Hyperkinetic conduct disorder (F90.1). Hyperkinetic disorders The psychiatrist put the child healthy f 90.0

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2010 (Order No. 239)

Hyperkinetic conduct disorder (F90.1)

general information

Short description

is a group of complex behavioral disorders characterized by the presence of a certain number of signs in three categories: inattention, impulsivity and hyperactivity (attention deficit hyperactivity disorder) with the presence of the criteria for the disorder social behavior.

Protocol"Hyperkinetic Conduct Disorder"

ICD 10 code: F 90.1

Classification

Clinical classification according to severity - mild, severe.

Diagnostics

Diagnostic criteria

To be diagnosed with hyperkinetic disorder, the condition must meet the following criteria:

1. Violation of attention. For at least six months, at least six signs of this group must be observed in severity incompatible with the normal stage of development of the child. Children:
- unable to complete a school or other assignment without errors caused by inattention to detail;
- often unable to complete the work or game performed;
- often do not listen to what they are told;
- usually fail to follow the clarifications needed to complete school or other assignments (but not because of oppositional behavior or failure to understand instructions);
- often unable to properly organize their work;
- avoid unloved work that requires perseverance, perseverance;
- often lose items that are important for performing some tasks (stationery, books, toys, tools);
- are usually distracted by external stimuli;
are often forgetful in daily activities.

2. Hyperactivity. For at least six months, at least three of the signs of this group are noted in severity that does not correspond to this stage of development of the child. Children:
- often swing their arms and legs or roll around in their seats;
- leave their place in the classroom or other situations in which perseverance is expected;
- running around or climbing somewhere in inadequate situations for this;
- often noisy in games or incapable of quiet pastime;
- demonstrate a persistent pattern of excessive physical activity, uncontrolled by the social context or prohibitions.

3. Impulsivity. For at least six months, at least one of the signs of this group is observed in severity that does not correspond to this stage of the child's development. Children:
- often jump out with an answer without listening to the question;
- often cannot wait their turn in games or group situations;
- often interrupt or interfere with others (for example, interfering in a conversation or game);
- are often unnecessarily wordy, not responding adequately to social restrictions.

4. Onset of the disorder before the age of 7 years.

5. Severity of symptoms: Objective information about hyperkinetic behavior must be obtained from more than one area of ​​ongoing observation (eg, not only at home, but also in a school or clinic), as Parents' stories about behavior at school may be unreliable.

6. Symptoms cause distinct impairments to social, academic, or work functioning.

7. The condition does not meet the criteria for general developmental disorder (F84), affective episode (F3), or anxiety disorder (F41).

Complaints and anamnesis

1. Attention disorders include:
- inability to maintain attention: the child cannot complete the task to the end, is not collected when it is completed;
- Decreased selective attention, inability to focus on a subject for a long time;
- frequent forgetting what needs to be done;
- increased distractibility, increased excitability: children are fussy, restless, often switch from one activity to another;
- an even greater decrease in attention in unusual situations when it is necessary to act independently.

2. Impulsivity - the inability to establish causal relationships, as a result of which the child is not able to foresee the consequences of his actions:
- sloppy completion of school assignments, despite efforts to do everything right;
- frequent shouting from the place and other noisy antics during the lessons;
- “intervening” in the conversation or work of other children;
- inability to wait their turn in games, during classes, etc.;
- frequent fights with other children (the reason is not bad intentions or cruelty, but the inability to lose).
With age, there may be - urinary and fecal incontinence; in the primary grades - excessive activity in defending one's own interests, despite the requirements of the teacher (despite the fact that the contradictions between the student and the teacher are quite natural), extreme impatience.

3. Increased hyperactivity, behavioral disorder, intentional social disorders, antisocial personality disorder. In older childhood and adolescence - hooligan antics and antisocial behavior (theft, drug use, promiscuity). The older the child, the more pronounced and noticeable impulsivity and behavioral disorders.

Physical examinations: neurological status - impaired coordination in the form of impaired fine movements (tying shoelaces, using scissors, coloring, writing), balance (it is difficult for children to ride a skateboard and a two-wheeled bicycle), visual-spatial coordination (inability to play sports, especially with a ball); behavioral disorders; emotional disturbances (unbalance, irascibility, intolerance to failures); relations with others are violated both with peers and with adults; partial developmental delays despite normal IQ in the form of dyslexia, dysgraphia, dyscalculia. There may be sleep disturbances, enuresis.

Laboratory research: general analysis of blood and urine without pathology.

Instrumental research:

1. Electroencephalography.

Changes are characteristic: excessive slow-wave activity in the anterior-central leads; bilateral-synchronous, slow-wave activity in the posterior leads; the appearance of activity that is not characteristic of a given age; a large representation of theta rhythm in the background recording; high-amplitude EEG; the appearance of bursts of theta activity in the occipital leads.

