Behaviour/emotional

Question 1

Child risk factors for behavioural problems?

Answer 1

Difficult temperament
Developmental delay
Poor self image
School failure
Co-morbid illness (e.g. DM)

Question 2

Risk actors within the family for child behavioural problems?

Answer 2

Large family
Busy/professional parents (poor discipline)
marital problems
Bereavement
Social deprevation/poverty
Mental health issues

Question 3

How can behavioural problems present?

Answer 3

Food refusal
Poor sleep patterns
Disruptive at school/tantrums

Question 4

What are important areas of focus in a history from a patient with behavioural problems?

Answer 4

Full picture of the problem
Child - personality/termperament
Recent events - e.g. bereavement, birth of a sibling
Family - divorce? single parent?
School - peer and teacher relationships

FH and developmental delay

Question 5

Management of behavioural problems?

Answer 5

Encourage good behaviour - STAR charts (make sure it is given clearly, consistently, immediately, contigently, contemporaneously)

Avoid punishment - can use ‘naughty step’ but not ‘go to your room’

Avoid unintentional positive reinforcement - letting child sleep in bed

Ensure consistent response from both parents

Question 6

What is useful pneumonic when taking a history of a tantrum?

Answer 6

A - Antecedents (what happened in the minutes preceding the tantrum)
B - Behaviour (exactly what did the tantrum consist of)
C - Consequences (What happened as a result, what did the parent do?)

Question 7

Medical management of a substantial Tourette’s?

Answer 7

Clonidine or resperidone (need specialist input)

Question 8

When does management of specific anxiety (e.g. a phobia) require more than reassurance?

Answer 8

When it is affecting activities of daily living

CBT is the first line treatment - with gradual exposure to trigger

Question 9

How does the more general form of anxiety often present in children?

Answer 9

Physically - Nausea, headache, abdominal pain
Mentally - may ask for reassurance that they are not going to die (feeling of impending doom)
May behave manipulatively to avoid feared situation

Good prognosis if trigger is linked (e.g. parental illness)
If arises insidiously –> referral to CAMS

Question 10

Types of anxiety?

Answer 10

Generalised anxiety disorder (GAD)
Social anxiety disorder (SAD)
Seperation anxiety disorder
Phobias
Obsessive compulsive disorder
Panic disorder

Question 11

What are the three phases of an acute separation reaction in children?

Answer 11

1. Protest - crying, distress, angry refusal to be comforted, asks for mummy
2. After a day or two = Despair - Moping, not playing, not eating
3. Detachment - apparent cheering up and recovery. relatively indifferent to parents when they return

Question 12

When does attachment particularly become apparent?

Answer 12

> 6 months

Question 13

Types of attachment?

Answer 13

Secure (65%) - child explores freely in presence of caregiver

Insecure:
Avoidant (20%) - explores little, ignores/avoids caregiver on seperation/return
Ambivalent (15%) - explores little, even with caregiver present, anxious of strangers - v. distressed when caregiver leaves, ambivalent on return

Disorgansied (4%) - behaviour not coordinated with presence/absence of caregiver

Question 14

What ares need investigating when assessing attachment?

Answer 14

Exploration
Seperation
Reunion behaviours
Stranger anxiety

Question 15

How long do transient childhood tics last for?

Answer 15

Usually a few months - may reoccur

Get worse when child is inactive, bored or anxious
get better when child is concentrating

Question 16

Common examples of tics?

Answer 16

Blinking
Frowning
Sniffing
Head flicking
Throat clearing
Grunting

Question 17

How does ADHD present?

Answer 17

Hyperkenesis - constant hyperactivity, fidgets/squirms, poorly-regulated activity
Lack of attention - poor concentration, disorganised, easily distracted
Social disinhibition/impulsivity - struggle to form relationships, butt into conversations, short tempers

Question 18

Management of ADHD?

Answer 18

Initially behavioural:
Talking therapies - develop focus, concentration and preoccupation, improving self-esteem, give parents coping strategies
Lifestyle - avoidance of caffeine and excess sugar

If >6years old can give medication:
Stimulant - ritalin and adderall
Non-stimulant - atomoxetine

Question 19

Epidemiology of anorexia nervosa?

Answer 19

F>M (10:1)

peak onset at 14 years

Question 20

Presentation of anorexia nervosa?

Answer 20

BMI = <17.5 or BMI% <85 (actual weight/median centile weight x 100)
Body dysmorphia - increased with further weight loss
+/- purging, restricting food, over-exercising

Physical - amenorrhoea, thinning hair, easy bruising, dry skin, constipation/bloating, low BP/peripheral pulses, bradycardia, palpitations

Question 21

Presentation of bulimia nervosa?

Answer 21

Low weight and fear of being fat
Binge eating episodes with periods of fasting, self induced vomiting
May use laxatives and diuretics

Physical - tooth enamel erosion, russell’s sign - callous on back of hand from making self sick

Question 22

management of eating disorders?

Answer 22

Referral to CAMS
Family based therapies are cornerstone
CBT - group and individual

Weight gain - ~0.5kg/kg/week

Question 23

Epidemiology of self-harm?

Answer 23

Common - 10%

F>M (4:1)

Question 24

Presentation of self-harm?

Answer 24

Cutting - usually arms/wrists, torso, upper thighs (places that can be hidden)
Poisoning - drug overdose (classically paracetamol)
Burning

Of those who overdose, half are clinically depressed

Question 25

Precipitants of self-harm?

Answer 25

At school - bullying, poor academic performance, lack of friends
At home - parental discord/separation
Drugs and alcohol misuse

Question 26

What is important to do in a consultation about self-harm with a child and their parent?

Answer 26

Ask for the parent to leave the room - can come back to have more open conversation

Question 27

management of self harm?

Answer 27

Admission to paediatric ward

Once medically fit referral to CAMHS - CBT

Question 28

How does conduct disorder present?

Answer 28

Antisocial behaviour

• breaking rules without a clear reason
• cruel or manipulative behavior towards people or animals (bullying, fighting, forced sexual activity, stealing)

Question 29

Side effects of ritalin (methylphenidate) and monitoring?

Answer 29

Abdominal pain, nausea and dyspepsia

Growth is not usually affected but monitor every 6 months
Also check blood pressure (every 6 months) and monitor for psychiatric conditions