hyperkinetic disorders. Case history F90.1 Severe hyperkinetic behavioral disorder of complex genesis with neurosis-like enuresis Diagnosis 90.0 of the child interpretation

ETIOLOGY, PREVALENCE, CLINIC, DIAGNOSIS

F90-F98 Behavioral and emotional disorders with onset usually in childhood and adolescence

F90 Hyperkinetic disorders

This group of disorders is characterized by an early onset; a combination of overly active, poorly modulated behavior with pronounced inattention and lack of perseverance in completing any tasks. Behavioral features are manifested in any situations and are constant in the time interval.

Hyperkinetic disorders usually occur in the first 5 years of life. 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 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.

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).

Prevalence

Hyperkinetic disorders are several times more common in boys (3:1) than in girls (9:1). IN primary school the disorder occurs in 4-12% of children.

The main signs are impaired attention and hyperactivity, which manifest themselves in various situations - at home, in children's and medical institutions. Frequent change and interruption of any activity without attempts to complete it is characteristic. Such children are overly impatient, restless. They can jump up and down during any work, chat excessively and make noise, fidget... Comparison of the behavior of such children with other children of this age group is diagnostically significant.

Associated clinical characteristics: disinhibition in social interaction, recklessness in dangerous situations, thoughtless violation of social rules, interruption of classes, rash and incorrect answers to questions. 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, hyperkietic disorder may manifest as dissocial personality disorder, substance abuse, or another condition with impaired social behavior.

Differential Diagnosis

Most difficult to differentiate from behavioral disorders. However, 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 may 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 is possible when there are separate symptoms of 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.

F90. 0 Violation of activity and attention

(Attention deficit hyperactivity disorder or syndrome, attention deficit hyperactivity disorder.)

Previously called minimal brain dysfunction, 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, hyperkinetic disorder was associated with intrauterine or postnatal brain damage ("minimal brain damage", MMD). 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. Parents of patients are more likely than the general population to have alcoholism, antisocial psychopathy, and affective disorders. 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.

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.

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. 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). With age, manifestations of impulsivity may change. At an early age, this is urinary and fecal incontinence; at school - excessive activity and extreme impatience; V adolescence- hooligan antics and antisocial behavior (theft, drug use, etc.). However, 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 often 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 (incapable, for sports games, cycling, ball games).
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-bredness" and "bad behavior" that are the main reason for visiting doctors.
Partial developmental delays. Despite a normal 10, 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 feature is the discrepancy between a high intellectual level and poor school performance. The partial delay criterion is considered to be less than 2 years behind the due Fie skills. However, it is necessary to exclude other causes of academic failure: perceptual disturbance, 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.
Bed-wetting. 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.

Diagnostics

Diagnostic criteria for activity and attention disorders (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Draft Criteria: 3/l/93/ DSM-IV):

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:

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

Carelessness. Inability to focus on details, mistakes due to inattention. Inability to maintain attention. Inability to listen to spoken language. Inability to complete tasks. Low organizational skills. Negative attitude to tasks that require mental stress. Loss of items needed to complete the task. Distractibility to extraneous stimuli. Forgetfulness. (Of the listed signs, at least six must persist for more than 6 months.)

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

Hyperactivity. The child is fussy, restless. Jumps up without permission. Runs aimlessly, fidgets, climbs, etc. Cannot rest, play quiet games.

Impulsiveness. Shouts out an answer without listening to the question. Can't wait in line.

Differential Diagnosis

A detailed medical history is required to make a diagnosis. It is important to find out information 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.

To make a diagnosis, special questionnaires have been developed. In the United States, the abbreviated Connors scale is most commonly used.

Manifestations of hyperactivity disorder with attention disorders in adults - the presence of manifestations of OHLS in childhood; constant motor activity, "nervousness"; impaired concentration, inattention, restlessness in adulthood; emotional lability; irascibility; stress intolerance; impulsivity, abuse of alcohol, drugs, psychotropic drugs; antisocial acts with frequent adultery, conflicts, divorces; the presence of similar signs in relatives, etc.

Information about the child's progress and behavior in an educational institution is required. 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.

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 disorders facilitates the intellectual and social development of the child. Drug treatment is subject to several principles. Effective only long-term therapy, 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 appears, sensitivity to parents and peers, social relations are established. Mental development may improve dramatically. Currently, amphetamines (dexamphetamine /Dexedrine/, methamphetamine), methylphenylate (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. Methylphenylate 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: methylpheniaate 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 methylphenylate to children under 6 years of age, dexamphetamine - to children under 3 years of age. Pemoline is prescribed for the ineffectiveness of amphetamines and methylphenylate, but its effect may be delayed for 3-4 weeks. Side effects - decreased appetite, irritability, epigastric pain, headache, insomnia. In pemoline - increased activity of liver enzymes, possible jaundice. Psychostimulants increase YaSS, 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.

Other drugs are also prescribed: H-1 blockers (diphenhydramine); tranquilizers; sleeping pills; clonidine (clophelin); anticonvulsant normotimic drugs (valproates, carbamazepines). However, their effectiveness has not been definitively established. Benzodiazepines and barbiturates are not only ineffective, but can also aggravate the disease.

Currently, it is believed that if a child with impaired activity and attention has a food allergy, then its cure contributes to the regression of psychopathological symptoms. In these cases, diet therapy and desensitization are indicated.

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.

F90.1 Hyperkinetic conduct disorder

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.

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.

F90.8 Other hyperkinetic disorders

F90.9 Hyperkinetic disorder, unspecified

The diagnosis is made if it cannot be differentiated between F90.0 and F90.1, but general criteria for hyperkinetic disorder are met.

F91 Conduct disorders

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 conduct disorders, as they are considered acceptable in conditions of socio-economic deprivation.

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

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 antisocial or alcoholic. The prevalence of this disorder correlates with socioeconomic factors.

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):

stealing something without the knowledge of the victim and fighting more than once (including forging documents);
escapes from debt all night at least 2 times or once without return (when staying with parents or guardians);
lying frequently (except when lying to avoid physical or sexual punishment);
special participation in arson;
frequent absenteeism of lessons (work);
unusually frequent and severe outbursts of anger;
special penetration into someone else's house, room, car; special destruction of someone else's property;
physical cruelty to animals;
forcing someone to have sexual relations;
use of weapons more than once; often the instigator of fights;
theft after a fight (for example, hitting the victim and snatching the purse; extortion or armed robbery);
physical cruelty to people;
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.

F91.0 Conduct disorder limited by family conditions

The presence of antisocial or aggressive behavior is characteristic only in a family setting. Outside the family, the child's social relationships are within the age norm.

Etiology and pathogenesis

This disorder occurs when a child’s relationship with one of the family members or close relatives is disrupted. (For example, with a new step-parent, stepfather, guardian). The nosological independence of this disorder remains uncertain; these are usually situationally determined specific disorders with a relatively favorable prognosis.

Diagnostics

The criteria for conduct disorder (F91.) and disorders of the parent-child relationship must be met for the diagnosis to be made. There is theft from one's own home, often predominantly from one of the persons; cruelty against family members. It could be an intentional arson of the house. The behavior is not only oppositional, defiant, but with elements of destruction, aimed mainly at one of the family members: in the form of breaking toys, jewelry, tearing clothes or shoes, breaking furniture, destroying valuable property.

F91.1 Unsocialized conduct disorder

Characterized by a combination of persistent dissocial or aggressive behavior (F91) and significant disruption of the child's relationships with other children. Aggressiveness of a child is rarely aimed at a specific goal, does not promise great success does not provide an advantage over peers or seniors. Previously defined by terms - conduct disorder, single type; unsocialized aggressive behavior; solitary aggressive type.

Etiology and pathogenesis

An unfavorable family situation is characteristic. Many children with this disorder are the only ones in the family from unwanted or unplanned pregnancies. Parents, especially the father, are often antisocial or alcoholic. The child with this disorder and his family exhibit a stereotypical pattern of unpredictable non-verbal and physical hostility.

Aggressive behavior has the character of solitary activity, manifests itself in the form of hooliganism, physical aggression and cruelty towards peers, excessive pugnacity. Such children are also prone to hostility, verbal abuse, defiance, arrogance and negativism towards adults. Constant lies, absenteeism, vandalism are typical. Many children have broken social ties, contact with peers and older people is impossible, they are often autistic or keep in isolation. Characterized by low self-esteem with the projection of the image of "cruelty". Such children do not stand up for others, are not interested in the feelings, desires and well-being of others, do not feel guilt or remorse for their soulless behavior. Insufficient sociability is manifested in excessive aggressiveness, sexual disinhibition. In conversations, such children are usually uncommunicative, hostile, defiant, deny behavioral problems, or try to justify their misbehavior by blaming others. Typical behavior includes bullying, extortion, violent attacks, rudeness, individualism and resistance to authority, severe outbursts of anger and uncontrollable rage, destruction of property, arson, cruelty to younger and older children, cruelty to animals. Usually the disorder manifests itself in various situations, but is most obvious in educational institutions.

Presents significant difficulties. The age of initiation of treatment is important. A large role is given to the participation of the family in treatment. Desirable severity and impartiality in the joint actions of the doctor and parents. Changes in behavior are possible in a hospital setting, after the child is removed from frustrating situations. Drug therapy is of limited value and is indicated for the relief of severe behavioral disorders. With agitation and attacks of rage with aggressive actions, phenothiazines are applicable. Psychostimulants are used for a comorbid disorder in the form of hyperactivity with impaired attention. In some cases, carbamazepines are effective. Psychotherapeutic measures should be aimed at creating a favorable atmosphere for the child, developing his internal control, restoring positive self-esteem and developing new adaptive skills.

F91.2 Socialized conduct disorder

This disorder is characterized by the dominance of dissocial or aggressive behavior in the form of group activity in the company of friends, usually of the same age, who have the same characteristics and to whom the subject is devoted. Group antisocial behavior usually manifests itself outside the home - this is absenteeism, vandalism, physical aggression with attacks from behind, the use of weapons or severe beatings.

The following types are included: conduct disorder, group type; group delinquency; gang offenses; stealing in company with others; group school trips.

Etiology and pathogenesis

There is a certain degree of social or psychological pathology in the family, marital disharmony, and a lack of genuine family cohesion and interdependence. Group offenders tend to come from large families living in economic insecurity. Delinquency may be the result of other behavioral or neurological disorders.

In most cases there is adequate development or even excessive conformity in early childhood, ending in adolescence. In the anamnesis, one can find indications of certain difficulties in the form of poor school performance, slight deviations in behavior, and neurotic symptoms. Offenses are usually committed by a group of peers. Often parents refer to this group, blaming them for their child's misbehavior, wanting to downplay their own guilt. Absenteeism, theft, delinquency, antisocial acts are the rule of these groups. Frequent aggression towards others, acts of vandalism. However, some violations are almost playful in nature - police officers and thieves. An important and constant characteristic is the significant influence of the group on the adolescent's behavior, the need to depend on the group in the form of membership in it. Conduct disorders are most noticeable outside the family and most specific in non-family settings, school. Emotional disturbances are usually minor. A very small number of teenagers go on to become criminals. They often quit delinquency after random positive changes in their lives (success in school, a romantic adventure, a change in role behavior in the family, etc.).