2. CT and MRI data. Changes are characteristic: minor subatrophic changes in the frontal and temporal lobes; slight expansion of the subarachnoid space; slight expansion of the ventricular system; asymmetry of basal structures (the left caudate nucleus is smaller than the right one).

Indications for specialist consultations:

1. Psychologist for psychological diagnosis and correction.

2. Physical therapy doctor for the appointment of individual physiotherapy exercises.

3. Physiotherapist for prescribing physiotherapeutic procedures.

4. Oculist to determine the condition of the fundus.

5. Orthopedist to exclude orthopedic pathology.

6. Audiologist to determine the acuity of hearing.

Minimum examination when referring to a hospital:

General analysis blood;

General urine analysis;

ALT, AST;

Cal on i/g.

The main diagnostic measures:

1. Complete blood count (6 parameters).

2. Electroencephalography.

3. Examination by a psychologist, speech therapist.

4. Computed tomography of the brain.

5. Examination by an ophthalmologist.

Additional diagnostic measures:

1. Magnetic resonance imaging of the brain.

2. Examination by an orthopedist.

3. Examination by an audiologist.

Differential Diagnosis

Disease	Manifestation	Clinic	Etiopathogenetic factors
ADHD	Up to 8 years	Impulsivity, attention disorder, hyperactivity, intellectual development by age, motor awkwardness, dyslexia, dysgraphia, dyscalculia	Genetic, perinatal, psychosocial factors
Hyperkinetic Conduct Disorder	Manifestation up to 7 years	Hyperactivity, impulsivity, aggressiveness, distractibility, intellectual development for age, motor clumsiness, dyslexia, dysgraphia, dyscalculia plus criteria for social behavior disorder	Biological factors, prolonged emotional deprivation; psychosocial stress
Psycho-organic syndrome	After 8 years	Signs of intellectual insufficiency of varying degrees: a decrease in intellectual productivity due to a sharp exhaustion of attention, lack of memory, criticality, carelessness, lack of cognitive interests with high possibilities of abstraction, inertia of thinking, difficulty switching, monotony of behavior	Perinatal and psychosocial factors
depression	12-15 years old	Decreased mood background, behavioral disorders, motor retardation, social isolation	Biological factors, psychosocial factors
Decreased acuity of hearing, vision	Since birth	Behavioral disorders, hyperactivity, decreased attention, pathology of the organs of hearing and vision with a decrease in acuity	Biological and exogenous factors

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Treatment

Treatment tactics

Goals of conservative treatment:

1. Correction of the neuropsychic status of patients.

2. Provide the patient with social adaptation.

3. Determine the degree of conduct disorder and ensure the selection of therapy.

Non-drug treatment

Educational work for parents and the child, to explain the features of the disease, be sure to explain the meaning of the upcoming treatment. It is necessary to discuss general and particular issues of upbringing, to acquaint parents with methods of reward, behavioral psychotherapy, etc. If it is difficult for a child to study in a regular class, he is transferred to a specialized class (correctional). Optimization of the external conditions of the child's stay in the team, his stay in a small school group, preferably with self-service in the classroom, thoughtful seating of children.

Compliance with the daily routine, pedagogical correction, creation psychological comfort;

Cognitive psychotherapy;

Classes with a psychologist;

exercise therapy in the group;

Massage of the cervical-collar zone;

Physiotherapy;

Conductive Pedagogy;

Lessons with a speech therapist.

Medical treatment

1. Methylphenidate is taken 1-3 times a day (depending on the form): in the morning once with prolonged forms (prolonged release), with the form of immediate release - in the morning, at noon and, if possible, after school. One difficulty is that taking the drug too late in the day can disrupt sleep. The dose of methylphenidate is 10-60 mg / day. inside, the dose should be selected individually, based on the needs of a particular patient and his response to treatment. Taking the drug at 18 mg once a day, in the morning with a liquid (do not break, chew), followed by an increase of 18 mg weekly, but not more than 54 mg / day.

The selection of the drug is made until the maximum therapeutic effect is achieved or side effects develop - loss of appetite, irritability, epigastric pain, headache, insomnia (usually - when taken late). In case of a paradoxical increase in symptoms or other adverse events, the dose of the drug should be reduced, and then only canceled. Physical dependence on psychostimulants in children usually does not develop. Tolerance is also not typical; as a short-term phenomenon, it is possible at the beginning of treatment, but usually disappears when the dose is increased.

2. Antipsychotics: chlorprothixene, thioridazine are indicated for severe hyperactivity and aggressiveness.

3. Antidepressants for secondary depression: fluoxetine, melipramine.

4. Tranquilizers with the ineffectiveness of the above treatment: grandaxin, clorazepate.

5. Anticonvulsant normotimic drugs (phenytoin-difenin, carbamazepine and valproic acid) are also used.

6. In case of intolerance to psychostimulants, nootropic therapy is indicated: glycine, pantocalcin, noofen.

7. Antioxidant therapy: oxybral, actovegin, instenon.

8. Restorative therapy: B vitamins, folic acid, magnesium preparations.

Preventive actions:

Improving the quality of life;

Good drug tolerance;

Prevention side effects psychostimulants, anticonvulsants;

Pedagogical control;

Creation of psychological comfort in the family;

When conducting drug therapy - daily telephone communication with school staff, periodic discontinuation of medication to decide whether it is necessary to continue it;

If drug therapy is ineffective, it is possible to use a behavioral therapy program with the participation of psychotherapists and specialist teachers.

