individual strategies to better cope with stress and social pressures, as well as identify the anxious patterns of thinking that might be influencing their disorder.
Other approaches include play therapy, which uses play to help individuals deal with their anxiety, and family therapy, where parents and siblings can learn new ways to interact with the individual and help them when anxiety spikes.Moving on to selective mutism, this is when individuals fail to speak at specific social situations, such as at school.

Selective mutism2:37–3:49

The problem typically starts before the age of 5, and lasts for at least one month. Another high yield fact is that selective mutism is often accompanied by social anxiety disorder or social phobia, which is characterized by excessive anxiety caused by social or performance situations like meeting groups of new people, going on dates, and job interviews, where people feel like they are under scrutiny or being judged.
What’s important to remember here is that these individuals speak normally in other, presumably more comfortable situations, such as at home, and the failure to speak isn’t due to a lack of teaching or a communication disorder.
Treatment of selective mutism typically comprises cognitive behavioral therapy, as well as play and family therapy. In some cases, medications might be recommended, especially selective serotonin reuptake inhibitors or ssris like fluoxetine, paroxetine, sertraline, citalopram, escitalopram.Next is oppositional defiant disorder, or ODD for short.

Oppositional defiant disorder3:49–4:30

This is marked by angry or irritable mood, like temper loss; as well as argumentative or defiant behavior, which is when individuals frequently argue with authority figures; and vindictiveness or spitefulness, where individuals may feel resentful or believe that others are to blame for their own behaviors and may want to seek revenge.
In order to be diagnosed with oppositional defiant disorder, these moods and behavioral patterns must be ongoing for at least 6 months.
Treatment mainly involves cognitive behavioral therapy to change the child’s mood or feelings and improve their behavior.Next is conduct disorder, where individuals recurrently violate other people’s basic rights, and may mistreat or show aggression to people or animals, steal from others, destroy property, or disregard moral values and norms of society.

Conduct disorder4:30–5:07

For your test, remember that to meet the diagnosis, individuals must be under 18 years of age. So if they are over the age of 18, it is diagnosed as antisocial personality disorder.
And that’s a high yield fact! Treatment once again involves cognitive behavioral therapy.Moving on to disruptive mood dysregulation disorder, which usually has its onset before the age of 10, and is characterized by recurrent explosive outbursts of intense anger and violence, sometimes causing injury to themselves or others.

Disruptive mood dysregulation disorder5:07–6:01

These outbursts occur in response to any real or perceived provocation, and are almost always out of proportion to the situation.
For your exams, remember that these outbursts occur three or more times a week for at least one year. A unique characteristic of disruptive mood dysregulation disorder is that even in-between outbursts, these children are constantly irritable or angry.
Treatment generally focused on changing their violent behaviors through cognitive behavioral therapy, while some individuals may also benefit from medications, such as stimulants or antipsychotics.Next is tourette syndrome, a disorder characterized by tics, which are involuntary, brief, purposeless, and stereotypical movements or vocalizations that occur over and over, and aren’t side effects of some other disorder or substance abuse.

Tourette syndrome6:01–8:12

For your exams, keep in mind that to diagnose tourette syndrome, three criteria must be met. First, the individual should present with at least two motor tics, such as twitching of the nose, jumping or head banging, as well as one vocal tic, which tend to manifest as grunting, barking, or throat clearing, but may also involve words, phrases, or sentences.
Some individuals may also present with specific vocal tics like echolalia, which is repeating the words or phrases of others, palilalia, which is repeating one’s own words, and a high yield one is coprolalia, which is verbally expressing inappropriate obscenities or curse words.
And that’s actually the most widely known symptom of tourette syndrome, and certainly the one examiners love the most! The second criterium is that the onset of symptoms must be before 18 years of age.
And third, the individual should have the symptoms for over a year. Another high yield fact is that tourette syndrome is often associated with other psychiatric conditions, such as attention deficit hyperactivity disorder or adhd and autism spectrum disorder, as well as obsessive compulsive disorder or ocd, which is a specific type of anxiety disorder characterized by obsessions or recurrent and unwanted thoughts that usually lead to compulsions, which are actions performed to try and reduce the anxiety.
Treatment of tourette syndrome involves cognitive behavioral therapy to help individuals identify triggering events or feelings that precede tics to prevent them.
In addition, individuals who don’t respond to cognitive behavioral therapy or present with distressing tics can be treated with medications, including alpha-2 receptor agonists like clonidine and guanfacine, typical antipsychotics like haloperidol, and atypical antipsychotics like risperidone or olanzapine.All right, now, the last topic we’re gonna discuss is child abuse.

