Clinical psychiatry of early childhood. Features of child psychiatry

The guide covers the main clinical issues, etiology, pathogenesis, prognosis and treatment of mental disorders occurring in children in the first three years of life. Not only diseases that begin primarily in early childhood are considered, but also those that are characteristic exclusively of a given age. The results of the authors' original research are presented. Data from modern domestic and foreign literature concerning the origin, course and prognosis of psychosomatic disorders in early childhood are summarized. Along with endogenous mental diseases, much attention is paid to borderline mental disorders. For pediatricians, psychiatrists, general practitioners and senior medical students.

Chapter 1. CHILD-MATERNAL ATTACHMENT AND ITS VIOLATIONS

1.1. Modern ideas about attachment

1.2. Factors influencing the formation of attachment

1.3. Attachment theories

1.4. Dynamics of attachment formation

1.5. Methodology for assessing attachment. Types of child-maternal attachment

1.6. Visual preference as an indicator of attachment

1.7. Causes of attachment disorders

1.8. Diagnostic criteria for attachment disorder

1.9. The influence of child-maternal attachment on the mental development of a child

Chapter 2. MATERNAL DEPRIVATION AND ITS CONSEQUENCES

2.1. Definition, classification

2.2. Psychological characteristics of mothers-refuseniks

2.3. Mental pathology arising under the influence of complete maternal deprivation

2.3.1. Disorder of personality formation

2.3.2. Disorders of mental and intellectual development

2.3.3. Mental disorders arising under the influence of complete maternal deprivation

Chapter 3. EATING DISORDERS IN YOUNG CHILDREN

3.1. Peculiarities of eating behavior in ontogenesis

3.2. Classification and clinical picture of eating disorders

3.2.1. Regurgitation and chewing disorder (“chewing gum”, mericism)

3.2.2. Infantile anorexia nervosa (infantile anorexia)

3.2.3. Chronic eating of inedible substances (PICA syndrome)

3.2.4. Nutritional underdevelopment

3.3. Differential diagnosis of eating disorders

3.4. Forecast of eating disorders

3.5. Therapy for eating disorders

Chapter 4. SLEEP DISORDERS IN YOUNG CHILDREN

4.1. Development of sleep in ontogenesis

4.2. Prevalence of sleep disorders

4.3. Etiology of sleep disorders

4.4. Classification of sleep disorders

4.5. Clinical picture of various forms of sleep disorders

4.6. Prognosis of sleep disorders

4.7. Therapy for sleep disorders

Chapter 5. EARLY CHILDHOOD AUTISM

5.1. Etiology

5.2. Pathogenesis

5.3. Clinical manifestations of early childhood autism syndrome

5.4. Forecast

5.5. Diagnostics

5.6. General principles of therapy

Chapter 6. PATHOLOGICAL HABITUAL ACTIONS IN EARLY CHILDHOOD

6.1. Prevalence

6.2. Etiology

6.3. Pathogenesis

6.4. Clinical picture

6.4.1. Thumb sucking

6.4.2. Yactation

6.4.3. Masturbation

6.4.4. Nail biting

6.4.5. Trichotillomania

6.5. Treatment

Chapter 7. CONSEQUENCES OF PERINATAL DRUG ADDICTION

7.1. Consequences of prenatal drug exposure

7.1.1. Metabolism of drugs by the fetus

7.1.2. The influence of anesthesia on the course and outcome of pregnancy

7.1.3. Effect of the drug on the fetus

7.1.3.1. Teratogenic effect

7.1.3.2. Effect on fetal development

7.1.4. The influence of intrauterine anesthesia on the condition of the newborn

7.1.5. Specific effect of the drug on the fetus

7.1.6. Long-term consequences of intrauterine drug exposure

7.2. Consequences of prenatal alcohol exposure

7.2.1. The effect of alcohol on pregnancy

7.2.2. The effect of alcohol on the fetus

7.2.3. Clinical picture of fetal alcohol syndrome

7.2.4. Alcohol neonatal withdrawal syndrome

7.2.5. Long-term consequences of prenatal alcohol exposure

Chapter8. SPEECH DEVELOPMENT IN EARLY CHILDREN AND ITS DISORDERS

8.1. Pre-speech development

8.1.1. Early infant vocalizations. Cry-cry

8.1.2. Booming

8.1.3. Babbling

8.1.4. Development of word understanding

8.1.5. Development of word generalization

8.2. Early speech development

8.2.1. First words

8.2.2. Dictionary development

8.2.3. Features of speech development in pupils of closed children's institutions

8.3. Disturbances of pre-speech and early speech development in conditions of complete maternal deprivation

8.3.1. Disorders of pre-speech development

8.3.2. Disorders of early speech development

8.3.3. Behavioral therapy for disorders of pre-speech and early speech development

Chapter 9. METHODS OF EXAMINATION OF AN EARLY CHILD

9.1. Psychiatric assessment

9.2. Experimental psychological examination

References

Preface

The publication of the book “Clinical Psychiatry of Early Childhood” by B. E. Mikirtumov, S. V. Grechany and A. G. Koshchavtsev is a significant event for the psychiatric community. Studying the mental health of infants allows us to understand the ways of forming a healthy psyche and to grasp the factors that, acting on a child, create the danger of pathological deviations already at the beginning of life. As a rule, the main obstacle to the normal development of an infant is disrupted relationships between family members and, first of all, in the mother-child dyad. The study of this important period of life for an individual creates the basis for obtaining new, unexplored approaches to the early diagnosis of developmental disorders, deviations in personality formation and identifying characteristics of reactivity. Such early diagnostic studies should facilitate both treatment and habilitation of children with pathology that arose in infancy. Understanding the developmental characteristics of young children is a real way to prevent neuropsychiatric disorders.

