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Psychiatry (Y4) > 3- Child and adolescent psychiatry > Flashcards

3- Child and adolescent psychiatry Flashcards

1
Q

what is childhood and adolescent psychiatry

A

What is it?
- Disorders which are usually identified in childhood and adolescence or are specific to that developmental period
- Usually multifactorial

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2
Q

categorisation of childhoold and adolescent psychiatry

A
  • behavioural
  • neurodevelopmental
  • emotional
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3
Q

aetiology of childhoold and adolescent psychiatry

A

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

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4
Q

RF for childhood psychiatric disorders: Biological

A

o Temperament
o Genetic
o Neurodevelopmental
o Biochemical

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5
Q

RF for childhood psychiatric disorders: developmental/psychological

A

o Attachment (very important)
o Learning
o Cognitive
o Emotional

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6
Q

RF for childhood psychiatric disorders: social/environmental

A

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

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7
Q

protective factors

A
  • Temperament
  • Coping strategy
  • Problem solving
  • Self esteem
  • Stability
  • Secure relationships and friendship
  • Achievement
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8
Q

How childhood can be divided

A
  • Under 5s
  • Childhood
  • Adolescence >12 years
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9
Q

Child mental health services

A
  • Health services
    o Specialist services
    o Universal services
  • Local authority
    o School based services
    o Community based services
  • Voluntary sector
  • Services often changing
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10
Q

Emotional disorders of childhood and adolescence

A
  • GAD
  • Separation anxiety disorder
  • Phobic disorders
  • OCD
  • PTSD
  • Depression
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11
Q

Neurodevelopmental disorders (NDD)

A

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).

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12
Q

Examples of neurodevelopmental disorders

A
  • ASD
  • ADHD
  • ID/LD
  • Specific learning disorders
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13
Q

Assessing child mental health

A

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

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14
Q

developmental assessment summary

A
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15
Q

Anxiety disorders in children

A
  • 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
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16
Q

separation anxiety in children

A
  • Anxiety manifest upon separation (or threat of separation) from attachment figures (usually parent, particularly mother)
  • Somatic manifestations
  • Nightmares with separation themes
  • School refusal
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17
Q

GAD in children

A

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
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18
Q

OCD in children

A
  • 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
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19
Q

PTSD in children

A
  • Persistently re-experiencing trauma
  • Avoidance of associated stimuli or numbing of responsiveness
  • Increased arousal
    o Sleep disturbance
    o Irritability
    o Poor concentration
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20
Q

treatment of anxiety disorders in children: biological

A

o Fluoxetine for children (SSRIs)

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21
Q

treatment of anxiety disorders in children: behavioural

A

o Systemic desensitisation
o Flooding
o Response prevention

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22
Q

treatment of anxiety disorders in children: psychological

A

Psychotherapies
 Brief psychodynamic
 Family
 Cognitive therapy

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23
Q

mood disorders in children

A
  • 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
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24
Q

Presentation of depressive disorders in children

A
  • 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
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25
Q

management of depression in children

A
  • Biological
    o Antidepressants (SSRIs)
    o Managing underlying or comorbid problems
  • Psychological
    o CBT
  • Behavioural
    o CBT
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26
Q

behavioural disorers in children

A
  • 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.
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27
Q

RF for behavioural disorders

A
  • Lack of boundaries/ inconsistent parenting
  • Rejection
  • Family conflict esp violence and aggression
  • Child abuse
  • Child temperament
  • Comorbid learning difficulties
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28
Q

types of behavioural disorders

A

oppositional vs conduct disorders

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29
Q

oppositional disorder

A
  • Uncooperative
    o Unwilling to comply with requests
    o Frequent temper tantrums
  • Wilful, defiant
  • Aggressive aggression
  • Unless managed, tends to escalate
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30
Q

conduct disorder

A

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

31
Q

socialised conduct disorder

A
  • part of a social group e.g. group truancy
  • Usually viewed as less serious and tends to be phasic in natural
32
Q

unsocialised conduct disorder

A

(socially isolated and no close friends)
- More serious
- Potentially leads to criminality and later diagnosis of antisocial personality disorder

33
Q

oppositional vs conduct disorder

A

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.