Further management: dispensary registration with a neurologist at the place of residence, when taking psychostimulants, it is necessary to control the quality of sleep, for side effects; when taking antidepressants - ECG control with palpitations; when taking anticonvulsants - a biochemical blood test - ALT, AST; creation optimal conditions for normal learning, successful socialization of the child and education of self-control.

Basic medicines:

1. Methylphenidate - concerta, extended release tablets 18 mg, 36 mg, 54 mg

2. Fluoxetine hydrochloride 20 mg capsules

3. Chlorprothixene, tablets 0.015 and 0.05

4. Thioridazine (sonapax), dragee 0.01, 0.025 and 0.1

5. Convulex, drops for oral administration with dosing dropper, 300 mg/ml, 1 drop 10 mg, 1 ml = 30 drops = 300 mg

6. Konvuleks, tablets of prolonged action 300 and 500 mg

7. Carbamazepine tablets 200 mg

8. Vincamine (oxybral), capsules 30 mg

9. Actovegin, 80 mg ampoules

10. Pyridoxine hydrochloride, ampoules, 1 ml 5%

11. Magne B6 tablets

12. Cyanocobalamin, 1 ml ampoules 200 mcg and 500 mcg

13. Thiamine bromide, ampoules 1 ml 5%

14. Clorazepate (tranxen), capsules 0.01 and 0.005

Additional medicines:

1. Grandaxin, 50 mg

2. Mebicar tablets 300 mg

3. Imipramine (melipramine), 25 mg

4. Tanakan tablets 40 mg

5. Pantocalcin, tablets 0.25

6. Neuromultivit, tablets

7. Folic acid tablets 0.001

8. Vinpocetine (Cavinton), tablets 5 mg

9. Glycine tablets

10. Noofen, tablets 0.25

11. Difenin, tablets 0.117

Treatment effectiveness indicators:

1. Increasing the level of active attention.

2. Improve behavior.

3. Reducing the level of impulsiveness, aggressiveness.

4. Improving school performance, independence.

Hospitalization

Indications for planned hospitalization: impaired attention, disinhibition, motor clumsiness, forgetfulness, inattention to details, lack of independence, purposefulness and concentration, school maladjustment and academic failure, dissociality, secondary depressive manifestations.

Information

Sources and literature

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 239 of 04/07/2010)
   1. "Neurology" edited by M. Samuels, 1997 Petrukhin A.S. Neurology childhood, Moscow 2004 "Psychiatry" edited by R. Shader, 1998 "Clinical Psychiatry" edited by V.D.Vid, Yu.V.Popov. SPb. - 2000.

Information

List of developers:

№	Developer	Place of work	Job title
	Kadyrzhanova Galiya Baekenovna	RCCH "Aksai", psycho-neurological department No. 3	Head of department
	Serova Tatyana Konstantinovna	RCCH "Aksay", psycho-neurological department No. 1	Head of department
	Mukhambetova Gulnara Amerzaevna	KazNMU, Department of Nervous Diseases	Assistant, Candidate of Medical Sciences
	Balbaeva Aiym Sergazievna	RCCH "Aksay", psycho-neurological department No. 3	Neurologist

Attached files

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Formerly called minimal brain dysfunction (MBD), hyperkinetic syndrome, minimal brain damage. It is one of the most common childhood behavioral disorders and persists into adulthood for many.

Prevalence

The disorder is more common in boys. The relative prevalence among boys and girls is from 3:1 to 9:1, depending on the criteria for diagnosis. Currently, the prevalence among schoolchildren is from 3 to 20%. In 30-70% of cases, the syndromes of the disorder pass into adulthood. Hyperactivity during adolescence decreases in many, even if other disorders remain, but the risk of developing antisocial psychopathy, alcoholism and drug addiction is high.

What provokes Violation of activity and attention:

Previously, hyperkinetic disorder was associated with intrauterine or postnatal brain damage ("minimal brain damage"). A genetic predisposition to this disorder has been identified. Identical twins have a higher concordance than fraternal twins. 20-30% of parents of patients suffered or suffer from impaired activity and attention. The innate tendency to hyperactivity is enhanced by certain social factors, since such behavior is more common in children living in adverse social conditions. Alcoholism, antisocial psychopathy, and affective disorders are more common in parents of patients than in the general population. The suspected causes of the disorder have been associated with food allergies, long-term lead intoxication, and exposure to food additives However, these hypotheses are not supported by convincing evidence. A strong association has been found between impaired activity and attention and insensitivity to thyroid hormones, a rare condition based on a mutation in the thyroid hormone receptor beta gene.