Unfortunately, this section of child psychiatry has not received special attention from pediatric doctors and psychiatrists for a long time. For the first time, interest in deviations in the mental development of young children was shown in the first half of the 20th century. Clinical and psychological studies of infants and young children originate in the psychoanalytic works of Z. Freud, S. Ferenczi, A. Freud, M. Klein. Psychoanalysts paid great attention to the problems of early childhood, primarily from the point of view of assessing child-mother relationships. They emphasized that the mother-child relationship is based on the infant’s dependence on the parent, and studied the mechanisms of infant frustration caused by disturbances in the relationship with the mother (J. Bowlby, D. W. Winnicott, R. A. Spitz, etc.).

Ethologists (K. Lorenz, N. Tinbergen) considered a strong emotional connection in the mother-child dyad as an innate motivational system. It was precisely by disturbances in the formation of this system that they explained the emerging pathology at an early age.

The works of L. S. Vygotsky, who laid the foundations for the study of developmental psychology in our country, were of great importance for understanding the psychological patterns of early childhood. The concepts of “age crisis”, “zone of proximal development”, etc., introduced by him, are the basis for explaining the age-related dynamics of some mental disorders of early age.

In domestic psychiatry, the first descriptions of mental disorders of early age belong to T. P. Simson, G. B. Sukhareva, S. S. Mnukhin, and others. However, for a long time, publications concerning the mental state of infants were random. Some concepts developed by child psychiatrists can only partially be used to understand the development of infants and early preschool children. Such approaches, in particular, are ideas about the age levels of somatoneuropsychic response of children of different ages, the concept of mental dysontogenesis (V.V. Kovalev, G.K. Ushakov).

Psychiatry of early childhood as a branch of domestic clinical psychiatry has reasserted itself in recent years. Its peculiarity is its close connection with experimental psychological studies of age-related patterns of early ontogenesis.

Manifestations of early childhood schizophrenia, childhood autism and other clinically similar conditions were also studied. Mental disorders and features of dysontogenesis were studied in children of the first three years of life from a high-risk group for endogenous mental diseases (V. M. Vatina, G. V. Kozlovskaya, A. V. Goryunova, G. V. Skoblo, O. V. Bazhenova , L. T. Zhurba, E. M. Mastyukova, A. A. Kashnikova, etc.).

Works devoted to psychosomatic and borderline disorders in children also covered early childhood (Yu. F. Antropov, D. N. Isaev, E. I. Kirichenko, Yu. S. Shevchenko).

In recent years, the number of works concerning the formation of maternal-child relationships in infants and their influence on the process of mental development of the child has increased (A. S. Vatuev, N. N. Avdeeva, E. O. Smirnova, R. Zh. Mukhamedrakhimov). Violations in the mother-child dyad lead to psychosomatic and borderline disorders of early childhood. Distortion of child-mother relationships due to endogenous mental illnesses in parents may be one of the causes of early psychotic disorders and distortions of mental development. Maternal deprivation is one of the factors in the occurrence of anaclitic depression and developmental retardation (N. M. Iovchuk, A. A. Severny, M. A. Kalinina, M. B. Proselkova). Mental disorders of early childhood are often combined with developmental disorders and neurological disorders. Clinical forms of neuropsychic disorders in infancy are determined by the somatic, vegetative and instinctive level of age-related reactivity. Their manifestations are rudimentary and transitory.

B. E. Mikirtumov, S. V. Grechany and A. G. Koshchavtsev, being representatives of the Pediatric Medical Academy, continued the long-standing tradition of its scientists (G. A. Bairova, M. S. Maslova, A. F. Tura, S. S. Mnukhin, N.P. Shabalov and many others), who studied and continue to study healthy and sick infants. The authors of the manual, based on numerous classical and modern sources of scientific literature, widely cover the above-mentioned aspects of normal and abnormal mental health of young children. The presented book outlines the most important issues concerning the clinical picture, etiopathogenesis, prognosis and treatment of mental disorders occurring in children in the first three years of life. Diseases are described as either beginning predominantly in early childhood or characteristic only of infancy. The guide reflects the problems of child-maternal attachment and its disorders, maternal deprivation and its consequences, sleep disorders, childhood autism, eating disorders, speech development in early childhood and its disorders, pathological habitual actions, consequences of perinatal dependence on psychoactive substances. One of the advantages of the book is that the content of most of its chapters is based on the results of the book’s authors’ own latest research, as well as many years of research.

The merit of the authors of this publication lies in the fact that they took the trouble to summarize the materials on early childhood psychiatry, which are so necessary for both the practitioner working with infants and the researcher (teacher). They deserve special thanks, in particular, due to the fact that the book cites sources that are inaccessible to the interested reader. I would like to wish them to continue the work they have begun to develop the still far from complete section of psychiatry - micropsychiatry and to introduce the materials obtained through research into practice.

