Early organic lesion of the central nervous system in children. CNS lesions in children: what are they? Muscle tone disorders

This diagnosis is currently one of the most common. An organic lesion of the central nervous system (central nervous system) in its classical content is a neurological diagnosis, i.e. is in the competence of the neuropathologist. But the symptoms and syndromes accompanying this diagnosis can refer to any other medical specialty.

This diagnosis means that the human brain is defective to a certain extent. But if mild degree(5-20%) of "organics" (organic damage to the central nervous system) is inherent in almost all people (98-99%) and does not require any special medical interventions, then the average degree (20-50%) of organics is not just quantitatively different condition, but a qualitatively different (fundamentally more severe) type of disturbance of the nervous system.

The causes of organic lesions are divided into congenital and acquired. Congenital cases include cases when, during pregnancy, the mother of the unborn child suffered any infection (ARI, influenza, tonsillitis, etc.), took certain medications, alcohol, and smoked. A unified blood supply system will bring stress hormones into the body of the fetus during periods of psychological stress of the mother. In addition, sudden changes in temperature and pressure, exposure to radioactive substances and X-rays, toxic substances dissolved in water, contained in the air, in food, etc. also affect.

There are several especially critical periods when even a small external influence on the mother's body can lead to the death of the fetus or cause such significant changes in the structure of the body (including the brain) of the future person, which, firstly, cannot be corrected by any medical intervention, and secondly, these changes can lead to to the early death of a child before 5-15 years of age (and usually mothers report this) or cause disability from a very early age. And in the best case, they lead to the appearance of a pronounced inferiority of the brain, when even at maximum voltage the brain is able to work only at 20-40 percent of its potential capacity. Almost always, these disorders are accompanied by varying degrees of disharmony of mental activity, when, with a reduced mental potential, far from always positive qualities of character are sharpened.

This can be facilitated by taking certain medications, physical and emotional overload, asphyxia during childbirth (oxygen starvation of the fetus), prolonged labor, early placental abruption, uterine atony, etc. After childbirth severe infections(with pronounced symptoms of intoxication, high fever, etc.) up to 3 years old can give rise to acquired organic changes brain. Brain injuries with or without loss of consciousness, prolonged or short general anesthesia, drug use, alcohol abuse, long-term (several months) independent (without prescription and constant supervision of an experienced psychiatrist or psychotherapist) taking some psychotropic drugs may lead to some reversible or irreversible changes in the functioning of the brain.

Diagnosis of organics is quite simple. A professional psychiatrist can already determine the presence or absence of organics by the face of a child. And, in some cases, even the degree of its severity. Another question is that there are hundreds of types of disorders in the functioning of the brain, and in each specific case they are in a very special combination and connection with each other.

Laboratory diagnostics is based on a series of procedures that are quite harmless to the body and informative for the doctor: EEG - electroencephalograms, REG - rheoencephalograms (study of cerebral vessels), UZDG (M-echoEG) - ultrasound diagnostics of the brain. These three examinations are similar in form to an electrocardiogram, only they are taken from a person’s head. Computed tomography, with its very impressive and expressive name, is actually capable of revealing a very small number of types of brain pathology - a tumor, a volumetric process, aneurysm (pathological expansion of a brain vessel), expansion of the main brain cisterns (with increased intracranial pressure). The most informative study is the EEG.

It should be noted that practically no disorders of the central nervous system disappear by themselves, and with age not only do not decrease, but increase both quantitatively and qualitatively. The mental development of a child directly depends on the state of the brain. If the brain has at least some defectiveness, then this will certainly reduce the intensity mental development child in the future (difficulty in the processes of thinking, remembering and remembering, impoverishment of imagination and fantasy). In addition, the character of a person is formed distorted, with varying degrees of severity of a certain type of psychopathization. The presence of even small, but numerous changes in the psychology and psyche of the child leads to a significant decrease in the organization of his external and internal phenomena and actions. There is an impoverishment of emotions and their flattening, which is directly and indirectly reflected in the facial expressions and gestures of the child.

The central nervous system regulates the work of all internal organs. And if it works defectively, then the rest of the organs, with the most careful care of each of them separately, will not be able to work normally in principle if they are poorly regulated by the brain. One of the most common diseases of our time - vegetative-vascular dystonia against the background of organic matter becomes more severe, peculiar and atypical course. And thus, it not only causes more trouble, but these "troubles" themselves are of a more malignant nature. The physical development of the body goes with any disturbances - there may be a violation of the figure, a decrease in muscle tone, a decrease in their resistance to physical exertion, even of a moderate magnitude. The likelihood of increased intracranial pressure increases by 2-6 times. This can lead to frequent headaches and various kinds of unpleasant sensations in the head area, which reduce the productivity of mental and physical labor by 2-4 times. Also, the likelihood of endocrine disorders increases by 3-4 times, which leads, with minor additional stress factors, to diabetes mellitus, bronchial asthma, imbalance of sex hormones, followed by a violation of the sexual development of the body as a whole (an increase in the amount of male sex hormones in girls and female hormones - in boys), increases the risk of developing a brain tumor, convulsive syndrome(local or general convulsions with loss of consciousness), epilepsy (group 2 disability), cerebrovascular accident in adulthood in the presence of even moderate hypertension (stroke), diencephalic syndrome (attacks of causeless fear, various pronounced discomfort in any part of the body, lasting from several minutes to several hours). Hearing and vision may decrease over time, coordination of movements of a sports, household, aesthetic and technical nature is disturbed, making it difficult for social and professional adaptation.

Organic treatment is a long process. It is necessary to take vascular preparations twice a year for 1-2 months. Related neuropsychiatric disorders also require their own separate and special correction, which must be carried out by a psychiatrist. To control the degree of effectiveness of the treatment of organics and the nature and magnitude of the resulting changes in the state of the brain, the control of the doctor himself at the reception and EEG, REG, and ultrasound is used.

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The diseases of this section have a diverse nature and various mechanisms of development. They are characterized by many variants of psychopathic or neurotic disorders. A wide range of clinical manifestations is explained by the different size of the lesion, the area of ​​the defect, as well as the main individual and personal qualities of a person. The greater the depth of destruction, the clearer is the insufficiency, which most often consists in a change in the function of thinking.

Why Organic Lesions Develop

The causes of organic lesions of the central nervous system include:

1. Peri- and intranatal pathology(brain damage during pregnancy and childbirth).
2. Traumatic brain injury(open and closed).
3. Infectious diseases(meningitis, encephalitis, arachnoiditis, abscess).
4. Intoxication(abuse of alcohol, drugs, smoking).
5. Vascular diseases of the brain(ischemic and hemorrhagic strokes, encephalopathy) and neoplasms (tumors).
6. Demyelination diseases(multiple sclerosis).
7. Neurodegenerative diseases(Parkinson's disease, Alzheimer's).

A huge number of cases of development of organic brain damage occurs through the fault of the patient himself (due to acute or chronic intoxication, traumatic brain injuries, improperly treated infectious diseases, etc.)

Let us consider in more detail each cause of CNS damage.

Peri- and intranatal pathology

There are several critical moments during pregnancy and childbirth, when even the smallest impact on the mother's body can affect the health of the child. oxygen starvation fetus (asphyxia), prolonged labor, premature detachment placenta, decreased uterine tone and other causes can cause irreversible changes in fetal brain cells.

Sometimes these changes lead to the early death of a child before the age of 5-15 years. If it is possible to save a life, then such children become disabled from a very early age. Almost always, the violations listed above are accompanied by varying degrees of disharmony. mental sphere. With a reduced mental potential, not always positive character traits are sharpened.

Mental disorders in children can manifest themselves:

- at preschool age: in the form of a delay in the development of speech, motor disinhibition, poor sleep, lack of interest, rapid mood swings, lethargy;
- during the school period: in the form of emotional instability, incontinence, sexual disinhibition, impaired cognitive processes.

Traumatic brain injury

Traumatic brain injury (TBI) is traumatic injury skull, soft tissues of the head and brain. The most common causes of TBI are car accidents and household injuries. Traumatic brain injuries are open and closed. If there is a message external environment with the cranial cavity, we are talking about an open injury, if not, a closed one. The clinic has neurological and mental disorders. Neurological consist in limiting the movements of the limbs, impaired speech and consciousness, the occurrence of epileptic seizures, lesions of the cranial nerves.

Psychiatric disorders include cognitive and behavioral disorders. Cognitive disorders are manifested by a violation of the ability to mentally perceive and process information received from the outside. Clarity of thinking and logic suffer, memory decreases, the ability to learn, make decisions and plan ahead is lost. Behavioral disorders are manifested in the form of aggression, slow reaction, fears, abrupt changes mood, disorganization and asthenia.

Infectious diseases of the CNS

The spectrum of infectious agents that cause brain damage is quite large. The main ones are: Coxsackie virus, ECHO, herpetic infection, staphylococcus. All of them can lead to the development of meningitis, encephalitis, arachnoiditis. Also, lesions of the central nervous system are observed with HIV infection in its last stages, most often in the form of brain abscesses and leukoencephalopathy.

Mental disorders in infectious pathology are manifested in the form of:

Asthenic syndrome - general weakness, fatigue, decreased performance;
- psychological disorganization;
- affective disorders;
- personality disorders;
- obsessive-convulsive disorders;
- panic attacks;
- hysterical, hypochondriacal and paranoid psychoses.

intoxication

The use of alcohol, drugs, smoking, mushroom poisoning, lead to intoxication of the body. carbon monoxide, salts heavy metals and various drugs. Clinical manifestations are characterized by a variety of symptoms depending on the specific poisonous substance. Perhaps the development of non-psychotic disorders, neurosis-like disorders and psychoses.

Acute intoxications in case of poisoning with atropine, diphenhydramine, antidepressants, carbon monoxide or mushrooms are most often manifested by delirium. In case of poisoning with psychostimulants, an intoxication paranoid is observed, which is characterized by vivid visual, tactile and auditory hallucinations, as well as delusional ideas. It is possible to develop a manic-like state, which is characterized by all the signs of a manic syndrome: euphoria, motor and sexual disinhibition, acceleration of thinking.

Chronic intoxications (alcohol, smoking, drugs) are manifested:

- neurosis-like syndrome- the phenomenon of exhaustion, lethargy, decreased performance, along with hypochondria and depressive disorders;
- cognitive impairment(impaired memory, attention, decreased intelligence).