Traditional individual psychotherapy is ineffective. Cognitive psychotherapy in group sessions has a good effect; dynamically oriented approach aimed at acceptance and approval. Sometimes teenagers who are group leaders need to be transferred to a new environment - a special school or a treatment camp. Many teenagers do not receive psychiatric treatment, but are re-educated in schools or correctional institutions.

A certain percentage of adolescents recover spontaneously as they reach puberty and enter into heterosexual relationships, take on family responsibilities, or participate in work. In general, the prognosis for this disorder is favorable. Any approach that destroys the attitudes of the group as a whole or separates the adolescent from the group of delinquents is justified and may be quite successful in overcoming antisocial or criminal behavior.

F91.3 Oppositional defiant disorder

Characteristically defiant, naughty, provocative behavior in children under 9-10 years old, often directed against parents, caregivers or teachers. Absent: behavior that violates the laws and rules of society; theft; cruelty; fights and attacks; vandalism.

Prevalence

This disorder occurs in 16-22% of schoolchildren. It can occur from the age of 3, most pronounced at the age of 8-10 years and ends by adolescence. This disorder is most common in boys before puberty, and after puberty is the same in both sexes.

Etiology and pathogenesis

Pathology occurs when the phase of developing one's own will and opposing it to the will of others becomes stable and does not undergo normal age-related changes. This is facilitated by excessive pressure from the guardians. Sometimes there is a constitutional or temperamental predisposition to pathological self-affirmation. External trauma, chronic inferiority can form stubbornness and oppositionism as a defense against anxiety, helplessness and loss of self-esteem. In adolescence, it may be an excessive need to separate from parents. Some families have overbearing or depressed mothers or passive-aggressive fathers. In many cases, the patients were unwanted children.

Classical psychoanalytic theory postulates that the etiological factor of this disorder is unresolved conflicts of the anal period. Representatives of the behavioral concept believe that the cause of this disorder may be learned behavior, with the help of which the child achieves control over the persons raising him.

Children with oppositional defiant disorder often argue with adults or peers, scold, get angry, resent, do not comply with the requirements of others, tease or annoy them on purpose. The disorder almost always manifests itself at home or at school, among adults or peers whom the child knows well. During a clinical study, these signs may not be noticeable. These children try to blame others for their mistakes and difficulties or attribute their actions to difficult circumstances. This disorder causes more trouble for those who come into contact with such children than for the children themselves. In typical cases, the behavior is provocative, defiant or hostile, children become the instigators of quarrels, are excessively rude and resist social norms. This disorder prevents normal relationships with others, successful learning, despite normal intelligence. These children often do not have friends.

Differential Diagnosis

It is necessary to carry out with periods of negativism, which is a stage of normal development (they are usually shorter and are not observed so often in children of this mental development). Adjustment disorder is a reaction to severe stress and is of shorter duration.

Behavioral disorders in the form of negativism within the framework of schizophrenia, mood disorders, and affective pathology should be excluded.

Sometimes oppositional defiant behavior occurs with pervasive behavioral disorders, chronic organic psychosyndrome, hyperactivity syndrome with attention disorders, and mental retardation. Preference is given to the underlying disorder, and the concomitant diagnosis of conduct disorder is based on the severity and duration of the oppositional defiant behavior.

The most significant individual psychotherapy and family therapy. Behavioral therapy is based on selective reinforcement and rewards for good behavior, while bad behavior is ignored or not reinforced. Drug therapy is auxiliary, symptomatic.

F91.8 Other behavioral disorders

F91.9 Conduct disorder, unspecified

Disorders that do not meet the criteria for a particular subtype but meet the general criteria for F91 -.

Behavioral disturbances in childhood NOS;
behavioral disorder childhood NOS.

F92 Mixed conduct and emotion disorders

This group of disorders is characterized by a combination of persistent aggressive or defiant behavior with overt symptoms of anxiety, depression, or other emotional disturbances. Includes: depressive conduct disorder (F 92.0) containing the general criteria for conduct disorder (F91) and the criteria for

one of the affective mood disorders (F30-39). Other mixed disorders of behavior and emotions (F92.8): characterized by the presence of general criteria for behavioral disorders (F91) and persistent pronounced emotional symptoms (anxiety, timidity, obsessions or compulsions, depersonalization or derealization, phobias, hypochondria), that is, a neurotic disorder (F40 -48) or emotional disorder (F93).

F93 Emotional disorders specific to childhood

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

The prevalence is 2.5% in both girls and boys.

No specific treatment has been found 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 eventually disappear 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.

F93.0 Childhood separation anxiety disorder

There is marked anxiety about real or threatening separation from the people to whom the children are attached, which is not part of the generalized anxiety about other situations. In most cases, the disorder begins at 6-11 years of age, most pronounced in cases where the child refuses to go to school.

Etiology and pathogenesis

Psychosocial factors play an important role. The syndrome is typical for childhood, especially in mild forms that do not lead to a visit to a doctor. Only when the syndrome prevents the development of adaptation at school, family, among peers, it is necessary to regard it as a disorder.

Phobic anxiety can be passed from parent to child through direct modeling. If the parent is fearful, the child is more likely to develop anxiety towards new situations, especially school.

There is also a genetic predisposition. Biological offspring of adults with anxiety disorder suffer from anxiety in childhood. External life stresses often coincide with the development of the disorder. Death of a relative child's illness, moving, moving to a new school are often found in the anamnesis of such children.

The main diagnostic feature is extreme anxiety, exacerbated by isolation from parents, home, or familiar environment. Anxiety can reach the level of horror and panic and significantly exceeds the features characteristic of this age, it cannot be explained by any other disorder. Anxiety can take many forms:

unrealistic, absorbing worries about the possible harm done to persons to whom the child feels affection. Fear that they might leave him and not return;
unrealistic, absorbing anxiety that some accident will separate the child from the subject of attachment. For example, a child will be lost, kidnapped, hospitalized, killed;
persistent reluctance or refusal to go to school because of fear of separation, and not for other reasons;
persistent unwillingness to go to sleep without the subject of attachment nearby;
persistent, inadequate fear of loneliness or fear of being alone at home without a person to whom affection is experienced;
recurring separation nightmares;
the recurrence of physical symptoms (nausea, abdominal pain, vomiting, headaches, etc.) when separated from a person to whom a strong attachment is experienced, for example, when you have to go to school;
manifestations of excessive distress in the form of anxiety, crying, irritability, suffering, apathy, autism in anticipation of, during or immediately after separation from a person to whom great attachment is experienced.

The diagnosis is made if any of the listed symptoms have been present for at least 2 weeks. Start before the age of 18.

This disorder is characterized by morbid fears that they will be kidnapped and never be able to find their parents. Many children worry that they or their parents will have an accident or fall ill at home. For such children, moving and adapting to a new life are extremely difficult. Separation episodes are often found in the child's life history, especially due to illness and hospitalization, illness of a parent, or geographic movement. Periods of exacerbation and remission alternate approximately every 7 years.

Differential Diagnosis

In extreme anxiety disorders, anxiety is not related to separation. In pervasive developmental disorder or schizophrenia, the anxiety is more often caused by the disease state than by separation anxiety. Panic disorder with agoraphobia is not common in people under 18 years of age.

Effective family and individual psychotherapy with modification of the behavior of both the child and the parents. Pharmacotherapy is useful for severe anxiety. Assign heterocyclic antidepressants (imipramine / tofranil) from 25 mg to 150-200 mg / day. In addition to its antidepressant effect, tofranil is believed to reduce separation anxiety and anxiety. Diphenhydramine (Benadryl) is effective for night terrors and sleep disturbances.

F93.1 Phobic anxiety disorder of childhood

Minor phobias are usually typical of childhood. The fears that arise are related to animals, insects, darkness, death. Their prevalence and severity varies with age. With this pathology, the presence of pronounced fears characteristic of a certain phase of development is noted, for example, fear of animals in the preschool period.

Diagnostics

The diagnosis is made if:

a) the beginning of fears corresponds to a certain age period;
b) the degree of anxiety is clinically pathological;
c) anxiety is not part of a generalized disorder.

Most childhood phobias go away without specific treatment, provided the parents take a consistent approach of supporting and encouraging the child. Simple behavioral therapy with desensitization of situations that cause fear is effective.

F93.2 Social anxiety disorder

Caution in front of strangers is normal for children aged 8-12 months. This disorder is characterized by persistent, excessive avoidance of contact with strangers and peers, interfering with social interaction, lasting more than 6 months. and combined with a distinct desire to communicate only with family members or persons whom the child knows well.

Etiology and pathogenesis

There is a genetic predisposition to this disorder. In families of children with this disorder, similar symptoms were observed in mothers. Psychological trauma, physical damage in early childhood can contribute to the development of the disorder. Differences in temperament predispose to this disorder, especially if the parents support the child's modesty, shyness, and withdrawal.

Prevalence

Social anxiety disorder is uncommon, predominantly seen in boys. It can develop as early as 2.5 years after a period of normal development or a state of minor anxiety.

A child with social anxiety disorder has persistent recurrent fear and/or avoidance of strangers. This fear takes place both among adults and in the company of peers, combined with normal attachment to parents and other relatives. Avoidance and fear go beyond age criteria and are combined with social functioning problems. Such children avoid contact for a long time even after meeting. They slowly "thaw out" and are usually only natural in a home environment. These children are characterized by reddening of the skin, speech difficulties, and slight embarrassment. Fundamental disturbances in communication and intellectual decline are not observed. Sometimes shyness and shyness complicate the learning process. The true abilities of a child can manifest themselves only under exceptionally favorable conditions of upbringing.

Diagnostics

The diagnosis is made on the basis of excessive avoidance of contact with strangers for 6 months. and more, interfering with social activity and relationships with peers. Characteristic is the desire to deal only with familiar people (family members or peers whom the child knows well), a warm attitude towards family members. The age of manifestation of the disorder is not earlier than 2.5 years, when the phase of normal anxiety towards strangers passes.

Differential Diagnosis

The differential diagnosis is with adjustment disorder, which is characterized by a clear association with recent stress. In separation anxiety, symptoms are shown in relation to the persons who are the subjects of attachment, and not in the need to communicate with strangers. In severe depression and dysthymia, there is a withdrawal towards all persons, including acquaintances.

Psychotherapy preferred. Effective development of communication skills in Ghana, singing, music lessons. Parents are explained the need to restructure relationships and the need to stimulate the child to expand contacts. Anxiolytics are given in short courses to overcome avoidance behavior.

F93.3 Sibling rivalry disorder

It is characterized by the appearance of emotional disorders in young children following the birth of a younger sibling.