The manual is quite reasonably intended for a wide range of specialists - pediatricians, child neurologists, child psychiatrists, family doctors, special psychologists, special and social teachers, speech therapists. It can also be recommended as a textbook for students of pediatric, medical, psychological and pedagogical faculties.

Professor of the Department of Clinical and Psychological Disciplines of the Institute of Special Pedagogy and Psychology of the Raoul Wallenberg International University, Professor, Doctor of Medical Sciences D.N. Isaev

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In the American Psychiatric Association's multiaxial syndromic classification (DSM III-R), autistic syndromes are considered “pervasive developmental disorders” separately from psychoses of childhood and adolescence. For the latter, the same classification criteria are used as for the corresponding conditions in adults. Thus, in the USA, as previously in German-speaking countries, it is customary to talk about “autistic disorders” or “syndromes” purely descriptively and not to consider them in a nosological connection with functional psychoses of childhood. In the DSM III-R classification, this diagnosis is classified as axis two (personality disorders). The current WHO classification (ICD-9), on the contrary, classifies them as a group of psychoses with code F20.8xx3, beginning in childhood. Non-psychotic depressive disorders are considered in the same group with psychotic ones under the heading “depressive syndromes in childhood and adolescence.” It is the experience of child psychiatry in the field of autistic syndromes and psychoses of childhood that shows how questionable the course of reasoning and their inclusion in a certain nosological framework is and how inconsistent the one-sided etiological approach with its traditional definitions is: “symptomatic” or functional", "somatogenic or psychogenic”, etc. Autistic syndromes in a large percentage of cases develop simultaneously with functional cerebral disorders, while the course of the disease and especially the development of intelligence are largely determined by the influence of external factors.
Conclusion for practice: description of syndromes and observation of the nature of the disease must include all information that may be relevant etiological/pathogenetic, somatic, mental, situational significance. In developmental psychiatry, readiness for specific phases and transitional crises in the development of a child plays an important role in the formation of psychopathological phenomena.

Autistic syndromes in childhood.

These behavioral disorders are expressed central symptom of autism or, to a much greater extent, complete or developing in this direction morningthat ability to emotional and social contact. At early childhoodautism The first signs of contact disturbances may appear already in the first year of life: the absence of a “responsive (social) smile” when a face approaches, eye contact and other expressive movements that normally appear as a response. In the future, these children do not develop the preliminary stages of formation "awarenessI", age appropriate. Compared to other healthy children of the same age, it is deeply altered and significantly behind. Interests, if any, are very limited and are directed towards inanimate objects or individual parts of objects, regardless of their functional purpose. At the same time, handling them is of a peculiar, mechanically repetitive nature. For example, autistic children may be obsessed with turning on and off a light bulb or turning on and off a faucet. Toys are often used for other purposes, for example, only for spinning rotating parts. They show a strong tendency linger onfamiliar situation(experience “fear of change”). even small changes in the usual environment (a new tablecloth, the absence of a carpet in the usual place) plunge the child into a state of panic with severe psychomotor restlessness. Conversational skills either do not develop(if autism begins in infancy), or can be lost again (if autism begins in early childhood), or change qualitatively, and the achieved level of speech development, as a rule, lags behind normal (repetition of spoken words, neologisms, strange colloquial expressions ). Strange repeatable shapesmovements(stereotypes) appear regularly. Functions of the sense organs, in In particular, hearing and vision are not developing sufficiently. The result is significant fromdevelopment in intellectual development. At the same time, certain and undeveloped intellectual abilities turn out to be hypertrophied: autistic children, for example, can repeat a family tree containing many names, or master other lexical complexities. Similar cases have been described. Only 3% of children have intellectual development approaching the age norm. About 1/3 of children are mentally retarded, and 1/5 have intelligence close to the borderline normal level. Typical of a developmental disorder of the self is that many of these children demonstrate the phenomenon of “reverse pronoun”, i.e. They use pronouns distortedly, saying “you” about themselves and “I” about others. Characteristic changes in peripheral perception are detected: objects, and sometimes even people, are not perceived as integral images with their inherent complex of qualities. Autistic children often stomp around a “blank wall” for hours or are satisfied with peripheral perceptions that are not related to the object (for example: the sound of crunching is identified with paper crumpled up near the ear, sparkling - with the movement of fingers in front of the eyes). Exists weakness of auditory and visual perception, which is functionally related to lack of motor coordination, impaired speaking, paroxysms of fear and obsessive rituals. B center, between sensory decoding weakness and impaired psychomotor expressiveness, there is emotional insufficiency, the child’s inability to relate to others and to himself according to his age. Typologically along with with early childhood autism differ: Asperger syndrome, or autistic “psychopathy”, which, as described above, appears in early childhood and characterized by autistic behavior disorders, mainly in boys: emotional withdrawaland self-isolation, the prince’s face with empty, looking into the distance, peculiarspeech and psychomotor skills neologisms, intonation disorders, rhythmic motor stereotypies with an average and sometimes high level of intelligence and specialized language readiness (children with Asperger's syndrome learn to speak earlier than to walk; children with Kanner's syndrome - vice versa).
Differential diagnosis. Autistic traits character can develop in the course of completely different disorders, for example, with schizophrenic psychoses of childhood or with predominantly somatogenic disorders in children with organic brain lesions and mental retardation. In case of deaf-muteness or other serious defects of the sensory organs, pronounced communication impairments (so-called pseudo-autism) may also appear.
Frequency. If diagnostic criteria are strictly observed, autistic syndromes are rarely diagnosed (0.1-0.4%). Autistic behavior in early childhood organic lesions is observed much more often. In these cases, we are talking primarily about autistic traits rather than about the full picture of autism. Kanner's and Asperger's syndromes occur almost exclusively in boys.
Etiology and pathogenesis unknown, although a number of studies point to organic, i.e. biological pathogenesis. In particular, in a good half of cases, (polyetiological) functional cerebral disorders were found in patients with autism, as well as disturbances in the nature of perceptions, speech disorders and intellectual disorders, and an increase in epileptic seizures in adolescence. Some authors suggest the presence of a hereditary “autism factor” that emerges from a latent state under certain circumstances (for example, with minor brain damage in early childhood, other disorders of brain function). The influence of external circumstances is of great importance for the course of autism, i.e. for the developmental possibilities of an autistic child, but pure psychogenesis or even family dynamics as the cause of the disease today can, based on in-depth research, be considered excluded. It would be short-sighted to attribute parents' behavior to a direct causal relationship with their children's autism (although selective social case-finding processes may play a role in some cases).
Therapy. It may be recommended to begin the earliest possible use of therapeutic, pedagogical and psychotherapeutic (especially for children) measures, which are aimed at gradually awakening in these patients the ability to communicate, a sense of identification and perception of people. At the same time, it is always necessary to involve parents, brothers and sisters in treatment activities, and teach them effective therapeutic and pedagogical behavior at home (“home‑training”). Convincing successes in the use of therapeutic and pedagogical methods are described. Antipsychotics and/or tranquilizers may be used for maintenance therapy, especially in cases where fear and psychomotor restlessness are prominent in the clinical picture.
Forecast. Especially with Kanner syndrome, it is unfavorable (2/3 of sick children are significantly retarded in development; y 1/3 have relatively favorable development). The later autism syndrome manifests itself, the more favorable the prognosis.

