The guide covers the main issues of the clinic, etiology, pathogenesis, prognosis and treatment of mental disorders that occur in children in the first three years of life. Considered not only diseases that begin mainly in early childhood, but also characteristic exclusively for this age. The results of the original research of the authors are presented. The data of modern domestic and foreign literature concerning the origin, course and prognosis of psychosomatic disorders of early childhood are summarized. Along with endogenous mental illness, much attention is paid to borderline mental disorders.

For pediatricians, psychiatrists, general practitioners and senior medical students.

FOREWORD

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

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

In childhood, a variety of diseases can manifest themselves - neuroses, schizophrenia, epilepsy, exogenous brain damage. Although the main signs of these diseases, most important for diagnosis, appear at any age, the symptoms in children are somewhat different from those observed in adults. At the same time, there are a number of disorders specific to childhood, although some of them may persist throughout a person's life. These disorders reflect disturbances in the natural course of development of the body, they are relatively stable, significant fluctuations in the state of the child (remission) are usually not observed, as well as a sharp increase in symptoms. As development progresses, some of the anomalies can be compensated for or disappear altogether. Most of the disorders described below are more common in boys.

Childhood autism

Childhood autism (Kanner's syndrome) occurs with a frequency of 0.02-0.05%. In boys, it is observed 3-5 times more often than in girls. Although developmental abnormalities can be detected as early as infancy, the disease is usually diagnosed at the age of 2 to 5 years, when social skills are formed. The classic description of this disorder [Kanner L., 1943] includes extreme isolation, a desire for loneliness, difficulties in emotional communication with others, inadequate use of gestures, intonation and facial expressions when expressing emotions, deviations in the development of speech with a tendency to repetition, echolalia, incorrect use of pronouns ("you" instead of "I"), monotonous repetition of noise and words, decreased spontaneous activity, stereotypy, mannerism. These disorders are combined with excellent mechanical memory and an obsessive desire to maintain everything unchanged, fear of changes, the desire to achieve completion in any action, the preference for communication with objects of communication with people. The danger is the tendency of these patients to self-harm (biting, pulling out hair, hitting the head). In senior school age, epileptic seizures are often associated. Concomitant mental retardation is observed in 2/3 of patients. It is noted that often the disorder occurs after intrauterine infection (rubella). These facts testify in favor of the organic nature of the disease. A similar syndrome, but without intellectual disabilities, was described by H. Asperger (1944), who considered it as a hereditary disease (concordance in identical twins in up to 35%). Di This disorder has to be differentiated from oligophrenia and childhood schizophrenia. The prognosis depends on the severity of the organic defect. Most patients show some improvement in behavior with age. For treatment, special teaching methods, psychotherapy, small doses of haloperidol are used.

Childhood hyperkinetic disorder

Hyperkinetic Conduct Disorder (hyperdynamic syndrome) is a relatively common developmental disorder (3 to 8% of all children). The ratio of boys and girls is 5: 1. Characterized by extreme activity, mobility, impaired attention, which prevents regular studies and the assimilation of school material. The business that has been started, as a rule, is not completed; with good mental abilities, children quickly cease to be interested in the task, lose and forget things, get involved in fights, cannot sit at the TV screen, constantly pester others with questions, push, pinch and tug on parents and peers. It is assumed that the disorder is based on minimal cerebral dysfunction, but clear signs of psychoorganic syndrome are almost never observed. In most cases, behavior normalizes at the age of 12-20 years, however, to prevent the formation of persistent psychopathic asocial traits, treatment should be started as early as possible. Therapy is based on persistent, structured parenting (strict supervision by parents and caregivers, regular sports). In addition to psychotherapy, psychotropic drugs are also used. Nootropic drugs are widely used - piracetam, pantogam, phenibut, encephabol. In the majority of patients, there is a paradoxical improvement in behavior against the background of the use of psychostimulants (sydnocarb, caffeine, phenamine derivatives, stimulating antidepressants - imipramine and sydnophen). With the use of phenamine derivatives, a temporary growth retardation and a decrease in body weight are occasionally observed, possibly the formation of dependence.

Isolated delays in skill formation

Often, children have an isolated delay in the development of a skill: speech, reading, writing or counting, motor functions. Unlike oligophrenias, which are characterized by a uniform lag in the development of all mental functions, with the above disorders, a significant improvement in the condition and a smoothing of the existing lag are usually observed as they grow older, although some disorders may remain in adults. Pedagogical methods are used for correction.

The ICD-10 includes several rare syndromes, presumably organic in nature, occurring in childhood and accompanied by an isolated disorder of some skills.

Landau-Kleffner syndrome manifests itself as a catastrophic impairment of pronunciation and understanding of speech at the age of 3-7 years after a period of normal development. Most patients develop epileptiform seizures, almost all of them have abnormalities on the EEG with mono- or bilateral temporal lobe pathological epiactivity. Recovery is observed in 1/3 of cases.

Rett syndrome occurs only in girls. It is manifested by loss of manual skills and speech, combined with head growth retardation, enuresis, encopresis and attacks of shortness of breath, sometimes epileptic seizures. The disease occurs at the age of 7-24 months against the background of relatively favorable development. At a later age, ataxia, scoliosis and kyphoscoliosis join. The disease leads to severe disability.

Disorders of some physiological functions in children

Enuresis, encopresis, eating inedible (peak), stuttering can occur as independent disorders or (more often) are symptoms of childhood neuroses and organic brain damage. Often, several of these disorders or their combination with tics can be observed in the same child at different age periods.

Stuttering occurs quite often in children. It is indicated that transient stuttering occurs in 4%, and persistent stuttering occurs in 1% of children, more often in boys (in various studies, the sex ratio is estimated from 2: 1 to 10: 1). Stuttering usually occurs between the ages of 4 and 5, with normal mental development. In 17% of patients, there is a hereditary burden of stuttering. There are neurotic variants of stuttering with psychogenic onset (after fright, against the background of severe intra-family conflicts) and organically conditioned (dysontogenetic) variants. The prognosis for neurotic stuttering is much more favorable; after puberty, the disappearance of symptoms or smoothing is noted in 90% of patients. Neurotic stuttering is closely related to traumatic events and personal characteristics of patients (anxious and suspicious traits prevail). Characterized by an increase in symptoms in a situation of great responsibility, a difficult experience of their illness. Quite often, this type of stuttering is accompanied by other symptoms of neurosis (logoneurosis): sleep disturbances, tearfulness, irritability, fatigue, fear of public speaking (logophobia). The prolonged existence of symptoms can lead to pathological personality development with an increase in asthenic and pseudoschizoid traits. An organically conditioned (dysontogenetic) variant of stuttering gradually develops regardless of traumatic situations, psychological experiences about the existing speech defect are less pronounced. Other signs of organic pathology (diffuse neurological symptoms, EEG changes) are often observed. Stuttering itself has a more stereotypical, monotonous character, reminiscent of teak-like hyperkinesis. Strengthening of symptoms is associated more with additional exogenous harm (trauma, infections, intoxication) than with psychoemotional stress. Stuttering treatment should be done in collaboration with a speech therapist. In the neurotic variant, speech therapy sessions should be preceded by relaxing psychotherapy ("silence mode", family psychotherapy, hypnosis, auto-training and other suggestions, group psychotherapy). In the treatment of organic variants, great importance is attached to the appointment of nootropics and muscle relaxants (mydocalms).

