Consultative-diagnostic and psycho -correctional assistance to children with social functioning disorders (tics, enuresis, stuttering)
Methodological recommendations were approved at a meeting of the Academic Council of the Federal State Budgetary Institution “GNTSSSP im. V.P. Serbian” of the Ministry of Health of Russia on December 7, 2012, Protocol No. 11.
N.V. Simashkova – Doctor of Medical Sciences, Head of the Department for the Study of Child Psychiatry Problems with the Child Autism Research Group of the Scientific Center for Mental Health of the Russian Academy of Medical Sciences;
E.V. Koren is a Candidate of Medical Sciences, Head of the Department of Childhood Mental Pathology of the Federal State Budgetary Institution MNIIP of the Ministry of Health of Russia. M15 Makushkin E.V., Retyunsky K.Yu., Shalimov V.F., Kalacheva I.O. Consultative-diagnostic and psycho -correctional assistance to children with social functioning disorders (tics, enuresis, stuttering):
Guidelines. – M.: FGBU “GNTSSSP im. V.P. Serbsky ”Ministry of Health of Russia, 2013. – 19 p. The paper presents the clinical and dynamic features of systemic disorders in childhood and adolescence (on the model of tics, enuresis, stuttering).
Clinical criteria for early diagnosis of systemic disorders with a protracted unfavorable course were determined. A new technology of medical- psycho -social rehabilitation has been developed. For health care organizers, heads of psychiatric institutions, researchers, child psychiatrists, clinical psychologists, educators and social workers.
List of abbreviations and symbols of terms
ICD-10 – international classification of diseases of the 10th revision;
PS, pathological system; SR, systemic disorders;
RIP – general intellectual indicator;
CEEG – computerized electroencephalography.
Currently, systemic disorders are considered as a clinical group and are classified as borderline psychogenic diseases.
Epidemiological studies of recent years indicate a rapid increase in the number of borderline neuropsychiatric disorders in the child and adolescent population of the Russian Federation.
The leading place among them is occupied by non -psychotic mental disorders of residual organic origin. Under the influence of various pathogenic factors of external and internal order, acting in the prenatal, perinatal and early postnatal periods, the reactivity of the damaged brain changes, the functional decompensation of which is manifested by clinically pronounced borderline states.
From the standpoint of the ontogenetic approach, the dynamics of borderline disorders and their comorbid disorders is fully determined by the age stage of the neuropsychic response.
In ICD-10, a significant part of borderline disorders of early age is given in section F9: “Other behavioral and emotional disorders that usually begin in childhood and adolescence”, among which most of the syndromes in domestic child psychiatry were considered as manifestations of neurotic and neurosis-like disorders. These, in particular, included the so-called “systemic” or ” monosymptomatic ” neuroses, represented by isolated or dominant monosymptoms .
The identification of various forms of systemic neuroses was due to the fact that their pathogenesis and clinical picture are due to disturbances in the activity of somatic functional systems, multilevel complex reflex formations.
At the same time, the constitutional (genetically determined) “weakness” of one or another functional system predetermines the selectivity of disorders.
Clinical-psychopathological and clinical-dynamic study of systemic neuroses suggests that their protracted course is determined by the influence of “soil” factors, primarily residual -organic cerebral insufficiency resulting from early brain damage.
The most common systemic disorders in the pediatric population include tics, enuresis, and stuttering.
The frequency of tic disorders and enuresis in children aged 3-6 years varies from 10 to 20%, stuttering – 3-7%. Upon reaching adolescence and adulthood, these SRs persist throughout life in 1–2% of the population.
The basis for the syndromological approach to the classification of tics (F95), inorganic enuresis (F98.0) and stuttering (F98.5) into the heterogeneous group F9 of the ICD-10 innovative approach was the age of manifestation of SR and their clinical content.
Unfortunately, as practice has shown, symptomatic therapy of these disorders is not very effective. In this regard, the study of pathogenetic patterns and the creation of optimal methods for the treatment of such disorders from the position of the biopsychosocial approach at the present stage seems to be quite promising.
The protracted course of SR has a serious impact on the development and formation of the child’s personality, disrupts social functioning and ensures persistent social maladaptation.
A serious obstacle in solving the problem of tics, enuresis, stuttering is the lack of knowledge of the etiology and pathogenesis, the principles of therapy that have not been fully developed, and, as a result, the low effectiveness of treatment.