Rivalry and jealousy may manifest as marked competition between children for the attention or love of their parents. This disorder must be combined with an unusual degree of negative feelings. In more severe cases, it may be accompanied by open cruelty or physical trauma to the younger child, humiliation and spite towards him. In milder cases, the disorder manifests itself in the form of unwillingness to share anything, lack of attention, friendly interactions with a younger child. Emotional manifestations take various forms in the form of some regression with the loss of previously acquired skills (control of bowel and bladder function), a tendency to infantile behavior. Such a child copies the behavior of an infant in order to attract more attention from parents. Often there is a confrontation with parents, unmotivated outbursts of anger, dysphoria, marked anxiety or social withdrawal. Sometimes sleep is disturbed, the demand for parental attention often increases, especially at night.

Diagnostics

Sibling rivalry disorder is characterized by a combination of

a) evidence of sibling rivalry and/or jealousy;
b) began within the months following the birth of the youngest (usually the next in a row) child;
c) emotional disturbances that are abnormal in degree and/or persistence and associated with psychosocial problems.

The combination of individual rational and family psychotherapy is effective. It is aimed at easing stressful influences, normalizing the situation. It is important to encourage the child to discuss relevant issues. Often, due to such techniques, the symptoms of disorders soften and disappear. For the treatment of emotional disorders, antidepressants are sometimes used, taking into account individual indications and in minimal dosages, anxiolytics in short courses to facilitate psychotherapeutic measures. It is important tonic and biostimulating treatment.

F93.8 Other childhood emotional disorders

This group of disorders includes identification disorders, hyperanxiety disorder, peer rivalry (non-sibling). An essential feature of this group of disorders is excessive anxiety, which has no real reason, periods of anxiety lasting 6 months. and more. In general, a pattern of shy, fearful and overly restless behavior is characteristic.

Etiology and pathogenesis

There is evidence that in children suffering from these disorders, mothers also suffer from them. As etiological moments, unconscious conflicts associated with fixation on the oedipal phase of psychosexual development are indicated. The disorders are often associated with situations in which it is very important for the child to perform well in tasks in order to meet the high demands of the parents.

Prevalence

Children with emotional disorders and excessive anxiety most often come from families with high socioeconomic status and are the firstborn. The disorder is more common in boys than girls and is more common in urban than in rural areas.

Characterized by constant anxiety, uncertainty about future events (meetings with peers, exams, parties, sports, etc.). Such children are very worried about their opportunities, they are afraid to get bad

peer reviews or disapproval. Sometimes these experiences are in the nature of obsession and "mental chewing gum." Typical attacks of insomnia, nail biting, disorders of the gastrointestinal tract and respiratory organs, which do not have an organic cause. Children are constantly in a state of anxiety or tension. Associated features are simple phobias. Characterized by a high level of verbal and intellectual abilities. The prognosis in most cases is favorable, but repeated stressful situations can worsen it. In such cases, excessive internal stress in children with hyperanxiety disorder may persist into adulthood in the form of anxiety and social phobias.

Diagnostics

Diagnostic criteria for generalized anxiety disorder:

Excessive or unreasonable anxiety or restlessness within 6 months or more with frequent manifestation of at least four of the following symptoms:

excessive or unrealistic anxiety about future events, about the correctness of one's behavior in the past;
excessive doubts about one's abilities, academic performance, social life that have no real basis;
somatic complaints, such as headaches, pain in the stomach, in the chest, for which organic causes are not determined;
pronounced shyness;
a strong feeling of tension or agitation and impatience, inability to relax;
excessive need for reassurance that everything is going well;
feeling tired, exhausted, or easily fatigued due to restlessness or anxiety; muscle tension;
Sleep disturbances (difficulty falling asleep or restless, restless sleep) due to restlessness or anxiety.

Onset in childhood or adolescence (before 18 years of age).
Anxiety, restlessness, or physical symptoms cause clinically significant distress or impairment in social, work, or academic performance.
The disorder is not due to the direct effects of substances (eg, psychoactive), a general medical condition (eg, hyperthyroidism), and does not occur solely in the setting of a mood disorder, psychotic disorder, schizophrenia, or a general developmental disorder.

Differential Diagnosis

Disorders differ from conditions of anxiety or isolation, in which separation from someone close comes first. Panic disorder is characterized by repeated panic attacks and fear of future attacks. Obsessive-compulsive disorder has more strictly structured obsessions and compulsions, while pervasive developmental disorder has an onset at an earlier age and has classic diagnostic criteria. In depression, the dominant symptoms of a mood disorder occur. Overlapping diagnoses may include disturbed sleep, functional enuresis, and personality disorders. Diagnosis - other emotional disorders of childhood is not made when manifestations of anxiety, restlessness, emotional disorders are symptoms of a psychotic state or mood disorder.

Anxiolytics (mainly diazepam) have a positive effect in acute situations. The use of longer courses of mebicar, phenibut, which have an anxiolytic, sedative and nootropic effect, is recommended. Attacks of unmotivated anxiety and insomnia are well stopped by short-term use of diphenhydramine (Benadryl). In some cases, bushpiron is effective. Doses of the above drugs are selected individually. With prolonged complaints of psychophysiological disorders, a thorough examination is necessary. In the absence of organic pathology, such complaints should be interpreted as equivalents of anxiety.

Children with these disorders respond well to individual and group psychotherapy aimed at developing criticism. During psychotherapeutic work with them, it is necessary to actualize the topics of rivalry, the oedipal complex, the desire for superiority, etc. With adequate complex treatment, the prognosis is favorable.

/F90 - F98/ Emotional and behavioral disorders, usually beginning in childhood and adolescence / F90 / Hyperkinetic disorders This group of disorders is characterized by: early onset; a combination of overly active, poorly modulated behavior with marked inattention and lack of perseverance in completing tasks; the fact that these behavioral characteristics appear in all situations and show constancy over time. It is believed that constitutional disorders play a decisive role in the genesis of these disorders, but knowledge of a specific etiology is still lacking. In recent years, the diagnostic term "attention deficit disorder" has been proposed for these syndromes. It is not used here because it presupposes knowledge of psychological processes. which is still not available, he suggests the inclusion of anxious, brooding or "dreamy" apathetic children, whose problems are probably of a different kind. However, it is clear that from a behavioral point of view, inattention problems are main feature hyperkinetic syndromes. Hyperkinetic syndromes always occur early in development (usually in the first 5 years of life). Their main characteristics are a lack of persistence in activities that require cognitive effort and a tendency to move from one activity to another without completing any of them, along with poorly organized, poorly regulated and excessive activity. These deficiencies usually persist during the school years and even into adulthood, but many patients experience a gradual improvement in activity and attention. Several other disorders may be associated with these disorders. Hyperkinetic children are often reckless and impulsive, prone to accidents, and receive disciplinary action due to thoughtless, rather than outright defiant, breaking of the rules. Their relationships with adults are often socially disinhibited, lacking normal caution and restraint; other children do not like them and they may become isolated. Cognitive impairments are common, and specific delays in motor and speech development are disproportionately common. Secondary complications include dissocial behavior and low self-esteem. There is significant overlap between hyperkinesia and other manifestations of brutal behavior, such as "unsocialized conduct disorder". However, current data support the identification of a group in which hyperkinesia is the main problem. Hyperkinetic disorders are several times more common in boys than in girls. Associated reading difficulties (and/or other school problems) are common. Diagnostic guidelines: Attention deficits and hyperactivity are the cardinal features required for the diagnosis and must be present in more than one setting (eg, home, classroom, hospital). Impaired attention is manifested by premature interruption of tasks when the lesson remains unfinished. Children often switch from one activity to another, apparently losing interest in one task as a result of being distracted by another (although laboratory data usually does not reveal an unusual degree of sensory or perceptual distractibility). These defects in persistence and attention should only be diagnosed if they are excessive for the child's age and IQ. Hyperactivity suggests excessive impatience, especially in situations requiring relative calm. This may, depending on the situation, include running and jumping around; or jumping up from a place when one is supposed to be sitting; or excessive talkativeness and boisterousness; or fidgeting and squirming. The standard for judgment should be that the activity is excessive in the context of what is expected in the situation and compared to other children of the same age and intellectual development. This behavioral feature becomes most evident in structured, organized situations that require a high degree of self-control of behavior. Impaired attention and hyperactivity must be present; in addition, they must be noted in more than one setting (eg, home, classroom, clinic). The accompanying clinical characteristics are not sufficient or even necessary for the diagnosis, but confirm it; disinhibition in social relationships; recklessness in situations representing some danger; impulsive violation of social rules (indicated by the child intruding or interrupting the activities of others, or prematurely blurting out answers to questions before they are finished, or having difficulty waiting in line) are all characteristics of children with this disorder. Learning disorders and motor clumsiness occur with high frequency; if present, they should be coded separately (under F80 to F89), but they should not form part of the present diagnosis of hyperkinetic disorder. Conduct disorder symptoms are not an exclusion or inclusion criterion for a primary diagnosis; but their presence or absence constitutes the main basis for the subdivision of the disorder (see below). Characteristic behavioral problems should be of early onset (before age 6 years) and long duration. However, prior to school entry age, hyperactivity is difficult to recognize due to the variety of normal variations: only extreme levels of hyperactivity should lead to a diagnosis in preschool children. In adulthood, a diagnosis of hyperkinetic disorder can still be made. The basis for the diagnosis is the same, but attention and activity should be considered with reference to the relevant norms associated with the developmental process. If hyperkinesia has existed since childhood but has subsequently been replaced by other conditions, such as antisocial personality disorder or substance abuse, then the current condition should be coded, not the past. Differential Diagnosis: These are often mixed disorders, in which case the diagnostic preference should be given to common developmental disorders, if present. A big problem in the differential diagnosis is differentiation from conduct disorder. Hyperkinetic disorder, when its criteria are met, should be given diagnostic preference over conduct disorder. However, milder degrees of hyperactivity and inattention are common in conduct disorders. When both signs of hyperactivity and conduct disorder are present, if the hyperactivity is severe and general, the diagnosis should be "hyperkinetic conduct disorder" (F90.1). A further problem is that hyperactivity and inattention (quite different from those that characterize hyperkinetic disorder) may be symptoms of anxiety or depressive disorders. Thus, anxiety, which is a manifestation of an agitated depressive disorder, should not lead to a diagnosis of a hyperkinetic disorder. Similarly, restlessness, which is often a manifestation of severe anxiety, should not lead to a diagnosis of hyperkinetic disorder. If the criteria for one of the anxiety disorders (F40.-, F43.- or F93.x) are met, then they should be given diagnostic preference over hyperkinetic disorder, unless it is clear that in addition to anxiety associated with anxiety, there is an additional presence of hyperkinetic disorder. Similarly, if the criterion for mood disorder (F30 - F39) is met, hyperkinetic disorder should not be further diagnosed simply because attention span is impaired and psychomotor agitation is noted. A dual diagnosis should only be made when it is clear that there is a separate symptom of a hyperkinetic disorder that is not simply part of the mood disorders. The acute onset of hyperkinetic behavior in a school-age child is more likely to be due to some type of reactive disorder (psychogenic or organic), a manic state, schizophrenia, or a neurological disease (eg, rheumatic fever). Excludes: - general disorders of psychological (mental) development (F84.-); - anxiety disorders (F40.- or F41.x); separation anxiety disorder in children (F93. 0); - mood disorders (affective disorders) (F30 - F39); - schizophrenia (F20.-).