Enuresis at various stages of development, it is noted in 12% of boys and 7% of girls. The diagnosis of enuresis is made in children over 4 years of age; in adults, this disorder is rarely observed (up to 18 years of age, enuresis persists only in 1% of boys, and is not observed in girls). Some researchers note the participation of hereditary factors in the occurrence of this pathology. It is proposed to distinguish primary (dysontogenetic) enuresis, which is manifested by the fact that the normal rhythm of urination is not established from infancy, and secondary (neurotic) enuresis, which occurs in children against the background of psychotraumas after several years of normal urination regulation. The latter variant of enuresis proceeds more favorably and disappears in most cases by the end of puberty. Neurotic (secondary) enuresis, as a rule, is accompanied by other symptoms of neurosis - fears, timidity. These patients often sharply emotionally react to the existing disorder, additional mental trauma provoke an increase in symptoms. Primary (dysontogenetic) enuresis is often combined with mild neurological symptoms and signs of dysontogenesis (spina bifida, prognathia, epicanthus, etc.); partial mental infantilism is often observed. A calmer attitude towards one's defect, a strict periodicity, not associated with the momentary psychological situation, are noted. Urination during nocturnal epileptic seizures should be distinguished from inorganic enuresis. For differential diagnosis, EEG is examined. Some authors consider primary enuresis as a sign that predisposes to the onset of epilepsy [Sprecher BL, 1975]. For the treatment of neurotic (secondary) enuresis, sedative psychotherapy, hypnosis and auto-training are used. Patients with enuresis are advised to reduce fluid intake before bedtime, as well as eat foods that promote water retention in the body (salty and sweet foods).

Tricyclic antidepressants (imipramine, amitriptyline) for enuresis in children have a good effect in most cases. Bedwetting often goes away without special treatment.

Tiki

Tiki occur in 4.5% of boys and 2.6% of girls, usually at the age of 7 years and older, usually do not progress and in some patients completely disappear upon reaching maturity. Anxiety, fear, attention of others, the use of psychostimulants increase tics and can provoke them in an adult who has recovered from tics. A link is often found between tics and obsessive-compulsive disorder in children. You should always carefully differentiate tics from other movement disorders (hyperkinesis), which are often a symptom of severe progressive nervous diseases (parkinsonism, Huntinggon's chorea, Wilson's disease, Lesch-Nyhan syndrome, chorea minor, etc.). Unlike hyperkinesis, tics can be suppressed by an effort of will. The children themselves treat them as a bad habit. Family therapy, hypnosuggestion and autogenous training are used to treat neurotic tics. It is recommended to involve the child in physical activity that is interesting for him (for example, playing sports). If psychotherapy is unsuccessful, mild antipsychotics (sonapax, ethaperazine, halotteridol in small doses) are prescribed.

A serious illness manifested by chronic tics isGilles de la Tourette's syndrome . The disease begins in childhood (usually between 2 and 10 years); in boys 3-4 times more often than in girls. First, tics appear in the form of blinking, head twitching, grimaces. A few years later, in adolescence, vocal and complex motor tics join, often changing localization, sometimes having an aggressive or sexual component. Coprolalia (swear words) is observed in 1/3 of cases. Patients are characterized by a combination of impulsivity and obsessions, a decrease in the ability to concentrate. The disease is hereditary. There is an accumulation among the relatives of sick patients with chronic tics and obsessive compulsive disorder. There is a high concordance in identical twins (50-90%), in fraternal twins - about 10%. Treatment is based on the use of antipsychotics (haloperidol, pimozide) and clonidine in minimal doses. The presence of profuse obsessions also requires the appointment of antidepressants (fluoxetine, clomipramine). Pharmacotherapy allows you to control the condition of patients, but does not cure the disease. Sometimes, the effectiveness of drug treatments diminishes over time.

Features of the manifestation of the main mental illness in children

Schizophrenia with a debut in childhood differs from typical variants of the disease in a more malignant course, a significant predominance of negative symptoms over productive disorders. Early onset of the disease is more common in boys (sex ratio is 3.5: 1). In children, it is very rare to see such typical manifestations of schizophrenia as delusions of exposure and pseudo-hallucinations. Disorders of the motor sphere and behavior predominate: catatonic and hebephrenic symptoms, disinhibition of drives, or, conversely, passivity and indifference. All symptoms are characterized by simplicity and stereotype. Attention is drawn to the monotonous nature of the games, their stereotypes and schematism. Often, children pick up special items for games (wires, plugs, shoes), and neglect toys. Sometimes there is a surprising one-sidedness of interests (see the clinical case illustrating body dysmorphism in section 5.3).

Although typical signs of a schizophrenic defect (lack of initiative, autism, indifferent or hostile attitude towards parents) can be observed in almost all patients, they are often combined with a kind of mental retardation, reminiscent of oligophrenia. E. Kraepelin (1913) singled out as an independent formpfropfschizophrenia, combining the features of oligophrenia and schizophrenia with a predominance of hebephrenic symptoms. Occasionally, forms of the disease are noted in which mental development preceding the manifestation of schizophrenia occurs, on the contrary, at an accelerated pace: children begin to read and count early, are interested in books that do not correspond to their age. In particular, it has been noted that the paranoid form of schizophrenia is often preceded by premature intellectual development.

At puberty, dysmorphomanic syndrome and symptoms of depersonalization are common signs of the onset of schizophrenia. The slow progression of symptoms, the absence of obvious hallucinations and delusions may resemble neurosis. However, unlike neuroses, such symptomatology does not in any way depend on the existing stressful situations, it develops autochthonously. Rituals and senestopathies are early added to the symptoms typical of neuroses (fears, obsessions).

Affective insanity does not occur in early childhood. Distinct affective seizures can be observed in children at least 12-14 years old. It is quite rare for children to complain of feelings of boredom. More often, depression is manifested by somatovegetative disorders, sleep and appetite disorders, and constipation. Depression can be evidenced by persistent lethargy, slowness, unpleasant sensations in the body, moodiness, tearfulness, refusal to play and communicate with peers, a feeling of worthlessness. Hypomanic states are more noticeable to those around them. They are manifested by unexpected activity, talkativeness, restlessness, disobedience, decreased attention, inability to measure actions with one's own strengths and capabilities. In adolescents more often than in adult patients, there is a continual course of the disease with a constant change in affective phases.

Outlined pictures are rarely seen in young children. neurosis. More often, there are short-term neurotic reactions due to fright, unpleasant for the child, the prohibition on the part of the parents. The likelihood of such reactions is higher in children with residual organic deficiency. It is not always possible to clearly identify the typical adult variants of neuroses (neurasthenia, hysteria, obsessive-phobic neurosis) in children. Attention is drawn to incompleteness, rudimentary symptoms, the predominance of somatovegetative and movement disorders (enuresis, stuttering, tics). G.E. Sukhareva (1955) emphasized that the regularity is that the younger the child, the more monotonous and monotonous the symptoms of neurosis.

A fairly common manifestation of childhood neuroses is a variety of fears. In early childhood, this is a fear of animals, fairy-tale characters, movie heroes, in preschool and primary school age - fear of darkness, loneliness, separation from parents, death of parents, anxious expectation of upcoming school, in adolescents - hypochondriacal and dysmorphophobic thoughts, sometimes fear of death ... Phobias more often occur in children with an anxious and suspicious character and increased impressionability, suggestibility, fearfulness. The emergence of fears is facilitated by hyperprotection on the part of the parents, which consists in constant anxious fears for the child. Unlike obsessions in adults, children's phobias are not accompanied by a consciousness of alienation and pain. As a rule, there is no purposeful drive to get rid of fears. Obsessive thoughts, memories, obsessive counting are not typical for children. Abundant ideatorial, emotionally uncolored obsessions, accompanied by rituals and isolation, require differential diagnosis with schizophrenia.

Detailed pictures of hysterical neurosis in children are also not observed. More often you can see affect-respiratory seizures with loud crying, at the height of which respiratory arrest and cyanosis develop. Psychogenic selective mutism is sometimes noted. The reason for such reactions may be the prohibition of the parents. In contrast to hysteria in adults, children's hysterical psychogenic reactions occur in boys and girls with the same frequency.

The basic principles of treatment of mental disorders in childhood do not differ significantly from those used in adults. Leading in the treatment of endogenous diseases is psychopharmacotherapy. In the treatment of neuroses, psychotropic drugs are combined with psychotherapy.