Optimization of the treatment and rehabilitation process of children and adolescents with SR requires the development of methods for their treatment and prevention in out-of-hospital, consultative medical institutions, including a multiprofessional and interdepartmental approach, based on the primary links of the general somatic service.
The purpose of these recommendations was to identify the clinical and dynamic features of systemic disorders in childhood and adolescence (on the model of tics, enuresis, stuttering), describe the clinical and paraclinical patterns of their occurrence, dynamics for the development of a pathogenetically oriented program of complex medical and psychological and pedagogical rehabilitation measures.
In accordance with the goal, the clinical patterns of the occurrence and dynamics of tics, enuresis and stuttering in the ontogenetic aspect were studied; a typology of comorbid conditions was developed for tics, enuresis and stuttering, depending on the age levels of the neuropsychic response.
With the help of neurophysiological, neuropsychological and ultrasound methods of diagnostics, the features of the pathogenesis of clinical forms of these systemic disorders were studied. A comprehensive program of treatment and rehabilitation measures for children and adolescents with SR has been developed.
287 children and adolescents of both sexes aged 6 to 17 years with SR were subjected to a comprehensive clinical and paraclinical study (main group).
Inclusion criteria: SD (tics, enuresis, stuttering) in children and adolescents that meet the ICD-10 diagnostic criteria; the duration of the continuous flow of SR from the moment of manifestation is at least 3 years;
IIP on the Wexler scale in all cases is not lower than the average level (90–109 points); resistance to previous therapy (lack of significant improvement or stable remission).
Exclusion criteria: symptomatic forms of tics, enuresis, stuttering resulting from structural brain damage in the aftermath of meningoencephalitis, acute poisoning, traumatic brain injury, acute cerebrovascular accident, drug use, mental retardation, neurodegenerative diseases of the central nervous system, epilepsy and schizophrenia.
A control comparison was made with similar indicators of 30 children and adolescents of the same age who attended general secondary schools.
Considering the age-comparative (ontogenetic) approach to the study, patients with SR were divided into age subgroups. The clinical method is the main one and includes clinical-anamnestic, clinical-psychopathological, clinical- dynamic and clinical-catamnestic studies.
Setting the goal and objectives of the study required a deeper analysis of all factors, biological and environmental, influencing the occurrence, clinical dynamics of SR and comorbid neuropsychiatric disorders, depending on the age stages of the neuropsychic response.
Evaluation of neurological examination is necessary to verify residual -organic cerebral insufficiency in individuals of the main group.
The psychological study included an assessment of intelligence in all age groups using the Wechsler test.
Quantitative and qualitative evaluation of the results made it possible to judge not only the level of intellectual development, but also its structure.
Topical diagnosis of brain lesions and structures of interhemispheric interaction was carried out using the methodology of adapted neuropsychological research developed by the All-Russian Center for Child Neurology, intended for children of preschool and primary school age.
CEEG was used as an effective method for determining the degree of changes in the functional state of the brain, the localization of the lesion, the dynamics of the pathological process, as well as the computer system for neurophysiological diagnostics “ Nicolet Bravo Spirit” modified in 1998–99, capable of recording the bioelectrical activity of the brain with induced somatosensory, visual, sound potential.
Clinical and dynamic features of the course of SR (on the model of tics, enuresis and stuttering) in children and adolescents The clinical method of research in all age groups makes it possible to establish a high probability of hereditary transmission of these disorders.
In almost every fifth case (18.0–19.3%), one of the parents suffered from tics, enuresis, or stuttering, which did not contradict the existing concept of a genetic predisposition to these disorders.
Attention is drawn to the fact of the high prevalence of pathogenic factors (90.5–93.7%) in the pre- and perinatal period, causing residual -organic cerebral insufficiency and reducing the protective and adaptive mechanisms of brain activity. Thus, in more than half of the cases in the main group, mothers during pregnancy showed an exacerbation of extragenital pathology.
The intrauterine period of development of children of the main group in most cases was complicated.
Pathology of pregnancy was characterized by toxicosis of 1-2 halves, nephropathy, threat of premature termination (67.5-77.9%) ( P < 0.05).
The prevalence of perinatal pathology in the SR group was high. Pathological births were often accompanied by fetal asphyxia and perinatal trauma.
