3- Child and adolescent psychiatry Flashcards
what is childhood and adolescent psychiatry
What is it?
- Disorders which are usually identified in childhood and adolescence or are specific to that developmental period
- Usually multifactorial
categorisation of childhoold and adolescent psychiatry
- behavioural
- neurodevelopmental
- emotional
aetiology of childhoold and adolescent psychiatry
Very multifactorial and cumulative. Factors are precipitating and perpetuating
Significant influences
- Parents and family
o Type of parenting/family structure
- School
o Academic success/ failure
o Friendships
o Bullying
- Culture
RF for childhood psychiatric disorders: Biological
o Temperament
o Genetic
o Neurodevelopmental
o Biochemical
RF for childhood psychiatric disorders: developmental/psychological
o Attachment (very important)
o Learning
o Cognitive
o Emotional
RF for childhood psychiatric disorders: social/environmental
o Acute stressors
Trauma
Accident
Illness
Death
o Chronic adversity
Socio-economic
Parental mental illness
Parental loss
Family conflict- violent
Parenting
Abuse (phys sexu, emotional)
Exposure to community violence
protective factors
- Temperament
- Coping strategy
- Problem solving
- Self esteem
- Stability
- Secure relationships and friendship
- Achievement
How childhood can be divided
- Under 5s
- Childhood
- Adolescence >12 years
Child mental health services
- Health services
o Specialist services
o Universal services - Local authority
o School based services
o Community based services - Voluntary sector
- Services often changing
Emotional disorders of childhood and adolescence
- GAD
- Separation anxiety disorder
- Phobic disorders
- OCD
- PTSD
- Depression
Neurodevelopmental disorders (NDD)
refer to conditions that have an onset in the developmental period and lead to impairment of important brain functions such as memory, emotion, learning, self-control, and social interaction. These conditions often co-exist (or associate with) a known medical condition (e.g. epilepsy), genetic condition (e.g. fragile X syndrome), or environmental factor (e.g. perinatal infection or hypoxia).
Examples of neurodevelopmental disorders
- ASD
- ADHD
- ID/LD
- Specific learning disorders
Assessing child mental health
What affects when children present?
- Age
- Frequency
- Severity
- Individual characteristics or temperament
- Impact on others
- Family/social circumstance
Important to assess for:
- Child disorders
- Childs development
o Physical
o Social
o Emotional
o Cognitive
o Moral
- Family relationships
History and observation
- Certain elements have greater relevance
- Present/Hx presenting complaint
- Development Hx
- Family Hx
- Social Hx
- School
Observation
- Observation of the child/child and carers
- Consider these when watching videos
developmental assessment summary
Anxiety disorders in children
- Common presentation in children of all ages with prevalence increasing with increasing age
- Presentation influenced by chronological and developmental age
- Presenting features can be similar to that in adults particular adolescence
- Can be influenced by parents having anxiety and by levels of reassurance
- Many can persist to adulthood especially OCD
separation anxiety 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
GAD in children
Generalised anxiety disorder
- Free floating anxiety
- Fears of death, loss (of child or parents)
- Somatic manifestations (more common in children)
- Nausea
- abdominal pain
- sickness
- headaches
- sweating
- palpitations
- tension
- Panic attacks (sudden onset, extreme fear, physical symptoms, faintness
OCD in children
- OBSESSIONAL THOUGHTS – intrusive persisting, awareness of their illogicality, resistance to them (e.g. counting, urge to wash hands or touch wood a certain number of times)
- COMPULSIVE ACTIONS – related to the thoughts
PTSD in children
- Persistently re-experiencing trauma
- Avoidance of associated stimuli or numbing of responsiveness
- Increased arousal
o Sleep disturbance
o Irritability
o Poor concentration
treatment of anxiety disorders in children: biological
o Fluoxetine for children (SSRIs)
treatment of anxiety disorders in children: behavioural
o Systemic desensitisation
o Flooding
o Response prevention
treatment of anxiety disorders in children: psychological
Psychotherapies
Brief psychodynamic
Family
Cognitive therapy
mood disorders in children
- Mood disorders become more common with increasing age
- In children with depressive illness the low mood may not be pervasive (important)
- Assessment of low mood can be difficult
- Main concern often is the risk of self-harm
- In boys can be masked by anger
- Have to consider how it is expressed in younger children
Presentation of depressive disorders in children
- Low mood which is persistent, but not necessarily pervasive
- anhedonia/lower levels of enjoyment
- Biological symptoms are not consistent i.e. appetite/ sleep may not be affected
- Concentration/motivation are generally worse
- Anxiety symptoms
management of depression in children
- Biological
o Antidepressants (SSRIs)
o Managing underlying or comorbid problems - Psychological
o CBT - Behavioural
o CBT
behavioural disorers in children
- This area is quite contentious
- Is it a mental health problem?
- Aetiology can be complex and interact
- Parenting is often cited as the issue but may not be so simple
- The majority of children “grow out” of behavioural problems but a few persist with significant effects.