Symptoms Violation of activity and attention:

The diagnostic criteria for the disorder have changed somewhat over the years. Symptoms almost always appear before 5-7 years of age. The average age of visiting a doctor is 8-10 years.

The main manifestations include:

• - Attention disorders. Inability to maintain attention, decreased selective attention, inability to focus on a subject for a long time, often forgetting what needs to be done; increased distractibility, excitability. Such children are fussy, restless. Even more attention is reduced in unusual situations, when it is necessary to act independently. Some kids can't even finish watching their favorite TV shows.
• - Impulsiveness. AT the form of sloppy completion of school assignments, despite efforts to do them correctly; frequent shouting from a place, noisy antics during classes; intervening in the conversation or work of others; impatience in the queue; inability to lose (as a result, frequent fights with children). With age, manifestations of impulsivity may change. At an early age, this is urinary and fecal incontinence; at school - excessive activity and extreme impatience; in adolescence - hooligan antics and antisocial behavior (theft, drug use, etc.). However, the older the child, the more pronounced and noticeable impulsiveness for others.
• - Hyperactivity. This is an optional feature. In some children, motor activity may be reduced. However, motor activity qualitatively and quantitatively differs from the age norm. At preschool and early school age, such children continuously and impulsively run, crawl, jump up, and are very fussy. Hyperactivity often decreases by puberty. Children without hyperactivity are less aggressive and hostile to others, but they are more likely to have partial developmental delays, including school skills.

Additional Features

• - Disturbances in coordination are noted in 50-60% in the form of the impossibility of fine movements (tying shoelaces, using scissors, coloring, writing); balance disorders, visual-spatial coordination (inability to play sports, ride a bike, play with a ball).
• - Emotional disturbances in the form of imbalance, irascibility, intolerance to failures. There is a delay in emotional development.
• - Relationships with others. In mental development, children with impaired activity and attention lag behind their peers, but strive to be leaders. It's hard to be friends with them. These children are extroverts, they are looking for friends, but they quickly lose them. Therefore, they often communicate with more "compliant" younger ones. Relationships with adults are difficult. Neither punishment, nor caress, nor praise act on them. From the point of view of parents and educators, it is precisely “ill-manneredness” and “bad behavior” that is the main reason for visiting doctors.
• - Partial developmental delays. Despite a normal IQ, many children do poorly in school. The reasons are inattention, lack of perseverance, intolerance for failures. Partial delays in the development of writing, reading, counting are characteristic. The main symptom is a discrepancy between a high intellectual level and poor school performance. The criterion for a partial delay is considered to be skills lagging behind the due ones by at least 2 years. However, other causes of underachievement must be ruled out: perceptual disturbances, psychological and social causes, low intelligence, and inadequate teaching.
• - Behavioral disorders. They are not always observed. Not all children with conduct disorders may have impaired activity and attention.
• - Nighttime urinary incontinence. Sleep disturbances and drowsiness in the morning.

Violations of activity and attention can be divided into 3 types: with a predominance of inattention; with a predominance of hyperactivity; mixed.

Diagnosis Violation of activity and attention:

It is necessary to have inattention or hyperactivity and impulsivity (or all manifestations at the same time) that do not correspond to the age norm.

Behavior features:

• 1) appear up to 8 years;
• 2) are found in at least two areas of activity - school, home, work, play, clinic;
• 3) are not caused by anxiety, psychotic, affective, dissociative disorders and psychopathy;
• 4) cause significant psychological discomfort and maladjustment.

Carelessness:

• 1. Inability to focus on details, mistakes due to inattention.
• 2. Inability to maintain attention.
• 3. Inability to listen to the addressed speech.
• 4. Inability to complete tasks.
• 5. Low organizational skills.
• 6. Negative attitude to tasks that require mental stress.
• 7. Loss of items needed to complete the task.
• 8. Distractibility to extraneous stimuli.
• 9. Forgetfulness. (Of the listed signs, at least six must persist for more than 6 months.)

Hyperactivity and impulsivity(out of the signs listed below, at least four must persist for at least 6 months):

• - hyperactivity: the child is fussy, restless. Jumps up without permission. Runs aimlessly, fidgets, climbs. Cannot rest, play quiet games;
• - impulsiveness: shouts out the answer without listening to the question. Can't wait in line.

Differential Diagnosis

To make a diagnosis, you need: a detailed history of life. Information must be obtained from everyone who knows the child (parents, caregivers, teachers). Detailed family history (presence of alcoholism, hyperactivity syndrome, tics in parents or relatives). Data about the child's behavior at present.

Information about the progress and behavior of the child in educational institution. There are currently no informative psychological tests to diagnose this disorder.