Thus, 85.5% of children from the tics group, 74.7% from the enuresis group, and 81.7% from the stuttering group were discharged from the maternity hospital with a diagnosis of perinatal encephalopathy ( P < 0.05).
Features of the psychophysical development of children depend on the influence of these pathogenic factors. It can be assumed that the psychopathological features of the early stages of ontogenesis reflect the clinical picture of age-related manifestations of residual organic disorders.
So, the somatovegetative period (up to 3 years) was characterized by timely psychophysical development against the background of a neuropathic symptom complex, structurally related to the concept of organic or residual neuropathy with monotony and stability of clinical manifestations, the presence of residual neurological symptoms, including signs of intracranial hypertension with vegetative-vascular and vestibular violations.
Organic neuropathy is manifested by increased general and autonomic excitability, a tendency to digestive disorders, nutrition, sleep. Starting from the age of 3 years, the psychomotor stage of the neuropsychic response, against the background of a gradual easing of neuropathic symptoms, asthenohyperdynamic manifestations of varying severity increased, causing hyperkinetic behavior with impaired attention function.
The initial manifestations of residual -organic disorders in the form of vestibular disorders are observed already from the age of 4.
Subsequently, cephalgia of a diffuse nature joins, more often in the afternoon against the background of physical fatigue, provoked by vestibular loads, meteorological lability , being in a hot and stuffy atmosphere and other factors.
Often there are fainting states.
Affective disorders, represented by irritable weakness syndrome, are manifested by increased irritability, high sensitivity and sensitivity to external psychostress factors, tearfulness, whims, and sometimes spontaneous episodes of explosive outbursts against the background of fatigue.
The monotony and persistence of clinical manifestations, regardless of psychotraumatic factors, allows us to classify them as neurosis-like disorders of a residual -organic nature.
As the study showed, the occurrence of tics, secondary enuresis, persistence of primary enuresis and stuttering in all cases occurred against the background of comorbid disorders of the psychoorganic circle, mainly at the age of 3–8 years.
With stuttering, in 82.6% of cases, the manifestation of primary speech convulsions occurred from 3 to 4 years. The course of the disorder was neurosis-like in nature and was manifested by clonic, and subsequently clonic- tonic speech convulsions.
“Light” intervals, periods of smooth speech were practically not observed. Tics occurred between the ages of 5 and 8 years (85.5%). Their course was chronic non- remission or recurrent.
With a relapsing course, periods of complete remission were spontaneously replaced by an exacerbation.
The non-remission course was characterized by stereotypy and monotony of clinical signs. Tics were represented by involuntary, predominantly blinking movements; synkinesis with involvement of the muscles of the shoulder girdle was less common.
Diagnosis of primary enuresis, according to ICD-10, is carried out from the age of 5 years. In this regard, secondary enuresis was of greater interest, the manifestation of which occurred at the age of 4 to 8 years (in half of the cases – from 5 to 6 years).
The frequency and intensification of the clinical manifestations of SR was noted against the background of infections, frequent colds, emotionally intense situations, overwork, disruption of the usual sleep-wake regime, and had a seasonal condition (autumn-spring period).
It should be noted that in some cases tics, enuresis and stuttering were combined disorders.
The presence of sympathetic systemic disorders could indicate a more widespread localization and severity of brain damage, which generally complicated the treatment and made the prognosis more difficult.
In addition, in the case of combined SR in adolescence, secondary neurotic disorders more often acquired a generalized character, increasing maladaptation.
The age factor of pathogenesis, which, according to V.V. Kovaleva, not only the nature of the predominant productive symptoms, but also the clinical form of mental illness, again modifies the appearance of those suffering from SD at the age of 7–8 years.
This period is remarkable in that, firstly, it coincides with the second critical age period, the beginning of the formation of self-consciousness, the ability to self-assess subjective experiences, and, secondly, the fact that an affective level is superimposed on the psychomotor level of neuropsychic response.
In addition, the beginning of schooling coincides with the second critical age period.
cerebrosthenic complaints in children , the appearance of behavioral disorders are naturally due to age-related decompensation of residual -organic cerebral insufficiency and a change in life stereotype that requires adaptation to increased psychophysical stress and intellectual stress in a new school life for the child.
The main difficulties in the assimilation of new educational material by children suffering from SR are associated with impaired active attention, restlessness, disinhibition and a low level of working capacity, significant exhaustion.