BIBLIOGRAPHY

• Bashina V.M. Early childhood schizophrenia (statics and dynamics). - 2nd ed. - M .: Medicine, 1989 .-- 256 p.
• Gurieva V.A., Semke V.Ya., Gindikin V.Ya. Psychopathology of adolescence. - Tomsk, 1994 .-- 310 p.
• Zakharov A.I. Neuroses in children and adolescents: anamnesis, etiology and pathogenesis. - JL: Medicine, 1988.
• Kagan V.E. Autism in children. - M .: Medicine, 1981 .-- 206 p.
• Kaplan G.I., Sadok B.J. Clinical Psychiatry: Per. from English - T. 2. - M .: Medicine, 1994 .-- 528 p.
• V.V. Kovalev Pediatric Psychiatry: A Guide for Physicians. - M .: Medicine, 1979 .-- 607 p.
• V.V. Kovalev Semiotics and diagnosis of mental illness in children and adolescents. - M .: Medicine, 1985 .-- 288 p.
• Oudtshoorn D.N. Child and adolescent psychiatry: Per. from netherland. / Ed. AND I. Gurovich. - M., 1993 .-- 319 p.
• Psychiatry: Per. from English / Ed. R. Shader. - M .: Practice, 1998 .-- 485 p.
• Simeon T.P. Early childhood schizophrenia. - M .: Medgiz, 1948 .-- 134 p.
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• Ushakov T.K. Child psychiatry. - M .: Medicine, 1973 .-- 392 p.

PART 2. EARLY CHILD PSYCHIATRY

EATING DISORDERS IN YOUNG CHILDREN

At first glance, infant nutrition seems to be a simple phenomenon, reduced to satisfying only a biological need, and nutritional disorders are traditionally limited to a list of disorders described in manuals on pediatrics, pediatric surgery and infectious diseases. A number of researchers in recent decades have shown that psychologically related eating disorders are more likely to cause low weight than underfeeding or specific infections, and reflect difficulties in the relationship between the child, the mother and other family members.

Features of eating behavior in ontogenesis. Eating behavior and associated behavioral reactions are a complexly integrated act that appears from the moment of birth and unites a number of structures and functions of the body into a single adaptive component, from anatomical and physiological links to higher mental ones. In the process of eating a child, various senses are activated: olfactory, gustatory, tactile-kinesthetic. In addition to the sucking movements in the child at the time of feeding, there is also a change in a number of vegetative parameters (respiration, cardiac activity, blood pressure, gastric motility, etc.), motor activity (movement of the fingers) and changes in internal homeostasis.

The main structural elements of the digestive system are laid already at 3-4 months of intrauterine life. Sucking and swallowing functions are formed before birth. Already at 4 months of intrauterine development, mouth opening and amniotic fluid swallowing are observed. A normally developing fetus swallows about 450 ml of amniotic fluid during the day. Its protein for the unborn child is an important source of nutrition and a factor in the development of the functional activity of the digestive system. At 5 months, the fetus begins to make spontaneous chewing and sucking movements. The preference for maternal odor, which underlies early eating behavior, develops throughout the prenatal period. Olfactory and gustatory stimulation received by the fetus from the amniotic fluid influences the selective formation of the corresponding sensory channels. Their specific mood, in turn, forms postnatal olfactory-gustatory preferences, which are significant both for maintaining the vital nutritional needs of the child and for the formation of early child-parental relationships.

by the time of birth, the feeding behavior of the fetus is represented by quite well-developed sucking and swallowing movements. The formation of olfactory and gustatory preferences is completed. After birth, temperature-tactile sensitivity is also included in the digestive system. During the neonatal period, the visual system gradually begins to take part in the regulation of nutrition. The system of child-maternal attachment that arises from the first hours of life will also influence the infant's feeding behavior.

The basis of feeding behavior in a newborn is sucking. In the first minutes and hours of life, sucking movements occur spontaneously, without contact with the breast and are more similar to chewing and licking, since the child cannot find the nipple on his own. However, in a child who has already lived a day, in the organization of eating behavior there are such components as: 1) the search for the mother; 2) search for the area where the nipple is located; 3) seizure of the nipple; 4) sucking. During a meal, the newborn has a synchronization of breathing, changes in cardiac activity and blood pressure, and specific movements of the fingers appear. A newborn baby is able to suck, breathe and swallow at the same time, although in adults, breathing stops during swallowing. This is due to the redistribution of the work of the respiratory muscles, the transition from mixed breathing to chest breathing. The exclusion of the abdominal component from the breathing process facilitates the passage of food into the stomach.

For the normal developed feeding behavior of the infant, stimuli such as the smell and warmth of the mother, as well as the taste of mother's milk, are of great importance. A similar pattern is of a phylogenetic nature and is noted in many mammalian species. For example, in puppies in the first hours of life, there is a strong preference for the smell of the mother's fur to other olfactory stimuli. In rat pups and kittens, whose early forms of behavior have been studied well enough, the stage of feeding behavior, including the search for a mother, is determined by temperature reception. In turn, the process of finding the nipple depends on the olfactory stimuli received by the mother.

The behavior of kittens, deprived of the sense of smell in the experiment, is distinguished by significant features. With the fundamental safety of the main digestive processes (acts of sucking and swallowing), they still do not gain weight and regain their sight 3-4 days later than kittens with a normal sense of smell. Their motor activity is sharply reduced. If the kittens lost their sense of smell immediately after birth, before the first feeding, they were not able to capture the nipple and soon died without artificial feeding.

The search for the nipple in newborn animals is largely carried out under the influence of the taste and smell of amniotic fluid applied by the mother to the surface of the abdomen after childbirth. It has been suggested that amniotic fluid and saliva applied to the surface of the abdomen during the entire lactation period are similar in composition. In humans, the composition of the mother's saliva, amniotic fluid and colostrum vi is also similar. After birth, babies unmistakably recognize their mother's scent and prefer it to all others.

Classification of eating disorders. There are 4 forms of eating disorders, mainly associated with violations of child-mother relations: D) regurgitant and "chewing" disorder ("chewing gum", mericism); 2) infantile anorexia nervosa (infantile anorexia); 3) constant eating of inedible substances (P1SD syndrome); 4) nutritional underdevelopment.

Development of sleep in ontogenesis

In older children and adults, two qualitatively different phases of sleep are distinguished: orthodox sleep or the phase of slow sleep (FMS) and paradoxical sleep or the phase of rapid sleep (REM).

Sleep begins in a slow phase. At the same time, the eyeballs make slow rotational movements, sometimes with a saccadic component. This is stage I of slow wave sleep, which lasts from 30 seconds to 7 minutes. Falling asleep at this stage is still shallow. Stage III of slow wave sleep occurs 5-25 minutes after II. At stages III and IV of FMS, it is already quite difficult to wake up a person.

Usually, an hour after the onset of sleep, the first period of REM sleep (REM) can be recorded. The manifestations of FBS are: rapid movements of the eyeballs, irregularity of the pulse, disturbances in breathing with its stops, micromovements of the limbs. During paradoxical sleep, the temperature of the brain and the intensity of metabolic processes increase, and cerebral blood flow increases. In most cases, if a person is awakened in this phase of sleep, he is able to talk about his dreams. The first FBS period is about 10-15 minutes.

During the night, FBS and FMS alternate at intervals of 90-120 minutes. Phases of slow wave sleep prevail in the first half of the night, phases of REM sleep - in the morning. During the night, 4-6 complete sleep cycles are recorded.

Sleep is accompanied by a variety of motor activity. You can distinguish movements specific to each phase of sleep. "Twitching" of muscle groups is typical for the phase of paradoxical sleep, body turns - for the first and fourth phases of slow wave sleep. The most "calm" in terms of the number of movements produced by the sleeper is the III stage of slow wave sleep. In a dream, both relatively simple movements and movements performed with an adaptive purpose are observed. Simple movements include: general movements of the body and limbs without changing posture, isolated movements of the head or limbs, local single movements (swinging), single movements of the type of jerking, twitching (myoclonus), rhythmic movements (sucking, "conducting"), isometric movements (for example, putting feet on a wall). Adaptive motor acts include: covering, manipulating clothes, stretching, assuming a comfortable posture. In addition, in a dream, movements associated with breathing, the work of the gastrointestinal tract and movements accompanied by vocalizations and speech are noted. These include: puffing, snoring, sighing, irregular breathing, coughing, swallowing, hiccupping, moaning, mumbling.