Schizophrenic syndromes.

The older the child is at the time of the first manifestation of psychosis, the more similar the psychopathological symptoms and the nature of the course of the disease are to schizophrenic psychoses of adolescence and adulthood. Characteristic disorders of thinking, emotionality and self-awareness, deceptions of feelings and delusions can appear only at a certain stage of personality development, i.e. may be perceived as such by others.
At the age before entering school, psychosis is expressed by significantly poorer symptoms, especially with regard to the most impressive atypical symptoms, such as deceptions of feelings and delusional interpretation. Productive psychotic manifestations require a certain personality development beyond the magical thinking of young children, thanks to which some psychopathological defense mechanisms can develop. In younger children (2-4 years), syndromes have been described that symbioticpsychoses(M. Mahler) can be classified as early forms of schizophrenia and the designation of which is determined by the psychodynamic concept of the pre-Oedipal process of separation-individuation. After a relatively uneventful infancy, sometimes after a short separation from the mother at the age of 2-3 years, a noticeable regression of acquired skills (emotional, speech, cognitive) and the achieved level of consciousness of the “I” occurs. Children perceive objects as a whole differently than autistic people, but treat them as if they are part of themselves. The newfound limitation of the self is eroded again, even before the child enters the oedipal phase. Severe diffuse fears, mood swings, autistic detachment, deep relationship disturbances are clinical picture. Among the notable manifestations in early forms of psychotic experiences are the following: simultaneity of aggressive behavior and a winning smile towards a partner, speech disorders (mutism, speech sperrungs, echolalia, automatic repetitions, pathetic artificial intonation of speech, etc.). Sometimes obsessive thoughts and actions are noted. Typical catatonic symptoms (attacks of motor agitation, or waxy flexibility, catalepsy) can appear very early. Starting from the 7th year of life, delusions and hallucinations appear more often, but they are unlikely to be systematized and still remain unstable.
Starting from early puberty, the frequencyschizophrenicsyndromes constantlyincreases and clinical manifestations become similar to the picture of the disease in young adults. In the run-up to a psychotic episode, there may be psychotic manifestations that are difficult to predict, e.g. depersonalization and derealization, depressive mood changes, sudden refusals from school activities, antisocial reactions, persistent reactions of protest and stubbornness. All these phenomena can also be observed within the framework of puberty and teenage crises. In most cases, they go away on their own, as soon as the teenager emerges from the crisis and gains a more mature awareness of his Self. Some adolescents (12-18 years old) and young men (18-21 years old) during this crisis period experience fluctuations in the psychosexual integration of the Self and with appropriate premorbid vulnerability it comes to the manifestation of schizophrenic disorders. They can develop acutely in the form schizophrenic fur coat, for example with elements catatonic stupor, catatonic excitation or delusional mood or finally from the very beginning in the form psychotic process chebethreal symptoms, or accept slow course with poor symptoms,characteristic of a simple form of schizophrenia. Schizophrenia in early childhood continues to occur with relatively mild symptoms, i.e. often without clearly defined delusional and hallucinatory experiences (like Schizophrenia simplex). Single-shot (functionnational) psychotic episodes, which appear in childhood or adolescence and then disappear completely, in most cases are not currently considered to the schizophrenic circle and, depending on the scientific school, taking into account the prevailing symptoms and age, are described as psychogenic psychoses,emotional psychoses, hysterical psychoses. To avoid confusion in terminology, a specific description of the leading symptoms from which the syndrome is formed should be recommended, for example: hallucinatory syndrome, oneiric paranoid syndrome, etc.
Some patients with borderline syndromes observed by child and adolescent psychiatrists in puberty and adolescence and very rarely in early school age. In these cases, with relatively good social adjustment or still quite satisfactory school success, pronounced attacks of fear and rage come to the fore. At the same time, very early defense mechanisms and short-term psychotic outbursts give these multidimensional disorders special shade: projective identification, identification with the aggressor, splitting process. Idealization transfers to the outside perceptions that are intolerable to one’s “I”, but not repressed by destructive impulses(an element similar to psychosis). A very wide variety of neurotic complaints and structural details appear in varying degrees of severity and in various combinations, creating a picture hysterical,depressive, obsessive, hypochondriacal. In psychosocial aggravating situations, patients with borderline syndrome may develop acute psychotic episodes with productive symptoms and a good prognosis in most cases (so-called micropsychoses).
Mentally retarded Children can develop (functional) psychoses despite and alongside intellectual disabilities. Despite the fact that the presence of mental retardation, which contributes to the manifestation of the hypothetical prerequisites for schizophrenia (with an equal frequency of cases as in the general population), is currently not confirmed, nevertheless, cognitive deficiency of certain abilities, determined by neuropsychological methods, in particular in situations with emotional overload may make it difficult selective filtration and processing internal and external stimuli and thus acquire pathogenetic significance. The special position of these psychoses in in a certain sense, depends on the fact that in difficult-to-explain content diffuse symptoms(these symptoms grow from a weakly structured world of experiences) affective components occupy a significant place (mixed psychoses), erased feelings of alienation and above all, obvious reactive reason, for example, in the form of excessive demands when adapting to a new environment.
Course, prognosis, frequency. Schizophrenic syndromes in early childhood also either occur in the form of acute episodes, which can be one-time or repeated and progressive, or from the very beginning they acquire a chronic procedural character. For childhood, the rule also remains in force: the more acute and productive the psychotic manifestations, the (relatively) more favorable the prognosis; The poorer the symptoms and the slower the development of psychosis, the more unfavorable its course.
Frequency accounts for 0.1% of the population, or 1% of the total number of schizophrenia.
Therapy. Certain types are recommended child psychotherapy, environmental treatmentenvironment and therapeutic pedagogy, which is often only possible in stationary conditions. These treatment interventions can provide support with or without antipsychotic medication during acute schizophrenic episodes. Attractionparents, brothers and sisters of patients for family therapy and/or in groups of relatives is effective for overcoming broken relationships in the family and feelings of guilt among parents. Practical consulting parents and educational working with them is mandatory.