Violations of activity and attention do not have clear pathognomonic signs. Suspicion of this disorder can be based on the history and psychological testing, taking into account diagnostic criteria. For the final diagnosis, a trial appointment of psychostimulants is shown.

The phenomena of hyperactivity and inattention can be symptoms of anxiety or depressive disorders, mood disorders. The diagnosis of these disorders is based on their diagnostic criteria. The presence of an acute onset of a hyperkinetic disorder at school age may be a manifestation of a reactive (psychogenic or organic) disorder, a manic state, schizophrenia, or a neurological disease.

Treatment of impaired activity and attention:

Drug treatment is effective in 75-80% of cases, with a correct diagnosis. Its action is mostly symptomatic. Suppression of symptoms of hyperactivity and attention deficits facilitates intellectual and social development child. Drug treatment is subject to several principles: only long-term therapy is effective, ending in adolescence. The selection of the drug and the dose are based on the objective effect, and not on the patient's feelings. If the treatment is effective, then it is necessary to take trial breaks at regular intervals to find out if the child can do without drugs. It is advisable to arrange the first breaks during the holidays, when the psychological burden on the child is less.

Pharmacological substances used to treat this disorder are CNS stimulants. Their mechanism of action is not completely known. However, psychostimulants not only calm the child, but also affect other symptoms. The ability to concentrate increases, emotional stability, sensitivity to parents and peers appear, social relations are being established. Mental development may improve dramatically. Currently, amphetamines (dexamphetamine (Dexedrine), methamphetamine), methylphenidate (Ritalin), pemoline (Zielert) are used. Individual sensitivity to them is different. If one of the drugs is ineffective, they switch to another. The advantage of amphetamines is a long duration of action and the presence of prolonged forms. Methylphenidate is usually taken 2-3 times a day, it often has a sedative effect. The intervals between doses are usually 2.5-6 hours. Prolonged forms of amphetamines are taken 1 time per day. Doses of psychostimulants: methylphenidate - 10-60 mg / day; methamphetamine - 5-40 mg / day; pemoline - 56.25-75 mg / day. Begin treatment usually with low doses with a gradual increase. Physical dependence usually does not develop. In rare cases, the development of tolerance is transferred to another drug. It is not recommended to prescribe methylphenidate to children under 6 years of age, dexamphetamine - to children under 3 years of age. Pemoline is prescribed for the ineffectiveness of amphetamines and methylphenidate, but its effect may be delayed, within 3-4 weeks. Side effects- decreased appetite, irritability, epigastric pain, headache, insomnia. In pemoline - increased activity of liver enzymes, possible jaundice. Psychostimulants increase heart rate, blood pressure. Some studies indicate negative influence drugs for height and weight, but these are temporary disorders.

With the ineffectiveness of psychostimulants, imipramine hydrochloride (Tofranil) is recommended in doses of 10 to 200 mg / day; other antidepressants (desipramine, amphebutamon, phenelzine, fluoxetine) and some antipsychotics (chlorprothixene, thioridazine, sonapax). Antipsychotics do not contribute to the social adaptation of the child, so the indications for their appointment are limited. They should be used in the presence of severe aggressiveness, uncontrollability, or when other therapy and psychotherapy are ineffective.

Psychotherapy

A positive effect can be achieved through psychological assistance to children and their families. Rational psychotherapy with an explanation to the child of the reasons for his failures in life is advisable; behavioral therapy with teaching parents methods of reward and punishment. Reducing psychological tension in the family and at school, creating a favorable environment for the child contribute to the effectiveness of treatment. However, as a method of radical treatment of activity and attention disorders, psychotherapy is ineffective.

Control over the child's condition should be established from the beginning of treatment and carried out in several directions - the study of behavior, school performance, social relationships.

The diagnosis is made by meeting the criteria for hyperkinetic disorder and the general criteria for conduct disorder. It is characterized by the presence of dissocial, aggressive or defiant behavior with a pronounced violation of the relevant age and social norms, which are not symptoms of other mental conditions.

Therapy

Applicable psychostimulants are amphetamine (5-40 mg/day) or methylphenidate (5-60 mg/day), neuroleptics with a pronounced sedative effect. The use of normothymic anticonvulsants (carbamazepines, valproic acid salts) in individually selected doses is recommended. Psychotherapeutic techniques are largely socially conditioned and are of an auxiliary nature.

Conduct disorders (F91).

They include disorders in the form of destructive, aggressive or antisocial behavior, in violation of the norms and rules accepted in society, with harm to other people. Violations are more serious than quarrels and pranks of children and adolescents.

Etiology and pathogenesis

Conduct disorder is based on a number of biopsychosocial factors:

connection with parental attitudes. Poor or mistreatment of children influences the development of maladaptive behavior. Etiologically significant is the struggle of parents among themselves, and not the destruction of the family. An important role is played by the presence of mental disorders, sociopaths or alcoholism in parents.

Sociocultural theory - the presence of difficult socio-economic conditions contributes to the development of behavioral disorders, as they are considered acceptable in terms of socio-economic deprivation.