F90.0 Disturbance of activity and attention

Uncertainty remains here as to the most satisfactory subdivision of hyperkinetic disorders. However, follow-up studies show that outcome in adolescence and adulthood is strongly influenced by the presence or absence of comorbid aggressiveness, delinquency, or dissocial behavior. Accordingly, the main subdivision is carried out depending on the presence or absence of these accompanying features. This code should be used when the general criteria for hyperkinetic disorder (F90.x) are met but the criteria for F91.x (conduct disorder) are not. Includes: - attention disorder with hyperactivity; - Attention deficit hyperactivity disorder; - Attention Deficit Hyperactive Disorder. Excludes: - hyperkinetic disorder associated with conduct disorder (F90.1). F90.1 Hyperkinetic conduct disorder This coding should be done when the full criteria for both hyperkinetic disorders (F90.x) and behavioral disorders (F91.x) are met. Includes: - conduct disorder-related hyperkinetic disorder; - motor disinhibition syndrome with behavior disorder; - hyperkinetic syndrome with conduct disorder.

F90.8 Other hyperkinetic disorders

F90.9 Hyperkinetic disorder, unspecified

This residual category is not recommended and should only be used when it is not possible to differentiate between F90.0 and F90.1, but common criteria for /F90/ are identified. Includes: - childhood hyperkinetic reaction NOS; - hyperkinetic reaction of adolescence NOS; - hyperkinetic syndrome of childhood NOS; - hyperkinetic syndrome of adolescence NOS.

/F91/ Conduct disorders

Conduct disorders are characterized by a persistent type of dissocial, aggressive, or defiant behavior. Such behavior, in its most extreme degree, amounts to a marked violation of age-appropriate social norms and is therefore more severe than ordinary childish malice or adolescent rebelliousness. Isolated dissocial or criminal acts are not in themselves grounds for a diagnosis of a permanent pattern of behavior. Signs of conduct disorder may also be symptoms of other psychiatric conditions for which the underlying diagnosis should be coded. In some cases, behavioral disturbances may develop into antisocial personality disorder (F60.2x). Conduct disorder is often associated with an unfavorable psychosocial environment, including unsatisfactory family relationships and school failures; it is more common in boys. Its distinction from emotional disorder is well established, while its distinction from hyperactivity is less clear and the two often overlap. Diagnostic guidelines: Conclusions about the presence of a conduct disorder should take into account the developmental level of the child. For example, temper tantrums are a normal part of a 3-year-old child's development and their presence alone cannot form the basis of a diagnosis. Equally, violation of the civil rights of others (as in violent crimes) is impossible for most 7-year-olds and is therefore not a necessary diagnostic criterion for this age group. Examples of behaviors on which the diagnosis is based include: excessive pugnacity or bullying; cruelty to other people or animals; heavy destruction of property; arson, theft, lying, absenteeism from school and leaving home, unusually frequent and severe outbursts of anger; causing provocative behavior; and constant outright disobedience. Any of these categories, if expressed, is sufficient to make a diagnosis; but isolated dissocial acts are not the basis for a diagnosis. Exclusion criteria include infrequent but serious underlying behavioral disorders such as schizophrenia, mania, pervasive developmental disorder, hyperkinetic disorder, and depression. It is not recommended to make this diagnosis until the duration of the above behavior is 6 months or more. Differential Diagnosis: Behavioral disorders often overlap with other conditions. Emotional disorders whose onset is specific to childhood (F93.x) should lead to a diagnosis of mixed behavioral and emotional disorders (F92.x). If the criteria for hyperkinetic disorder (F90.x) are met, then it is diagnosed. However, milder and more situationally specific levels of hyperactivity and inattention are not uncommon among children with conduct disorders, as are low self-esteem and mild emotional distress; they do not exclude the diagnosis. Excludes: - mood disorders (affective disorders) (F30 - F39); - general disorders of psychological (mental) development (F84.-); - schizophrenia (F20.-); - mixed disorders of behavior and emotions (F92.x); - hyperkinetic conduct disorder (F90.1). F91.0 Family-bound conduct disorder This group contains behavioral disorders that include antisocial or aggressive behavior (not just oppositional, defiant, brutal behavior) in which the abnormal behavior is wholly or almost wholly confined to the home and/or relationships with closest relatives or household members. The disorder requires all of the criteria for F91.x to be met, and even severely impaired parent-child relationships are not sufficient on their own for diagnosis. Theft from home may occur, often specifically focused on the money or property of one or two individuals. This may be accompanied by behavior that is intentionally destructive and also focused on certain family members, such as breaking toys or jewelry, ripping shoes, clothing, cutting furniture, or destroying valuable property. Violence against family members (but not others) and intentional burning of the house are also the basis for the diagnosis. Diagnostic guidelines: Diagnosis requires that there be no significant conduct disorder outside the family setting and that the child's social relationships outside the family are within normal limits. In most cases, these family-specific conduct disorders occur in the context of some manifestation of a marked disturbance in the child's relationship with one or more of the next of kin. In some cases, for example, a violation may arise in connection with a recently arrived step-parent. The nosological identity of this category remains uncertain, but it is possible that these situationally highly specific conduct disorders do not usually carry a poor prognosis associated with general behavioral disturbances.

F91.1 Unsocialized conduct disorder

This type of conduct disorder is characterized by a combination of persistent dissocial or aggressive behavior (meeting the general criteria / F91 / and not covering only oppositional, defiant, brutal behavior) with a significant general violation of the child's relationships with other children. Diagnostic guidelines: Lack of effective integration in the peer group constitutes a key difference from "socialized" conduct disorders, and this is the most important differential difference. Broken relationships with peers are mainly evidenced by isolation from and/or rejection by them or unpopularity with other children; lack of close friends or ongoing empathic reciprocal connections with other children in the same age group. In relationships with adults, there is a tendency to show disagreement, cruelty and resentment; however, good relationships with adults can also occur, and if they do, this does not rule out the diagnosis. Often, but not always, comorbid emotional disorders are noted (but if these are sufficient to meet the criteria for a mixed disorder, then it should be coded F92.x). It is typical (but not necessary) that the perpetrator is alone. Typical behaviors include bullying, excessive pugnacity, and (in older children) extortion or violent attacks; excessive disobedience, rudeness, individualism and resistance to authority; severe outbursts of anger and uncontrollable rage, destruction of property, arson, and cruelty to other children and animals. However, some children held alone may still become involved in a group of offenders; therefore, in making a diagnosis, the nature of the act is less important than the quality of the personal relationship. The disorder usually manifests itself in a variety of situations, but may be more evident at school; compatible with the diagnosis is situational specificity to a location other than home. Included: - unsocialized aggressive behavior; - pathological forms of deviant behavior; - departures from school (at home) and vagrancy alone; - syndrome of increased affective excitability, solitary type; - solitary aggressive type. Excludes: - leaving school (at home) and vagrancy in a group (F91.2); - syndrome of increased affective excitability, group type (F91.2). F91.2 Socialized conduct disorder This category applies to conduct disorders involving persistent dissocial or aggressive behavior (meeting the general criteria /F91/ and not limited to oppositional, defiant, brutal behavior) and occurring in children who are usually well integrated in a peer group. Diagnostic guidelines: The key differentiating feature is the presence of adequate long-term relationships with peers of approximately the same age. Often, but not always, the peer group consists of minors involved in delinquent or dissocial activity (in which the child's socially unacceptable behavior may be approved by the peer group and regulated by the subculture to which they belong). However, this is not a necessary requirement for a diagnosis; the child may be part of a non-delinquent peer group with their own dissocial behavior outside of it. In particular, if the antisocial behavior includes bullying, relationships with victims or other children may be affected. This does not exclude the diagnosis if the child has a peer group to which he is devoted and in which long-term friendships have developed. There is a tendency to have poor relationships with those adults who are government officials, but there may be good relationships with some adults. Emotional disturbances are usually minimal. Conduct disorders may or may not include the family sphere, but if they are limited to the home, then this rules out the diagnosis. Often the disorder is most prominent outside the family, and the specificity of the disorder's presentation in a school setting (or other non-family setting) is consistent with the diagnosis. Included: - conduct disorder, group type; - group delinquency; - offenses in terms of membership in a gang; - stealing in company with others; - leaving school (at home) and vagrancy in the group; - syndrome of increased affective excitability, group type; - skipping school, absenteeism. Excludes: - gang activity without overt mental disorder (Z03.2).

F91.3 Oppositional defiant disorder

This type of behavioral disorder is typical for children under 9-10 years old. It is defined by the presence of markedly defiant, rebellious, provocative behavior and the absence of more severe dissocial or aggressive acts that violate the law or the rights of others. The disorder requires that the general criteria for F91 be met; even severe disobedience or mischievous behavior alone is not sufficient for a diagnosis. Many consider oppositional defiant behavior to represent a less severe type of conduct disorder rather than a qualitatively different type. Research evidence is insufficient as to whether the difference is qualitative or quantitative. However, the available evidence suggests that the self-sufficiency of this disorder can be accepted mostly only in young children. This category should be used with caution, especially in older children. Clinically significant conduct disorders in older children are usually accompanied by dissocial or aggressive behavior that exceeds open defiance, disobedience, or brutality; although they may often be preceded by oppositional defiant disorders at an earlier age. This category is included to reflect common diagnostic practice and to facilitate the classification of disorders occurring in young children. Diagnostic guidelines: The main feature of the disorder is persistently negative, hostile, defiant, provocative, and brutal behavior that is outside the normal range of behavior for a child of the same age in the same socio-cultural setting and does not include more serious violations of the rights of others. , which are marked with aggressive and dissocial behavior in subheadings F91.0 - F91.2. Children with this disorder tend to frequently and actively ignore adult requests or rules and intentionally annoy others. They are usually angry, touchy and easily annoyed by other people whom they blame for their own mistakes and difficulties. They usually have a low level of frustration tolerance and a slight loss of self-control. In typical cases, their defiant behavior is provocative in nature, so that they become the instigators of quarrels and usually show excessive rudeness, unwillingness to cooperate and resistance to authorities. Often the behavior is more evident in interactions with adults and peers whom the child knows well, and signs of the disorder may not appear during the clinical interview. The key difference from other types of conduct disorder is the absence of behavior that violates the laws and basic rights of others, such as theft, violence, fighting, assault, and destructiveness. The definite presence of any of the above behavioral features rules out the diagnosis. However, oppositional defiant behavior, as defined above, is often seen in other types of conduct disorder. If another type (F91.0 - F91.2) is detected, then it shall be encoded instead of the oppositional defiant behavior. Excludes: - conduct disorder, including overt or dissocial or aggressive behavior (F91.0 - F91.2).