The division of sleep into two phases can first be recorded from 28 weeks of intrauterine development, when movements of the eyeballs first appear in a dream. During this period, calm (SS) and active sleep (AS), which are “prototypes” of slow and paradoxical sleep in adults, are recorded. According to other sources, a fast cycle of fetal motility (within 40-60 minutes) as an AC phase. can be registered already from 21 weeks of the prenatal period. It is called fast, in contrast to the second, slower (90-100 minutes), which is observed only before birth and is associated with a similar maternal cycle. The fast cycle coincides with the average duration of the rapid eye movement cycle in newborns, which in the first weeks of life is regularly repeated with an interval of 40-60 minutes and does not depend on the condition of the child.

In active sleep, synchronous eye movements are observed with closed eyelids. Such movements are numerous in newborns, decrease in the first week of life and may disappear altogether up to a period of 3-4 months. when again well expressed. In active sleep, sucking, tremors of the chin and hands, grimaces, smiles, and stretching are observed. Cardiac and respiratory activity is irregular. On the contrary, restful sleep is characterized by more rhythmic cardiac and respiratory activity, minimal body and eye movements.

In the early stages of development, active sleep predominates over restful sleep, then their ratio is redistributed towards an increase in the proportion of SS. Active sleep accounts for 90% of the sleep duration of premature babies with a gestational age of 30 weeks and only 50% of those born at term. At the age of 5-7 days, it is already 40%. At 3-5 months of life, it is also 40%. Only by 3-5 years, the duration of sleep decreases to 20-25%, approaching those of adults. During the neonatal period, the SS phase consists of only one stage, corresponding to the IV stage of slow sleep of adults, By 2-3 months of life, maturation stage III, at 2-3 years stage II, at 8-12 years I. According to other sources, stage II appears from 6 months of age.

In addition to polysomnographic indicators, important criteria for sleep in the first year of life are its duration and distribution throughout the day. During the newborn period, children sleep 16-17 hours, at 3-4 months - 14-15 hours, at 6 months - 13-14 hours. From 3 to 14 months, the daily sleep duration is constant and is 14 hours. Daily sleep compared to daily wakefulness decreases from 79% in newborns to 52-48% at the age of 2 years. The decrease in this indicator occurs more intensively up to 3 months and 1 g. During the neonatal period, the child wakes up every 4 hours. which mainly depends on feeding, from 5 weeks of life, sleep begins to depend on the change of day and night, and the periods of sleep at night are lengthened. By 2–3 months, the nighttime sleep periods increase compared to the daytime. At this age, about 44% of children are already asleep all night. Further, this figure increases, and by the age of one year, most children sleep at night without awakening for 8-9 hours. This phenomenon is called "immersion".

Daytime sleep decreases from 3-4 times in 6 months to 2 times in 9-12 months. A significant part of children over 8 months do not need a day's sleep at all. During 1 year of life, the posture of the child in a dream changes. So, a newborn sleeps in an embryonic position and has an increase in muscle tone. From the 9th day of life, plastic tone appears ("freezing" during sleep of the extremities in the adopted position or in the position that the child will be given). After 6 months, the muscle tone in sleep decreases rapidly, and the child takes a position of complete relaxation. The favorite pose of children under 3 years of age is on the stomach (43% of children).

The final phase structure of sleep will be formed after stages IV, III, II, and I of slow wave sleep have matured. Slow sleep develops under the influence of a variety of rhythmic stimuli and the correct regimen. These are motion sickness, lullabies, stroking. If the natural stsreolip changes (for example, during hospitalization or early weaning), then the maturation of sleep synchronization mechanisms ("internal clock" of the body) is disrupted. This may be associated with the appearance of a large number of motor stereotypes in sleep (rocking, beating, increased motor activity). The latter arise as compensation for the lack of external stimulation. Timely maturation of all phases of slow wave sleep. especially stage I and the period preceding it, leads to the child's subjective feeling "I want to sleep." In case of insufficient development of this feeling, it is necessary to observe a certain sequence of the child's going to sleep, consisting of the usual manipulations, rocking, lullabies.

Considering that up to 6 months active sleep accounts for 40-50% of total sleep duration, the process of falling asleep often begins with it. This leads to the fact that children often wake up after 40-50 minutes in the stage of active sleep. Due to the fact that dreams usually occur during the AS phase, there is a high probability of the appearance of night fears at this moment. This hypothesis is based on the assumption that children in the first half of their life do not distinguish between sleep and reality. When they awaken from AS, they expect to see the real embodiment of their dreams, for example, the person whom the child has just dreamed next to him. At the same time, children often "check" their surroundings. before falling asleep again.

The prevalence of sleep disorders. Sleep disorders in children in the first three years of life are the most common mental pathology. 30% up to 3 months wake up repeatedly between the first and fifth hours of the night. In 17% of these children, such intermittent sleep lasts up to 6 months, and in 10% - up to 12 months. At the age of 3 years, difficulty falling asleep is noted in 16% of children, 14.5% wake up at night about three times a week.

There is a high comorbidity of sleep disorders with borderline mental illness of an early age. Among them, first of all, neuropathy, residual organic cerebral disorders of perinatal genesis (attention deficit disorder, partial developmental delays, etc.) should be noted. psychosomatic eating disorders. Sleep disorders are detected in 28.7%.) Children of early and preschool age suffering from hyperdynamic syndrome.

With age, the incidence of sleep disorders in children decreases. However, the prevalence of pathogenetically related borderline disorders of the neurotic register increases. The greatest prevalence of sleep disorders is observed in infancy. Further, in the early age, it progressively decreases, reaching stable numbers by the age of 3 years. At 3-8 years, the prevalence of sleep disorders does not change significantly, amounting to about 10-15%. Up to 14 months, sleep disorders are noted in 31% of children. At 3 years old, they persist in 40% of them, and in 80% others join sleep disorders borderline mental disorders.

Analysis of the age-related dynamics of various forms of mental pathology of early age allows us to conclude that sleep disorders are one of the main components of the so-called "preneurotic" state, which is a polymorphic transient disorder (sleep disorders, appetite, mood swings, episodic fears, etc.) associated mainly with psychotraumatic factors and do not add up to a distinct clinical syndrome. Further age-related dynamics of these conditions, according to V.V. Kovalev, is usually associated with their transformation into general and systemic neurotic disorders (most often neurasthenic neurosis).

Etiology of sleep disorders. Several factors play a role in the origin of sleep disorders in young children. First of all, it is a traumatic factor common to all psychogenic diseases. However, an important role is played by the hereditary characteristics of the temperament of children, which affect the individual characteristics of the neuropsychic response of children, including the individually formed patterns of the processes of falling asleep, awakening, depth and duration of sleep.

In the origin of dyssomnic disorders in children of the first three years of life, the age factor plays a special role. According to the ideas about the leading age level of mental response, in children of the first 3 years of life, there is a selective sensitivity of the somato-vegetative sphere. ease of occurrence of sleep disorders, appetite, disorders of autonomic regulation, etc.

Cerebral-organic insufficiency of perinatal genesis should also be considered a predisposing factor for the occurrence of sleep disorders at an early age. One third of children have a history of pregnancy and childbirth pathology (chronic intrauterine hypoxia, severe toxicosis, intrauterine infections, birth asphyxia, rapid or prolonged labor, caesarean section, etc.). Clinically pronounced perinatal brain damage is observed in 30% of children with dyssomnia, and only in 16 ° of children with healthy sleep. Residual-organic pathology of the brain is of particular importance in cases of disturbances in the sleep-wake cycle,

A study of children with dyssomnias found a link between sleep disorders and other diseases of early age. Thus, it has been shown that 55% of children suffering from sleep disorders have other mental disorders of the borderline level. In most cases, these are various manifestations of neuropathy and hyperkinetic syndrome.

