11 - CAHMS Flashcards
What are the different categories of mental disorders within CAHMS?
- Behavioural
- Neurodevelopmental
- Emotional
Can be overlap between them
What is the aetiology of Child Mental Health Disorders?
- Biological: genetic, neurodevelopment, biochemical
- Psychological/Development: attachment, learning, cognitive
- Social: acute and chronic stressors, protective factors, schooling, culture
What are some difficulties with doing a mental state examination on a child?
- Age
- Cognitive ability
- Emotional understanding
- Communication problems
- Willingness to engage
- What they can say with parents present
- Need to see them engaging with parents but may be difficult to engage parents
What are some emotional disorders of childhood and adolescence?
How may GAD present in children and how prevalent is it?
Prevalence increases with age and can continue into adulthood and become OCD
Somatic symptoms common in children
More common if parent has anxiety
How may separation anxiety present in children?
- Anxiety manifest upon separation (or threat of separation) from attachment figures (usually parent, particularly mother)
- Somatic manifestations
- Nightmares with separation themes
- School refusal
What is school refusal and how is it dealt with?
Severe difficulty in attending school, often amounting to prolonged absence with parental knowledge, due to emotional upset and excessive fearfulness, and somatic complaints.
Features: Emotional overprotection, high social class, neurotic parents
Treatment: Liaise with head teacher, parents, and an educational psychologist. Escort by an education welfare officer aids prompt return. Other methods: educational-support therapy, CBT, and parent-teacher interventions
How is GAD treated in children?
- Assess and address environmental triggers: family relationships, friendships, bullies, school pressures, alcohol and drug use
- Mild anxiety: watchful waiting and advice about self-help strategies (e.g. meditation), diet, exercise
- Moderate to severe anxiety can be referred to CAMHS services for: -Counselling, CBT, Fluoxetine
How is OCD managed in children?
- Referral to CAMHS
- Patient and carer education
- CBT
- SSRIs medications (under the guidance of a CAMHS specialist)
What are the 3 key signs of PTSD?
- Hyperarousal e.g poor sleep, irritability, poor concentration
- Reliving e.g acting out with toys
- Avoidance
What is the prevalence of depression in CAHMS and how does it present differently to in adults?
3% of children, 5.6% of adolescents
Features less constant and more subtle:
- •** Mood changes: grumpy or irritable rather than sad. *NOT PERVASIVE
- *•** Thought changes: loss of self-esteem, confidence, and concentration
- *•** Physical changes: reduced energy, sleep, appetite; self-harming behaviour
Impairment of functioning: missing school and social life.
What are some important psychosocial contributions to childhood depression?
- Potential triggers (e.g. loss of a family member)
- Home environment
- Family relationships
- Relationship with friends
- Sexual relationships
- School situations and pressures
- Bullying
- Drugs and alcohol
- History of self harm
- Thoughts of self harm or suicide
- Family history
- Parental depression
- Parental drug and alcohol use
- History of abuse or neglect
What is the biggest concern with childhood depression?
Self Harm
Always ask the patient directly about alcohol and drug use, bullying, abuse, and suicidal thoughts
How is depression in childhood managed?
Mild depression** **or low mood associated with a single negative event (e.g. loss of a family member):
Watchful waiting and advice about healthy habits, such as healthy diet, exercise and avoiding alcohol and cannabis. Follow up within 2 weeks
Moderate to severe depression: Refer to CAMHS
- Full assessment to establish a diagnosis
- First Line: CBT, non-directive supportive therapy, IPT and family therapy
- Second Line: medication
- If do not respond to above then intense psychlogical therapy
- Admission if high risk of self harm, suicide, self-neglect or immediate safeguarding issue
How may depression present in young boys?
Anger
Not pervasive in all areas of life like in adults
What is first and second line antidepressants in CAHMS?
First Line: Fluoxetine
Second Line: Sertraline and Citalopram
Need to be kept on it for 6 months after remission
What tool can you use to monitor depression in CAHMS?
Mood and Feelings Questionnaire (MFQ)
What is the prognosis with depression in CAHMS?
Recovery: 10% at 3 months, 50% at 1 year, and 80% at 2 years
Even after recovery 3% risk of completed suicide over next 10 years
Follow-up monitoring is essential
Psychotic symptoms are common in children as they are part of neurodevelopment. When are they classed as having psychosis and how do you assess this?
Psychotic symptoms for over 4 weeks
Always take collateral history
Important as 20% of schizophrenia starts before the age of 20
What are some causes of psychosis in children?
- Substance abuse
- Psychosis (schizophrenia)
- Anxiety
- Depression
- Hypomania
- Head injury
- Epileptic aura
- SLE
- Anti-NMDA receptor antibody encephalitis
- Alice-in-Wonderland syndrome
How is psychosis in children managed and what is the prognosis?
- Early intervention for treatment plan
- Every treatment plan should include a named worker and incorporate antipsychotics (if indicated) in conjunction with psychoeducational work, psychotherapy (individual CBT and family interventions), and social components
What are conduct disorders?
Disorders characterised by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct that significantly deviate from age-related, socially acceptable norms.
Last over 6 months
Examples of the behaviours: excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience
What is the difference between social and unsocial conduct disorder?
Unsocialised conduct disorder
Disorder characterized by the combination of persistent dissocial or aggressive behaviour with significant pervasive abnormalities in the individual’s relationships with other children
Socialised conduct disorder
Disorder involving persistent dissocial or aggressive behaviour occurring in individuals who are generally well integrated into their peer group e.g gangs, stealing with others
How are conduct disorders diagnosed?