F91.8 Other behavioral disorders

F91.9 Conduct disorder, unspecified

This is a non-recommended residual category only for disorders that meet the general criteria for F91 but are not subtyped, or do not qualify for any specific subtype. Includes: - behavioral disorders in childhood NOS; - childhood behavioral disorder NOS.

/F92/ Mixed behavioral and emotional disorders

This group of disorders is characterized by a combination of persistently aggressive, dissocial or defiant behavior with overt and prominent symptoms of depression, anxiety, or other emotional disturbances. Diagnostic guidelines: The severity of the condition must be sufficient to simultaneously meet the criteria for both behavioral disorders of childhood (F91.x) and emotional disorders of childhood (F93.x) or neurotic disorders characteristic of adulthood (F40-F49) or mood disorders (F30 - F39). The studies performed are insufficient to be sure that this category is indeed independent of behavioral disorders. This subcategory is included here because of its potential etiological and therapeutic importance, as well as its implications for classification reproducibility.

F92.0 Depressive conduct disorder

This category requires a combination of childhood conduct disorder (F91.x) with persistent severe depression, manifested by symptoms such as excessive suffering, loss of interest and pleasure in ordinary activities, self-blame and hopelessness. Sleep or appetite disturbances may also occur. Includes: - conduct disorder of F91.x combined with depressive disorder of F32.- F92.8 Other mixed behavioral and emotional disorders This category requires a combination of a childhood conduct disorder (F91.x) with persistent, prominent emotional symptoms such as anxiety, timidity, obsessions or compulsions, depersonalization or derealization, phobias or hypochondria. Anger and resentment are more of a behavioral disorder than an emotional disorder; they neither refute nor support the diagnosis. This includes: - conduct disorder of F91.x combined with an emotional disorder of F93.x; - conduct disorder of heading F91.x in combination with neurotic disorders of headings F40 to F48. F92.9 Mixed disorder of behavior and emotions, unspecified

/ F93 / Emotional disorders,

the onset of which is specific to childhood

In child psychiatry, a differentiation has traditionally been made between emotional disorders specific to childhood and adolescence and a type of neurotic disorder in adulthood. This differentiation was based on 4 arguments. First, research data has consistently shown that the majority of children with emotional disorders become normal adults: only a minority develop neurotic disorders in adulthood. On the contrary, many neurotic disorders that appear in adulthood do not have significant psychopathological precursors in childhood. Therefore, there is a significant gap between the emotional disorders encountered in these two age periods. Second, many childhood emotional disturbances represent exaggerations of normal developmental tendencies rather than phenomena that are themselves qualitatively abnormal. Thirdly, in connection with the last argument, there is often a theoretical suggestion that the mental mechanisms involved are not the same as in adult neuroses. Fourth, childhood emotional disorders are less clearly differentiated into supposedly specific conditions such as phobic disorders or obsessive-compulsive disorders. The third of these items lacks empirical support, and epidemiological evidence suggests that if the fourth is correct, it is only a matter of severity (given that poorly differentiated emotional disorders are quite common in both childhood and adulthood). Accordingly, the second item (ie developmental fit) is used as a key diagnostic feature in distinguishing between childhood-onset emotional disorders (F93.x) and neurotic disorders (F40-F49). The validity of this difference is uncertain, but there is some empirical evidence suggesting that developmentally appropriate childhood emotional disorders have a better prognosis. Excludes: - emotional disorders associated with conduct disorder (F92.x). F93.0 Separation anxiety disorder in children It is normal for infants and preschool children to show some degree of anxiety about real or threatening separation from the people they are attached to. The same disorder is diagnosed when the fear of separation is the main anxiety and when such anxiety first occurs in the early years of life. It is differentiated from normal separation anxiety by a degree that is beyond the statistically possible (including abnormal persistence beyond the normal age range) and by association with significant problems in social functioning. In addition, the diagnosis requires that there be no generalized disorder of personality development or functioning (if present, consider coding from F40 to F49). Separation anxiety disorder occurring at a developmentally inappropriate age (eg, adolescence) is not coded here unless it constitutes an abnormal continuation of a developmentally appropriate separation anxiety disorder. Diagnostic guidelines: A key diagnostic feature is excessive anxiety about separation from those to whom the child is attached (usually parents or other family members), which is not part of the generalized anxiety in many situations. Anxiety can take the form of: (a) an unrealistic, overwhelming worry about possible harm to the persons to whom the attachment is experienced, or fear that they will leave him and not return; b) an unrealistic overwhelming worry that some adverse event will separate the child from a person to whom there is great affection, for example, the child will get lost, be kidnapped, admitted to a hospital or be killed; c) persistent reluctance or refusal to go to school for fear of separation (and not for other reasons, for example, that something will happen at school); d) persistent unwillingness or refusal to go to sleep in order to be close to a person to whom great affection is experienced; e) persistent inadequate fear of loneliness or fear of staying at home during the day without a person to whom great affection is experienced; e) recurring nightmares about separation; g) the recurrence of physical symptoms (such as nausea, abdominal pain, headache, vomiting, etc.) when separated from the person to whom the attachment is experienced, for example, when you have to go to school; h) excessive repetitive distress (manifested by anxiety, crying, irritation, suffering, apathy, or social autism) at the anticipation of separation, during or immediately after separation from the person to whom the strong attachment is experienced. Many separation situations also involve other potential stressors or sources of anxiety. The diagnosis relies on the identification of what is common in the various situations that give rise to anxiety is separation from the person to whom the greater attachment is experienced. This occurs most often, apparently, with refusals to attend school (or "phobias"). Often, this is really about separation anxiety disorder, but sometimes (especially in adolescents) it is not. School refusals occurring for the first time during adolescence should not be coded under this heading unless they are primarily a manifestation of separation anxiety and this anxiety first manifested itself pathologically during preschool age. In the absence of criteria, the syndrome should be coded in one of the other categories F93.x or F40 - F48. Included: - transient mutism as part of separation anxiety in young children. Excludes: - affective disorders (F30 - F39); - mood disorders (F30 - F39); - neurotic disorders (F40 - F48); - phobic anxiety disorder in childhood (F93.1); - social anxiety disorder in childhood (F93.2).

F93.1 Phobic anxiety disorder of childhood

Children, like adults, may have fears that focus on a wide range of objects and situations. Some of these fears (or phobias) are not a normal part of psychosocial development, such as agoraphobia. When such fears occur during childhood, they should be coded in the appropriate category under F40 - F48. However, some fears indicate a particular phase of development and occur to some degree in most children; for example, fears of animals in the preschool period. Diagnostic guidelines: This category should only be used for fears specific to certain developmental phases when they satisfy additional criteria that apply to all disorders in F93.x, namely: a) onset during developmental age ; b) the degree of anxiety is clinically pathological; c) anxiety is not part of a more generalized disorder. Excludes: - generalized anxiety disorder (F41.1). F93.2 Social anxiety disorder of childhood Caution in front of strangers is a normal phenomenon in the second half of the first year of life, and some degree of social apprehension or anxiety is normal during early childhood when the child is faced with a new socially threatening situation unfamiliar to him. Therefore, this category should only be used for disorders that occur before the age of 6 years, are unusual in severity, are accompanied by social functioning problems, and do not form part of a more generalized disorder. Diagnostic guidelines: A child with this disorder has persistent recurrent fear and/or avoidance of strangers. Such fear can mainly take place in adults or peers or both. This fear is combined with a normal degree of selective attachment to parents and other loved ones. The avoidance or fear of social surprises is, in its degree, beyond the normal limits for the child's age and is associated with clinically significant problems in social functioning. Includes: - disorder of communication with unfamiliar faces in children; - disorder of communication with unfamiliar faces in adolescents; - avoidant disorder of childhood; - avoidant disorder of adolescence.

F93.3 Sibling rivalry disorder

A high percentage, or even most, of young children show some degree of emotional distress following the birth of a younger sibling (usually the next in line). In most cases, this disorder is mild, but rivalry or jealousy after the birth of a sibling can be persistent. It should be noted: IN In this case, sibs (half-sibs) are children who have at least one common parent (native or adoptive). Diagnostic guidelines: The disorder is characterized by a combination of the following: a) evidence of sibling rivalry and/or jealousy; b) onset during the months following the birth of the youngest (usually next in a row) sibling; c) emotional disturbances that are abnormal in degree and/or persistence and associated with psychosocial problems. Rivalry, jealousy of siblings can manifest itself as a noticeable competition between children in order to obtain the attention or love of parents; in order to be regarded as a pathological disorder, it must be accompanied by an unusual degree of negative feelings. In severe cases, this may be accompanied by open cruelty or physical trauma to the sibling, animosity towards him, belittling of the sibling. In lesser cases, this can manifest as a strong reluctance to share, a lack of positive attention, and a lack of friendly interactions. Emotional disturbances can take many forms, often including some regression with loss of previously acquired skills (such as bowel and bladder control) and a tendency towards infantile behaviour. Often also the child wants to copy the infant in activities that require parental attention, such as eating. There is usually an increase in confrontational or oppositional behavior with parents, outbursts of anger and dysphoria, manifested in the form of anxiety, unhappiness or social withdrawal. Sleep may be disturbed and there is often increased pressure on parents to get their attention, especially at night. Included: - sibling jealousy; - jealousy of half-sibs. Excludes: - rivalry with peers (non-sibling) (F93.8). F93.8 Other childhood emotional disorders Includes: - identification disorder; - hyperanxiety disorder; - rivalry with peers (non-sibling). Excludes: - gender identity disorder in childhood (F64.2x). F93.9 Childhood emotional disorder, unspecified Includes: - childhood emotional disorder NOS /F94/ Disorders of social functioning, beginning which are typical for childhood and adolescence A rather heterogeneous group of disorders that share common disturbances in social functioning that begin during development but (unlike both developmental disorders) do not appear to be characterized by a constitutional social incapacity or deficit that extends to all areas of functioning. Severe distortions of adequate environmental conditions or deprivation of favorable environmental factors are often combined and in many cases are believed to play a decisive role in etiology. There are no significant gender differences here. This group of social functioning disorders is widely recognized by specialists, but there is uncertainty regarding the allocation of diagnostic criteria, as well as disagreement regarding the most appropriate division and classification.

