16. Child & Adolescent Psychiatry Flashcards by Amanda Sim

Autism is characterised by

Repetitive restricted behaviour
- restricted interests
- routines/rituals
Communication difficulty*
- delayed verbal development
- conversation cannot be sustained
Impairment in social interaction
- difficulties demonstrating appropriate behaviour
- difficulties a/w non-verbal comms used for social interactions
- difficulties a/w failure to initiate or adapt to social interactions

*refer for hearing test, speech therapist for ix

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Clinical features of Autism

Attach to odd objects
Unusual mannerism
Thought without creativity
Injury: self biting
Stereotypies (hand flapping, nodding, rocking)
Motor incoordination

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Aetiology of Autism

Genetics
Chromosome
Congenital infections/diseases

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Onset of autism

Before the first 3 years of life

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Instruments used to evaluate autism

Autism Diagnostic Observation Schedule (for patients)
Autism Diagnostic Interview (for parents)
Child behaviour checklist
IQ test (performance IQ > verbal IQ)

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Children with ASD with the following features should have a genetic evaluation

Micro/macro-cephaly
Positive family history (of a genetic syndrome)
Dysmorphic features

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EEG should be considered if any of the following are present

Clinical seizures
Sx suggestive of sub-clinical seizures eg. staring spells
Hx of developmental regression

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Non-pharmaco management of autism

Individualised intervention plan
Alternative augmentative communication systems
Visual strategies
Social skills programme

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Pharmaco management of autism

Fluvoxamine: for repetitive thought
Risperidone: for irritability, hyperactivity and stereotypic behaviour
Methylphenidate
Melatonin: for disturbed sleep patterns

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Autism vs Asperger’s syndrome (High functioning ASD)

Asperger’s syndrome:
- M:F is 9:1
- communication is not affected, normal language development
- Verbal IQ > performance IQ (reverse in autism)

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3S treatment for Asperger’s syndrome

SSRI
Structured programme orientated treatment
Social skill training

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Attention Deficit and Hyperkinetic Disorder

Intention and/or impulsivity and hyperactivity
- impair function in more than 2 setting (eg. school and home)

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Onset of ADHD

Before 12 years old

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Symptoms of Inattention

SOLID

Starts tasks without finishing through
Organisation of tasks impaired
Lose important things
Instructions not followed
Distraction by external stimuli

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Symptoms of hyperactivity and impulsivity

WORST FAIL

Waiting for turn causes frustration
On the move most of the time
Restless and jittery
Squirms when seated
Talks excessively without appropriate response to social constraints

Fidgets with hands and feet
Answers blurted out before questions
Interruption of others’ conversations
Loud noises when playing

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Screening for parents and teachers to use

Connor’s Performance Test
Connor’s Rating Scale

Pharmacological treatment for ADHD

FIRST LINE: Methylphenidate (stimulant)
- Ritalin
- Concerta (long-acting)

Second line:
Atomoxetine (non-stimulant)

MOA of methylphenidate (stimulant)

Dopamine reuptake inhibitor and direct release of dopamine

S/E of methylphenidate (stimulant)

Appetite loss
Growth suppression
HTN, tachy
Tics, anxiety, psychosis symptoms
Headache, insomnia

MOA of atomoxetine (non-stimulant)

Noradrenaline re-uptake inhibitor

Non-pharmacological management of ADHD

Training/reeducation programmes
- CBT, social skills training
Behaviour therapy
- positive reinforcement, environmental modification

Monitoring of ADHD is done…
What to look out for?

every 6 months
Cardiac and growth suppression,
suicide and self harming

Management of tics due to stimulant use

Monitor for 3 months
Reduce dose of psychostimulant
Substitute with atomoxetine
KIV antipsychotics

Oppositional defiant disorder

Irritable mood:
- lose temper easily
- annoyed easily
- always angry and resentful

Argumentative behaviour:
- trouble with authority figures
- defiant towards requests made by authority figures
- annoys others
- blames others for his mistakes

Vindictiveness: spiteful or vindictive at least twice within the past 6 months

At least 6 months in duration
4/8 symptoms

Conduct disorder

Aggression to people and animals - bullies, threatens, intimidates - start fights - use weapons in fights - forces another person into sexual activity - commits a crime Destruction of property - fire setting to cause damage - destroyed other's property Deceitfulness or theft - break into someone's property or car - lies to obtain favours - stolen objects of value Serious violations of rules - run away from homes - truants - staying out at night despite parental prohibitions

Risk factors of conduct disorder

More common in boys Lower social economic status Large family size, overcrowding School factor Poor relationship with parents

Management for conduct disorder

Behaviour therapy Stimulant medication for hyperactivity Lithium with outburst Family therapy Parent management training Consistent parenting Positive reinforcement of positive behavior Take video to analyze conflict

Enuresis

1. Repetitive involuntary or intentional voiding of urine into bed or clothes 2. At least 2 times a week for the past 3 months - functional impairment - diagnosis can only be made for children of at least 5 years of age

Encopresis

1. Repetitive involuntary or intentional passage of faeces 2. At least once a month for the past 3 months - functional impairment - diagnosis can only be made for children of at least 4 years of age

Separation Anxiety Disorders of Childhood

- Unrealistic persistent worry (harm befalling on attached figure, anticipatory symptoms) - Daytime symptoms (refusal to go school, physical sx) - Nighttime symptoms (refusal to sleep, nightmares) Onset is before 6 years of age, duration is at least 4 weeks

Gillick competence

Child below 16yo can give consent to treatment without parental agreement provided that the child has achieved sufficient maturity to understand the treatment fully - child has no right to refuse treatment that is his or her best interest

When to use atomoxetine over methylphenidate?

- inability to tolerate the side effects - poor response - history of substance misuse

Pediatric autoimmune neuropsychiatric disorder associated with streptoccocal infections

- affects males > females - associated with emotional lability, separation anxiety, cognitive deficits, oppositional behaviours - choreiform movements or motor hyperactivity - relapsing remitting episodic course - prepubertal age of onset - neuroimaging shows increased basal ganglia volumes - OCD &/or tic disorder

Tx for MDD in adolescents

Fluoxetine, escitalopram