Vascular diseases of the brain and neoplasms

To vascular diseases of the brain include hemorrhagic and ischemic strokes, as well as dyscirculatory encephalopathy. Hemorrhagic strokes occur as a result of rupture of brain aneurysms or soaking blood through the walls of blood vessels, forming hematomas. Ischemic stroke characterized by the development of a focus that receives less oxygen and nutrients due to blockage of the feeding vessel by a thrombus or atherosclerotic plaque.

Dyscirculatory encephalopathy develops with chronic hypoxia(lack of oxygen) and is characterized by the formation of many small foci throughout the brain. Tumors in the brain arise from a variety of causes, including genetic predisposition, ionizing radiation, and exposure to chemicals. Doctors are debating the effect of cell phones, bruises and injuries in the head.

Mental disorders in vascular pathology and neoplasms depend on the location of the focus. Most often they occur with damage to the right hemisphere and manifest themselves in the form of:

Cognitive impairment (to mask this phenomenon, patients begin to use notebooks, tie knots "for memory");
- reducing criticism of one's condition;
- nocturnal "states of confusion";
- depression;
- insomnia (sleep disorder);
- asthenic syndrome;
- Aggressive behavior.

Vascular dementia

Separately, we should talk about vascular dementia. It is divided into various types: associated with a stroke (multi-infarct dementia, dementia due to infarcts in "strategic" areas, dementia after a hemorrhagic stroke), non-stroke (macro- and microangiopathic), and variants due to impaired cerebral blood supply.

Patients with this pathology are characterized by slowing down, rigidity of all mental processes and their lability, narrowing the range of interests. The severity of cognitive impairment in vascular lesions of the brain is determined by a number of factors that have not been fully studied, including the age of patients.

Demyelination diseases

The main disease in this nosology is multiple sclerosis. It is characterized by the formation of foci with a destroyed sheath of nerve endings (myelin).

Mental disorders in this pathology:

Asthenic syndrome (general weakness, increased fatigue, decreased performance);
- cognitive disorders (impaired memory, attention, decreased intelligence);
- depression;
- affective insanity.

Neurodegenerative diseases

These include: Parkinson's disease and Alzheimer's disease. These pathologies are characterized by the onset of the disease in old age.

The most common psychiatric disorder in Parkinson's disease (PD) is depression. Its main symptoms are a feeling of emptiness and hopelessness, emotional poverty, decreased feelings of joy and pleasure (anhedonia). Dysphoric symptoms (irritability, sadness, pessimism) are also typical manifestations. Depression often co-occurs with anxiety disorders. Thus, anxiety symptoms are detected in 60-75% of patients.

Alzheimer's disease is a degenerative disease of the central nervous system characterized by progressive cognitive decline, personality disorder, and behavioral changes. Patients with this pathology are forgetful, cannot remember recent events, and are unable to recognize familiar objects. They are characterized emotional disorders, depression, anxiety, disorientation, indifference to the outside world.

Treatment of organic pathology and mental disorders

First of all, it is necessary to establish the cause of the occurrence organic pathology. This will depend on the treatment strategy.

In infectious pathology, antibiotics sensitive to the pathogen should be prescribed. With a viral infection - antiviral drugs and immunostimulants. In hemorrhagic strokes, surgical removal of the hematoma is indicated, and in ischemic strokes, decongestant, vascular, nootropic, anticoagulant therapy is indicated. Prescribed for Parkinson's disease specific therapy- drugs containing levodopa, amantadine, etc.

Correction of mental disorders can be drug and non-drug. The best effect shows a combination of both methods. Drug therapy includes the appointment of nootropic (piracetam) and cerebroprotective (citicoline) drugs, as well as tranquilizers (lorazepam, tofisopam) and antidepressants (amitriptyline, fluoxetine). Used to correct sleep disorders sleeping pills(bromisoval, phenobarbital).

Psychotherapy plays an important role in treatment. Hypnosis, auto-training, gestalt therapy, psychoanalysis, art therapy have proven themselves well. This is especially important in the treatment of children due to the possible side effects of drug therapy.

Information for relatives

It should be remembered that patients with organic brain damage often forget to take prescribed drugs and attend a psychotherapy group. You should always remind them of this and make sure that all the doctor's instructions are carried out in full.

If you suspect a psychoorganic syndrome in your relatives, contact a specialist (psychiatrist, psychotherapist or neurologist) as soon as possible. Early diagnosis is the key successful treatment such patients.

Lecture XIV.

Residual organic lesions of the CNS

Consequences of early residual-organic lesions of the central nervous system with cerebrasthenic, neurosis-like, psychopathic-like syndromes. Organic mental infantilism. Psychoorganic Syndrome. Attention deficit hyperactivity disorder in children. Mechanisms of social and school disadaptation, prevention and correction of residual effects of residual organic cerebral insufficiency and child hyperactivity syndrome.

Clinical illustrations.

^ EARLY RESIDUAL-ORGANIC CEREBRAL INSUFFICIENCY in children - a condition caused by persistent consequences of brain damage (early intrauterine brain damage, birth trauma, traumatic brain injuries in early childhood, infectious diseases). There are serious reasons to believe that in recent years the number of children with the consequences of early residual organic lesions of the central nervous system has become more and more, although the true prevalence of these conditions is not known.

The reasons for the increase in the residual effects of residual-organic damage to the central nervous system in recent years are diverse. These include environmental problems, including chemical and radiation contamination of many cities and regions of Russia, malnutrition, unjustified abuse of drugs, untested and often harmful dietary supplements, etc. The principles of physical education of girls - expectant mothers, development which are often violated due to frequent somatic diseases, sedentary lifestyle, restrictions in movement, fresh air, feasible housework or, on the contrary, excessive activities professional sports and early initiation of smoking, drinking alcohol, toxic substances and drugs. Improper nutrition and heavy physical work women during pregnancy, mental anxieties associated with an unfavorable family situation or unwanted pregnancy, not to mention the use of alcohol and drugs during pregnancy, disrupt its proper course and adversely affect intrauterine development child. The result of imperfect medical care, primarily the lack of any representation of the medical contingent antenatal clinics about the psychotherapeutic approach to a pregnant woman, full-fledged patronage during pregnancy, informal practice of preparing pregnant women for childbirth and not always qualified obstetric care, are birth injuries that disrupt the normal development of the child and subsequently affect his entire life. The introduced practice of “birth planning” is often brought to the point of absurdity, turning out to be useful not for the woman in labor and the newborn, but for the staff of the maternity hospital, who have received the legal right to plan their vacation. Suffice it to say that in recent years, children are born not at night or in the morning, when they are supposed to be born according to biological laws, but in the first half of the day, when a new shift takes over from tired staff. Excessive enthusiasm also seems unjustified. caesarean section, in which not only the mother, but also the baby receives anesthesia for quite a long time, which is completely not indifferent to him. The above is only part of the reasons for the increase in early residual organic lesions of the central nervous system.

In the very first months of a child’s life, an organic lesion of the central nervous system manifests itself in the form of neurological signs that are detected by a pediatric neurologist, and all the familiar external signs: trembling of the hands, chin, muscle hypertonicity, early holding of the head, tilting it back (when the child seems to be looking at something behind your back), restlessness, tearfulness, unjustified screaming, interrupted night sleep, delay in the formation of motor functions and speech. In the first year of life, all these signs allow the neurologist to register the child for the consequences birth injury and prescribe treatment (cerebrolysin, cinnarizine, cavinton, vitamins, massage, gymnastics). Intensive and properly organized treatment in non-severe cases, as a rule, has a positive effect, and by the age of one the child is removed from the neurological register, and for several years a child brought up at home does not cause much concern for parents, with the possible exception of some delay in speech development. Meanwhile, after being placed in a kindergarten, the child's characteristics begin to attract attention, which are manifestations of cerebral palsy, neurosis-like disorders, hyperactivity and mental infantilism.

The most common consequence of residual organic cerebral insufficiency is cerebrosthenic syndrome. Cerebrosthenic syndrome is characterized by exhaustion (inability to concentrate for a long time), fatigue, mood instability associated with minor external circumstances or fatigue, intolerance loud sounds, bright light and in most cases is accompanied by a noticeable and prolonged decrease in performance, especially with a significant intellectual load. Schoolchildren have a decrease in memorization and retention of educational material in memory. Along with this, irritability is observed, taking the form of explosiveness, tearfulness, capriciousness. Cerebrosthenic conditions caused by early brain damage become a source of difficulty in developing school skills (writing, reading, counting). The mirror character of writing and reading is possible. Speech disorders are especially frequent (delay in the development of speech, articulatory deficiencies, slowness or, conversely, excessive speed of speech).

Frequent manifestations of cerebrosthenia may be headaches that occur upon awakening or when tired at the end of lessons, accompanied by dizziness, nausea and vomiting. Often, such children have transport intolerance with dizziness, nausea, vomiting, and a feeling of lightheadedness. They also do not tolerate heat, stuffiness, high humidity, reacting to them with a rapid pulse, increase or decrease blood pressure, fainting states. Many children with cerebrovascular disorders cannot tolerate merry-go-rounds and other rotational movements, which also result in dizziness, lightheadedness, and vomiting.

In the motor sphere, cerebrosthenia manifests itself in two equally common variants: lethargy and inertia, or, on the contrary, motor disinhibition. In the first case, children look lethargic, they are not active enough, they are slow, they get involved in work for a long time, they need much more time than ordinary children to comprehend the material, solve problems, do exercises, think about answers; the mood background is most often reduced. Such children become especially unproductive in activities after 3-4 lessons and at the end of each lesson, when tired, they become drowsy or whiny. They are forced to lie down or even sleep after returning from school, in the evenings they are lethargic, passive; with difficulty, reluctantly, for a very long time preparing homework; difficulty concentrating and headaches are aggravated by fatigue. In the second case, fussiness, excessive motor activity, and restlessness are noted, which prevents the child from not only engaging in purposeful educational activities, but even playing a game that requires attention. At the same time, the child's motor hyperactivity increases with fatigue, becomes more and more disorderly, chaotic. It is impossible to involve such a child in the evenings in a consistent game, and in school years - in preparing homework, repeating the past, reading books; he almost fails to get to bed on time, so that from day to day he sleeps much less than his age.