Among the causes leading to dyssomnia, a special place is occupied by acute and chronic psychotraumas. Constant conflicts occurring in the family in the evening hours, shortly before the child goes to bed, lead to disturbances in falling asleep and frequent awakenings in children. In most cases, these are quarrels between parents, including over the right to control the behavior of children. For sleep disorders, traumatic circumstances associated with the experience of a sharp fright, fear of being alone, fear of loneliness, confined space, etc. are also important.

From the first Months of life, the emergence and consolidation of the wrong stereotype of sleep in children is facilitated by the violation of emotional attachment in the "mother-child" system. Such features of the attitude of parents to children, as overcontrol and overprotection, lead to suppression of initiative and independence and, as a result, excessive dependence of the child on the closest adult. The strengthening of the pathological stereotype of sleep is facilitated by the parents' ignorance of the permissible ways of influencing the child, a lack of understanding of the needs of children and the inability to navigate the behavior of children in general. A common condition for the onset of dyssomnic disorders in children is the lack of a well-established sleep pattern in adult family members.

Classification of sleep disorders. By etiology, the following dyssomnias are distinguished: 1) primary, which are the only or leading manifestation of the disease (insomnia, chronic hypersomnia, narcolepsy, etc.);

2) secondary, which are manifestations of another disease (schizophrenia, manic-depressive syndrome, neurosis, etc.). Pathological (including paroxysmal) sleep phenomena are referred to as parasomnias. Disorders provoked by sleep (nictalgic syndrome, attacks of sleep apnea, etc.) are considered separately within the framework of dyssomnic disorders.

Pathological sleep phenomena are divided into 5 groups: 1) stereotypical movements associated with sleep (swinging, beating, “folding”, the phenomenon of “shuttle”, sucking fingers in a dream, etc.); 2) paroxysmal phenomena during sleep (convulsions, night fears, enuresis, bruxism, nocturnal asthma, nictalgia, night vomiting, etc.),

3) static sleep phenomena (strange postures, sleep with open eyes);

4) complex forms of mental activity in a dream (sleepwalking, dreaming, nightmares); 5) violation of the cycle "sleep-wakefulness" (sleep disturbance, disturbance of awakening, inversion of sleep and wakefulness).

According to the American Association for the Psychophysiological Study of Sleep, according to the clinical manifestations of dyssomnia, they are divided into 3 large groups: 1) disorders of the actual processes of sleep and awakening; 2} excessive sleepiness; 3) violations of the sleep-wake cycle. Dyssomnias include: 1) hypersomnia - increased sleepiness, associated mainly with internal causes; 2) insomnia - insomnia associated mainly with external causes; 3) disorders associated with disturbance of circadian rhythms of sleep. Parasomnias include: 1) arousal disorders; 2) disorders arising from the transition from sleep to wakefulness; 3) parasomnias arising in the phase of paradoxical sleep; 4) mixed disorders

(Table 21.22).

Table 21 Dyssomnia

Table 22 Parasomnias

From a clinical point of view, it is most justified to divide sleep disorders into the following groups: 1) primary sleep disorders of various etiologies (protodmsomnia, insomnia, disturbance of the sleep-wake cycle); 2) secondary sleep disorders, which are a manifestation of other diseases (mental, neurological, somatic).

The clinical picture of various forms of sleep disorders. Protodysomnia is the most common sleep disorder in young children. Protodysomnia includes disorders of various etiology, in which sleep disturbances are the primary and leading clinical manifestation. They occur in 25-50% of children, starting from the second half of life, and are characterized by: a) difficulty falling asleep in the evening, lasting more than 20 minutes: b) night awakenings (after 6 months of life, healthy full-term babies should sleep all night without night feedings); c) night fears that arise 60-120 minutes after falling asleep, with disorientation, anxiety, screaming, awakening. As a result, the mother is forced to take the child to her bed.

Proto-dysomnias may be associated with arousal disorder. The so-called "internal stimulation to awakening" usually occurs at the end of the first or 11th phase of slow wave sleep. If children, for example, are tired, then they cannot fully wake up, but begin to moan, stretch, fight. If these phenomena become longer in time and more intense in severity, then night fears and sleepwalking can easily appear. This variant of protodysomnia is called "disorderly awakening." Indiscriminate awakenings occur in the first half of the night, usually one hour after falling asleep. Most of these episodes are 5-15 minutes long. Morning awakenings are usually lighter than those. which are observed a short time after falling asleep.

The differences between children with protodysomnia and healthy children are not in the number of nighttime awakenings, but in the ability to fall asleep again quickly after awakening. If, for example, children wake up at night in an uncomfortable position (for example, they cannot free their hands) and are not able to change it on their own, then the help of their parents is needed. If the child can turn himself, but is used to being helped in this by his parents, then origin sleep disorders will be associated with inappropriate parenting behavior. Putting children to bed before going to bed in a position in which they most often wake up at night can in some cases help to avoid prolonged night awakenings.

The difficulty of diagnosing protodysomnia in a particular child may be associated with the individual characteristics of his sleep. To establish the diagnosis of "protodysomnia" is also important not so much the clarification of the duration of sleep. how much its depth, the duration of falling asleep, the ease of awakening, as well as the impact of sleep deviations on the behavior of the child as a whole. When diagnosing "protodysomnia", the criterion for the duration of sleep disorders should also be taken into account. Sleep disorders are considered only those disorders that last more than 3 months in children, during which 5 or more nights a week the child does not sleep well.

Protodysomnia should be distinguished from sleep disorders in hypertensive-hydrocephalic syndrome as a consequence of perinatal brain damage. The peculiarities of such sleep disorders is their frequent occurrence in the second half of the night, in response to a minor impact - opening the door in the room, light touch, change in body position. Insomnia is accompanied by a characteristic cry of high intensity, loud, tense, irritable, monotonous ("crying on one note").

Paroxysmal sleep disorders associated with increased convulsive readiness are most often manifested by nighttime fears and bruxism. Night fears arise 2-4 hours after falling asleep, characterized by rapid breathing and heartbeat, increased sweating, disorientation ("glass gaze"), inability to wake up the child. Concomitant manifestations are often a history of febrile seizures or neonatal seizures.

Protodyssomnia and paroxysmal sleep disorders often do not have a clear boundary between themselves. Therefore, the final diagnosis is based on additional research methods (EEG, computed tomography of the brain. Ultrasound of the brain, etc.). Therapeutic tactics should include the impact on the residual organic and psychotraumatic mechanisms of the pathogenesis of sleep disorders in children.

Disorders, associated with disturbances in the sleep-wake cycle are manifested by late falling asleep (after midnight) and difficulty waking up in the morning. A feature of these disorders is the absence of disturbance in the depth of sleep. Children do not wake up at night, sleep all night without waking up and nocturnal feedings. Disorders of the sleep-wake cycle in children may be associated with the peculiarities of their parents' sleep patterns. Often, parents are awake and sleeping with their children. So, for example, the mother of one one-year-old child at 11 o'clock in the evening began cleaning the apartment, turned on the vacuum cleaner and the washing machine. It is customary to sleep in such families until noon, and sometimes longer.

Disruptions to the sleep-wake cycle may be associated with early bedtime. Children, like adults, before going to bed. the period of active wakefulness necessary for the onset of full sleep pass. If the children are put to bed at 8 o'clock in the evening, and the child is ready to fall asleep only at 10, then the remaining 2 hours the baby does not sleep. In addition, sleeping early can contribute to nighttime fears.

The diagnosis of "violation of the sleep-wake cycle" is made if the child does not get used to the regimen for 6 months and wakes up more than 3 times a week at night. These disorders should be distinguished from short-term and reversible disturbances in sleep cycles that arise under the influence of short-term traumatic factors (moving to a new place, hospitalization, etc.).