RF for behavioural disorders
- Lack of boundaries/ inconsistent parenting
- Rejection
- Family conflict esp violence and aggression
- Child abuse
- Child temperament
- Comorbid learning difficulties
types of behavioural disorders
oppositional vs conduct disorders
oppositional disorder
- Uncooperative
o Unwilling to comply with requests
o Frequent temper tantrums - Wilful, defiant
- Aggressive aggression
- Unless managed, tends to escalate
conduct disorder
to a group of behavioural and emotional problems characterized by a disregard for others. Children with conduct disorder have a difficult time following rules and behaving in a socially acceptable way. Their behaviour can be hostile and sometimes physically violent.
split into:
- socialised
- unsocialised
socialised conduct disorder
- part of a social group e.g. group truancy
- Usually viewed as less serious and tends to be phasic in natural
unsocialised conduct disorder
(socially isolated and no close friends)
- More serious
- Potentially leads to criminality and later diagnosis of antisocial personality disorder
oppositional vs conduct disorder
A key difference between ODD and conduct disorder lies in the role of control. Kids who are oppositional or defiant will fight against being controlled. Kids who have begun to move—or have already moved—into conduct disorder will fight not only against being controlled, but will attempt to control others as well.
features of conduct disorder
o Lying
o Stealing
o Truanting
o Violence to people and animals
eating disorders in children
- Rare in pre-adolescent period
- Increasingly prevalence in adolescence
- Similar symptoms to adult presentation
- Delayed puberty and growth are significant issue
- Prognosis worse if younger or male
define autism
Autism is a pervasive developmental disorder characterized by a triad of impairment in social interaction, impairment in communication, and restricted, stereotyped interests and behaviours
- Neurodevelopmental disorder
umbrella terms for autism
- Classic autism
- Asperger
prevalence of autism
1%
pathophysiolog of autism can be split into
prenatal
antental
postnatal
prenatal causes of autism
- Genetics: There is a complex polygenic relationship, with a number of chromosomes implicated, such as chromosome 7. There is a significantly increased risk of autism associated with genetic syndromes such as fragile X syndrome and tuberous sclerosis.
- Parental age: A study found that women who are 40 years old have a 50% greater chance of having a child with autism as compared with women aged 20–29 years.
- Drugs: Babies who have been exposed to certain medications in the womb have a greater risk of developing autism. These include sodium valproate in particular.
- Infection: Prenatal viral infections (e.g. rubella) increase the risk of autism
antenatal causes of autism
- Obstetric complications such as hypoxia during childbirth, decreased gestational age at birth, as well as very low birthweight offer increased risk of autism.
postnatal causes of autis
- Toxins such as lead and mercury may increase the risk of autism.
- Pesticide exposure may affect those genetically predisposed to autism.
risk factors for autism
Clinical presentation of autism
- Presents in early childhood- 50% of parents have cause for concern by 12-18 months
- Onset is before 3 years
presentation of autism: triad
1) Asocial (impairment of social communication and interaction)
2) Behaviour restricted (repetitive)
3) Communication impaired
Other features:
- Intellectual disability
- Temper tantrums
- Impulsivity
- Cognitive impairments
**
ICD 10 criteria for autism
- Presence of abnormal or impaired development before the age of three.
- Qualitative abnormalities in social interaction.
- Qualitative abnormalities in communication.
- Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities.
- The clinical picture is not attributable to other varieties of pervasive developmental disorder.
related conditions to autism
- ADHD (50%)
- LD (45%)
- Anxiety
- Tic disorders
- Sleep problems
- Specific learning disorders
differentials for autism
-
Asperger’s syndrome: Similar
to autism with abnormalities in social interaction and restricted, stereotyped, repetitive interests and behaviours. However, unlike autism, there is no impairment
in language, cognition or intelligence (IQ normal). It is more prevalent in boys. - Rett’s syndrome: Severe, progressive disorder starting in early life. Results in language impairment, repetitive stereotyped hand movements, loss of fine motor skills, irregular breathing and seizures. Almost exclusively seen in girls. The MECP2 gene’s role in Rett’s syndrome has been identified.
- Childhood disintegrative disorder (Heller’s syndrome): Characterized by two years of normal development followed by loss of previously learned skills (language, social and motor). Also associated with repetitive, stereotyped interests and behaviours as well as cognitive deterioration.
diagnosis/investigations for autism
For a formal diagnosis, symptoms must impair daily function as evidenced by their effect on social interaction, academic studies and daily routines.
