Behaviour/emotional Flashcards
Child risk factors for behavioural problems?
Difficult temperament Developmental delay Poor self image School failure Co-morbid illness (e.g. DM)
Risk actors within the family for child behavioural problems?
Large family Busy/professional parents (poor discipline) marital problems Bereavement Social deprevation/poverty Mental health issues
How can behavioural problems present?
Food refusal
Poor sleep patterns
Disruptive at school/tantrums
What are important areas of focus in a history from a patient with behavioural problems?
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
Management of behavioural problems?
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
What is useful pneumonic when taking a history of a tantrum?
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?)
Medical management of a substantial Tourette’s?
Clonidine or resperidone (need specialist input)
When does management of specific anxiety (e.g. a phobia) require more than reassurance?
When it is affecting activities of daily living
CBT is the first line treatment - with gradual exposure to trigger
How does the more general form of anxiety often present in children?
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
Types of anxiety?
Generalised anxiety disorder (GAD) Social anxiety disorder (SAD) Seperation anxiety disorder Phobias Obsessive compulsive disorder Panic disorder
What are the three phases of an acute separation reaction in children?
- Protest - crying, distress, angry refusal to be comforted, asks for mummy
- After a day or two = Despair - Moping, not playing, not eating
- Detachment - apparent cheering up and recovery. relatively indifferent to parents when they return
When does attachment particularly become apparent?
> 6 months
Types of attachment?
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
What ares need investigating when assessing attachment?
Exploration
Seperation
Reunion behaviours
Stranger anxiety
How long do transient childhood tics last for?
Usually a few months - may reoccur
Get worse when child is inactive, bored or anxious
get better when child is concentrating
Common examples of tics?
Blinking Frowning Sniffing Head flicking Throat clearing Grunting
How does ADHD present?
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
Management of ADHD?
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
Epidemiology of anorexia nervosa?
F>M (10:1)
peak onset at 14 years
Presentation of anorexia nervosa?
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
Presentation of bulimia nervosa?
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
management of eating disorders?
Referral to CAMS
Family based therapies are cornerstone
CBT - group and individual
Weight gain - ~0.5kg/kg/week
Epidemiology of self-harm?
Common - 10%
F>M (4:1)
Presentation of self-harm?
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
Precipitants of self-harm?
At school - bullying, poor academic performance, lack of friends
At home - parental discord/separation
Drugs and alcohol misuse
What is important to do in a consultation about self-harm with a child and their parent?
Ask for the parent to leave the room - can come back to have more open conversation
management of self harm?
Admission to paediatric ward
Once medically fit referral to CAMHS - CBT
How does conduct disorder present?
Antisocial behaviour
- breaking rules without a clear reason
- cruel or manipulative behavior towards people or animals (bullying, fighting, forced sexual activity, stealing)
Side effects of ritalin (methylphenidate) and monitoring?
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