Daytime hypersomnia usually occurs in children who lack adult attention and care. This situation is less common in families, and more often in childcare facilities (orphanages), where staff have little time to take care of children. Adults welcome children to sleep for a long time, since the sleeper is less of a hassle. The reasons for such violations, especially in closed institutions for children, are often not recognized, and children do not receive timely assistance.

Early awakenings can be caused by drowsiness in the morning. The child can wake up at 5 am, and at 7 am again "take a nap." The sleep cycle will start again and sleep will move to a later time. Early morning awakenings can also be caused by constant feedings in the early morning hours.

Forecast. Sleep disorders, unlike eating disorders, can persist for a long time. 17% of young children suffering from sleep disorders have them even at 8 years old. Over time, other borderline mental illnesses can join sleep disorders. Transformation of dis-doubts into general or systemic neuroses is possible. Nocturnal movement stereotypes at an early age can extend into the daytime, acquiring the properties of obsessive 1 movements.

Therapy. Complex therapy of sleep disorders includes the use of psychotherapeutic methods in combination with medications. The main goal of psychotherapy for sleep disorders should be considered the normalization of child-mother relations. The main principle of psychotherapy is to influence the mother-child system as a whole. The child and the mother are a single object of psychotherapeutic influence. The principle is based on the well-known position I. In \\ 4by that "for the undifferentiated psyche of the infant, the influence of the mother's mental organizer is necessary." Due to the fact that “any contact of a baby with the outside world is mediated by an adult environment that is significant for him,” psychotherapeutic influence on a child includes an obligatory influence on the parents.

Rational psychotherapy is primarily used for sleep disorders. The conversation with the mother is based on the explanation of the basic provisions necessary for the formation of an adequate sleep pattern for the child. These include:

1. Compliance with a certain sequence of measures when putting the child to sleep ("ritual" of going to bed). The ritual of going to bed includes: bathing the child, reading a book, turning off the lights while the night light is on, singing a lullaby, stroking the baby, but on the head, arms, torso ("maternal massage").

2. For a newborn and a child in the first months of life, the use of motion sickness is necessary. It is known that with monotonous movement, the baby calms down and falls asleep quickly. For these purposes, the child can be placed in cradles that can be swayed from side to side. Rolling beds are used for older children and are not suitable for motion sickness.

3. Singing lullabies. The rhythm of the lullaby, as well as the variety of hissing and sibilant sounds, has a calming effect.

4. Exclusion of increased activity of the child before bedtime, preference for quiet and calm activities.

5. Establishing a sleep schedule that includes waking up in the morning at the same time, including weekends.

6. Reasonable attitude to daytime sleep. Long naps for children
is optional. After 8 months of age, many babies do not need any naps at all. At the age of 3 months and older, a child's daily sleep averages 14 hours. It is desirable that the main part of this time falls on the night hours. If you have a long daytime sleep,
then, most likely, the night's sleep will be shortened, accompanied by numerous awakenings.

7. Exclusion of night awakenings. Most babies after 6 months of age sleep all night. After six months, it is necessary to exclude breastfeeding, a horn, and drinking water. Even a sleeping child is able to learn habitual stereotypes of behavior one or two times. If a mother picks up the baby in her arms or into her own bed during awakening, such a baby is unlikely to sleep all night later.

8. When a child wakes up at night, do not go to his bed and take him in your arms. Remember that you can “rock” a baby at a distance, USING a gentle voice, lullabies.

9. Laying the child into bed should take place in the most comfortable conditions with the minimum level of noise and light and at the usual temperature. A baby's sleep with the TV, radio, etc. on. unacceptable.

EARLY CHILD AUTISM

In the foreign literature, the syndrome of early childhood autism was first described by L. Kappieg. In our country, the syndrome was described by G.E.Sukhareva and T.P.Sim-son.

According to V.V. Kovalev, the prevalence ranges from 0.06 to 0 17 per 1000 child population. The ratio of boys and girls, according to various sources, ranges from 1.4: 1 to 4.8: 1. Concordance for early childhood autism in dizygotic twins is 30-40%, in monozygotic twins - 83-95%

The syndrome of early childhood autism is observed in schizophrenia, constitutional autistic psychopathy, and residual organic brain disease. VM Bashina described Kanner's syndrome as a special constitutional condition. M. Sh. Vrono and V. M. Bashina, referring the syndrome to disorders of the schizophrenic register, considered it as pre-manifest dysontogenesis. the initial stage of schizophrenia or post-procedural changes as a result of an undiagnosed fur coat. S. S. Mnukhin described various manifestations of early childhood autism within the framework of a special atonic variety of mental underdevelopment that arose as a result of exogenous organic brain damage in the early stages of development. Disorders similar to early childhood autism are described in some congenital metabolic defects - phenylketonuria, histidinemia, cerebral lipidosis, mucopolysaccharidosis, etc., as well as progressive degenerative brain diseases (Rett syndrome). With them, autistic disorders are always combined with pronounced intellectual underdevelopment, often growing over time.

There are several variants of the syndrome, common to which is autism - a painful lack of contact with others, which has its own specifics in early childhood. In most cases, the disease is non-procedural.

Etiology. Due to the clinical heterogeneity of the syndrome, the different severity of the intellectual defect and the different degree of social maladjustment, there is still no single point of view regarding the origin of the disease.

The American Psychiatric Association's Multi-Axis Syndrome Classification (DSM III-R) treats autistic syndromes as “pervasive developmental disorders” apart from psychoses in childhood and adolescence. For the latter, the same classification criteria are used as for the corresponding conditions in adults. Thus, in the USA, as earlier in German-speaking countries, it is customary to speak of "autistic disorders" or "syndromes" purely descriptively and not to consider them in nosological connection with functional psychoses of childhood. In the DSM III-R classification, this diagnosis is referred to the second axis (personality disorders). the currently valid WHO classification (ICD-9), on the contrary, classifies them as a group of psychoses with the code F20.8хх3, beginning in childhood. Non-psychotic depressive disorders are considered in the same group with psychotic ones under the heading "depressive syndromes in childhood and adolescence." It is the experience of child psychiatry in the field of autistic syndromes and psychosis of childhood that shows how doubtful the line of reasoning and their inclusion in certain nosological frameworks are and how much the one-sided etiological approach with its traditional definitions does not correspond to this experience: “symptomatic or functional "," somatogenic or psychogenic ", etc. Autistic syndromes in a large percentage of cases develop simultaneously with functional cerebral disorders, while the course of the disease and especially the development of intelligence are largely determined by the influences of external factors.
Conclusion for practice: description of syndromes and observation of the nature of the course of the disease should include all information that may have etiological / pathogenetic, somatic, mental, situational significance. In developmental psychiatry, readiness for specific phases and transitional crises in the development of a child plays an important role in the formation of psychopathological phenomena.

Autistic syndromes in childhood.