1) History
2) MSE
3) Investigations
history for autism
- ‘Does your child ever engage in pretend play alone or with others?’, ‘Does your child struggle to interact with others and make friends?’ (social interaction poor)
- ‘Have you noticed any patterns in their behaviour?’, ‘Does your child insist on the same toys, activities or foods?’, ‘Have you noticed them making any abnormal movements such as flapping their hands or walking on tiptoes?’ (repetitive, stereotypical behaviour)
- ‘Do they struggle to communicate with you?’, ‘Have you noticed that their speech is monotonous or repetitive?’ (impaired communication)
- ‘What sort of games does your child play and with what toys?’ (unimaginative play)
- ‘Do you have any concerns about your child’s development?’ (developmental history)
MSE for autism
investigations if autism suspected
- Full developmental assessment including family history, pregnancy, birth, medical history, developmental milestones, daily living skills and assessment of communication, social interaction and stereotyped behaviours (see OSCE tips).
- Hearing tests if required.
- Screening tools including CHAT (CHecklist for Autism in Toddlers).
management of autism
BIOPSYCHOSOCIAL
- Ensure all physical, mental and behavioural issues are addressed
- Families and carers should offered personal, social and emotional support
- Special schooling may be considered
- Speech and language therapy
- Melatonin for sleep problems refractory to behavioural intervention
define ADHD- hyperkinetic disorder
Hyperkinetic disorder (commonly referred to as ADHD: attention deficit hyperactivity disorder) is characterized by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development, and are present in more than one situation. Children may present with difficulties at school and at home
prevalence of ADHD
- More common in males 3-5%
- Girls may be underrepresented
- Symptoms persist into adulthood in approx. 2/3s of cases
pathophysiology of ADHD
Multifactorial
o Genetic
o Neurochemical
o Neurodevelopmental
o Social
risk factors for ADHD
- More common in males
- Age of onset commonly between 3 and 7 years
- Family history
- Parental cannabis and alcohol exposure
conditions associated with ADHD
- Dyslexia
- Dyspraxia
- Social communication disorder
3 core features of ADHD
1) Inattention
2) Hyperactivity
3) Impulsivity
inattention
o Not listening when spoken to
o Highly distractible
o Reluctant to engage in activities that require persistent mental effort
o Losing belongings
hyperactivity
o Restlessness and fidgeting or tapping with hands or feet
o Recklessness
o Running and jumping in inappropriate places
o Difficulty engaging in quiet activities
o Excessive talking or noisiness
impulsivity
o Difficulty waiting for their turn
o Interrupting others
o Prematurely blurting out answers
o Temper tantrums
o Disobedient
o Running into the street without looking
ICD-10 critria for ADHD
- Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child.
- Demonstrable abnormality of attention and activity at school or nursery (if applicable), for the age and developmental level of the child.
- Directly observed abnormality of attention or activity. This must be excessive for the child’s age and developmental level.
- Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
- Onset before the age of 7 years.
- Duration of at least 6 months.
- IQ above 50.
diagnosis/investigation for ADHD
No specific tests- cannot be confirmed until around 6 years old
1) History
2) Observation in different settings
3) MSE
4) Investigations
hisotry for ADHD
- Inattention: ‘…is reluctant to engage in activities which need sustained mental effort, such as schoolwork?’, ‘…often leaves play activities unfinished?’, ‘…regularly loses their possessions?’, ‘…does not listen when spoken to?’
- Hyperactivity: ‘…is constantly fidgeting, jumping or running around?’, ‘…is unable to remain still?’, ‘…is difficult to engage in quiet activities?’
- Impulsivity:‘…cannot wait their turn when playing in groups?’, ‘…blurts out answers
to questions before the question has been completed?’ - Psychosocial history
MSE for ADHD
investigations for ADHD
- Blood tests including TFTs
- Hearing tests
- Rating scales
o Conners rating scale and the strength sand difficulties questionnaire - QB test
differential diagnosis for ADHD
Management of ADHD: General points
- Hyperkinetic disorder is diagnosed by specialists and treatment depends on whether the patient is pre-school, school-age or adult, as well as the severity of symptoms.
- Support for parents and teachers is crucial. Support groups include add+up and ADDISS.
- If there is a clear link between food or drink consumed and behaviour, parents should be advised to keep a food diary and a referral to a dietician can be made if appropriate.
Management of ADHD: Pre-school
- Parent-training and education programmes (psychoeducation) are first-line.
- Parent-training is behavioural with parents being helped to reinforce positive behaviour and to find alternative ways of managing disruptive behaviour.
- Drug treatments are not recommended.
Management of ADHD: School-goers
- Psychoeducation and CBT (and/or social skills training) should be provided.
- In severe hyperkinetic disorder in school-age children, drug treatment is first-line with the CNS stimulant methylphenidate (Ritalin) being the usual choice.
- Atomoxetine (and if this fails, dexamfetamine) is the alternative when methylphenidate has been ineffective. Side effects should be monitored for.
side effects of ADHD medication
- Side effects of CNS stimulants include headache, insomnia, loss of appetite and weight loss.
- Recent studies show no clear link between extended stimulant use and growth retardation
Medications for severe ADHD
- Methylphenidate (Ritalin)
o Short or long acting stimulant - Dexamphetamine
- Atomoxetine