Many children with the consequences of early residual organic cerebral insufficiency have features of dysplasia (deformation of the skull, facial skeleton, auricles, hypertelorism - widely spaced eyes, high palate, abnormal growth of teeth, prognathism - protruding upper jaw, etc.).

In connection with the disorders described above, schoolchildren, starting from the first grades, in the absence of individual approach in training and mode, they experience great difficulties in adapting to school. They are more than their healthy peers, sit through the lessons and even more decompensated due to the fact that they need a longer and more complete rest than ordinary children. Despite all efforts, they, as a rule, do not receive encouragement, but, on the contrary, are subjected to punishments, continuous remarks and even ridicule. After a more or less long time, they stop paying attention to their failures, interest in learning drops sharply and there is a desire for an easy pastime: watching all television programs without exception, outdoor games and, finally, craving for the company of their own kind. In this case, direct skimming is already taking place. schoolwork: absenteeism, refusal to attend classes, runaways, vagrancy, early drinking, which often causes home theft. It should be noted that residual organic cerebral insufficiency greatly contributes to the rapid emergence of dependence on alcohol, drugs and psychoactive substances.

^ neurosis-like syndrome in a child with a residual organic lesion of the central nervous system, it is characterized by stability, monotony, stability of symptoms, and its low dependence on external circumstances. In this case, neurosis-like disorders include tics, enuresis, encopresis, stuttering, mutism, obsessive symptoms - fears, doubts, fears, movements.

The above observation illustrates cerebrasthenic and neurosis-like syndromes in a child with early residual-organic lesion of the CNS.

Kostya, 11 years old.

The second child in the family. He was born from a pregnancy that proceeded with toxicosis of the first half (nausea, vomiting), the threat of miscarriage, edema and increased blood pressure in the second half. Childbirth for 2 weeks ahead of time, was born with a double entanglement of the umbilical cord, in blue asphyxia, screamed after resuscitation. Birth weight 2700. Attached to the breast on the third day. He sucked sluggishly. Early development with a delay: he began to walk at the age of 1 year 3 months, utters individual words from 1 year 10 months, phrasal speech - from 3 years. Until the age of 2, he was very restless, whiny, and had a lot of colds. Up to 1 year, she was observed by a neuropathologist for trembling of the hands, chin, hypertonicity, convulsions (2 times) at high temperature against the background of acute respiratory disease. He grew up quiet, sensitive, inactive, awkward. He was overly attached to his mother, did not let her go from him, got used to kindergarten for a very long time: he did not eat, did not sleep, did not play with children, cried almost all day, refused toys. Until the age of 7, he suffered from nighttime urinary incontinence. He was afraid to be alone at home, fell asleep only by the light of a night lamp and in the presence of his mother, was afraid of dogs, cats, sobbed, resisted when he was taken to the clinic. With emotional stress, colds, troubles in the family, the boy had blinking and stereotypical shoulder movements, which disappeared with the appointment of small doses of tranquilizers or sedative herbs. Speech suffered from the incorrect pronunciation of many sounds and became clear only by the age of 7 after speech therapy classes. I went to school from the age of 7.5, willingly, quickly got acquainted with the children, but almost did not talk to the teacher, for 3 months. He answered questions very quietly, behaved timidly, uncertainly. Tired by the 3rd lesson, "lying" on the desk, could not absorb educational material, ceased to understand the explanations of the teacher. After school he went to bed and sometimes fell asleep. Lessons taught only in the presence of adults, often in the evenings complained of a headache, often accompanied by nausea. Slept restlessly. He could not stand the ride in the bus and the car - nausea, vomiting were noted, he turned pale, covered with perspiration. Felt bad on cloudy days; at this time, the head almost always hurt, dizziness, decreased mood, and lethargy were noted. In summer and autumn I felt better. The condition worsened at high loads, after diseases (acute respiratory infections, tonsillitis, childhood infections). He studied at "4" and "3", although, according to others, he was distinguished by high intelligence and good memory. He had friends, walked alone in the yard, but preferred quiet games at home. He began to study at a music school, but attended it reluctantly, cried, complained of fatigue, was afraid that he would not have time to do his homework, became irritable, restless.

Starting from the age of 8, as prescribed by a psychiatrist, twice a year - in November and March - he received a course of diuretics, nootropil (or cerebrolysin in injections), Cavinton, a mixture with citral, and a sedative mixture. If necessary, an additional day off was assigned. In the process of treatment, the boy's condition improved significantly: headaches became rare, tics disappeared, he became more independent and less fearful, and his academic performance improved.

In this case, it is about pronounced signs cerebrosthenic syndrome, acting in combination with neurosis-like symptoms (tics, enuresis, elementary fears). Meanwhile, with adequate medical supervision, the correct treatment tactics and a sparing regimen, the child fully adapted to the conditions of the school.

Organic damage to the CNS can also be expressed in psychoorganic syndrome (encephalopathy), characterized by a greater severity of disorders and containing, along with all the signs of cerebrosthenia described above, a decrease in memory, a decrease in the productivity of intellectual activity, a change in affectivity (affect incontinence). These features are called the Walter-Buhel triad. Affect incontinence can manifest itself not only in excessive affective excitability, inadequately violent and explosive manifestation of emotions, but also in affective weakness, which includes a pronounced degree of emotional lability, emotional hyperesthesia with excessive sensitivity to everything. external stimuli: the smallest changes in the situation, an unexpected word causes irresistible and uncorrectable stormy emotional states in the patient: crying, sobbing, anger, etc. Memory impairment in psychoorganic syndrome varies from its slight weakening to pronounced mnestic disorders (for example, difficulties in remembering momentary events and the current material).

With a psychoorganic syndrome, the prerequisites for intelligence are insufficient, first of all: a decrease in memory, attention and perception. The amount of attention is limited, the ability to concentrate decreases, absent-mindedness, exhaustion and satiety with intellectual activity increase. Violations of attention lead to a violation of the perception of the environment, as a result of which the patient is not able to cover the situation as a whole, capturing only fragments, separate aspects of events. Violations of memory, attention and perception contribute to the weakness of judgments and inferences, which is why patients give the impression of helpless and stupid. There is also a slowdown in the pace of mental activity, inertness and rigidity of mental processes; this manifests itself in slowness, stuck on certain ideas, in the difficulty of switching from one type of activity to another. Characterized by the lack of criticism of their abilities and behavior with a careless attitude to their condition, loss of a sense of distance, familiarity and familiarity. Low intellectual productivity becomes apparent when additional load, but unlike mental retardation, the ability to abstract is preserved.

Psychoorganic syndrome can be temporary, transient (for example, after a traumatic brain injury, including birth trauma, neuroinfection) or be a permanent, chronic personality trait in the long-term period of organic damage to the central nervous system.

Often, with residual-organic cerebral insufficiency, signs appear psychopathic syndrome which becomes especially obvious in prepubertal and pubertal age. For children and adolescents with psycho-organic syndrome, the most serious forms of behavioral disorders are characteristic, due to a pronounced change in affectivity. Pathological character traits in this case are mainly manifested by affective excitability, a tendency to aggression, conflict, disinhibition of drives, satiety, sensory thirst (the desire to receive new experiences, pleasures). Affective excitability is expressed in a tendency to overly easy occurrence of violent affective outbursts, inadequate to the cause that caused them, in fits of anger, rage, impatience, accompanied by motor excitement, thoughtless, sometimes dangerous for the child himself or those around him, and often narrowed consciousness. Children and adolescents with affective excitability are capricious, touchy, overly mobile, prone to unbridled pranks. They shout a lot, get angry easily; any restrictions, prohibitions, remarks cause them violent reactions of protest with malice and aggression.

Together with symptoms organic mental infantilism(emotional-volitional immaturity, uncriticality, lack of purposefulness of activity, suggestibility, dependence on others) psychopathic disorders in a teenager with residual organic damage to the central nervous system create the prerequisites for social disadaptation with criminal tendencies. Offenses are often committed by them in a state of alcohol intoxication or under the influence of drugs; moreover, for the complete loss of criticism or even amnesia (lack of memory) of the criminal act itself, a relatively small dose of alcohol and drugs is sufficient for a teenager with residual organic damage to the central nervous system. It should be noted once again that in children and adolescents with residual organic cerebral insufficiency, addiction to alcohol and drugs develops faster than in healthy children, leading to severe forms of alcoholism and drug addiction.

The most important means of preventing school disadaptation in residual organic cerebral insufficiency is the prevention of intellectual and physical overload by normalizing the daily routine, the correct alternation of intellectual work and rest, and the exclusion of simultaneous classes in general education and special schools (music, art, etc.). Residual effects of residual-organic lesions of the central nervous system in severe cases are a contraindication for admission to a specialized type of school (with in-depth study foreign language, physical and mathematical, gymnasium or college with an accelerated and extended curriculum).

With this type of mental pathology, for the prevention of educational decompensation, it is necessary to timely introduce adequate drug course therapy (nootropics, dehydration, vitamins, light sedatives, etc.) with constant supervision of a psychoneurologist and dynamic electroencephalographic, craniographic, pathopsychological control; early start of pedagogical correction, taking into account individual characteristics child; classes with a defectologist individual scheme; socio-psychological and psychotherapeutic work with the child's family to develop the right attitudes towards the child's capabilities and his future.

^ HYPERACTIVITY IN CHILDHOOD. A certain connection with residual-organic cerebral insufficiency in childhood is also hyperactivity, which occupies a special place, first of all, in connection with the pronounced school disadaptation caused by it - educational failure and (or) behavioral disorders. Motor hyperactivity is described in child psychiatry under different names Key words: minimal brain dysfunction (MMD), motor disinhibition syndrome, hyperdynamic syndrome, hyperkinetic syndrome, attention deficit hyperactivity disorder in children, active attention disorder syndrome, attention deficit syndrome (the latter name corresponds to the modern classification).

The standard for evaluating behavior as "hyperkinetic" is the complex the following signs:

1) physical activity is excessively high in the context of what is expected in this situation and in comparison with other children of the same age and intellectual development;

2) has an early onset (before 6 years);

3) long duration (or constancy in time);

4) is found in more than one situation (not only at school, but also at home, on the street, in a hospital, etc.).