F94.0 Selective mutism

A condition characterized by marked, emotionally conditioned selectivity in speaking, such that the child finds his or her speech sufficient in some situations, but is unable to speak in other (certain) situations. The disorder most often first appears in early childhood; it occurs with approximately equal frequency in the two sexes and is characterized by association with marked personality traits, including social anxiety, withdrawal, sensitivity, or resistance. It is typical that the child speaks at home or with close friends, but is silent at school or with strangers; however, other patterns of communication (including opposite ones) may also occur. Diagnostic guidelines Diagnosis involves: a) a normal or near-normal level of speech comprehension; b) a sufficient level in speech expression, which is sufficient for social communication; c) demonstrable evidence that the child can speak normally or almost normally in some situations. However, a significant minority of children with selective mutism have a history of either some kind of speech delay or articulation problems. The diagnosis can be made in the presence of such speech problems, but if there is adequate speech for effective communication and a large discrepancy in the use of speech depending on social conditions, so that the child speaks fluently in some situations and is silent in others or almost silent. It should be obvious that in some social situations the conversation fails, while in others it is successful. The diagnosis requires that the inability to speak be constant over time and that the situations in which speech is or is not present be consistent and predictable. In most cases, there are other socio-emotional disorders, but they are not among the features necessary for the diagnosis. Such disturbances are not permanent, but pathological character traits are common, especially social sensitivity, social anxiety and social withdrawal, and oppositional behavior is common. Included: - selective mutism; - selective mutism. Excludes: - general disorders of psychological (mental) development (F84.-); - schizophrenia (F20.-); - specific developmental disorders of speech and language (F80.-); - transient mutism as part of separation anxiety in young children (F93.0). F94.1 Reactive attachment disorder of childhood This disorder, which occurs in infants and young children, is characterized by persistent disturbances in the child's social relationships, which are combined with emotional disorders and are a reaction to changes in environmental conditions. Characteristic are timidity and increased alertness, which do not disappear with consolation, poor social interaction with peers is typical, aggression towards oneself and others is very frequent; suffering is common, and in some cases there is no growth. The syndrome may arise as a direct result of severe parental neglect, abuse, or serious parenting errors. The existence of this type of behavioral disorder is well recognized and accepted, but uncertainty remains regarding its diagnostic criteria, the boundaries of the syndrome, and nosological autonomy. However, this category is included here because of the importance of the syndrome to public health, because there is no doubt about its existence, and this type of behavioral disorder clearly does not fit the criteria for other diagnostic categories. Diagnostic guidelines: The key feature is an abnormal type of relationship with caregivers that occurs before the age of 5 years, which includes maladaptive manifestations that are usually imperceptible in normal children, and which is constant, although reactive in relation to sufficiently pronounced changes in parenting. Young children with this syndrome exhibit highly conflicting or ambivalent social responses that are most evident during the period of separation or reunion. Thus, infants may approach the caregiver with their eyes turned away, or stare away intently while being held; or may respond to caregivers with a response that combines approach, avoidance, and resistance to care. Emotional disturbances may manifest as external suffering, lack of emotional responsiveness, autism responses (eg, children may curl up on the floor), and/or aggressive reactions to their own or others' distress. In some cases there is timidity and heightened alertness (sometimes described as "frozen vigilance") that is not affected by attempts at comfort. In most cases, children show interest in interactions with peers, but social play is delayed due to negative emotional reactions. An attachment disorder may be accompanied by a lack of complete physical well-being and impaired physical growth (which should be coded under the appropriate somatic rubric (R62)). Many normal children show insecurities in the nature of their selective attachment to one parent or another, but this should not be confused with reactive attachment disorder, which has several crucial differences. The disorder is characterized by a pathological type of insecurity, manifested by apparently contradictory social reactions that are usually imperceptible in normal children. Pathological reactions are identified in various social situations and are not limited to a dyadic relationship with a specific caregiver; there is no responsiveness to support and consolation; there are accompanying emotional disorders in the form of apathy, suffering or timidity. There are five main features that differentiate this condition from general developmental disorders. First, children with reactive attachment disorder have a normal capacity for social interaction and responsiveness, while those with general developmental disorders do not. Secondly, although the pathological type of social reactions in reactive attachment disorder is initially common feature behavior of the child in various situations, abnormal reactions are reduced to a greater extent if the child is placed in a normal upbringing environment, which provides for the presence of a permanent responsive caregiver. This is not the case with general developmental disorders. Third, although children with reactive attachment disorder may have impaired speech development, they do not exhibit the pathological communication features characteristic of autism. Fourth, unlike autism, reactive attachment disorder is not associated with a persistent and severe cognitive defect that is markedly unresponsive to environmental changes. Fifth, a persistently limited, repetitive, and stereotyped pattern of behavior, interests, and activities is not a sign of reactive attachment disorder. Reactive attachment disorder almost always occurs in connection with grossly inadequate care for the child. This may take the form of psychological abuse or neglect (as evidenced by severe punishment, persistent failure to respond to the child's attempts to communicate, or apparent inability to parent); or physical abuse and neglect (as evidenced by persistent neglect of the child's basic physical needs, repeated intentional injury or inadequate nutrition). Due to the lack of knowledge about whether the relationship between inadequate child care and disorder is persistent, the presence of environmental deprivation and distortion is not a diagnostic requirement. However, caution is required in making a diagnosis in the absence of evidence of child abuse or neglect. Conversely, a diagnosis cannot be made automatically on the basis of child abuse or neglect: not all children who have been abused or neglected will have this disorder. Excludes: - sexual or physical abuse in childhood leading to psychosocial problems (Z61.4 - Z61.6); maltreatment syndrome leading to physical problems (T74) - normal variation in the structure of selective attachment; Disinhibited attachment disorder in childhood (F94.2) - Asperger's syndrome (F84.5). F94.2 Disinhibited childhood attachment disorder A particular manifestation of abnormal social functioning which occurs during the first years of life and which, once established, tends to persist despite marked changes in the environment. Around the age of 2 years, this disorder usually manifests as stickiness in relationships with diffuse, indiscriminately directed attachments. By age 4, diffuse attachments remain, but stickiness tends to be replaced by attention-seeking and indiscriminately friendly behavior; in middle and late childhood, the child may or may not develop selective attachments, but attention-seeking behavior often persists and poorly modulated peer interactions are common; depending on the circumstances, comorbid emotional or behavioral disturbances may also occur. The syndrome is most clearly identified in institutionalized children from infancy, but it occurs in other settings as well; it is believed to be partly due to a persistent lack of favorable opportunity to develop selective affections, as a result of excessively frequent changes in caregivers. The conceptual unity of the syndrome depends on the early onset of diffuse attachments, ongoing poor social interaction, and lack of situational specificity. Diagnostic guidelines: Diagnosis is based on evidence that the child exhibits an unusual degree of diffuse selective attachment in the first 5 years of life, and this is associated with general clinging behavior in infancy and/or indiscriminately friendly, attention-seeking behavior in early and middle childhood. Difficulties in forming trusting close relationships with peers are usually noted. They may or may not be associated with emotional or behavioral disorders, depending in part on the circumstances in which the child is placed. In most cases, there are clear indications in the anamnesis that in the first years of life there were changes in caregivers or numerous family changes (as with repeated placement in foster families). Included: - "unattached psychopathy"; - psychopathy from a lack of affection; - Syndrome of children's closed institution; - institutional (institutional) syndrome. Excludes: - hyperkinetic or attention-deficit disorder (F90.-); reactive attachment disorder in childhood (F94. 1); - Asperger's syndrome (F84.5); - hospitalism in children (F43.2x). F94.8 Other disorders of social functioning in childhood Included: - social functioning disorders with autism and shyness due to lack of social competence. F94.9 Childhood social functioning disorder, unspecified /F95/ Tiki Syndromes in which some type of tic is the predominant manifestation. A tic is an involuntary, rapid, repetitive, non-rhythmic movement (usually involving limited muscle groups) or vocal production that begins suddenly and apparently aimlessly. Tics tend to be experienced as irresistible, but they can usually be suppressed for different periods time. Both motor and vocal tics can be classified as either simple or complex, although the lines of demarcation are poorly defined. Common simple motor tics include blinking, jerking the neck, shrugging the shoulder, and grimacing. Common simple and vocal tics include coughing, barking, snorting, sniffing, and hissing. Common complex motor tics include tapping oneself, jumping up and down, and jumping. The usual complex of vocal tics includes the repetition of specific words and sometimes the use of socially inappropriate (often obscene) words (coprolalia), and the repetition of one's own sounds or words (palilalia). There is a huge variety in the severity of tics. On the one hand, the phenomenon is almost the norm, when one in five, ten children have transient tics at any time. On the other hand, Gilles de la Tourette syndrome is a rare chronic, disabling disorder. There is uncertainty as to whether these extremes represent different states or opposite poles of the same continuum, with many researchers seeing the latter as more likely. Tics are significantly more common in boys than in girls, and hereditary burden is common. Diagnostic guidelines The main features to distinguish tics from other movement disorders are sudden, rapid, transient, and limited movement pattern along with no evidence of an underlying neurological disorder; repetitiveness of movements, (usually) their disappearance during sleep; and the ease with which they can be voluntarily called in or suppressed. The lack of rhythm allows the tics to be differentiated from the stereotypical repetitive movements seen in some cases of autism or mental retardation. The mannerisms seen in the same disorders tend to involve more complex and varied movements than those usually seen in tics. Obsessive-compulsive activity sometimes resembles complex tics, but the difference is that its form tends to be determined by the target (for example, touching certain objects or turning them a certain number of times), rather than by the muscle groups involved; however, differentiation is sometimes very difficult. Tics often occur as an isolated phenomenon, but often they are associated with a wide range of emotional disturbances, especially compulsive and hypochondriacal phenomena. Specific developmental delays are also associated with tics. There is no clear dividing line between tics with any associated emotional disorders and emotional disorders with any associated tics. However, the diagnosis should represent the main type of pathology.

F95.0 Transient tics

General criteria for a tic disorder are met, but tics do not persist for more than 12 months. This is the most common type of tic, and is most common at 4 or 5 years of age; tics usually take the form of blinking, grimacing, or twitching of the head. In some cases, tics are reported as a single episode, but in other cases there are remissions and relapses over a period of time. F95.1 Chronic motor tics or vocalisms Meet the general criteria for a tic disorder in which there is a motor or vocal tic (but not both); tics can be either single or multiple (but usually multiple) and last for more than a year. F95.2 Combination of vocalisms and multiple motor tics (Gille de la Tourette syndrome) A type of tic disorder in which there are, or have been, multiple motor tics and one or more vocal tics, although they do not always occur simultaneously. The onset is almost always noted in childhood or adolescence. The development of motor tics before vocal ones is common; symptoms often worsen during adolescence; and the disorder is characterized by persistence into adulthood. Vocal tics are often multiple with explosive, repetitive vocalizations, coughing, grunting, and obscene words or phrases may be used. Sometimes there is an accompanying echopraxia of gestures, which can also be obscene (copropraxia). Like motor tics, vocal tics may be spontaneously suppressed for short periods of time, may be exacerbated by stress, and disappear during sleep.