Depressive syndromes.

Depressive syndromes before puberty are extremely rare. In the structure of symptoms, an age dependence on the achieved level of mental development is clearly visible. Depressive mood disorders in childhood are difficult to diagnose due to their atypical symptoms. They appear in the form depressive reactions and developments(dysthymic disorders) or with deep vital disorders(For example, sleep disturbances, loss of appetite, fluctuations in state during the day, somatization manifestations). Often, depressive symptoms can appear after connecting typical triggers and situations: after death the most beloved person (mother) or forced repeated separation from him, due to serious narcissistic problems in situations social andemotional deprivation or affectively colored pedagogicalinjustice, after threatening or committing punishment, during depression of one of the parents(primarily mothers), with acute and chronic somatic diseases. U In younger schoolchildren, it is sometimes difficult to establish whether school problems and associated fears are the cause or consequence of depressive mood disorders, or whether in differential diagnostic terms we are talking about an isolated fear of separation.
At the age of 1 to 2 years. Early infantile (pre-oedipal) deprivation depressions are found mainly in abortive or methylated forms of anaclitic depression, which is rarely observed in full at present. Such depression develops when a child experiences separation or loss of a loved one, due to early emotional loneliness (abandonment). At the onset of the disease, fear and psychomotor restlessness come to the fore; later apathy, autoerotic and destructive actions, as well as weight loss, delayed development of cognitive and sensorimotor functions.
Between the ages of 2 and 4 years. In connection with conflicts, specificsheskthemfor this phase of development(cultivating neatness skills, conflicts of ambivalence, gaining autonomy, separation crises) may be observed quickly transient and sometimes prolonged depressive reactions, which often leak with pronounced fears and can also be related with the experience of separation, (affective respiratory spasms, fear of separation).
Between the ages of 4 and 6 years. Depressive symptoms may first appear in the form of feelings of guilt, fear of failure, ideas of sinfulness, since during this period the regulatory requirements and expectations of parents are being implemented into child's mental structure (“introjection”, i.e. secondary identification, secondary narcissism) and contribute to the formation of the idea of ​​the “Ideal Self” and the “Super-Ego”. Only during this period can the child’s “I”, in its own actual representation, be contrasted with its ideal requirements. It is possible that this is due to the process of personality development and psychobiological maturation, the first appearance transformation(noticeable increase in height, loss of signs of a small child). Therefore, the first signs of depression flowing inphase form, and cyclothymic course illnesses with depressive And manic phases can be observed no earlier than in the seventh year of life and until late puberty, and even then only in very rare cases. In most cases, the symptoms are abortive and unclearly expressed and veiled by other, less typical depressive behavior disorders: school debt, aggressive and threatening behavior, desire for privacy, colored by a feeling of fear, difficulties in the school community, etc. Diagnosis requires the participation of an experienced child psychiatrist, specialist in therapeutic pedagogy and educational psychologist. Prehoongoing and more prolonged depressive reactions (dysthymia), which appear in close connection with the demands made by school and family, are much more common in this age group.
During puberty (12-18 years) depressive reactions also occur against the background of emotional lability and egocentrism “second transformation of appearance”(puberty, development of secondary sexual characteristics, completion of the growth process). A specific background in this age period is the theme of loneliness and world sorrow. Cyclothymic course(mono- and bipolar) is observed at this age more often in the form juvenile depression and/or mania and is becoming increasingly similar to similar conditions in adults. Depressive conditions in childhood are also may cause suicidal behavior. Suicide attempts and completed suicides before puberty are extremely rare, although in Western industrialized countries there is a clear increase in suicidal acts in children. Only in puberty and adolescence, the rate of suicide attempts and suicides gradually increases and reaches a critical value in this period (along with the crises of maturation at this age, compared to younger children, a more mature concept of death plays a significant role).
Therapy. The younger the depressed child, the more important it is to find out the situational triggers before starting treatment, eliminate them or try to compensate. To do this, it is necessary to create an appropriate environment, a therapeutic-pedagogical and psychological-pedagogical approach. Depression with vitally colored, somatized disorders and a pronounced cyclothymic course requires the use of antidepressant psychopharmacological treatment.