Data on the prevalence of hyperkinetic disorders vary widely - from 2 to 23% of the child population. Hyperkinetic disorders that occur in childhood, in the absence of preventive measures often lead not only to school disadaptation - poor progress, repetition, behavioral disorders, but also to severe forms of social disadaptation, far beyond childhood and even puberty.

Hyperkinetic disorder, as a rule, manifests itself already in early childhood. In the first year of life, the child shows signs of motor excitation, constantly spins, makes a lot of unnecessary movements, because of which it is difficult to put him to sleep and feed him. Formation motor functions occurs in a hyperactive child faster than in his peers, while the formation of speech does not differ from the usual terms or even lags behind them. When a hyperactive child begins to walk, he is characterized by speed and an excessive number of movements, unrestraint, cannot sit still, climbs everywhere, tries to get different objects, does not respond to prohibitions, does not feel danger, edges. Such a child very early (from 1.5-2 years old) stops sleeping during the day, and in the evening it is difficult to put him to bed due to the chaotic excitement that grows in the afternoon, when he cannot play with his toys at all, do one thing, is naughty , playing around, running. Falling asleep is disturbed: even when physically restrained, the child constantly moves, tries to slip out from under the mother's arms, jump up, open his eyes. With pronounced daytime arousal, there may be a deep night's sleep with long-term incessant enuresis.

However, hyperkinetic disorders in infancy and early preschool years are often regarded as ordinary vivacity within the framework of normal child psychodynamics. In the meantime, restlessness, distractibility, satiety with the need for frequent changes of impressions, and the impossibility of playing alone or with children without the persistent organization of adults gradually increase and begin to attract attention. These features already become apparent at the senior preschool age, when the child begins to prepare for school - at home, in the preparatory group of the kindergarten, in the preparatory groups of the general education school.

Starting from the 1st grade, hyperdynamic disorders in a child are expressed in motor disinhibition, fussiness, inattention and lack of perseverance when performing tasks. At the same time, there is often an increased background of mood with an overestimation of one's own capabilities, mischief and fearlessness, insufficient perseverance in activities that especially require active attention, a tendency to move from one activity to another without completing any of them, poorly organized and poorly regulated activity. Hyperkinetic children are often reckless and impulsive, prone to accidents and disciplinary action due to violations of the rules of conduct. They usually have broken relationships with adults due to the lack of caution and restraint, low self-esteem. Hyperactive children are impatient, do not know how to wait, cannot sit during the lesson, are in constant non-purposeful movement, jump up, run, jump, if necessary, sit still, constantly move their legs and arms. They are, as a rule, talkative, noisy, often complacent, constantly smiling, laughing. Such children need a constant change of activity, new experiences. A hyperactive child can consistently and purposefully engage in one thing only after significant physical exertion; at the same time, such children themselves say that they "need to discharge", "discharge energy."

Hyperkinetic disorders act in combination with cerebrosthenic syndrome, signs of mental infantilism, pathological personality traits, expressed against the background of motor disinhibition to a greater or lesser extent and further complicating the school and social adaptation of a hyperactive child. Often, hyperkinetic disorders are accompanied by neurosis-like symptoms: tics, enuresis, encopresis, stuttering, fears - long-term common childhood fears of loneliness, darkness, pets, white coats, medical manipulations, or quickly arising obsessive fears based on a traumatic situation. Signs of mental infantilism in hyperkinetic syndrome are expressed in the game interests characteristic of an earlier age, gullibility, suggestibility, subordination, affectionateness, spontaneity, naivety, dependence on adults or more self-confident friends. Due to hyperkinetic disorders and features of mental immaturity, the child prefers only play activity, but it does not capture him for a long time either: he constantly changes his mind and direction of activity in accordance with who is near him; he, committing a rash act, immediately repents of it, assures adults that "he will behave well," but, getting into a similar situation, again and again repeats sometimes not harmless pranks, the outcome of which he cannot foresee, calculate. At the same time, because of affection, good-naturedness, sincere repentance for what he has done, such a child is extremely attractive and loved by adults. Children, on the other hand, often reject such a child, since it is impossible to play productively and consistently with him because of his fussiness, noisiness, the desire to constantly change the conditions of the game or move from one type of game to another, because of his inconsistency, variability, superficiality. A hyperactive child quickly becomes acquainted with children and adults, but also quickly "changes" friendships in the pursuit of new acquaintances and new experiences. Mental immaturity in children with hyperkinetic disorders determines the relative ease of the occurrence of various transient or more persistent deviations in them, violations of the process of personality formation under the influence of adverse factors - both microsocial-psychological and biological. The most common in hyperactive children are pathological character traits with a predominance of instability, when the lack of volitional delays, the dependence of behavior on momentary desires and inclinations, increased subordination to outside influences, lack of skill and unwillingness to overcome the slightest difficulties, interest and skill in work come to the fore. The immaturity of the emotional and volitional personality traits of adolescents with an unstable variant determines their increased tendency to imitate the forms of behavior of others, including negative ones (leaving home, school, foul language, petty theft, drinking alcohol).

Hyperkinetic disorders in the vast majority of cases are gradually reduced by the middle of puberty - at 14-15 years. It is impossible to wait for the spontaneous disappearance of hyperactivity without taking corrective and preventive measures due to the fact that hyperkinetic disorders, being a mild, borderline mental pathology, give rise to severe forms school and social disadaptation, leaving an imprint on the entire later life person.

From the very first days of schooling, the child finds himself in the conditions of the necessary fulfillment of disciplinary norms, the assessment of knowledge, the manifestation of his own initiative, and the formation of contact with the team. Due to excessive motor activity, restlessness, distractibility, satiety, a hyperactive child does not meet the requirements of the school and in the coming months after the start of studies becomes the subject of constant discussion in the teaching staff. Every day he receives comments, diary entries, he is discussed at parent and class meetings, he is scolded by teachers and the school administration, he is threatened with expulsion or transfer to individual education. Parents cannot but react to all these actions, and in the family a hyperactive child becomes the cause of constant discord, quarrels, disputes, which gives rise to a system of education in the form of constant penalties, prohibitions and punishments. Teachers and parents are trying to restrain his physical activity, which in itself is impossible due to physiological features child. A hyperactive child interferes with everyone: teachers, parents, older and younger siblings, children in the classroom and in the yard. His success in the absence of special methods of correction never corresponds to his intellectual natural data, i.e. he learns much worse than his abilities. Instead of motor discharge, which the child himself tells adults about, he is forced to sit for many hours completely unproductively preparing lessons. Rejected by family and school, misunderstood, unsuccessful child sooner or later begins to frankly skimp on school. Most often this happens at the age of 10-12, when parental control weakens and the child gets the opportunity to use transport on his own. The street is full of entertainment, temptations, new acquaintances; street is varied. It is here that the hyperkinetic child is never bored, the street satisfies his inherent passion for a continuous change of impressions. Here no one scolds, no one asks about academic performance; here peers and older children are in the same position of rejection and resentment; new acquaintances appear daily here; here for the first time the child tries the first cigarette, the first glass, the first joint, and sometimes the first shot of the drug. Due to suggestibility and subordination, the lack of momentary criticism and the ability to predict the near future, children with hyperactivity often become members of an antisocial company, commit criminal acts or are present at them. With the layering of pathological character traits, social disadaptation becomes especially deep (up to registration in the children's room of the police, judicial investigation, colony for juvenile offenders). in prepubertal and puberty, almost never being the initiators of a crime, hyperactive schoolchildren often join the criminal ranks.

Thus, although the hyperkinetic syndrome, becoming especially noticeable already at a younger preschool age, is significantly (or completely) compensated during adolescence due to a decrease in motor activity and improvement of attention, such adolescents, as a rule, do not reach the level of adaptation corresponding to their natural data, since they are socially decompensated already at primary school age, and this decompensation can increase in the absence of adequate corrective and therapeutic approaches. Meanwhile, with proper, patient, constant treatment-and-prophylactic and psychological-pedagogical work with a hyperactive child, it is possible to prevent deep forms of social disadaptation. In adulthood, in most cases, signs of mental infantilism, mild cerebrosthenic symptoms, pathological character traits, as well as superficiality, lack of purposefulness, and suggestibility remain noticeable.

Misha, 10 years old.

Pregnancy with mild toxicosis in the first half; delivery at term, with a long anhydrous period, with stimulation. Born with a weight of 3300, cried after spanking. Early development of motor functions with advance (for example, he began to sit at 5 months, stood independently at 8 months, walks independently from 11 months), speech - with some delay (phrasal speech appeared by 2 years 9 months). He grew up very mobile, grabbed everything around, climbed everywhere, not being afraid of heights. Up to a year, he repeatedly fell out of the crib, hurt himself, constantly walked in bruises and bumps. He fell asleep with difficulty, he had to be rocked for hours, at the same time holding him so that he would not jump up. From the age of 2 he stopped sleeping during the day; in the evening he became more and more agitated, noisy, constantly moving, even when he was forced to sit. At the same time, he completely stopped playing with toys, did not find an occupation for himself, "lost about" idle, was naughty, interfered with everyone. In kindergarten - from 4 years. I got used to it right away, played only with the boys, not particularly singling out any of them; educators complained about his excessive mobility, senseless mischief, pugnacity. In the preparatory group, attention was drawn to restlessness, a lot of unnecessary movements, even in relative calm, unwillingness to engage, lack of curiosity, distractibility. He was affectionate to his parents, loved younger sister, which did not prevent him from constantly bullying her, provoking scandals and fights. He repented of his pranks, but then thoughtlessly he could repeat the mischief. He started going to school at the age of 7. At the lessons he could not sit still, constantly fidgeting, chatting, playing with toys brought from home, making airplanes, rustling papers, not always fulfilling the tasks of the teacher. Distinguished by a good memory, he studied poorly - mainly at "3"; from the 5th grade, academic performance worsened even more, he did not always teach home lessons, only with the vigilant control of his parents and grandmother. During the lessons he was constantly distracted, whined, looked with empty eyes, not absorbing the material, asked extraneous questions; left alone, he immediately found something to do - played with a cat, made airplanes, drew "horror stories" directly on notebooks, etc. He preferred to spend time on the street, came home later than the appointed time, every day promising to "correct himself." Remained overly mobile, did not feel the danger. Twice with a diagnosis of "brain concussion" (at the age of 7 he was hit on the head by a swing, at 9 years old he fell from a tree) and once due to a broken arm (8 years old) he was in the hospital. He quickly got acquainted with both children and adults, but there were no permanent friends. He did not know how to play one, even an outdoor game for a long time, interfered with the children or left in search of other entertainment. I have been smoking since the age of 8. From the 5th grade, he began to skip classes, several times did not spend the night at home for three days; after the police found him, he explained that he was afraid to go home after receiving several twos, fearing punishment. Sometimes he spent time in the boiler room, where he met adults, and spent the night there when he disappeared from the house. At the insistence of his parents, he began to attend sports sections and circles at school several times, but stayed there for a short time - he left them without explaining the reasons and without informing his relatives. After consulting a psychiatrist (at the age of 11), he began to receive phenibut and small doses of neuleptil, and was assigned to a folk dance school. A few months later he became calmer, more focused in his studies, at first under the supervision of adults, and then on his own, without missing, attended a dance school, was proud of his success, participated in competitions, and went on tour with the team. Achievement and discipline in the general education school have improved significantly.