Predisposing factors are the presence of minimal dysfunction or organic brain damage; rejection by parents, early placement in boarding schools; improper upbringing with strict discipline; frequent change of educators, guardians; illegitimacy.

Prevalence

It is quite common in childhood and adolescence. It is determined in 9% of boys and 2% of girls under the age of 18 years. The ratio of boys and girls ranges from 4:1 to 12:1. It is more common in children whose parents are asocial individuals or suffer from alcoholism. The prevalence of this disorder correlates with socioeconomic factors.

Clinic

Conduct disorder must last at least 6 months, during which there are at least three manifestations (diagnosis is made only until the age of 18):

1. Stealing something without the knowledge of the victim and fighting more than once (including forging documents).

2. Escapes from the house for the whole night at least 2 times, or once without returning (when living with parents or guardians).

3. Frequent lying (except when lying to avoid physical or sexual punishment).

4. Special participation in arson.

5. Frequent absenteeism of lessons (work).

6. Unusually frequent and severe outbursts of anger.

7. Special penetration into someone else's house, room, car; deliberate destruction of another's property.

8. Physical cruelty to animals.

9. Forcing someone to have sexual relations.

10. Use of weapons more than once; often the instigator of fights.

11. Theft after a fight (for example, hitting the victim and snatching the purse; extortion or armed robbery).

12. Physical cruelty to people.

13. Defiant provocative behavior and constant, outright disobedience.

Differential Diagnosis

Separate acts of antisocial behavior are not enough to make a diagnosis. Bipolar disorder, schizophrenia, general developmental disorder, hyperkinetic disorder, mania, depression should be excluded. However, the presence of mild, situationally specific phenomena of hyperactivity and inattention; low self-esteem and mild emotional manifestations does not rule out a diagnosis of conduct disorder.

Emotional disorders specific to childhood (F93).

The diagnosis of emotional (neurotic) disorder is widely used in child psychiatry. In terms of frequency of occurrence, it is second only to behavioral disorders.

Etiology and pathogenesis

In some cases, these disorders develop when the child has a tendency to overreact to everyday stressors. It is assumed that such features are inherent in the character and are genetically determined. Sometimes such disorders arise as a reaction to constantly anxious and overprotective parents.

Prevalence

It is 2.5% for both girls and boys.

Therapy

No specific treatment has been identified to date. Some types of psychotherapy and work with families are effective. In most forms of emotional disorders, the prognosis is favorable. Even severe disorders gradually improve and resolve over time without treatment, leaving no residual symptoms. However, if an emotional disorder that began in childhood continues into adulthood, then it more often takes the form of a neurotic syndrome or an affective disorder.

This includes:

impaired activity and attention (F90.0) (Attention deficit hyperactivity disorder or syndrome, attention deficit hyperactivity disorder) ;

hyperkinetic conduct disorder (F90.1).

Hyperkinetic syndrome - disorder characterized by violation attention, motor hyperactivity and impulsive behavior .

The term "hyperkinetic syndrome" has several synonyms in psychiatry: "hyperkinetic disorder" (hyperkinetic disorder), "hyperactive disorder" (hyperactivity disorder), " attention deficit disorder"(attention deficite syndrome), "attention deficit hyperactivity disorder" (attention-deficite hyperactivity disorder) (Zavadenko N. N. et al., 1997).

AT ICD-10 this syndrome is classified in the class "Behavioral and emotional disorders usually beginning in childhood and adolescence" (F9), constituting the group " Hyperkinetic disorders» (F90).

Prevalence. The frequency of the syndrome among children of the first years of life ranges from 1.5-2, among children of school age - from 2 to 20%. In boys, hyperkinetic syndrome occurs 3-4 times more often than in girls.

Etiology and pathogenesis . There is no single cause of the syndrome and its development can be caused by various internal and external factors(traumatic, metabolic, toxic, infectious, pathology of pregnancy and childbirth, etc.). Among them, there are also psychosocial factors in the form of emotional deprivation, stress associated with various forms of violence, etc. A large place is given to genetic and constitutional factors. All of these influences can lead to that form of brain pathology, which was previously designated as " minimal brain dysfunction". In 1957 M. Laufer associated with her the clinical syndrome of the above-described nature, which he called hyperkinetic.

Molecular genetic studies, in particular, have suggested that 3 dopamine receptor genes may increase the susceptibility to the syndrome.

Computed tomography confirmed dysfunctions of the frontal cortex and neurochemical systems projecting into the frontal cortex, involvement of the fronto-subcortical pathways. These pathways are rich in catecholamines (which may partly explain the therapeutic effect of stimulants). There is also a catecholamine hypothesis of the syndrome.

The clinical manifestations of the hyperkinetic syndrome correspond to the concept of delayed maturation of the brain structures responsible for the regulation and control of the attention function. This makes it legitimate to consider it in the general group of developmental distortions.