The affective instability of children, manifested by increased irritability, explosive outbursts, tearfulness and a tendency to whims, led to violations of discipline.
Increasing fatigue, a decrease in interest in the lesson is accompanied by an inability to understand the essence of the material being explained by the end of the lesson, which makes it difficult to successfully master the school curriculum.
Incorrect pedagogical measures of influence easily provoke the formation of oppositional pathocharacterological reactions, violating the already weak adaptive capabilities.
At the same time, there is an increase in speech convulsions during stuttering, generalization of tic manifestations, an increase in episodes of enuresis in combination with an increase in cephalgic syndrome, fatigue in the evening, drowsiness in the afternoon, sleep and appetite disorders.
psychoorganic disorders of varying severity were observed in 85.0–88.0% of children with SR.
Affective disorders in children with SR at the age of 7–10 years are mainly represented by irritable weakness, episodes of unreasonable, short-term (no more than 5–10 minutes) quickly exhausted emotional outbursts with irritation, tearfulness, protest reactions, and verbal aggression.
Most children retain a critical attitude towards inappropriate behavior with sincere remorse and experiencing a sense of shame after an affective episode.
Reactions of the excitable circle in children with SR quickly become fixed, influencing the formation of characterological features.
Thus, in children with stuttering (35.8% of cases), tics (50.6%) and enuresis (41.1%), the leading characterological features from school age were conflict, stubbornness, selfishness and vindictiveness.
Spontaneously occurring states of depressed mood were observed with increased irritability, captiousness, sullenness, explosiveness and anger.
Paroxysmal conditions lasting from several minutes to 2 hours occurred with a frequency of up to 3-4 times a month.
According to the clinical content, affective disorders should be attributed to dysphoric conditions.
Along with the indicated affective disorders in children with SR, starting from the age of 7, in most cases (67.5–74.7%), the formation of secondary neurotic reactions is observed.
Their peculiarity consisted in short duration, instability, syndromal incompleteness, low degree of severity.
The final structuring of secondary neurotic disorders in SR occurs at the turn of 12–13 years.
The structure of the depressive- phobic syndrome is represented by four main features.
1. The presence of so-called monosymptomatic disorders that support a neurotic disorder. Speech stuttering in stuttering, tic muscle contractions in tics, involuntary urination during sleep in enuresis.
2. Phobic component. In stuttering with a protracted course, starting from the age of 7, logophobic reactions of varying severity were determined, represented by an incomplete structure of the syndrome. The reactions were short-lived and unstable.
Excessive excitement was manifested only during the onset of speech convulsions. Upon reaching the age of 11–12 years, a pronounced fear arose already when waiting for speech situations with attempts to limit communicative activity.
Children avoided any opportunity to communicate in unusual conditions, in the presence of a large audience, in an emotionally charged situation.
By the age of 12, logophobic reactions acquired syndromic delineation , due to the appearance of an ideator component – the fear of making an unfavorable impression on the listeners, of not being able to express a thought. With tics with a protracted course, starting from 7–8 years, short-term phobic reactions of varying severity were also determined.
A chronic state of anxiety due to the fear of making a bad impression on others with involuntary impulsive movements upon reaching the age of 11–12 was accompanied by a fear of waiting for a communication situation.
In this connection, children with tics preferred to be in familiar conditions, in the circle of close and familiar faces, avoiding emotional situations. With enuresis with a protracted course, neurotic reactions in the form of short-term fears of the possibility of revealing one’s illness, being exposed by others, began to manifest themselves from the age of 7.
By the age of 12, the formed ideational component in the form of fear of disclosing the innermost secret of one’s illness, making a bad impression on others and becoming rejected among peers created all the conditions for the transformation of neurotic reactions into a neurotic state.
3. The subdepressive reaction of the individual to a specific failure, as a rule, reaching only a subdepressive level.
4. Passive-defensive reactions in the form of avoiding behavior. In stuttering, avoidance behavior is explained by the desire of children and adolescents to exclude or limit speech as much as possible in an emotionally rich situation, which could weaken logophobic experiences.
Children and adolescents with tic disorder with concomitant avoidance behavior reduced the intensity of phobic experiences by limiting the very possibility and time of demonstrating their uncontrolled movements.
Passive-defensive reactions in enuresis were aimed at eliminating the very possibility of night or daytime sleep outside the home and the environment of close family members who are familiar with the child’s problem.