The present case is an example of a hyperdynamic syndrome in childhood, in which gross social disadaptation was avoided due to treatment and the correct actions of the parents.

When determining preventive tactics in relation to a child with hyperactivity, first of all, it is necessary to think about the organization of the living space of a hyperactive child, which should include all the possibilities for the implementation of his increased motor activity. The morning hours preceding classes at school or attending a kindergarten, such a child should be filled with increased physical activity - the most appropriate running in the air, a fairly long morning exercise, training on simulators. As practice shows, after 1-2 hours of sports activities, hyperactive children sit more calmly in the classroom, are able to concentrate, and better learn the material. Most appropriate for elementary school organizing the first two lessons of physical education for such children. Unfortunately, in fact, this practice is not used in any school institution due to difficulties with the class schedule. Parents who understand the characteristics of the child sometimes organize physical exercises themselves, running in the fresh air before the start of classes, which immediately has a positive effect on the child's academic performance and discipline. Having dozens of children suffering from hyperkinetic disorder in one school, in order to predict school and social disadaptation in the future, the administration of each school is able to provide hyperactive children with the opportunity for adequate physical activity during breaks and after school. To do this, it is advisable to put simulators, trampolines, wall bars, etc. in a gym or other fairly spacious room (perhaps even in recreational corridors) and allow hyperactive children, under the control of one teacher on duty, to make changes in such a room. Along with the organization of increased physical activity during breaks, such children are also recommended increased physical activity during physical education classes at school. In addition, for children with motor disinhibition, for the development of perseverance, classes in sports sections are also useful, requiring great physical tension and movement and, at the same time, plasticity, attention, and fine motor actions; strength sports are not recommended. The earlier sports are introduced, the higher the positive effect, which primarily affects the performance of a hyperactive child. At the same time, the educational role of the coach is very important: if both the sport itself and the personality of the coach impress the child, then the coach is in the power to gradually and consistently demand that the student improve academic performance. The psychiatrist must explain to the parents the characteristics of their child, the origin of his excessive motor activity, lack of attention, inform them of a possible social prognosis, convince them of the need proper organization living space, as well as in the negative effect of violent restriction of movements.

Among non-drug forms of prevention of social disadaptation in children with hyperkinetic disorders, it is also possible to conduct psychotherapy. The preferred approach in this case is behavioral psychotherapy. Considering wide range family problems involved in pathoplasty disorders and arising in response to them, family therapy is indicated. After the end of the course, supportive psychotherapy, also including the child and the family, is advisable. The availability of medical and psychological services makes it possible to include work with teachers and educators in the assistance system, aimed at the possibility of supporting the child on their part. With signs of disadaptation in children's institutions and schools, the preferred psychotherapeutic approach is psychodynamic. It allows you to work with manifestations individual reactions on school and emotional attitudes. Behavioral therapy addresses the problem behavior of the child himself. Cognitive therapy is applicable to older students and is aimed at reorganizing the understanding of the school situation and the existing difficulties.

When hyperkinetic disorders are combined with cerebrasthenic and signs of increased intracranial pressure, for the prevention of educational decompensation, timely administration of adequate drug course therapy (nootropics, diuretics, vitamins, sedative herbs, etc.) is necessary with constant monitoring by a psychiatrist and neuropathologist and dynamic electroencephalographic, craniographic, pathopsychological control.

LITERATURE:

1. V.V. Kovalev. Psychiatry of childhood. - Moscow. "The medicine". - 1995.

2. Guide to psychiatry. Edited by A.V. Snezhnevsky. - Moscow. - Medgiz. - 1983, Vol. 1

3. G.E. Sukharev. Clinical lectures on childhood psychiatry. - vol. I. - Moscow. "Medgiz". - 1955.

4. Handbook of psychology and psychiatry of children and adolescence. - St. Petersburg - Moscow - Kharkov - Minsk. - Peter. - 1999.

5. G.K. Ushakov. Child psychiatry. - Moscow. "The medicine". - 1973.

QUESTIONS:

1. What psychopathological disorders are typical for early residual organic lesions of the CNS?

2. What is the difference between cerebral palsy and encephalopathy?

3. Please name the basic principle of correcting the behavior of a hyperactive child.

7.2. Clinical variants of residual-organic insufficiency of the CNS

Let's bring short description some options.

1) cerebrosthenic syndromes. Described by many authors. Residual cerebrasthenic syndromes are basically similar to asthenic conditions of another origin. Asthenic syndrome is not a static phenomenon, it, like other psychopathological syndromes, goes through certain stages in its development.

At the first stage, irritability, impressionability, emotional tension, inability to relax and wait, haste in behavior to fussiness and, outwardly, increased activity, the productivity of which is reduced due to the inability to act calmly, systematically and prudently - “fatigue that does not seek rest” (Tiganov A.S., 2012). it hypersthenic variant of asthenic syndrome or asthenohyperdynamic syndrome in children (Sukhareva G.E., 1955; and others), it is characterized by a weakening of the processes of inhibition of nervous activity. Asthenohyperdynamic syndrome is more often a consequence of early organic lesions of the brain.

The second stage of development of asthenic syndrome is characterized by irritable weakness- approximately parity combination of increased excitability with rapid exhaustion, fatigue. At this stage, the weakening of the processes of inhibition is complemented by a rapid depletion of the processes of excitation.

In the third stage of the development of asthenic syndrome, lethargy, apathy, drowsiness predominate, a significant decrease in activity up to inactivity - astheno-adynamic option asthenic syndrome or asthenodynamic syndrome in children (Sukhareva G.E., 1955; Vishnevsky A.A., 1960; and others). In children, it is described mainly in the late period of severe neuro- and general infections with secondary brain damage.

Subjectively, patients with cerebral palsy experience heaviness in the head, inability to concentrate, a persistent feeling of fatigue, overwork, or even impotence, which grows under the influence of habitual physical, intellectual, and emotional stress. Ordinary rest, unlike physiological fatigue, does not help patients.

In children, points out V.V. Kovalev (1979), irritable weakness comes to light more often. At the same time, asthenic syndrome with residual organic insufficiency of the central nervous system, i.e., the cerebrasthenic syndrome itself, has a number of clinical features. Thus, the phenomena of asthenia in schoolchildren are especially intensified with mental load, while memory performance is significantly reduced, resembling erased amnestic aphasia in the form of transient forgetting of individual words.

In post-traumatic cerebral palsy, affective disturbances are more pronounced, emotional explosiveness is observed, and sensory hyperesthesia is more common. In post-infectious cerebral palsy, among affective disorders, dysthymic phenomena predominate: tearfulness, capriciousness, discontent, sometimes anger, and in cases of early neuroinfection, violations of the body scheme occur more often.

After perinatal and early postnatal organic processes, violations of higher cortical functions may persist: elements of agnosia (difficulties in distinguishing figures and backgrounds), apraxia, disturbances in spatial orientation, phonemic hearing, which can cause a belated development of school skills (Mnukhin S.S., 1968) .

As a rule, more or less pronounced disorders of autonomic regulation, as well as scattered neurological microsymptoms, are found in the structure of the cerebrasthenic syndrome. In cases of organic damage in the early stages of intrauterine development, anomalies in the structure of the skull, face, fingers, internal organs, expansion of the ventricles of the brain, etc. are often detected. Many patients experience headaches that worsen in the afternoon, vestibular disorders (dizziness, nausea, feeling of when driving), signs are revealed intracranial hypertension(paroxysmal headaches, etc.).

According to a follow-up study (in particular, V.A. Kollegov, 1974), cerebrosthenic syndrome in children and adolescents in most cases has a regressive dynamics with the disappearance of post-pubertal asthenic symptoms, headaches, smoothing of neurological microsymptoms and fairly good social adaptation.

However, states of decompensation may occur, usually this occurs during periods of age-related crises under the influence of training overloads, somatic diseases, infections, repeated head injuries, and psychotraumatic situations. The main manifestations of decompensation are increased asthenic symptoms, vegetative dystonia, especially vasovegetative disorders (including headaches), as well as the appearance of signs of intracranial hypertension.

2) Violations sexual development in children and teenagers. In patients with disorders of sexual development, residual organic neurological psychiatric pathology is often detected, but there are also procedural forms of nervous and endocrine pathology, tumors, as well as congenital and hereditary disorders of the hypothalamic-pituitary system, adrenal glands, thyroid gland, gonads.

1. premature sexual development (PPR). PPR is a condition characterized in girls by the appearance of thelarche (growth of the mammary glands) before 8 years of age, in boys by an increase in testicular volume (volume of more than 4 ml or length of more than 2.4 cm) before 9 years. The appearance of these signs in girls 8–10 years old, and in boys 9–12 years old is considered as early sexual development, which most often does not require any medical intervention. There are the following forms of PPR (Boyko Yu.N., 2011):

• true PPR when the hypothalamic-pituitary system is activated, which leads to an increase in the secretion of gonadotropins (luteinizing and follicle-stimulating hormones), which stimulate the synthesis of sex hormones;
• false PPR due to autonomous (not dependent on gonadotropins) excessive secretion of sex hormones by the gonads, adrenal glands, tissue tumors that produce androgens, estrogens or gonadotropins, or excessive intake of sex hormones into the child's body from the outside;
• partial or incomplete PPR characterized by the presence of isolated thelarche or isolated adrenarche without the presence of any other clinical signs of PPR;
• diseases and syndromes accompanied by PPR.