The issue of mental disorders in childhood and adolescence is a topic that will always be acute for psychiatrists and parents. I would like to reflect on the general issues of this problem and consider the approaches to resolving them that exist today in medicine in our country. This work is not a specialized medical article. It is aimed at a wide range of readers, parents, their children, as well as all other persons for whom this issue is interesting and relevant.

Objectives and history of child psychiatry

Many authors note that psychiatry has recently greatly expanded the scope of its activities and, going beyond the walls of psychiatric hospitals, has included initial and borderline forms in its terms of reference. However, this expansion has not gone deep enough in all respects, and this primarily applies to neuropsychiatric diseases of childhood. Very little is taken into account that it is at this age that most of the changes occur, which have to be looked at as the beginnings of future serious diseases.

More attention to children's health

In general, child psychiatry has not emerged from the disparagement to which it was subjected before the war and revolution. Since the last, there has been hope that in connection with the full inclusion of issues of child upbringing and education, the position of child psychiatry will change. Unfortunately, of the very broad program of activities planned at the beginning, which for various reasons could not be fully developed, very little fell to the share of child psychiatry. The reason for this must be considered not only significant financial difficulties, but also the fact that in general there are very few widespread ideas in wide circles about the importance of child psychiatry, its tasks and significance in general psychiatry and medicine. Unfortunately, this also applies to many doctors, especially general practitioners, who often underestimate, and sometimes simply do not want to notice, disorders in children that require referring the child for consultation with a child psychiatrist. It should be noted that the later the patient was seen by a pediatric specialist, the later the treatment and correction of mental disorders in the child were started, the less effective this treatment is and the more time it will take to compensate for the child’s problems without allowing transition of the disease into a phase of stable disorders, often not amenable to medication and psychological correction.

Of course, child psychiatry has its own tasks and its own characteristics compared to general psychiatry, the most important of which are that it is even more connected with neurology and internal medicine, it is more complex in diagnosis and prognosis, more unstable, but that is why the specialists who have dedicated their lives in this specialty, are often professionals with a capital “P”.

The most common mental disorders in children

I consider it appropriate to structure my article according to the following principle: first, to present the most common mental disorders in children and adolescents that require observation and treatment by a child psychiatrist; secondly, talk about the general principles for correcting these violations; thirdly, try to justify the need for treatment of these diseases and try to provide brief information on the prognosis for children receiving and, accordingly, not receiving treatment.

Delayed psycho-speech development

In first place in terms of frequency of occurrence in early childhood are currently various forms of delays in psycho-speech development. Often, in the absence of significant motor disorders (the child begins to roll over, sit up, walk, etc. in a timely manner), caused by early combined pathology of pregnancy and childbirth (chronic infections in the mother during pregnancy, abuse of tobacco, alcohol, toxic and narcotic drugs, childbirth injuries of varying severity, prematurity, congenital chromosomal abnormalities (Down syndrome, etc.), etc.), the problems of untimely speech development of the child come first.

Developmental norm, assessment of a child’s level of speech development

It is quite difficult to talk about the presence of any clear temporal norms of speech development, but still we believe that the absence of individual words at the age of 1.5 years or the immaturity of phrasal speech (the child pronounces short sentences that carry full semantic content) by 2, maximum 2 .5 years is the basis for determining that a child has delayed speech development. The very fact of the presence of delayed speech development may be due to both hereditary factors (“mom and dad spoke late”), and the presence of any significant mental disorders, including early childhood autism or mental retardation; but the fact is that only specialists who know the pathology of this circle and know how to identify and treat it can make a decision, the right decision, about the true causes of these disorders, identify the roots of the problem and offer a real, effective solution.