34
Q

features of conduct disorder

A

o Lying
o Stealing
o Truanting
o Violence to people and animals

35
Q

eating disorders in children

A
  • 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
36
Q

define autism

A

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

37
Q

umbrella terms for autism

A
  • Classic autism
  • Asperger
38
Q

prevalence of autism

A

1%

39
Q

pathophysiolog of autism can be split into

A

prenatal
antental
postnatal

40
Q

prenatal causes of autism

A
  • 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
41
Q

antenatal causes of autism

A
  • Obstetric complications such as hypoxia during childbirth, decreased gestational age at birth, as well as very low birthweight offer increased risk of autism.
42
Q

postnatal causes of autis

A
  • Toxins such as lead and mercury may increase the risk of autism.
  • Pesticide exposure may affect those genetically predisposed to autism.
43
Q

risk factors for autism

A
44
Q

Clinical presentation of autism

A
  • Presents in early childhood- 50% of parents have cause for concern by 12-18 months
  • Onset is before 3 years
45
Q

presentation of autism: triad

A

1) Asocial (impairment of social communication and interaction)
2) Behaviour restricted (repetitive)
3) Communication impaired

Other features:
- Intellectual disability
- Temper tantrums
- Impulsivity
- Cognitive impairments
**

46
Q

ICD 10 criteria for autism

A
  1. Presence of abnormal or impaired development before the age of three.
  2. Qualitative abnormalities in social interaction.
  3. Qualitative abnormalities in communication.
  4. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities.
  5. The clinical picture is not attributable to other varieties of pervasive developmental disorder.
47
Q

related conditions to autism

A
  • ADHD (50%)
  • LD (45%)
  • Anxiety
  • Tic disorders
  • Sleep problems
  • Specific learning disorders
48
Q

differentials for autism

A
  • 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.
49
Q

diagnosis/investigations for autism

A

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

50
Q

history for autism

A
  • ‘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)
51
Q

MSE for autism

A
52
Q

investigations if autism suspected

A
  • 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).
53
Q

management of autism

A

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

54
Q

define ADHD- hyperkinetic disorder

A

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

55
Q

prevalence of ADHD

A
  • More common in males 3-5%
  • Girls may be underrepresented
  • Symptoms persist into adulthood in approx. 2/3s of cases
56
Q

pathophysiology of ADHD

A

Multifactorial
o Genetic
o Neurochemical
o Neurodevelopmental
o Social

57
Q

risk factors for ADHD

A
  • More common in males
  • Age of onset commonly between 3 and 7 years
  • Family history
  • Parental cannabis and alcohol exposure
58
Q

conditions associated with ADHD

A
  • Dyslexia
  • Dyspraxia
  • Social communication disorder
59
Q

3 core features of ADHD

A

1) Inattention
2) Hyperactivity
3) Impulsivity

60
Q

inattention

A

o Not listening when spoken to
o Highly distractible
o Reluctant to engage in activities that require persistent mental effort
o Losing belongings

61
Q

hyperactivity

A

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

62
Q

impulsivity

A

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

63
Q

ICD-10 critria for ADHD

A
  1. Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child.
  2. Demonstrable abnormality of attention and activity at school or nursery (if applicable), for the age and developmental level of the child.
  3. Directly observed abnormality of attention or activity. This must be excessive for the child’s age and developmental level.
  4. Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
  5. Onset before the age of 7 years.
  6. Duration of at least 6 months.
  7. IQ above 50.
64
Q

diagnosis/investigation for ADHD

A

No specific tests- cannot be confirmed until around 6 years old
1) History
2) Observation in different settings
3) MSE
4) Investigations

65
Q

hisotry for ADHD

A
  1. 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?’
  2. Hyperactivity: ‘…is constantly fidgeting, jumping or running around?’, ‘…is unable to remain still?’, ‘…is difficult to engage in quiet activities?’
  3. Impulsivity:‘…cannot wait their turn when playing in groups?’, ‘…blurts out answers
    to questions before the question has been completed?’
  4. Psychosocial history
66
Q

MSE for ADHD

A
67
Q

investigations for ADHD

A
  • Blood tests including TFTs
  • Hearing tests
  • Rating scales
    o Conners rating scale and the strength sand difficulties questionnaire
  • QB test
68
Q

differential diagnosis for ADHD

A
69
Q

Management of ADHD: General points

A
  • 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.
70
Q

Management of ADHD: Pre-school

A
  • 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.
71
Q

Management of ADHD: School-goers

A
  • 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.
72
Q

side effects of ADHD medication

A
  • 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
73
Q

Medications for severe ADHD

A
  • Methylphenidate (Ritalin)
    o Short or long acting stimulant
  • Dexamphetamine
  • Atomoxetine

Psychiatry (Y4) (15 decks)

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