Child abuse8:12–12:26

This is defined as anything that the parent or caregiver does or doesn’t do that causes harm to a child. For your test, remember that there are four main types of child abuse.
These include physical abuse, which refers to any intentional physical injury that results in a physical mark or bruise, and in an extreme form leads to fractures, internal bleeding, or even death.
There’s also emotional abuse, which involves saying or doing things that undermine a child’s emotional development or self-esteem, such as threats, criticisms, or rejection.
Next, sexual abuse includes any form of sexual contact or exploitation of a child. Finally, the fourth type of child abuse is neglect, which is failure of the caregiver to cater for the basic needs of a child, ranging from food, clothing, and shelter, to medical attention, education, and also love and support.
Neglect also includes abandonment, which involves leaving a child alone or unsupervised for a long period of time. Now, some common injuries to keep in mind include bruises, and often, abused children may present with multicolored bruises, which indicates they’re in different stages of healing.
Also, you should take note of the bruised area, since unintentional bruises typically occur on the knees, shins, or forehead.
So the areas that should raise supicion of child abuse are the soft parts of the body, like the cheeks, ears, eyes, neck, buttocks, flexor surfaces, or around the genitals.
Another common finding includes unusual patterns of injury, like belt and rope marks, hand marks, and bite marks. When it comes to burns, these are usually induced by a child being forcibly submersed into hot water.
Signs of this include spared creases in the abdomen and parts of the palms and soles of the feet, reflecting a crouched, curled up position of the child.
Likewise, the area from which the child was held by will also be spared and show a prominent edge. Round, punctate burns may also be caused by cigarettes.
Finally, abused children may present with fractures involving unusual bones, such as the skull or the ribs. If child abuse is suspected, it’s ideal to interview the child and caregivers separately whenever possible.
Now, there are some important clues that can suggest that a child is being abused. Often, a child may seem to lack attachment or even fear their caregiver, or they might be extremely anxious or apprehensive.
Other high yield clues include a history of a sexually transmitted disease or repeated hospitalizations for unexplained injuries.
Another thing to pay attention to is if the explanation provided by the caregiver seems inconsistent with the severity or pattern of the child’s injury.
For example, the caregiver may claim that the child was accidentally splashed by hot oil, but on physical examination, the child might present a burn injury that has a prominent edge, like they were being forcibly submersed into something hot, rather than a splash pattern.
Alternatively, the explanation might be inconsistent with the developmental stage of the child. For example, the caregiver may tell you that a 3 month old baby crawled and fell down the stairs, but crawling doesn’t usually begin until 6 to 10 months of age.
Finally, if child abuse is suspected, a full skeletal survey should be obtained to look for possible fractures. For treatment, the first thing to do is to care for any immediate injuries, like burns or fractures.
In addition, remember that it’s the healthcare provider’s responsibility to report any suspicion of child abuse to child protective services, and to get a team involved to keep the child safe and help the family cope.All right, as a quick recap...

Review12:26–14:04

In separation anxiety disorder, children feel overwhelming fear or anxiety when they are separated from someone that they are very attached to, and this lasts at least four weeks; whereas those with selective mutism fail to speak when they are supposed to on more than one occasion, starting before the age of five and lasting for at least one month.
In oppositional defiant disorder, children present with angry or irritable mood; argumentative or defiant behavior; and vindictiveness for at least 6 months.
On the other hand, conduct disorder is when an individual under 18 years of age recurrently violates other people’s rights, moral values, or norms of society.
In disruptive mood dysregulation disorder, children under the age of 10 present with recurrent temper outbursts out of proportion to the situation, occurring three or more times a week for at least one year, as well as persistent irritability in between the outbursts.
In tourette syndrome, there are at least two motor and one vocal tics with onset before the age of 18 and persist for more than one year.
Finally, child abuse can be physical, emotional, sexual, or neglect of the child’s basic needs; physical examination might show multiple bruises, burns, or fractures in unusual locations and patterns, while important clues include the behavior of the child, as well as a history of sexually transmitted disease or repeated injuries with no or inconsistent explanations provided by the caregiver.
Okay, back to our cases. Tayla is a 16 year old female, who comes in complaining of urges to repeatedly blink her eyes and shake her head from side to side, which are both motor tics, as well as a need to clear her throat, which is a vocal tic.

Summary14:04–14:36

The biggest clue though is that during the conversation, she suddenly slurred out an inappropriate curse word, without meaning to, which points to coprolalia.
All this, along with the fact that Tayla is under 18, and her symptoms have been going on for more than a year, help us conclude that she has tourette