Often, general practitioners, speech therapists at general kindergartens, friends and neighbors, who do not fully possess specialized information, reassure parents by saying phrases that are painfully familiar to everyone: “Don’t worry, by the age of 5 he will catch up, grow up, speak,” but often in For 4-5 years, these same people tell their parents: “Well, why did you wait so long, you should have been treated!” It is at this age, at the age of 4-5 years, that children most often come to see a child psychiatrist for the first time, and they come with concomitant behavioral and emotional disorders, and retardation in intellectual and physical development. The human body, and especially a child’s, is a single system in which all components are closely interconnected, and when the work of one of them is disrupted (in this case, speech formation), gradually other structures begin to fail, making the course of the disease more severe and aggravating.

Symptoms of mental disorders, childhood autism

As mentioned above, a child’s speech and motor developmental delay can be not only an independent diagnosis, but also be one of the symptoms of more significant mental disorders. In confirmation of this, it should be noted that in recent years there has been a significant increase in the incidence of childhood autism in our country. Over the past 3 years, the frequency of detection of this disease in children 3-6 years of age has increased more than 2 times, and this is due not only and not so much to the improvement in the quality of its diagnosis, but also to a significant increase in incidence in general.

It should be said that the course of this process today has become significantly more complicated: it is almost impossible to meet in medical practice today a child with “pure” autism (social isolation). This disease often combines severe developmental delays, decreased intelligence, behavioral disorders with clear auto- and hetero-aggressive tendencies. And at the same time, the later treatment begins, the slower compensation occurs, the worse social adaptation and the more severe the long-term consequences of this disease. More than 40% of childhood autism at the age of 8-11 years develop into endogenous diseases, such as schizotypal disorder or childhood type of schizophrenia.

Behavioral disorder in children, hyperactivity

A special place in the practice of a psychiatrist is occupied by behavioral, attention and activity disorders in children. Attention deficit hyperactivity disorder is currently probably the most widely used diagnosis, which therapists, pediatricians, and neurologists are happy to make. But few people remember that according to the nomenclature of diseases, this disease belongs to mental disorders and most often the most effective treatment for children with such disorders is from a child psychiatrist and psychotherapist, who can fully use in their practice all the necessary methods and methods of drug correction of data violations.

Often, mildly expressed violations can be compensated on their own as the child grows and physiologically matures, but often, even with a favorable course of the process, the results of inattention to such violations at an early age are pronounced difficulties in learning at school, as well as behavioral disorders with a tendency to do everything “ negative" in adolescence. Moreover, it should be noted that getting used to everything “bad” (various addictions, antisocial behavior, etc.) in such children occurs much more quickly and decompensation of the condition with depletion of physiological compensatory mechanisms also occurs faster than in persons who have no history of this kind of violation.

Mental retardation in children

There is a high percentage of children diagnosed with mental retardation of varying severity. This diagnosis, of course, is never established before the age of 3, because Determining the level of intellectual impairment in a child under 3 years of age presents certain difficulties. The criteria for establishing this diagnosis are the lack of effect from the treatment, the uncompensability of the condition against the background of intensive treatment at an early age.

The goal of educating children diagnosed with mental retardation is not intellectual compensation and an attempt to bring them to the general age level, but social adaptation and the search for that type of activity, even if not difficult from an intellectual point of view, that can enable them to exist independently in adulthood and provide for yourself. Unfortunately, this is often only possible with a mild (rarely moderate) degree of this disease. With more severe disorders, these patients require monitoring and care from relatives throughout their lives.

Mental disorders of the endogenous circle, schizophrenia

The percentage of children and adolescents with purely mental disorders of the endogenous circle is quite large. In this case, we are talking about schizophrenia and disorders similar to it, in which thinking processes are disrupted and personal characteristics are grossly changed. Untimely identification and initiation of treatment for these disorders leads to a very rapid increase in the personality defect and aggravates the course of this disease in adulthood.

Children's mental illnesses need to be treated

Summarizing all that has been said, I would like to note that this article presents a very short and rough list of the main mental illnesses of childhood. Perhaps, if this turns out to be interesting, in the future we will continue the series of articles and then we will dwell in detail on each type of mental disorder, methods for identifying them and the principles of effective therapy.

Don't delay visiting your doctor if your child needs help.

But I want to say one thing now: do not be afraid of a visit to a child psychiatrist, do not be afraid of the word “psychiatry”, do not hesitate to ask about what worries you about your child, what seems “wrong” to you, do not turn a blind eye to any behavioral features and the development of your child, convincing yourself that “it just seems.” A consultative visit to a child psychiatrist will not oblige you to anything (the topic of observation forms in psychiatry is a topic for a separate article), and at the same time, often timely contact with a psychiatrist with your child prevents the development of severe mental disorders at a later age and makes it possible Your child will continue to live a full, healthy life.

Pozdnyakov S.S.

Psychiatrist at the children's dispensary department of the Central Moscow Regional Clinical Hospital.