Core Symptoms:
1 Defiance of will of authority (usually police)
2 Aggression
3 Anti- social behaviour (eg property damage, vandalism, theft, truancy)
Three acts must have been exhibited in the last 12 months with at least one present in the last 6 months in multiple places (school, home, community)
What are some risk factors for a conduct disorder?
What is oppositional defiant disorder (ODD)?
Subsection of Conduct disorder with an enduring pattern of negative, hostile, and defiant behaviour without serious violation of societal norms or rights of others
May only be present in one environment and is more evident in interactions with familiar adults or peers
What are the differences between conduct disorders and ODD?
ODD usually not aggressive like conduct
Angry/Irritable Mood
- Losing one’s temper
- Getting easily annoyed
- Feels resentful or angry
Argumentative/Defiant Behavior
- Arguing with others
- Defying rules or requests
- Annoying others deliberately
- Blaming others for one’s mistakes
Vindictiveness
- Being spiteful
How are conduct disorders managed?
- Parent Training Programs
- Individual cognitive therapy for older children
- Multisystemic therapy (eg with young person, family, school, criminal justice system)
What is the prognosis with conduct disorders?
POOR
- 50% will develop antisocial personality disorder
- 50% develop substance misuse issues
- 40% become re-offending juvenile delinquents
What is the prevalence of Autistic Spectrum Disorders and what are some co-morbid conditions?
1% of children
Common to have epilepsy and learning difficulties as well
What is the spectrum in ASD?
One end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others (Asperger syndrome)
On the other end, patients can be severely affected and unable to function in normal environments
What are the features of ASD? (3 sections)
Social Interaction
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
Communication
- Delay, absence or regression in language development
- Lack of non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
Behaviour
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements such as hand-flapping or rocking that can be self-stimulating to soothe themselves
- Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine
- Extremely restricted food preferences
How is a diagnosis of autism made?
Need detailed history, collateral from school, and observation across different settings
- Symptoms must be present before 3 years of age
- Symptoms need to occur in more than one environment
What tools can be used to aid the diagnosis of ASD?
- Autism Diagnostic Observation Schedule (ADOS)
- Developmental, dimensional, and diagnostic interview (3di)
What are some management options of ASD?
- Early intensive behavioural intervention and speech therapy
- Parent training
- Support: eg National Autism Society
- Social skills training
- Drugs: risperidone (agression), melatonin (sleep), and SSRIs (repetitive behaviour)
What is the prevalence and aetiology of Attention Deficit Hyperactivity Disorder?
3-5% of children
80% genetically inherited, issue with reduced activity in the frontal lobe, resulting in problems with executive function
What is the core diagnostic criteria of ADHD?
- Impulsivity
- Inattention
- Hyperactivity
Needs to occur in more than one environment and can be diagnosed after 6 years old
What are some differentials for ADHD?
- Low/High IQ
- Hearing impairment
- Conduct disorders
What are some common features of ADHD?
- Very short attention span
- Quickly moving from one activity to another
- Quickly losing interest in a task and not being able to persist with challenging tasks
- Constantly moving or fidgeting
- Impulsive behaviour
- Disruptive or rule breaking
How is ADHD diagnosed?
- History inc collateral from school and parents
- Observation in different settings
- Screen for organic causes
What is the prognosis with ADHD?
- ⅔ carry on symptoms into adulthood
- Emotional volatility and anxiety in adulthood
What is a common comorbidity with ADHD?
Neurodevelopment difficulties e.g Dyslexia
Others: oppositional defiant disorder (ODD), conduct disorder, depression, mania, anxiety, substance misuse
How is ADHD managed?
- Parental and child education: positive parenting and behavioural techniques
- Establishing a healthy diet and exercise with food diary to find trigger foods
- Medication is an option after conservative management has failed or in severe cases (Methylphenidate 1st line)
What are the three medications used in ADHD?
CNS Stimulants given first line if severe ADHD:
- Methylphenidate: short or long-acting stimulant
- Atomoxetine
- Guanfacine
What do you need to advise parents when prescribing Ritalin (Methylphenidate)?
- Do not give it to them at weekends or school holidays as suppresses appetite so can stunt growth
- Need to beware of risk of substance abuse and of street value of the drug
How long does Atomoxetine take to work for ADHD?
6 weeks but can still have effects after withdrawal of drug so better than Methylphenidate that is just on/off
Why are modified release methylphenidate and lisdexamfetamine preferred?
- Convenience
- Improved adherence
- Reduced risk of drug diversion
- Lack of need to be taken to work
Use for 6 weeks and if both do not work separately after 6 weeks then consider Atomoxetine
What is Tourette’s?
Development of tics that are persistent for over a year
Tics are involuntary movements or sounds that the child performs repetitively throughout the day. Tics are more pronounced when person is excited or under pressure
Tics often present around or after 5 years of age
What are some common comorbid conditions with Tourette’s?
- OCD
- ADHD
How is Tourette’s managed?
Usually will improve over time
Mild: Reassure and monitor. Reduce stress, anxiety and triggers
More severe or troublesome tics: refer to a specialist They may benefit from:
- Habit reversal training
- Exposure with response prevention
- Medications usually with antipsychotic medications
- Co-morbid conditions such as OCD and ADHD may benefit from treatment
How is ADHD managed?
- Parental and child education: positive parenting and behavioural techniques
Establishing a healthy diet and exercise can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician
Medication is an option after conservative management has failed or in severe cases. This should be coordinated by a specialist. Contrary to what you might think, they are central nervous system stimulants. Examples are:
- Methylphenidate (“Ritalin“)
- Dexamfetamine
- Atomoxetine