Clinical manifestations. Their main features are the lack of perseverance in cognitive activity, the tendency to move from one task to another without completing any of them; excessive but unproductive activity. These characteristics persist through school age and even into adulthood.

Hyperkinetic disorders often begin in early childhood ( up to 5 years), although they are diagnosed much later.

Disorders attention are manifested by increased distractibility and inability to perform activities that require cognitive effort. The child cannot keep attention on the toy, activities, wait and endure for a long time.

motor hyperactivity manifests itself when the child has difficulty sitting still, while he often restlessly moves his arms and legs, fidgets, starts to get up, run, has difficulty in spending leisure time quietly, preferring motor activity. In prepubertal age, a child can briefly restrain motor restlessness, while feeling a sense of internal tension and anxiety.

Impulsiveness is found in the child's answers, which he gives without listening to the question, as well as in the inability to wait for his turn in play situations, in interrupting the conversations or games of others. Impulsivity is also manifested in the fact that the child's behavior is often unmotivated: motor reactions and behavioral actions are unexpected (jerks, jumps, runs, inadequate situations, abrupt changes in activities, interruption of the game, conversations with the doctor, etc.).

Hyperkinetic children are often reckless, impulsive, prone to getting into difficult situations due to rash actions.

Relationships with peers and adults are broken, without a sense of distance.

With the beginning of schooling, children with hyperkinetic syndrome often have specific learning problems: writing difficulties, memory disorders, hearing and speech dysfunctions; intelligence is usually not impaired .

Emotional lability, perceptual movement disorders and coordination disorders are observed almost constantly in these children. In 75% of children, aggressive, protest, defiant behavior or, on the contrary, depressed mood and anxiety, often appear as secondary formations associated with a violation of intra-family and interpersonal relationships.

At neurological examination children show "mild" neurological symptoms and coordination disorders, immaturity of hand-eye coordination and perception, and auditory differentiation. The EEG reveals features characteristic of the syndrome.

In some cases, the first manifestations of the syndrome found in infancy: children with this disorder are overly sensitive to stimuli and are easily injured by noise, light, temperature changes environment, environment. Typical are restlessness in the form of excessive activity in bed, in wakefulness and often in sleep, resistance to swaddling, short sleep, emotional lability.

Secondary Complications include dissocial behavior and reduced self-esteem. There are often accompanying difficulties in mastering school skills (secondary dyslexia, dyspraxia, dyscalculia and other school problems).

Learning disorders and motor clumsiness are quite common. They should be coded under (F80-89) and should not be part of the disorder.

Most clearly, the clinic of the disorder manifests itself at school age.

In adults, hyperkinetic disorder may manifest as dissocial personality disorder, substance abuse, or another condition with impaired social behavior.

Flow hyperkinetic disorders individually. As a rule, the relief of pathological symptoms occurs at the age of 12-20 years, and at first they weaken, and then motor hyperactivity and impulsivity disappear; Attention disorders are the last to regress. But in some cases, a predisposition to antisocial behavior, personality and emotional disorders may be detected. In 15-20% of cases, the symptoms of attention disorder with hyperactivity persist for the rest of a person's life, manifesting themselves at the subclinical level.

Differential Diagnosis from other behavioral disorders, which may be manifestations of psychopathic disorders against the background of cerebro-organic residual dysfunctions, and also represent the debut of endogenous mental illness.

If most of the criteria for hyperkinetic disorder are present, then the diagnosis should be made. When there are signs of severe general hyperactivity and conduct disorders, the diagnosis is hyperkinetic conduct disorder (F90.1).

The phenomena of hyperactivity and inattention can be symptoms of anxiety or depressive disorders (F40 - F43, F93), mood disorders (F30-F39). The diagnosis of these disorders is based on their diagnostic criteria. Dual Diagnosis possible when there is a separate symptomatology of a hyperkinetic disorder and, for example, mood disorders.

The presence of an acute onset of a hyperkinetic disorder at school age may be a manifestation of a reactive (psychogenic or organic) disorder, a manic state, schizophrenia, or a neurological disease.

Treatment. There is no single point of view on the treatment of hyperdynamic syndrome. In foreign literature, the emphasis in the treatment of these conditions is on cerebral stimulants: methylphenidate (Ritilin), pemoline (Cilert), Dexadrine. It is recommended to use drugs that stimulate the maturation of nerve cells (Cerebrolysin, Kogitum, nootropics, B vitamins, etc.), which improve cerebral blood flow (Cavinton, Sermion, Oxybral, etc.) in combination with etaperazine, sonapax, teralen, etc. An important place in therapeutic measures are given to the psychological support of parents, family psychotherapy, establishing contact and close cooperation with the educator and teachers of children's groups where these children are brought up or study.

Disturbance of activity and attention (F90.0)

(Attention Deficit Hyperactivity Disorder or Syndrome, Attention Deficit Hyperactive Disorder)

Formerly called minimal brain dysfunction(MMD), hyperkinetic syndrome, minimal brain damage. It is one of the most common childhood behavioral disorders and persists into adulthood for many.