Such disorders are related to phobias of moral and ethical content. The severity of neurotic experiences increases significantly when the child is teased by peers, having learned about his violation.
This category of children primarily needs psychotherapeutic assistance.
The teenage period was characterized by significant compensation of cerebrasthenia with the dominance of secondary neurotic symptoms with a tendency to generalization, with stuttering – in the form of an isolated logophobic syndrome, with enuresis and tics – asthenophobic syndrome.
Complex pathogenetic psychopharmacotherapy of systemic disorders
Based on the above considerations, the principles of complex psychopharmacotherapy of SR in children and adolescents are formulated.
At the same time, scientific provisions on the treatment of epilepsy and organic brain diseases, developed by leading domestic researchers, were taken into account.
Principle 1. Early intervention “at the origin of the disease”. Delay in treatment leads to stabilization of intracerebral PS, chronic SR, and increased therapeutic resistance. Persistent SR during puberty determine the manifestation of secondary neurotic disorders and social maladaptation of adolescents.
Principle 2. Pathogenetic validity and complexity of therapy. Complex pathogenetic psychopharmacotherapy is aimed at eliminating PS and restoring the functional activity of brain structures.
Dyscirculatory disorders, cerebrospinal fluid syndrome distension , residual lesions of brain structures in SR lead to neurometabolism disorder , maintaining PS. In this regard, it seems logical to use simultaneously nootropic, vascular, dehydration , biostimulating agents that have a specific effect on all links of pathogenesis.
as the key pathogenetic agents for the treatment of SR and sympathetic neuropsychiatric disorders of the psychoorganic circle.
If necessary, treatment can be supplemented with agents that eliminate metabolic, allergic, neurohumoral disorders, etc.
Treatment of concomitant pathology should be recognized as mandatory. Chronic infections, somatic diseases, weakening the body’s defenses, impede compensatory processes.
Principle 3. Individualization of medicines and their dosages. The greatest difficulty in the initial period of therapy is associated with the selection of drugs and the determination of individual dosages, depending on a number of factors, such as age, physiological characteristics of the patient, toxicity of drugs and their side effects, the nature of the course and the severity of tics, enuresis, stuttering and comorbid neurological disorders . mental disorders.
Principle 4. Continuity and duration of therapy. The effectiveness of therapy for SR and comorbid neuropsychiatric disorders to a large extent depends on the ability of the functional systems of the brain to restore and regulate physiological functions.
The terms of recovery with adequately selected therapy are determined by the prevalence and severity of damage to neuronal fields. The three-phase model of SR therapy reflects current treatment technology.
In the initial acute phase of therapy, more than 50% of symptoms are reduced by the end of 6 weeks; by the end of 8–12 weeks, complete remission can be achieved in the vast majority of cases.
From this moment, an ongoing phase of therapy (2 years) begins, aimed at achieving high quality remission.
The main task of the maintenance ( anti-relapse ) phase of therapy is to prevent the recurrence of the occurrence of SR and the disorders that commiserate with it.
The duration of the maintenance ( anti-relapse ) phase is at least 1.5–2 years. Taking into account the peculiarities of the clinical course of SR in each individual case, the terms of treatment are determined by the doctor.
1. Psychological correction. The choice of psychological correction techniques is determined by the purpose and objectives of the treatment process. In complex rehabilitation work with children and adolescents suffering from stuttering, tics and enuresis, the most effective are behavioral, cognitive-behavioral, suggestive methods in terms of group and individual psychotherapy.
The strategy of the psychotherapeutic process is built taking into account the indicated consequences of the disease, the individual psychological properties of the patient, and the motivation for treatment.
In childhood, special importance is attached to family psychotherapy. The family is the main source of neurotic states in children and adolescents.
The emerging emotional system, immature personality structures of children and adolescents with systemic disorders against the background of residual -organic cerebral insufficiency become an easily vulnerable target of conflict in conditions of family disintegration.
Chronic psychogeny causes an overstrain of the child’s adaptive capabilities, which leads to a breakdown of biological mechanisms.
The use of various structured family therapy techniques is aimed at overcoming the disharmony of interpersonal interaction in the family, restoring the family hierarchy and uniting parents for the sake of caring for their child.
In adolescence, a powerful means of changing the system of relations of an emerging personality, correcting inadequate reactions and forms of behavior for the sake of restoring full-fledged social functioning is group personality-oriented psychotherapy of systemic disorders.