PSYCHIATRY, the science of mental illness, History of psychology. As a scientific discipline, psychology was formed only in the 19th century. , although the diseases it interprets began to attract the interest and attention of people at the earliest stages of human society.... ... Great Medical Encyclopedia

Date of birth: 1891 (1891) Date of death: 1981 (1981) Place of death: Moscow Country ... Wikipedia

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In a broad sense, it includes professional intervention aimed at resolving or preventing psychological problems in children. Psychological disorders in childhood. Studies conducted in the United States and other countries show... ... Collier's Encyclopedia

I (morbilli) is an acute infectious disease accompanied by intoxication, catarrhal inflammation of the mucous membranes of the upper respiratory tract and eyes, and a maculopapular rash. Etiology. The causative agent is K. virus of the family Paramyxoviridae genus... ... Medical encyclopedia

I Neuropathy in psychiatry (Greek neuron nerve + pathos suffering, disease) is one of the forms of developmental anomalies (dysontogenesis) of the nervous system, characterized by its increased excitability in combination with increased exhaustion. The concept of "neuropathy" ... ... Medical encyclopedia

- (lat. infantilis infantile; children's; synonym mental immaturity) psychopathological condition characterized by childishness, immaturity of the psyche. I. p. is based on a delay in the rate of mental development. There are I. p. congenital... ... Medical encyclopedia

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- (Greek hēbe youth, puberty + eidos species; synonym: criminal heboid, mattoid, parathymia) a mental disorder characterized by a pathological distortion of the features of the pubertal period. Occurs predominantly in males.... ... Medical encyclopedia

I Dysmorphophobia (Greek dys + morphē image, form + phobos fear) a mental disorder characterized by the patient’s conviction that he has some kind of physical defect that does not actually exist, or a sharp overestimation... ... Medical encyclopedia

I Kanner syndrome (L. Kanner, Austrian psychiatrist, born in 1894; synonymous with early childhood autism) psychopathological symptom complex characterized by autism (weakening or loss of connection with reality, loss of interest in ... ... Medical encyclopedia

Child psychiatry is primarily a reflection of the internal formation of the body, as well as the influence of multiple environmental factors. First of all, these are parents, close relatives, and school teachers. They either contribute to normal and harmonious personal development, or, on the contrary, without even realizing it, they create a number of obstacles. This process is absolutely individual for all children, since each has its own genetic characteristics. Mental development has a long period, and practically, it lasts a lifetime. But the particular intensity of the dynamics in this direction is typical specifically for childhood.

Manifestations of childhood nervousness are observed at any age. For example, up to three years of age, paroxysmal conditions occur, such as affective-respiratory seizures, spasmophilia, convulsive states during infections, etc. Preschoolers often experience sleep-talking, sleepwalking, restlessness during sleep, hysterical fits, and pycnoleptic seizures, which are of residual organic origin. In this case, a pediatrician must correctly recognize mental disorders and carry out differentiated treatment of such paroxysmal conditions in children, including epilepsy.

Childhood psychiatry, up to three years of age, often reveals neuropathy, and in certain cases, early neurotic reactions. Manifestations of nervousness in children are rudimentary, peculiar, and can manifest themselves in the form of somatovegetative disorders, while imitation of somatic diseases occurs, for example, low-grade fever, loss of appetite, stool. If a child has infectious diseases, then in preschool age there is a feeling of anxiety, delirious excitement, and dreamlike experiences. After a child has suffered from infectious diseases, a residual condition sometimes develops, which in most cases can be prevented by a special regime.

Features of childhood psychiatry

It is known that initially, in case of any complaints, the child is examined by a pediatrician, who, if necessary, gives a referral to other pediatric specialists. Childhood psychiatry implies that the pediatrician must identify a number of basic symptoms in the child, as well as signs of mental disorders, and make a competent clinical description of them. Also, the pediatrician has the opportunity to restrain an excited child or teenager and prescribe the necessary medications that successfully correct the pathological condition. At the same time, it is necessary to take into account that after completing a course of treatment with a child psychiatrist, the local pediatrician continues treatment of existing somatic diseases.

The doctor must know in detail about all the features of the course of somatic diseases in a child with a mental disorder. Also, great importance is attached to possible complications during the treatment of a patient with the use of psychopharmacological drugs, since neuroleptic syndrome may occur. Older children with severe dissociation may experience sensations in which they feel like they are going crazy, and therefore remain in a constant state of confusion and need help. It has been established that during dissociation, not only the child’s psyche is affected, but also his psychomotor skills, expressed in the mismatch of movements and facial expressions.

In most cases, such a condition does not allow an assessment of the patient’s emotional characteristics, so the impression of some kind of bizarre pretentiousness, pretentiousness, and inappropriate mannerism is created. Schizophrenic autism, which is often found in children, forces the patient to immerse himself in a world of internal experiences that are distinguished by their isolation from the reality of experiences. For some, this mental disorder manifests itself in the form of limited communication, or its complete cessation. Other patients, on the contrary, demonstrate absolute openness, the so-called inside-out autism.

The complexities of child psychiatry

Due to their special emotionality and unformed psyche, children are always difficult patients, regardless of the complexity of the disease. It is known that if the disease is mild, or is at the very beginning of its development, then contact with the patient is maintained, and a certain revival is observed. But, at the same time, the intuitive and emotional side, the sense of reality, and general empathy are subject to suffering. This phenomenon in psychiatry is called the symptom of regressive syntony. Emotional behavior gives the impression of dullness in the emotional sphere. This is largely due to the autistic and dissociated content of the patient’s behavioral manifestations and experiences.

If a child suffers from a disease such as asthenic psychopathy, then his feelings are particularly deep. They determine the patient’s well-being, direction of activity, and his plans for the near and future. Also, taking into account his own feelings, the child evaluates the activities of others and considers his own behavior. If serious disappointments or significant losses arise in life, then this ends in severe neuroses and active depression. With asthenic psychopathy in childhood, there are signs of neuropathy, which are expressed in poor sleep, excessive moodiness of children, fearfulness, etc.