F95.8 Other tics

F95.9 Tics, unspecified

A non-recommended residual category for a disorder that meets the general criteria for a tic disorder but where a specific subcategory is not specified or where the features do not meet criteria F95.0, F95.1, or F95.2. Included: - tics NOS. /F98/ Other emotional and behavioral disorders with onset usually in childhood and adolescence This category covers a heterogeneous group of disorders that have a common onset in childhood but differ in many other respects. Some of these conditions represent well-established syndromes, but others are nothing more than a collection of symptoms for which there is no evidence of nosological independence, but which are included here because of their frequency and association with psychosocial problems, and because they cannot be classified. to other syndromes. Excludes: - attacks of breath holding (R06.8); - gender identity disorder in childhood (F64.2x); - hypersomnolence and megaphagia (Kleine-Levin syndrome) (G47.8); - sleep disorders of non-organic etiology (F51.x); - obsessive-compulsive disorder (F42.x).

F98.0 Inorganic enuresis

A disorder characterized by the involuntary loss of urine, day and/or night, which is abnormal in relation to the mental age of the child; it is not due to a lack of bladder control due to any neurological disorder or epileptic seizures or structural abnormality of the urinary tract. Enuresis may be present from birth (abnormal retention of normal infantile incontinence or occur following a period of acquired bladder control. Late onset (or secondary) usually presents at age 5–7 years. Enuresis may be monosymptomatic or may be associated with more widespread In the latter case, there is uncertainty about the mechanisms involved in this combination.Emotional problems may occur secondary to the distress or shame associated with enuresis, enuresis may contribute to the formation of other mental disorders, or enuresis and emotional (behavioral) disorders may arise in parallel from related etiological factors.In each individual case, there is no direct and unquestionable decision between these alternatives, and the diagnosis must be made on the basis of which type of disorder (i.e. enuresis or emotional (behavioral) disturbance) is the main problem. Diagnostic guidelines There is no clear demarcation between normal ages of bladder control acquisition and bedwetting disorder. However, enuresis should not usually be diagnosed in a child under 5 years of age or with a mental age of 4 years. If enuresis is associated with some other emotional or behavioral disorder, it usually constitutes the primary diagnosis only if involuntary urination occurs at least several times a week or if other symptoms show some temporal association with enuresis. Enuresis sometimes occurs in combination with encopresis; in this case, encopresis should be diagnosed. Sometimes a child has transient enuresis due to cystitis or polyuria (as in diabetes). However, this does not constitute the primary explanation for enuresis that persists after the infection has been treated or after the polyuria has been brought under control. Often, cystitis can be secondary to enuresis, resulting from infection in the urinary tract (especially in girls) as a result of constant humidity. Included: - functional enuresis; - psychogenic enuresis; - urinary incontinence of inorganic origin; - primary enuresis of inorganic nature; - enuresis secondary inorganic nature. Excludes: - enuresis NOS (R32).

F98.1 Encoprese, inorganic

Repetitive, voluntary or involuntary passage of feces, usually of normal or near-normal consistency, in places that in the given socio-cultural environment are not intended for this purpose. The condition may be a pathological continuation of normal infantile incontinence or may include loss of fecal continence skills following a period of acquired bowel control; or it is the deliberate deposition of feces in inappropriate places, despite normal physiological control of bowel function. The condition may occur as a monosymptomatic disorder or be part of a wider disorder, especially an emotional disorder (F93.x) or a behavioral disorder (F91.x). Diagnostic guidelines: The decisive diagnostic sign is the discharge of feces in inappropriate places. The condition can occur in several different ways. First, it may represent a lack of toilet training or a lack of an adequate learning outcome. Secondly, it may reflect a psychologically based disorder in which there is normal physiological control over defecation, but for some reason, such as disgust, resistance, inability to conform to social norms, defecation occurs in places not intended for this. Thirdly, it may result from a physiological retention of feces, including its tight compression with secondary overflow of the intestine and deposition of feces in inappropriate places. This retention of bowel movements may occur as a result of arguments between parent and child in learning to control bowel movements, as a result of retention of feces due to painful defecation (for example, due to anal fissure), or for other reasons. In some cases, encopresis is accompanied by smearing of feces on the body or surroundings, and less often there may be insertion of a finger into the anus or masturbation. There is usually some degree of accompanying emotional (behavioral)

Discharge summary from the medical history
mental hospital patient
Full name, male, 8 years old
COMPLAINTS: "brought the teacher", disinhibited, restless, distracting, disrupts lessons, walks around the classroom, interferes. Fights with kids.
ANAMNESIS: the mother left for the Nskaya region, took the child away, did not care, did not feed, was deprived parental rights in 2009 Lost outpatient card. Mother with the education of 8 classes, was narrow-minded, "weird", now she is wanted. My paternal grandfather was an officer, he served in Nsk in naval aviation, now he is a pensioner, his grandmother-guardian, worked at various jobs, takes care of his grandson. The mother, allegedly, traveled to different places, lived in St. Petersburg for about 6 months with a "gypsy baron", got married again, gave birth to another child, is now on the federal wanted list. Father born in 1971, arr. ZhDtekhnikum, electrician, skillful, has been abusing alcohol in recent years, gets into a sobering-up station, has not worked for about 5 years, has been deprived of parental rights. From 1 marriage has a daughter, 20 years old, student, healthy. The family moved from Nska to Nk in 2002, they live in a 3-room apartment.
Pregnancy 2nd, 1st miscarriage, during the 2nd pregnancy, the mother smoked, lay on conservation. Delivery on time, heavy, supposedly, "were going to squeeze out", weight 2600g, screamed immediately, discharged on the 6th day. He was healthy, artificial feeding, sits from 5 months, went to 10 months, the first words at 1 year, a phrase by 3 years, at first he was calm, at the age of 2, the mother took the child and went to her relatives on a farm, where for a child did not care, was hungry, after 4 months the grandmother took her grandson, because. mother went wandering. He attended kindergarten from the age of 2, where he was poorly kept, was noisy, restless, broke toys. At school from the age of 7, he learned the material, but his behavior was grossly violated. Teachers insist on home schooling, tk. at the gymnasium school is not retained.
He suffered from acute respiratory infections, chicken pox at the age of 6, tonsillitis. At the age of 5, he was poisoned with cinnarizine, spent 3 days in the RO. TBI, no seizures.
ADMISSION STATUS: the boy is 8 years old, looks age-appropriate, the skin and mucous membranes are clean, the pharynx is calm, there is a bruise on the left cheekbone, there are many small scratches on the body, abrasions under the crusts, small bruises. Extensive abrasions under the crusts on the knees (fell off the bike). Stool, diuresis in no.
N.s. scattered microsymptoms.
PSYCHO STATUS: rushing about the office, constantly interfering in the conversation between the guardian and the doctor, letting go of remarks, shaking, distanceless, euphoric, sticky, grabs everything from the tables without permission, slams the pyramid against the pyramid with force, so that fragments fly, knocks the organizer on the table, depicting shooting, sounds of cars, persuasion fails to calm down, disturbs the guardian, demands to let him out into the street, immediately grabs a toy cow and guts it. Impulsive, loud, yells loudly, but can make a well-aimed remark. Intelligence saved. Attention is extremely distracted, grossly disturbed.
SURVEY: Clinical tests of blood, urine, feces no.
Neurologist: Complaints: no. Neurological status: From the side of C.M.N.: we have oral avmatism. Muscle tone and strength were unchanged. Tendon reflexes D=S. Pat. reflexes: no. Sensory disturbances: none. In the Romberg position: stable. Coordination tests: performs satisfactorily. Meningeal signs: no. Functions of the pelvic organs: preserved. Diagnosis: P11.8 Consequences of perinatal CNS damage with diffuse microsymptoms. Neurosis-like enuresis, encopresis.
Pediatrician: Complaints: no. Condition - satisfactory, health does not suffer. BP 90|50 mm Hg, height 132 cm, weight 34 kg, body temperature 36.7. Skin and mucous membranes are pale pink, clean. Nasal breathing is free. The pharynx is clean, b / o, the tonsils are b / o. Peripheral l / nodes - painless on palpation, not enlarged. In the lungs breathing is vesicular, no wheezing. Heart sounds are clear, rhythmic. The abdomen is soft, accessible to deep palpation, painless. The liver is at the edge of the costal arch, cystic symptoms are negative. The spleen is not enlarged. Urination is free, painless. Stool - 1 time per day, no pathological impurities. Diagnosis: Chronic cystitis. ARI, catarrhal tonsillitis.
Optometrist: Ch. bottom without pathology.
ECHO-ES: No M-ECHO offset. There were no signs of intracranial hypertension.
ECG: Sinus rhythm 72 beats per minute, vertical position of eos.
Ultrasound of MPS organs: Ultrasound pathology was not revealed.
Lore: Good.
R-gr. POP: On lumbosacral spondillograms in 2 ave. from 22.08.11 Without pathological changes. D 0.3 mzv
EEG: Against the background of disorganized alpha activity in the parieto-occipital region. irritative-diffuse changes with signs of dysfunction of nonspecific midline structures of the brain. The reactivity of the cortex to opening the eyes is weakened. The lability of nervous processes is disturbed. At the time of recording of interhemispheric asymmetry, slow-wave and typical epiactivity was not detected.
REG: PC is enough. Angiocerebral dystonia of hyper-hypotonic type. Venous outflow is not obstructed. No vertebrogenic effect on PC was found in VBB.
Psychologist: there is a slight decrease in mnestic functions, a pronounced decrease in attention, absent-mindedness, difficulty concentrating, exhaustion, a decrease in the sequence and purposefulness of thinking, a low stock of knowledge, a borderline level of intelligence (IQ = 75 b); emotional immaturity, instability, fussiness, anxiety, impulsivity, motor disinhibition, decreased control over impulses, decreased motivational-volitional and organizational components of activity, difficulties in contacts and social adaptation.
Speech therapist: Reading and writing disorders due to OHP level 3.
IN THE DEPARTMENT: disinhibition has decreased, but cockiness and pugnacity persist, climbs to the boy. In the classroom, with a frown, the designer collects, grumblingly accuses other children. It is difficult to keep it among children, often changes places in the classroom, cannot put together large puzzles, refuses to challenge, does not stay in the game for a long time. He conflicts with children, quarrels, but in the playroom he is kept, collects puzzles, ornaments. In the department, at first, we are extremely excitable, expressed hyperkinetic s-m, did not stay in place, crushed, broke everything, motor disinhibition decreased on the background of treatment, is kept in board games, but inclined to break toys, conflicts with children, impulsive. The intellect is not disturbed, but the attention is extremely unstable, we distract. In the first days, encopresis and enuresis were noted. Sitting in the classroom, he collects puzzles or plays loto. At times it can conflict with children, bullies them. Responds superficially to comments. At times, he gets excited, scandalizes, screams, but reacts to comments, justifies himself. Episodically enuresis, can soak panties during the day. Diagnostic training started. He stays in class, but is distracted. He got into a fight with the boy, not yielding to each other's shoves. He studies badly, gets distracted, works very slowly, writes dirty. He quarrels with children, provokes conflicts, hurriedly complains to the doctor with a stutter, blaming others. Enuresis sporadically, treatment is received.
At the request of the guardian, he was placed on medical leave for control. Medications, a certificate to school, a memo on treatment were issued.
STATUS AT DISCHARGE discharged with improvement under the supervision of a child psychiatrist, he became calmer, motor disinhibition decreased, he began to stay in class, enuresis less often.
TREATED- Neuleptil 2cap-3r, Finlepsin 0.2 1/4t-3r, Pantogam 0.25 1t-3r, FTL, EHF, massage, exercise therapy, psychocorrection, symptomatic treatment.
RECOMMENDED: continue maintenance therapy with Finlepsin 0.2 1/2t-3r, Neuleptil 2cap-3r. Conduct courses of nootropics 3 times a year, EEG control, psychological and pedagogical correction. In case of behavioral decompensation, address the issue of homeschooling. Epicrisis in the KPD and the child psychiatrist in Nska.
DIAGNOSIS- F90.1 Severe hyperkinetic behavioral disorder of complex origin with speech disorders, neurosis-like enuresis.
ASSOCIATED DIAGNOSIS - ARI, catarrhal tonsillitis. J00, J03.8

Note: An exploratory diagnosis of hyperkinetic disorder requires the distinct presence of abnormal levels of inattention, hyper-reactivity, and restlessness, which are a common feature across situations and persisting over time that can be ascertained by direct observation and is not due to other disorders such as autism or affective disorders. .