These behavioral disorders are expressed central symptom of autism or, to a much greater extent, complete or developing in this direction in the morningthat ability to emotional and social contact. At early childhoodautism the first signs of contact disorders may appear already in the first year of life: the absence of a "responsing smile" when the face approaches, eye contact and other expressive movements that normally appear as a response. In the future, these children do not develop the preliminary stages of formation "AwarenessI AM", age appropriate. In comparison with other healthy children of the same age, it is deeply changed and lags far behind. Interests, if any, are very limited and focused on inanimate objects or on separate parts of objects, regardless of their functional purpose. At the same time, dealing with them is of a peculiar, mechanically repetitive nature. For example, autistic children may “obsessively” engage in turning a light bulb on and off, or unscrewing and twisting a faucet. Toys are often misused, such as just turning rotating parts. They show a pronounced tendency linger onfamiliar situation(experiencing "fear of change"). even small changes in the usual environment (new tablecloth, absence of a carpet in the usual place) plunge the child into a state of panic fear with pronounced psychomotor anxiety. Conversation skills either do not develop(if autism begins in infancy), or they can be lost again (if autism begins in early childhood), or they change qualitatively, and the achieved level of speech development, as a rule, lags behind normal (repetition of spoken words, neologisms, strange conversational turns ). Strange forms of repeatablemovements(stereotypes) appear regularly. The functions of the sense organs, in particular hearing and vision are developing insufficiently. The result is significant fromstanding in intellectual development. At the same time, certain and not developed intellectual abilities turn out to be hypertrophied: autistic children, for example, can repeat a pedigree containing many names, or master other lexical difficulties. Similar cases are described. Only 3% of children have intellectual development approaching the age norm. About 1/3 of the children turn out to be mentally retarded, and in 1/5 the intellect approaches the borderline with the norm. Typical of the developmental disorder of the "I" is that many of these children exhibit the phenomenon of "reverse pronoun", ie. use pronouns in a distorted way, speaking about themselves "you", and about others "I". Characteristic changes in peripheral perception are revealed: objects, and sometimes people, are not perceived as whole images with an inherent complex of qualities. Autistic children often trample for hours on the "blank wall" or are satisfied with peripheral perceptions not related to the object (eg: the sound of a crunch is identified with paper crumpled near the ear, sparkling - with the movement of fingers in front of the eyes). Exists weakness of auditory and visual perception, which is functionally related to lack of motor coordination, violations of spoken language, paroxysms of fear and obsessive rituals. B center, between sensory weakness deciphering and impaired psychomotor expressiveness, there is emotional insufficiency, the inability of the child to relate to others and to himself according to his age. Typologically alongside with early childhood autism differ: Asperger's syndrome, or autistic "psychopathy" which, like the one described above, appears in early childhood and characterized by autistic behavioral disorders, mainly in boys: emotional withdrawaland self-isolation, the face of a prince with empty, looking into the distance, peculiarspeech and psychomotor skills with neologisms, intonation disorders, rhythmic motor stereotypes with an average and sometimes high level of intelligence and specialized language readiness (children with Asperger's syndrome learn to speak earlier than to walk; children with Kanner's syndrome - vice versa).
Differential diagnosis. Autistic traits character can develop in the course of completely different disorders, for example, with schizophrenic psychoses of childhood or with predominantly somatogenic disorders in children with organic brain lesions and mental retardation. With deafness or other serious defects in the sensory organs, severe communication disorders (so-called pseudo-autism) may also appear.
Frequency. With strict adherence to diagnostic criteria, autistic syndromes are rarely diagnosed (0.1-0.4%). Autistic behavior in early childhood organic lesions is observed much more often. In these cases, it is mainly about autistic traits, and not about the complete picture of autism. Kanner's and Asperger's syndromes occur almost exclusively in boys.
Etiology and pathogenesis unknown, although a number of studies indicate organic, i.e. biological pathogenesis. In particular, in a good half of cases in autistic patients (polyetiological) functional cerebral disorders, as well as disturbances in the nature of perception, speech disorders and intellectual disorders, and an increase in epileptic seizures in adolescence were found. Some authors suggest the presence of a hereditary "factor of autism", which comes out of the latent state under certain circumstances (for example, with minor brain damage in early childhood, other disorders of brain function). The influence of external circumstances is of great importance for the course of autism, i.e. for the developmental possibilities of an autistic child, but pure psychogenesis or even family dynamics as the cause of the disease today can be considered excluded on the basis of in-depth research. It would be shortsighted to put parenting style in a direct causal relationship with the autism of their children (although in some cases selective social processes "case-finding" may play a certain role).
Therapy. It can be recommended that the earliest possible start of the use of medical-pedagogical and psychotherapeutic (especially for children) measures, which are aimed at gradually awakening in these patients the ability to communicate, a sense of identification and perception of people. At the same time, it is always necessary to involve parents, brothers and sisters in treatment activities, to teach them effective treatment and pedagogical behavior at home (“home-training”). Convincing successes in the application of medical and pedagogical methods are described. Antipsychotics and / or tranquilizers can be used for supportive therapy, especially in cases where fear and psychomotor anxiety come to the fore in the clinical picture.
Forecast. Especially in the case of Kanner's syndrome, it is unfavorable (2/3 of sick children are significantly behind in development; in 1/3, a relatively favorable development is observed). The later the autism syndrome manifests, the more favorable the prognosis.

Schizophrenic syndromes.

The older the child is at the time of the first manifestation of psychosis, the more similar are the psychopathological symptoms and the nature of the course of the disease with schizophrenic psychoses of adolescence and adulthood. Typical disorders of thinking, emotionality and self-awareness, deception of feelings and delirium can appear only at a certain stage of personality development, i.e. can be perceived as such by others.
At the age before entering school, psychosis is expressed with significantly poorer symptoms, especially with regard to the most impressive atypical symptoms, such as deception of feelings and delusional interpretation. Productive psychotic manifestations require a certain personality development beyond the magical thinking of young children, thanks to which some psychopathological defense mechanisms can be developed. In early childhood (2-4 years), syndromes are described that are symbioticpsychosis(M. Mahler) can be ranked among the early forms of schizophrenia and the designation of which is determined by the psychodynamic concept of the pre-oedipal process of separation-individualization. After a relatively cloudless infancy, sometimes after a short separation from the mother at the age of 2-3 years, a noticeable regression of the acquired skills (emotional, speech, cognitive) and the achieved level of “I” consciousness occurs. Children perceive objects in general, differently than autistic people, but treat them as if they are part of themselves. The acquired limitation of one's own “I” is blurred again, even before the child enters the Oedipus phase. Expressed diffuse fears, mood swings, autistic detachment, profound disturbances in relationships are in clinical picture. As notable manifestations in early forms of psychotic experiences, the following are observed: the simultaneity of aggressive behavior and a supportive smile addressed to a partner, speech disorders (mutism, speech sperrungs, echolalia, automatic repetitions, pathetic artificial speech intonation, etc.). Obsessive thoughts and actions are sometimes noted. Typical catatonic symptoms (bouts of motor excitement, or waxy flexibility, catalepsy) can appear very early. Starting from the 7th year of life, delusions and hallucinations appear more often, but they are unlikely to be systematized and so far remain unstable.
From early puberty, the frequency ofschizophrenicsyndromes constantlyincreases and clinical manifestations become similar to those of young adults. On the eve of a psychotic episode, psychotic manifestations may be observed that are difficult to predict, such as phenomena depersonalization and derealization, depressive mood changes, sudden abandonment of schoolwork, antisocial reactions, persistent reactions of protest and stubbornness. All these phenomena can also be observed within the framework of puberty and adolescent crises. In most cases, they go away on their own, as soon as the teenager comes out of the crisis and acquires a more mature awareness of his I. with appropriate premorbid vulnerability it comes to the manifestation of schizophrenic disorders. They can develop sharply in shape schizophrenic fur coat, for example with elements catatanic stupor, catatonic excitement or delusional mood or finally from the very beginning in the form psychotic process cgebefserious symptoms, or accept slow course with poor symptoms,characteristic of a simple form of schizophrenia. Schizophrenia of early childhood continues with relatively mild symptoms, i.e. often without clearly pronounced delusional and haplucinating experiences (like Schizophrenia simplex). Single (funcmental) psychotic episodes, which appear in childhood or adolescence, and then completely disappear, in most cases are not currently counted to the schizophrenic circle and, depending on the scientific school, taking into account the prevailing symptoms and age, are described as psychogenic psychoses,emotional psychosis, hysterical psychosis. To avoid confusion in terminology, a specific description of the leading symptomatology from which the syndrome is formed should be recommended, for example: hallucinatory syndrome, oneiric paranoid syndrome, etc.
Some patients with borderline syndromes are observed by child and adolescent psychiatrists during puberty and adolescence and very rarely in early school age. In these cases, with a relatively good social fitness or with still quite satisfactory school success, pronounced attacks of fear and rabies come to the fore. At the same time, very early defense mechanisms and short-term psychotic outbreaks contribute to these multidimensional disorders special shade: projective identification, identification with the aggressor, splitting process. Idealization transfers outward perceptions that are unbearable for their "I", but not displaced by destructive impulses(an element similar to psychosis). A wide variety of neurotic complaints and structural details appear in varying degrees of severity and in various combinations, creating a picture hysterical,depressive, obsessive, hypochondriacal. In psychosocial aggravating situations, patients with borderline syndrome may develop acute psychotic episodes with productive symptoms and a good prognosis in most cases (the so-called micropsychoses).
Mentally retarded children can develop (functional) psychoses despite and with intellectual disabilities. Despite the fact that the presence of mental retardation, contributing to the manifestation of hypothetical prerequisites for schizophrenia (with an equal frequency of cases, as in the general population), is currently not confirmed, nevertheless, cognitive impairment of some abilities, determined by neuropsychological methods, in particular in situations with emotional overload, can make it difficult selective filtration and processing internal and external stimuli and thus acquire pathogenetic significance. The special position of these psychoses in in a certain sense depends on the fact that in a difficult to explain content diffuse symptoms(these symptoms grow out of a poorly structured world of experiences) affective components (mixed psychoses) occupy a significant place, erased feelings of alienation and above all obvious reactive reason, for example in the form of excessive demands when adjusting to a new environment.
Course, forecast, frequency. Schizophrenic syndromes in early childhood also either proceed in the form of acute episodes, which can be single or recurrent and progressive, or from the very beginning acquire a chronic procedural character. For childhood, the rule also remains in force: the sharper and more productive psychotic manifestations, the (relatively) more favorable the prognosis; the poorer the symptoms and the slower the development of psychosis, the more unfavorable its course.
Frequency accounts for 0.1% of the population, or 1% of the total number of schizophrenias.
Therapy... Certain types are recommended child psychotherapy, environmental treatmentenvironment and curative pedagogy, which is often only possible under stationary conditions. These treatments can provide support with or without antipsychotic therapy for acute schizophrenic episodes. Attractionparents, brothers and sisters of the sick to carry out family therapy and / or in groups of relatives is effective in overcoming disturbed family relationships and feelings of guilt in parents. Practical counseling parents and educational work with them is required.