1.1. True PPR. It is due to the premature onset of impulse secretion of GnRH and is usually only isosexual (corresponds to the genetic and gonadal sex), always only complete (there is a consistent development of all secondary sexual characteristics) and always complete (menarche occurs in girls, virilization and stimulation of spermatogenesis in boys).

True PPR can be idiopathic (more common in girls), when there are no obvious reasons for early activation of the hypothalamic-pituitary system, and organic (more common in boys), when various diseases The central nervous system leads to stimulation of impulse secretion of gonadoliberin.

The main causes of organic PPS: brain tumors (chiasmatic glioma, hypothalamic hamartoma, astrocytoma, craniopharyngioma), non-tumor brain damage (congenital brain anomalies, neurological pathology, increased intracranial pressure, hydrocephalus, neuroinfections, TBI, surgery, head irradiation, especially in girls, chemotherapy). In addition, late treatment of virilizing forms congenital hyperplasia adrenal cortex due to disinhibition of the secretion of GnRH and gonadotropins, as well as, which rarely happens, long-term untreated primary hypothyroidism, in which a high level of thyroliberin stimulates not only the synthesis of prolactin, but also the impulse secretion of GnRH.

True PPR is characterized by the sequential development of all stages of puberty, but only by the premature, simultaneous appearance of secondary effects of androgen action (acne, change in behavior, mood, body odor). Menarche, which normally occurs no earlier than 2 years after the first signs of puberty appear, can appear much earlier (after 0.5–1 year) in girls with true PPR. The development of secondary sexual characteristics is necessarily accompanied by an acceleration in growth rates (more than 6 cm per year) and bone age (which is ahead of chronological age). The latter progresses rapidly and leads to premature closure of the epiphyseal growth zones, which ultimately leads to short stature.

1.2. False PPR. It is caused by hyperproduction of androgens or estrogens in the ovaries, testicles, adrenal glands and other organs or hyperproduction of chorionic gonadotropin (CG) by CG-secreting tumors, as well as by the intake of exogenous estrogens or gonadotropins (false iatrogenic PPR). False PPR can be both isosexual and heterosexual (in girls - according to the male type, in boys - according to the female). False PPR is usually incomplete, i.e., menarche and spermatogenesis do not occur (excluding McCune syndrome and familial testotoxicosis syndrome).

The most common causes of the development of false PPR: in girls - estrogen-secreting ovarian tumors (granulomatous tumor, luteoma), ovarian cysts, estrogen-secreting tumors of the adrenal glands or liver, exogenous intake of gonadotropins or sex steroids; in boys - virilizing forms of congenital adrenal hyperplasia (CAH), androgen-secreting tumors of the adrenal glands or liver, Itsenko-Cushing's syndrome, androgen-secreting testicular tumors, CG-secreting tumors (including often in the brain).

Heterosexual false PPR in girls can be with virilizing forms of CAH, androgen-secreting tumors of the ovaries, adrenal glands or liver, Itsenko-Cushing's syndrome; in boys - in the case of tumors that secrete estrogens.

The clinical picture of the isosexual form of false PPR is the same as in true PPR, although the sequence of development of secondary sexual characteristics may be somewhat different. Girls may have uterine bleeding. In the heterosexual form, there is hypertrophy of the tissues that are affected by the excess hormone, and atrophy of those structures that normally secrete this hormone at puberty. Girls have adrenarche, hirsutism, acne, clitoral hypertrophy, low voice, male physique, boys have gynecomastia and female-type pubic hair. In both forms of false PPR, growth acceleration and a significant progression of bone age are always present.

1.3. Partial or incomplete PPR:

• premature isolated thelarche. It is more common in girls aged 6-24 months, as well as in 4-7 years. The reason is a high level of gonadotropic hormones, especially follicle-stimulating hormone in the blood plasma, which is normal for children under 2 years of age, as well as periodic estrogen surges or increased sensitivity of the mammary glands to estrogens. It is manifested only by an increase in the mammary glands on one or two sides and most often regresses without treatment. If there is also an acceleration of bone age, this is assessed as an intermediate form of PPR, requiring more careful monitoring with control of bone age and hormonal status;
• premature isolated adrenarche associated with an early increase in the secretion of testosterone precursors by the adrenal glands, which stimulate pubic and axillary hair growth. It can be triggered by non-progressive intracranial lesions that cause hyperproduction of ACTH (meningitis, especially tuberculosis), or be a symptom of a late form of CAH, tumors of the gonads and adrenal glands.

1.4. Diseases and syndromes, accompanying PPR:

• syndrome Poppy-Kyuna-Albright. This is a congenital disease, more common in girls. It occurs at an early embryonic age as a result of a mutation of the gene responsible for the synthesis of G-protein, through which the signal is transmitted from the hormone-LH and FSH receptor complex to the germ cell membrane (LH - luteinizing hormone, FSH - follicle-stimulating hormone). As a result of the synthesis of abnormal G-protein, hypersecretion of sex hormones occurs in the absence of control from the hypothalamic-pituitary system. Other tropic hormones (TSH, ACTH, growth hormone), osteoblasts, melanin, gastrin, etc. interact with receptors through the G-protein. Main manifestations: PPR, menarche in the first months of life, dark spots on the skin of the color "coffee with milk" mainly on one side of the body or face and in the upper half of the body, bone dysplasia and cysts in the tubular bones. There may be other endocrine disorders (thyrotoxicosis, hypercortisolism, gigantism). Often there are ovarian cysts, lesions of the liver, thymus, gastrointestinal polyps, cardiac pathology;
• syndrome family testotoxicosis. An inherited disease, transmitted in an autosomal dominant manner with incomplete penetrance, occurs only in males. Caused by a point mutation in the LH and CG receptor gene located on Leydig cells. As a result of constant stimulation, Leydig cell hyperplasia and hypersecretion of testosterone uncontrolled by LH occur. Signs of PPG appear in boys aged 3–5 years, while androgen-mediated effects (acne, Strong smell sweat, lowering the timbre of the voice) can occur as early as 2 years. Spermatogenesis is activated early. Fertility in adulthood is often not impaired;
• syndrome Russell-Silvera. Congenital disease, mode of inheritance unknown. The cause of development is an excess of gonadotropic hormones. The main features: intrauterine developmental delay, short stature, multiple dysembryogenesis stigmas (small triangular "bird" face, narrow lips with lowered corners, moderately blue sclera, thin and brittle hair on the head), impaired skeletal formation in early childhood(asymmetry), shortening and curvature of the 5th finger, congenital dislocation of the hip, café-au-lait spots on the skin, renal anomalies and PPR from 5–6 years of age in 30% of children;
• primary hypothyroidism. It occurs, presumably, because due to the constant hyposecretion of thyroid-stimulating hormone in long-term untreated primary hypothyroidism, chronic stimulation of gonadotropic hormones and the development of PPR with an increase in the mammary glands and occasionally galactorrhea occur. There may be ovarian cysts.

In the treatment of true PPR, analogues of gonadoliberin or gonadotropin-releasing hormone (analogues of gonadoliberin are 50–100 times more active than the natural hormone) are used to suppress the impulse secretion of gonadotropic hormones. Long-acting drugs are prescribed, in particular diphereline (3.75 mg or 2 ml once a month i / m). As a result of therapy, the secretion of sex hormones decreases, growth slows down and sexual development stops.

Isolated premature thelarche and adrenarche do not require medical treatment. In the treatment of hormonally active tumors, surgical intervention is required; in case of primary hypothyroidism, thyroid hormone replacement therapy (to suppress TSH hypersecretion) is required. CAH is treated with corticosteroid replacement therapy. Therapy for McCune-Albright syndromes and familial testotoxicosis has not been developed.

2. Delayed sexual development (ZPR). It is characterized by the absence of growth of the mammary glands in girls at the age of 14 years and older, in boys - the absence of growth in the size of the testicles at the age of 15 years and older. The appearance of the first signs of sexual development in girls aged 13 to 14 years, and in boys - from 14 to 15 years is considered as later sexual development and does not require medical intervention. If sexual development began in a timely manner, but menstruation does not occur within 5 years, they speak of isolated delayed menarche. If we are talking about a true delay in sexual development, this does not at all mean the presence of a pathological process.

In 95% of children with mental retardation, there is a constitutional delay in puberty, in the remaining 5% of cases, mental retardation is due to severe chronic diseases rather than primary endocrine pathology. They differ: a) a simple delay in puberty; b) primary (hypergonadotropic) hypogonadism; c) secondary (hypogonadotropic) hypogonadism.

2.1. Simple delay puberty (PZP). It occurs most often (95%), especially in boys. Reasons for development:

• heredity and / or constitution (cause of the bulk of cases of PZP);
• untreated endocrine pathology (hypothyroidism or isolated growth hormone deficiency that appeared at the age of normal puberty);
• severe chronic or systemic diseases (cardiopathy, nephropathy, blood diseases, liver diseases, chronic infections, psychogenic anorexia);
• physical overload (especially in girls);
• chronic emotional or physical stress;
• malnutrition.

Clinically, PZP is characterized by the absence of signs of sexual development, growth retardation (starting at 11-12 years old, sometimes earlier) and delayed bone age.

One of the most reliable signs of PZP (its non-pathological form) is the complete correspondence of the child's bone age to the chronological age, which corresponds to his real height. Another equally reliable clinical criterion- the degree of maturation of the external genital organs, i.e. the size of the testicles, which in the case of PZP (2.2–2.3 cm in length) borders on normal sizes characterizing the onset of sexual development.

Diagnostically very informative test with chorionic gonadotropin(HG). It is based on the stimulation of Leydig cells in the testicles that produce testosterone. Normally, after the introduction of hCG, there is an increase in the level of testosterone in the blood serum by 5–10 times.

Most often, no treatment is required for PPD. Sometimes, in order to avoid undesirable psychological consequences, substitution therapy with small doses of sex steroids is prescribed.