Individual work only complements group methods. In the course of group classes for systemic disorders, functional trainings are successfully used, during which general and specific tasks caused by the disorder are solved.
For example, the elimination of fixation on a specific defect, the restructuring of communicative behavior, the acquisition of flexible interaction skills using the language of non-verbal signals, the desire for dialogue, the synthesis and restoration of harmony in verbal and non-verbal communication, changes at all levels of activity, from motivational to behavioral.
Behavioral therapy is aimed at developing social interaction skills. It includes directive behavioral techniques such as goal setting, modeling, sandplay therapy, behavioral repetition, reinforcement, and homework.
Behavioral therapy is carried out by a specially trained medical psychologist.
2. Biofeedback (learning auto-correction of brain activity).
3. Neuropsychological correction. The justification for the expediency of using neuropsychological correction is the numerous violations of higher mental functions in systemic disorders.
A systematic approach to neuropsychological correction consists in the application of cognitive and motor methods in a hierarchized complex, taking into account their complementary influence.
Body-oriented, ethological, theatrical and psychotechnical techniques adapted to childhood are used.
A set of exercises is used, including stretching, breathing exercises, oculomotor exercises, exercises for the tongue and jaw muscles, cross (reciprocal) bodily exercises, exercises for the development of hand motor skills, exercises for relaxation and visualization, functional exercises, exercises for the development of communicative and cognitive spheres.
The main goal of neuropsychological correction is the activation and development of all higher mental functions.
Classes vary in time and quantity.
The minimum number of lessons for the 1st course is 15–20.
Homework is supposed to be done with one of the parents or relatives of the child.
4. Speech therapy correction is prescribed if necessary for violations of speech development, sound pronunciation.
When stuttering, general didactic techniques, breathing exercises, etc.
5. Psychoeducational work with the family.
Work with the family includes psychoeducational programs (explaining to parents the main methods of the essence of the disorder and its treatment, the features of building interaction with a sick child, resolving behavioral problems).
Not only children, but also their parents need help, including psychotherapeutic support, learning how to get out of a crisis situation, and how to constructively interact with all family members.
6. Psychosocial therapy.
The role of psychosocial therapy will increase in adolescence, when problems due to social maladjustment begin to form.
Psychosocial therapy cannot be managed only by the methods and methods of influence that are available in psychiatric institutions.
It is necessary to provide medical, psychological and social support for a child or adolescent together with his family on the basis of interdepartmental and interprofessional interaction.
Psychosocial therapy includes the restoration or formation of insufficient cognitive, emotional, motivational-volitional resources of the individual in the conditions of a particular society, the skills of conflict-free communication with others, and the prevention of socio-psychological deformation of the individual.
It requires the creation of a therapeutic environment, training in communication and social skills, measures to increase responsibility for one’s social behavior, work to improve the social functioning of patients in the family, school, informal groups, measures for social and legal protection and support for patients.
Thus, the complex use of drug and non-drug methods of treatment in combination with neuropsychological and psychological and pedagogical correction, social work with the family and the patient is the basis of the treatment and rehabilitation approach for MS (tics, enuresis, stuttering)
The effectiveness of an integrated approach to the diagnosis, treatment and rehabilitation of children and adolescents with SR
With tics, recovery was observed in 65% of cases, a significant improvement in 10%, a slight improvement, or a complete absence of positive dynamics, was noted in 25% of children and adolescents.
With enuresis, a complete cure was achieved in 75% of cases, a significant improvement – in 15%. A slight improvement, or a complete absence of positive dynamics , was established in 10% of cases.
With stuttering, recovery occurred in 55% of cases, a significant improvement in 25%. A slight improvement or complete absence of positive dynamics was detected in 20% of cases.
A follow-up study for 2-3 years in 42.8% of the total number of patients made it possible to establish the number of relapses: in the “stuttering” group – 35-40%, in the “tics” group – 25-30%, in the “enuresis” group ” – 15–20%.
The analysis of the data obtained convincingly showed that the main cause of relapses of SR should be attributed to a violation of the therapy regimen ( compliance ).
This rehabilitation approach in the treatment of SR can be carried out with great success not only in specialized inpatient departments.
Polyprofessional teams are most effective in school and psychological centers.
The organization of such a form of work is expedient and cost-effective.