Etiology and pathogenesis. Previously, the disorder was associated with intrauterine or postnatal brain damage ("minimal brain damage"). A genetic predisposition to this disorder has been identified. The innate tendency to hyperactivity is enhanced by certain social factors, since such behavior is more common in children living in adverse social conditions.

Prevalence among schoolchildren from 3 to 20%. The disorder is more common in boys from 3:1 to 9:1. In 30-70% of cases, the syndromes of the disorder pass into adulthood. in adolescence, the activity of disorders decreases in many, but the risk of developing antisocial psychopathy, alcoholism and drug addiction is high.

Clinic. Symptoms almost always appear before 5-7 years of age. The average age of visiting a doctor is 8-10 years. Activity and attention disorders can be divided into 3 types: with the predominance of inattention; with a predominance of hypeactivity; mixed.

The main manifestations include:

- Attention disorders. Inability to maintain attention, decreased selective attention, inability to focus on a subject for a long time, often forgetting what needs to be done; increased distractibility, excitability. Such children are fussy, restless. Even more attention is reduced in unusual situations, when it is necessary to act independently. Some kids can't even finish watching their favorite TV shows.

- Impulsiveness. In the form of sloppy completion of school assignments, despite efforts to do them correctly; frequent shouting from a place, noisy antics during classes; intervening in the conversation or work of others; impatience in the queue; inability to lose (as a result, frequent fights with children). At an early age, this is urinary and fecal incontinence; at school - excessive activity and extreme impatience; in adolescence - hooligan antics and antisocial behavior (theft, drug use, etc.). The older the child, the more pronounced and noticeable impulsivity for others.

- Hyperactivity. This is an optional feature. In some children, motor activity may be reduced. However, motor activity qualitatively and quantitatively differs from the age norm. At preschool and early school age, such children continuously and impulsively run, crawl, jump up, and are very fussy. Hyperactivity often decreases by puberty. Children without hyperactivity are less aggressive and hostile to others, but they are more likely to have partial developmental delays, including school skills.

Additional Features

Coordination disorders are noted in 50-60% in the form of the impossibility of fine movements (tying shoelaces, using scissors, coloring, writing); balance disorders, visual-spatial coordination (inability to play sports, ride a bike, play with a ball).

Emotional disturbances in the form of imbalance, irascibility, intolerance to failures. There is a delay in emotional development.

Relationships with others. In mental development, children with impaired activity and attention lag behind their peers, but strive to be leaders. It's hard to be friends with them. These children are extroverts, they are looking for friends, but they quickly lose them. Therefore, they often communicate with more "compliant" younger ones. Relationships with adults are difficult. Neither punishment, nor caress, nor praise act on them. From the point of view of parents and educators, it is precisely “ill-manneredness” and “bad behavior” that is the main reason for visiting doctors.

Partial developmental delays. The criterion is the lag of skills from the due ones by at least 2 years. Despite a normal IQ, many children do poorly in school. The reasons are inattention, lack of perseverance, intolerance for failures. Partial delays in the development of writing, reading, counting are characteristic. The main symptom is a discrepancy between a high intellectual level and poor school performance.

behavioral disorders. They are not always observed. Not all children with conduct disorders may have impaired activity and attention.

Bed-wetting. Sleep disturbances and drowsiness in the morning.

Diagnostics. It is necessary to have inattention or hyperactivity and impulsivity (or all manifestations at the same time) that do not correspond to the age norm.

Behavioral features:

1. appear up to 8 years;

2. are found in at least two areas of activity - school, home, work, play, clinic;

3. not caused by anxiety, psychotic, affective, dissociative disorders and psychopathy;

4. cause significant psychological discomfort and maladaptation.

inattention:

1. Inability to focus on details, mistakes due to inattention.

2. Inability to maintain attention.

3. Inability to listen to the addressed speech.

4. Inability to complete tasks.

5. Low organizational skills.

6. Negative attitude to tasks that require mental stress.

7. Loss of items needed to complete the task.

8. Distractibility to extraneous stimuli.

9. Forgetfulness. (Of the listed signs, at least six must persist for more than 6 months.)

Hyperactivity and impulsivity(out of the signs listed below, at least four must persist for at least 6 months):

hyperactivity: the child is fussy, restless. Jumps up without permission. Runs aimlessly, fidgets, climbs. Cannot rest, play quiet games;

impulsiveness: shouts out the answer without listening to the question. Can't wait in line.

Differential diagnosis. The phenomena of hyperactivity and inattention can be symptoms of anxiety or depressive disorders, mood disorders. The diagnosis of these disorders is based on their diagnostic criteria.

Hyperkinetic conduct disorder (F90.1)

Diagnosis is made when there is criteria for hyperkineticdisorders and general criteria for conduct disorder.