Depressive syndromes.

Depressive syndromes before puberty are extremely rare. In the structure of symptoms, age-related dependence on the achieved level of mental development is clearly visible. Depressive mood disorders in childhood are difficult to diagnose due to their atypical symptoms. They manifest in the form depressive reactions and developments(dysthymic disorders) or with deep vital disorders(for example, sleep disorders, loss of appetite, fluctuations in the state during the day, somatized manifestations). Often, depressive manifestations can appear after connecting typical triggers and situations: after of death the most beloved person (mother) or a forced re- parting c him, due to serious narcissistic problems in situations social andemotional deprivation or affectively colored pedagogicalinjustice after a threat or punishment, during depression of one of the parents(first of all to the mother), with acute and chronic somatic diseases. Have it is sometimes difficult for younger schoolchildren to establish whether school problems and the associated fears are a cause or a consequence of depressive mood disorders, or in the differential diagnostic plan we are talking about an isolated fear of separation.
Between the ages of 1 and 2. Early infantile (preoedipal) deprivation depressions are found mainly in abortive or methylated forms of anaclitic depression, which is rarely observed at present in full. Such depression develops when a child experiences separation or loss of a loved one, due to early emotional loneliness (abandonment). At the onset of the disease, fear and psychomotor anxiety come to the fore; later apathy, autoerotic and destructive actions, as well as weight loss, delay in the development of cognitive and sensorimotor functions.
Between the ages of 2 and 4... B connection with conflicts, specificheskby themfor this phase of development(education of neatness skills, conflicts of ambivalence, gaining autonomy, crises of separation), can be observed quickly transient and sometimes prolonged depressive reactions, which often occur with pronounced fears and can also be related with feelings of separation, (affective respiratory cramps, fear of separation).
Between the ages of 4 and b... Depressive symptoms may first appear in the form feelings of guilt, fear of being untenable, ideas of sinfulness, since during this period the regulatory requirements and expectations of parents are being introduced into mental structure of the child ("Introjection", i.e. e. secondary identification, secondary narcissism) and contribute to the formation of the idea of ​​the "Ideal I" and "Super-I". Only during this period can the child's "I" in its own actual representation be opposed to its ideal requirements. It is possible that this is due to the process of personality development and psychobiological maturation, the first transformation of appearance(noticeable increase in height, loss of signs of a small child). Therefore, the first signs of depression flowing inform of phases, and cyclothymic flow diseases with depressive and manic phases can be observed no earlier than in the seventh year of life and up to late puberty, and even then only in very rare cases. In most cases, the symptoms are abortive and vaguely expressed and veiled by other, less typical depressive disorders of behavior: school debt, aggressive and threatening behavior, the desire for solitude, colored by a feeling of fear, difficulties in the school team, etc. Diagnosis requires the participation of an experienced child psychiatrist, specialist in curative pedagogy and educational psychologist. Prehopersistent and more protracted depressive reactions (dysthymia), which appear in close connection with the requirements of the school and family, are much more common in this age group.
In puberty (12-18 years old) depressive reactions also occur against the background of emotional lability, egocentrism "Second transformation of appearance"(puberty, development of secondary sexual characteristics, completion of the growth process). A specific background in this age period is the theme of loneliness and world grief. Cyclothymic flow(mono- and bipolar) is observed at this age more often in the form juvenile depression and / or mania and becomes more and more similar to similar conditions in adults. Depressive states in childhood also can cause suicidal behavior. Suicide attempts and committed suicides before puberty are extremely rare, although in Western industrialized countries there is a clear increase in suicidal actions in children. It is only in puberty and adolescence that the rate of suicidal attempts and suicides gradually increases and reaches a critical value in this period (along with the crises of maturation at this age, in comparison with the younger childhood, a more mature concept of death plays a significant role).
Therapy... The younger the depressed child, the more important it is to find out the situational triggers before starting treatment, to eliminate them or try to compensate. For this, it is necessary to create an appropriate environment, a medical-pedagogical and psychological-pedagogical approach. Depression with vitally colored, somatized disorders and a pronounced cyclothymic course require the use of antidepressant psychopharmacological treatment.

PSYCHIATRY, the science of mental illness, history of P. As a scientific discipline P. was formed only in the 19th century. , although the diseases she interpreted began to attract the interest and attention of people at the earliest stages of human society. ... ... Great medical encyclopedia

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

- (Greek dys + Ontogenesis is a violation of the mental development of an individual. The causes of P. are various. These include hereditary factors (at the level of gene changes and chromosomal aberrations), intrauterine lesions (for example, viral infections, ... ... Medical encyclopedia

In the broadest sense of the word, it includes professional intervention aimed at resolving or preventing psychological problems in children. Psychological disorders in childhood. Research in the United States and elsewhere shows ... ... Collier's Encyclopedia

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

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

- (lat.infantilis infant; child; synonym for mental immaturity) a psychopathological condition characterized by childhood, immaturity of the psyche. At the heart of I. p. Is a delay in the rate of mental development. Distinguish I. p. Congenital ... ... Medical encyclopedia

Literature- ◘ Astapov V.M. Introduction to defectology with the basics of neuro and pathopsychology. M., 1994. ◘ Basova A.G., Egorov S.F. M., 1984. ◘ Bleikher V.M., Kruk I.V. Dictionary of Psychiatric Terms. Voronezh, 1995. ◘ Buyanov M. ... ... Defectology. Reference dictionary

- (Greek hēbe adolescence, puberty + eidos view; synonym: criminal heboid, mattoid, parathymia) a mental disorder characterized by a pathological distortion of the features of the puberty period. It occurs mainly in males. ... ... Medical encyclopedia

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

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