G1. Carelessness. At least 6 of the following symptoms of inattention persist for at least 6 months in a degree that is indicative of poor adaptability and is inconsistent with the child's developmental level:

1) Frequent inability to pay close attention to details or reckless errors in the school curriculum, work or other activities;

2) often fails to maintain attention on tasks or play activities;

3) it is often noticeable that the child does not listen to what is being said to him;

4) the child is often unable to follow instructions or complete schoolwork, daily activities and duties at the workplace (not due to oppositional behavior or inability to understand instructions);

5) the organization of tasks and activities is often disrupted;

6) often avoids or strongly dislikes tasks, such as homework that requires constant mental effort;

7) frequently loses items needed for certain tasks or activities, such as school items, pencils, books, toys or tools;

8) often easily distracted by external stimuli;

9) is often forgetful in the course of daily activities.

G2. Hyperactivity. At least three of the following symptoms of hyperactivity persist for at least 6 months in a degree that is indicative of poor adaptability and is inconsistent with the child's developmental level:

1) often restlessly moves his arms or legs or fidgets in place;

2) leaves his seat in the classroom or in another situation where it is required to remain seated;

3) often begins to run or climb somewhere when it is inappropriate (in adolescence or adulthood, only a feeling of anxiety may be present);

4) is often inappropriately noisy in games or has difficulty in quiet leisure activities;

5) a persistent nature of excessive motor activity is found, which is not significantly influenced by social situations and requirements.

G3. Impulsiveness. For at least 6 months, at least one of the following symptoms of impulsivity has persisted to a degree that is indicative of poor adaptability and is inconsistent with the child's developmental level:

1) often blurts out answers before questions are completed;

2) is often unable to wait in lines, wait his turn in games or group situations;

3) frequently interrupts or interferes with others (for example, in other people's conversations or games);

4) often talks too much without an adequate response to social restrictions.

G4. The onset of the disorder is no later than 7 years of age.

G5. The general nature of the disorder. The above criteria should not be identified in a single situation, for example, a combination of inattention and hyperactivity should be noted both at home and at school or at school and other institution in which the child is seen, in particular in a clinic. (Information from more than one source is usually required to identify the cross-situational nature of the disorder; reports from parents about classroom behavior, for example, are unlikely to be sufficient.)

G6. Symptoms in G1-G3 cause clinically significant distress or impairment in social, educational, or occupational functioning.

G7. The disorder does not meet the criteria for general developmental disorders (F84-), manic episode (F30.-), depressive episode (F32.-) or anxiety disorders (F41-).

Note

Many reputable psychiatrists also identify conditions that are subthreshold in relation to hyperkinetic disorder. Children who meet the criteria other than hyperactivity and impulsivity fit the concept of attention deficit; on the contrary, if the criteria for impaired attention are insufficient, but other criteria are present, we are talking about an activity disorder. Similarly, if the necessary criteria are identified in only one situation (for example, only at home or only in the classroom), one can speak of a home-specific or school-specific disorder. These conditions are not yet included in the main classification due to insufficient empirical predictive validation, and because many children with prethreshold disorders present with other syndromes (such as oppositional defiant disorder, F91.3) and should be coded in the appropriate headings.

"F90" Hyperkinetic disorders

This group of disorders is characterized by: early onset; a combination of overly active, poorly modulated behavior with marked inattention and lack of perseverance in completing tasks; the fact that these behavioral characteristics appear in all situations and show constancy over time. It is believed that constitutional disorders play a decisive role in the genesis of these disorders, but knowledge of a specific etiology is still lacking. In recent years, the diagnostic term "attention deficit disorder" has been proposed for these syndromes. It is not used here because it presupposes knowledge of psychological processes. which is still not available, he suggests the inclusion of anxious, brooding or "dreamy" apathetic children, whose problems are probably of a different kind. However, it is clear that from a behavioral point of view, inattention problems constitute a major feature of hyperkinetic syndromes.

Hyperkinetic syndromes always occur early in development (usually in the first 5 years of life). Their main characteristics are a lack of persistence in activities that require cognitive effort and a tendency to move from one activity to another without completing any of them, along with poorly organized, poorly regulated and excessive activity. These deficiencies usually persist during the school years and even into adulthood, but many patients experience a gradual improvement in activity and attention.

Several other disorders may be associated with these disorders. Hyperkinetic children are often reckless and impulsive, prone to accidents, and receive disciplinary action due to thoughtless, rather than outright defiant, breaking of the rules. Their relationships with adults are often socially disinhibited, lacking normal caution and restraint; other children do not like them and they may become isolated. Cognitive impairment is common, and specific delays in motor and speech development are disproportionately common.

Secondary complications include dissocial behavior and low self-esteem. There is significant overlap between hyperkinesia and other manifestations of brutal behavior, such as "unsocialized conduct disorder". However, current data support the identification of a group in which hyperkinesia is the main problem.

Hyperkinetic disorders are several times more common in boys than in girls. Associated reading difficulties (and/or other school problems) are common.

Diagnostic instructions:

The cardinal features required for the diagnosis are impaired attention and hyperactivity and must be present in more than one setting (eg, home, classroom, hospital). Impaired attention is manifested by premature interruption of tasks when the lesson remains unfinished. Children often switch from one activity to another, apparently losing interest in one task as a result of being distracted by another (although laboratory data usually does not reveal an unusual degree of sensory or perceptual distractibility). These defects in persistence and attention should only be diagnosed if they are excessive for the child's age and IQ.

Hyperactivity suggests excessive impatience, especially in situations requiring relative calm. This may, depending on the situation, include running and jumping around; or jumping up from a place when one is supposed to be sitting; or excessive talkativeness and boisterousness; or fidgeting and squirming. The standard for judgment should be that the activity is excessive in the context of what is expected in the situation and compared to other children of the same age and intellectual development. This behavioral feature becomes most evident in structured, organized situations that require a high degree of self-control of behavior.

Impaired attention and hyperactivity must be present; in addition, they must be noted in more than one setting (eg, home, classroom, clinic).

The accompanying clinical characteristics are not sufficient or even necessary for the diagnosis, but confirm it; disinhibition in social relationships; recklessness in situations representing some danger; impulsive violation of social rules (indicated by the child intruding or interrupting the activities of others, or prematurely blurting out answers to questions before they are finished, or having difficulty waiting in line) are all characteristics of children with this disorder.

Learning disorders and motor clumsiness occur with high frequency; if present, they should be coded separately (under F80 to F89), but they should not form part of the present diagnosis of hyperkinetic disorder.

Conduct disorder symptoms are not an exclusion or inclusion criterion for a primary diagnosis; but their presence or absence constitutes the main basis for the subdivision of the disorder (see below).

Characteristic behavioral problems should be of early onset (before age 6 years) and long duration. However, prior to school entry age, hyperactivity is difficult to recognize due to the variety of normal variations: only extreme levels of hyperactivity should lead to a diagnosis in preschool children.

In adulthood, a diagnosis of hyperkinetic disorder can still be made. The basis for the diagnosis is the same, but attention and activity should be considered with reference to the relevant norms associated with the developmental process. If hyperkinesia has existed since childhood but has subsequently been replaced by other conditions, such as antisocial personality disorder or substance abuse, then the current condition should be coded, not the past.

Differential Diagnosis:

Often these are mixed disorders, in which case the diagnostic preference should be given to general developmental disorders, if any. A big problem in the differential diagnosis is differentiation from conduct disorder. Hyperkinetic disorder, when its criteria are met, should be given diagnostic preference over conduct disorder. However, milder degrees of hyperactivity and inattention are common in conduct disorders. When both signs of hyperactivity and conduct disorder are present, if the hyperactivity is severe and general, the diagnosis should be "hyperkinetic conduct disorder" (F90.1).

A further problem is that hyperactivity and inattention (quite different from those that characterize hyperkinetic disorder) may be symptoms of anxiety or depressive disorders. Thus, anxiety, which is a manifestation of an agitated depressive disorder, should not lead to a diagnosis of a hyperkinetic disorder. Similarly, restlessness, which is often a manifestation of severe anxiety, should not lead to a diagnosis of hyperkinetic disorder. If the criteria for one of the anxiety disorders (F40.-, F43.- or F93.x) are met, then they should be given diagnostic preference over hyperkinetic disorder, unless it is clear that in addition to anxiety associated with anxiety, there is an additional presence of hyperkinetic disorder. Similarly, if the criterion for mood disorder (F30 - F39) is met, hyperkinetic disorder should not be further diagnosed simply because attention span is impaired and psychomotor agitation is noted. A dual diagnosis should only be made when it is clear that there is a separate symptom of a hyperkinetic disorder that is not simply part of the mood disorders.

The acute onset of hyperkinetic behavior in a school-age child is more likely to be due to some type of reactive disorder (psychogenic or organic), a manic state, schizophrenia, or a neurological disease (eg, rheumatic fever).

Excluded:

General disorders of psychological (mental) development (F84.-);

Anxiety disorders (F40.- or F41.x);

separation anxiety disorder in children (F93.0);

Mood disorders (affective disorders) (F30 - F39);

Schizophrenia (F20.-).

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).

IN 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 are psychosocial factors in the form of emotional deprivation, stress associated with different forms 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 therapeutic effect 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 feeling internal stress 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, changes in environmental temperature, 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.

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. important place in therapeutic measures, psychological support for 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 are given.

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.