2.2. Primary (hypergonadotropic) hypogonadism. It develops due to a defect at the level of the gonads.

1) Congenital primary hypogonadism (HSV) occurs in the following diseases:

• intrauterine gonadal dysgenesis, can be combined with Shereshevsky-Turner syndrome (karyotype 45, XO), Klinefelter syndrome (karyotype 47, XXY);
• congenital syndromes not associated with chromosomal disorders(20 syndromes associated with hypergonadotropic hypogonadism, such as Noonan's syndrome, etc.);
• congenital anorchism (lack of testicles). A rare pathology (1 in 20,000 newborns), accounts for only 3-5% of all cases of cryptorchidism. Develops due to gonadal atrophy late stages intrauterine development, after the end of the process of sexual differentiation. The cause of anorchism is presumably trauma (torsion) of the testicles or vascular disorders. The child has a male phenotype at birth. If testicular agenesis occurs due to impaired testosterone synthesis at 9-11 weeks of gestation, the phenotype of the child at birth will be female;
• true gonadal dysgenesis (female phenotype, karyotype 46, XX or 46, XY, the presence of a defective sex chromosome, as a result of which the gonads are presented in the form of rudimentary strands);
• genetic disorders in the production of enzymes involved in the synthesis of sex hormones;
• insensitivity to androgens due to genetic disorders of the receptor apparatus, when the gonads function normally, but peripheral tissues they are not perceived: testicular feminization syndrome, female or male phenotype, but with hypospadias (congenital underdevelopment of the urethra, in which its external opening opens on the lower surface of the penis, on the scrotum or in the perineum) and micropenia (small penis).

2) Acquired primary hypogonadism (PPG). Causes of development: radio or chemotherapy, trauma to the gonads, surgery on the gonads, autoimmune diseases, infection of the gonads, untreated cryptorchidism in boys. Antitumor agents, especially alkylating agents and methylhydrazines, damage Leydig cells and spermatogenic cells. In prepubertal age, damage is minimal, since these cells are in a dormant state and are less sensitive to the cytotoxic effect of anticancer drugs.

In postpubertal age, these drugs can cause irreversible changes in the spermatogenic epithelium. Often, primary hypogonadism develops as a result of past viral infections (virus mumps, Coxsackie B and ECHO viruses). Gonadal function is impaired after high doses of cyclophosphamide and whole-body irradiation in preparation for bone marrow transplantation. There are such variants of PPG:

• BCP without hyperandrogenization. More often it is caused by an autoimmune process in the ovaries. It is characterized by a delay in sexual development (in the case of complete testicular failure) or, with an incomplete defect, a slowdown in puberty when primary or secondary amenorrhea occurs;
• PPG with hyperandrogenization. May be due to polycystic ovary syndrome (PCOS) or the presence of multiple follicular cysts ovaries. It is characterized by the presence of spontaneous puberty in girls, but is accompanied by a violation of the menstrual cycle;
• multiple follicles ovaries. They can develop in girls at any age. Most often, signs of premature sexual development are not observed, cysts can spontaneously resolve.

The clinical presentation of PPG depends on the etiology of the disorder. Secondary sexual characteristics are completely absent or pubic hair is present due to the timely normal maturation of the adrenal glands, however, as a rule, it is not enough. With PCOS, acne, hirsutism, obesity, hyperinsulinism, alopecia, absence of clitoromegaly, and a history of premature pubarche are detected.

Treatment by an endocrinologist. In PCOS, hormone replacement therapy is prescribed with moderate doses of estrogens orally along with progestogens.

2.3. Secondary (hypogonadotropic) hypogonadism (VG). It develops due to a defect in the synthesis of hormones at the hypothalamic-pituitary level (FSH, LH - low). May be congenital or acquired. Causes of congenital VH:

• Kallman's syndrome (isolated gonadotropin deficiency and anosmia) (see hereditary diseases);
• Lynch syndrome (isolated gonadotropin deficiency, anosmia and ichthyosis);
• Johnson syndrome (isolated gonadotropin deficiency, anosmia, alopecia);
• Pasqualini syndrome or low LH syndrome, fertile eunuch syndrome (see hereditary diseases);
• deficiency of gonadotropic hormones (FSH, LH) as part of multiple pituitary insufficiency (hypopituitarism and panhypopituitarism);
• Prader-Willi syndrome (see hereditary diseases).

The most common cause of acquired VH are tumors of the hypothalamic-pituitary region (craniopharyngioma, dysgerminoma, suprasellar astrocytoma, chiasmatic glioma). VH can also be post-radiation, post-surgical, post-infectious (meningitis, encephalitis) and due to hyperprolactinemia (more often prolactinoma).

Hyperprolactinemia always leads to hypogonadism. Clinically, it is manifested in adolescent girls by amenorrhea, in boys by gynecomastia. Treatment is lifelong replacement therapy sex steroids, starting before age 13 in boys and before age 11 in girls.

cryptorchidism characterized by the absence of palpable testicles in the scrotum in the presence of a normal male phenotype. It occurs in 2-4% of full-term and 21% of premature boys. Normally, fetal testicular descent occurs between 7 and 9 months of gestation due to an increase in the level of placental chorionic gonadotropin (CG).

The causes of cryptorchidism are different:

• deficiency of gonadotropins or testosterone in the fetus or newborn, or insufficient intake of hCG from the placenta into the blood;
• testicular dysgenesis, including chromosomal abnormalities;
• inflammatory processes during intrauterine development (orchitis and peritonitis of the fetus), as a result of which the testicles and spermatic cord grow together, and this prevents the testicles from descending;
• autoimmune damage to gonadotropic pituitary cells;
• anatomical features of the structure of the internal genital tract (narrowness of the inguinal canal, underdevelopment of the vaginal process of the peritoneum and scrotum, etc.);
• cryptorchidism can be combined with congenital malformations and syndromes;
• in premature babies, the testicles can descend into the scrotum during the 1st year of life, which happens in more than 99% of cases.

Treatment of cryptorchidism begins as early as possible, from 9 months of age. It begins with drug therapy with human chorionic gonadotropin. Treatment is effective in 50% for bilateral cryptorchidism and 15% for unilateral cryptorchidism. With ineffective drug treatment surgery is indicated.

Microsinging characterized by a small penis that is less than 2 cm at birth or less than 4 cm at prepubertal age. Causes of micropenia:

• secondary hypogonadism (isolated or combined with other pituitary deficiencies, especially growth hormone deficiency);
• primary hypogonadism (chromosomal and non-chromosomal diseases, syndromes);
• incomplete form of androgen resistance (isolated micropenia or in combination with violations of sexual differentiation, manifested by indefinite genitalia);
• congenital anomalies of the central nervous system (defects in the median structures of the brain and skull, septo-optic dysplasia, hypoplasia or aplasia of the pituitary gland);
• idiopathic micropenia (the cause of its development has not been established).

In the treatment of micropenia, intramuscular injections of prolonged testosterone derivatives are prescribed. With partial resistance to androgens, the effectiveness of therapy is negligible. If there is no effect at all in early childhood, the problem of gender reassessment arises.

Features of sexual development, possible sexual anomalies in patients with premature sexual development and delayed sexual development are known only in general terms. Precocious sexual development is usually accompanied by early onset of sexual desire, hypersexuality, early onset of sexual activity, high probability development of sexual perversions. The delay in sexual development is most often associated with the late appearance and weakening of sexual desire up to asexuality.

V.V. Kovalev (1979) points out that among the residual-organic psychopathic disorders, a special place is occupied by psychopathic states with an accelerated rate of puberty, studied in the clinic headed by him by K.S. Lebedinsky (1969). The main manifestations of these states are increased affective excitability and a sharp increase in drives. In adolescent boys, the component of affective excitability with explosiveness and aggressiveness predominates. In a state of passion, patients can pounce with a knife, throw an object that accidentally falls under the arm at someone. Sometimes, at the height of affect, a narrowing of consciousness occurs, which makes the behavior of adolescents especially dangerous. There is an increased conflict, constant readiness to participate in quarrels and fights. Possible dysphoria with tense-malicious affect. Girls are less likely to be aggressive. Their affective outbursts have an hysteroid color, are distinguished by the grotesque, theatrical nature of their behavior (shouts, wringing of hands, gestures of despair, demonstrative suicidal attempts, etc.). Against the background of a narrowed consciousness, affective-motor seizures may occur.

In the manifestations of psychopathic states with an accelerated rate of puberty in adolescent girls, an increased sexual desire comes to the fore, sometimes acquiring an irresistible character. In this regard, all the behavior and interests of such patients are aimed at the realization of sexual desire. Girls abuse cosmetics, are constantly looking for acquaintances with men, young men, teenagers, some of them, starting from the age of 12-13, have an intense sex life, having sex with casual acquaintances, often become victims of pedophiles, people with other sexual perversions, venereal pathology .

Especially often, teenage girls with accelerated sexual development are involved in antisocial companies, they begin to joke dirty and scold, smoke, drink alcohol and drugs, and commit offenses. They are easily drawn into brothels, where they also experience sexual perversions. Their behavior is distinguished by swagger, arrogance, nakedness, lack of moral delays, cynicism. They prefer to dress in a special way: loudly caricatured, with an exaggerated representation of secondary sexual characteristics, thereby attracting the attention of a specific audience.

Some teenage girls have a tendency to make up sexual content. Most often there are slanders from classmates, teachers, acquaintances, relatives that they are subjected to sexual persecution, rape, that they are pregnant. The slander can be so skillful, vivid and convincing that even miscarriages of justice happen, not to mention difficult situations, in which there are victims of slander. Sexual fantasies are sometimes stated in diaries, as well as in letters, often containing various threats, obscene expressions, etc., which teenage girls write to themselves, changing their handwriting, on behalf of imaginary admirers. Such letters can become a source of conflict in the school, and sometimes give rise to a criminal investigation.

Some girls with precocious puberty leave home, run away from boarding schools, wander. Usually only a few of them retain the ability to critically assess their condition and behavior and accept medical assistance. The prognosis in such cases may be favorable.

3) neurosis-like syndromes. They are disorders of the neurotic level of response caused by residual-organic lesions of the central nervous system and characterized by features of symptoms and dynamics that are not characteristic of neuroses (Kovalev V.V., 1979). The concept of neurosis turned out to be among the discredited due to different reasons and is now used rather in a conditional sense. The same seems to be happening with the concept of "neurosis-like syndromes."

Until recently, Russian child psychiatry provided descriptions of various neurosis-like disorders, such as neurosis-like fears (occurring in the form of attacks panic fear), senestopathic-hypochondriac neurosis-like states, hysteriform disorders (Novlyanskaya K.A., 1961; Aleshko V.S., 1970; Kovalev V.V., 1971; etc.). It was emphasized that systemic or monosymptomatic neurosis-like conditions are especially common in children and adolescents: tics, stuttering, enuresis, sleep disturbances, appetite disorders (Kovalev V.V., 1971, 1972, 1976; Buyanov M.I., Drapkin B.Z. , 1973; Gridnev S.A., 1974; and others).

It was noted that neurosis-like disorders, in comparison with neurotic disorders, are more resistant, prone to protracted treatment, resistance to therapeutic measures, a weak reaction of the personality to the defect, as well as the presence of mild or moderate psycho-organic symptoms and residual neurological micro-symptoms. Pronounced psycho-organic symptoms limit the possibilities of a neurotic response, and neurosis-like symptoms in such cases are relegated to the background.

4) psychopathic syndromes. The general basis of psychopathic states associated with the consequences of early and postnatal organic brain lesions in children and adolescents, as V.V. Kovalev (1979), is a variant of the psycho-organic syndrome with a defect in the emotional-volitional properties of the personality. The latter, according to G.E. Sukhareva (1959), manifests itself in a more or less pronounced insufficiency of the highest personality traits (absence intellectual interests, pride, a differentiated emotional attitude towards others, weakness of moral attitudes, etc.), violation of instinctive life (disinhibition and sadistic perversion of the instinct of self-preservation, increased appetite), insufficient focus and impulsiveness of mental processes and behavior, and in young children, in addition, motor disinhibition and weakening of active attention.

Against this background, some personality traits may dominate, which makes it possible to identify certain syndromes of residual-organic psychopathic conditions. So, M.I. Lapides and A.V. Vishnevskaya (1963) distinguish 5 such syndromes: 1) organic infantilism; 2) syndrome mental instability; 3) syndrome of increased affective excitability; 4) impulsive-epileptoid syndrome; 5) a syndrome of disturbance of inclinations. Most often, according to the authors, there is a syndrome of mental instability and a syndrome of increased affective excitability.

According to G.E. Sukhareva (1974), one should speak of only 2 types of residual psychopathic states.

The first type is brakeless. It is characterized by underdevelopment of volitional activity, weakness of volitional delays, the predominance of the motive for obtaining pleasure in behavior, instability of attachments, lack of self-love, a weak reaction to punishment and censure, lack of purposefulness of mental processes, especially thinking, and, in addition, the predominance of the euphoric background of mood, carelessness , frivolity and disinhibition.

The second type is explosive. He is characterized by increased affective excitability, explosiveness of affect and at the same time stuck, prolonged nature of negative emotions. Also characteristic are the disinhibition of primitive drives (increased sexuality, voracity, a tendency to vagrancy, alertness and distrust towards adults, a tendency to dysphoria), as well as inertia of thinking.

G.E. Sukhareva draws attention to some somatic features of the two described types. In children belonging to the non-braking type, there are signs of physical infantilism. Children of the explosive type are distinguished by a dysplastic physique (they are stocky, with shortened legs, a relatively large head, an asymmetrical face, and wide, short-fingered hands).

The rough nature of behavioral disorders usually entails pronounced social maladjustment and often the inability of children to stay in preschool child care institutions and attend school (Kovalev V.V., 1979). It is advisable to transfer such children to individual education at home or to educate and educate in the conditions of specialized institutions (specialized preschool sanatoriums for children with organic lesions of the central nervous system, schools with some psychiatric hospitals etc., if any have been preserved). In any case, inclusive education of such patients in a public school, as well as children with mental retardation and some other violations, inappropriate.

Despite this, the long-term prognosis of residual-organic psychopathic conditions in a significant part of cases can be relatively favorable: psychopathic personality changes are partially or completely smoothed out, while acceptable social adaptation is achieved in 50% of patients (Parkhomenko A.A., 1938; Kolesova V.I. A., 1974; and others).

Perinatal damage to the central nervous system includes all diseases of the brain and spinal cord.

They occur in the process of intrauterine development, during the birth process and in the first days after the birth of a newborn.

The course of perinatal CNS damage in a child

The disease occurs in three periods:

1. Acute period. It occurs in the first thirty days after the birth of the child,

2. Recovery period. Early, from thirty to sixty days of a baby's life. And late, from four months to one year, in children born after three trimesters of pregnancy, and up to twenty four months at early birth.

3. The initial period of the disease.

AT individual periods various clinical manifestations perinatal lesions of the central nervous system in a child, accompanied by syndromes. One baby can immediately manifest several syndromes of the disease. Their combination helps to determine the severity of the course of the disease and prescribe qualified treatment.

Features of syndromes in the acute period of the disease

In the acute period, the child experiences depression of the central nervous system, coma, increased excitability, manifestation of convulsions of various etiologies.

In a mild form, with a slight perinatal lesion of the central nervous system in a child, he notices an increase in excitability nervous reflexes. They are accompanied by shudders in silence, muscle hypertonicity, and may also be accompanied by muscle hypotension. In children, there is a tremor of the chin, trembling of the upper and lower extremities. The child behaves capriciously, sleeps badly, cries for no reason.

With perinatal damage to the central nervous system in a child of an average form, he is not very active after birth. The baby does not take the breast well. He has reduced milk swallowing reflexes. After living for thirty days, the symptoms disappear. They are changed by excessive excitability. With an average form of damage to the central nervous system, the baby has skin pigmentation. It looks like marble. The vessels have a different tone, the work of the heart is disrupted - vascular system. Breathing is uneven.

In this form, the child's gastrointestinal tract is disrupted, the stool is rare, the child spits up hard-eaten milk, bloating occurs in the tummy, which is well heard by the mother's ear. In rare cases, the legs, arms and head of the baby tremble seizures.

Ultrasound examination shows in children with perinatal lesions of the central nervous system the accumulation of fluid in the compartments of the brain. The accumulated water contains spino-cerebrospinal fluid, which provokes in children intracranial pressure. With this pathology, the baby's head increases every week by one centimeter, this can be noticed by the mother by the rapid growth of the caps and the appearance of her child. Also, because of the liquid, a small fontanel on the head of the child bulges out. The baby often burps, behaves restlessly and capriciously due to constant pain in the head. Can roll your eyes upper eyelid. The child may show nystagmus, in the form of startle eyeball when placing pupils in different directions.

During a sharp depression of the central nervous system, the child may fall into a coma. It is accompanied by a lack or confusion of consciousness, a violation of the functional properties of the brain. In such a serious condition, the child should be under the constant supervision of medical personnel in the intensive care unit.

Features of syndromes in the recovery period

Syndromes of the recovery period in case of perinatal damage to the central nervous system in a child have a number of symptomatic features: increased nervous reflexes, epileptic seizures, disruption of the musculoskeletal system - locomotive apparatus. Also, in children, delays in psychomotor development are noticed, caused by hypertonicity and hypotonicity of the muscles. With a prolonged course, they cause involuntary movement of the facial nerve, as well as the nerve endings of the trunk and all four limbs. Muscle tone interferes with normal physical development. Does not allow the child to make natural movements.

With a delay in psycho-motor development, the child later begins to hold his head, sit down, crawl and walk. The baby has an apathetic daily state. He does not smile, does not make grimaces characteristic of children. He is not interested in educational toys and in general what is happening around him. There is a delay in speech. The baby later begins to pronounce "gu - gu", cries quietly, does not utter clear sounds.

Closer to the first year of life, with the constant supervision of a qualified specialist, the appointment of the correct treatment, and depending on the form of the initial disease of the central nervous system, the symptoms and signs of the disease may decrease or disappear altogether. The disease carries consequences that persist at the age of one:

1. Psycho-motor development slows down,

2. The child starts talking later,

3. Mood swings,

4. Bad sleep

5. Increased meteorological dependence, especially the condition of the child worsens when strong wind,

6. Some children are characterized by hyperactivity, which is expressed by bouts of aggression. They do not concentrate on one subject, are hard to learn, have a weak memory.

Serious complications lesions of the central nervous system can become epileptic seizures and cerebral palsy.

Diagnosis of perinatal CNS lesions in a child

To make an accurate diagnosis and prescribe qualified treatment, diagnostic methods are carried out: Doppler ultrasound, neurosonography, CT and MRI.

Ultrasound of the brain is one of the most popular in the diagnosis of the brain of newborns. It is done through a fontanel on the head that is not strong with bones. Ultrasound examination does not harm the health of the child, can be performed frequently, as needed to control the disease. Diagnosis can be done in small patients who are hospitalized in the ARC. This study helps to determine the severity of CNS pathology, determine the amount of cerebrospinal fluid and identify the cause of its formation.

Computed and magnetic resonance imaging will help determine little patient problems with vascular network and brain disorders.

Doppler ultrasound will check the blood flow. Its deviations from the norm lead to perinatal damage to the central nervous system in a child.

Causes of perinatal CNS damage in a child

The main reasons are:

1. Hypoxia of the fetus during fetal development, caused by a limited supply of oxygen,

2. Injuries received during birth. Often occur with slow labor and retention of the child in the mother's pelvis,

3. Diseases of the central nervous system of the fetus can be caused toxic drugs used by the expectant mother. Often this medicines, alcohol, cigarettes, drugs,

4. Pathology is caused by viruses and bacteria during fetal development.

Treatment for perinatal CNS damage in a child

If a child has problems with the central nervous system, it is necessary to contact a qualified neurologist for recommendations. Immediately after birth, it is possible to restore the baby's health by maturing dead brain cells, instead of those lost during hypoxia.

First of all, the child is provided with emergency care in the maternity hospital, aimed at maintaining the functioning of the main organs and breathing. Medicines are prescribed and intensive therapy, which includes IVL. Continue the treatment of perinatal lesions of the central nervous system in a child, depending on the severity of the pathology at home or in the children's neurological department.

The next stage is aimed at the full development of the child. It includes constant monitoring by a pediatrician at the site and a neurologist. Drug therapy, massage with electrophoresis to relieve muscle tone. Treatment is also given impulse currents, therapeutic baths. A mother should devote a lot of time to the development of her child, conduct massage at home, walk in the fresh air, fight ball classes, monitor proper nutrition baby and fully introduce complementary foods.