CAHMS

Question 1

How can you classify childhood psychiatric disorders?

Answer 1

• Developmental disorders such as autism and Asperger’s syndrome.
• Disorders that are specific to childhood and adolescence such as ADHD, conduct disorders and tic disorders
• ‘Adult’ disorders occurring in childhood such as mood and anxiety disorders.

Question 2

What are the main differences between adult and child psychiatry?

Answer 2

• Children’s problems must be looked at in context of developmental stage; some problems are normal at one stage but no longer so at a later one.
• Children’s distress is expressed more in terms of behavioural problems than in terms of clear cut symptoms, so informant histories may differ significantly from one informant to another.
• Carers must be closely involved in the management plan, not least because they may themselves be contributing to the child’s presenting problem.
• Medication should be used less often and more cautiously than in adult psychiatry.

Question 3

What are the three core features of autism?

Answer 3

1 Impairments in social interactions, despite a desire for them
2 Abnormalities in patterns of communication
3 A restricted and repetitive repertoire of behaviours, interests, and activities.

Question 4

HOw common are learning disabilities and epilepsy in autism?

Answer 4

• Learning disabilities are present in about three- quarters, and epilepsy in about one-quarter

Question 5

How common are savant skills in autism?

Answer 5

• Savant’ skills such as calendar, mathematical, or musical skills may be present in a minority but are generally restricted to a specific area

Question 6

What do children with autism often have?

Answer 6

• Children with autism often have SENSORY PROCESSING DISORDERS Can be hyper- or hypo-sensitive
o can lead to challenging behaviours e.g. biting, pinching self or dislike for loud noises/bright lights
o May need lots of sensory input to meet sensory needs, or actively avoid sensory input

Question 7

When does autism have to be diagnosed by?

Answer 7

3 years

Question 8

What are your differentials for ASD?

Answer 8

o other developmental disorders
 learning disorder, developmental language disorder, Rett’s syndrome, Fragile X, disintegrative psychosis
 childhood- onset schizophrenia
 deafness.
• About 5% of children with autism have fragile X syndrome and about 3% have tuberous sclerosis.

Question 9

How do you treat ASD?

Answer 9

There is no specific treatment for autism.
o neuropsychological and psychiatric testing
o patient and family education and support
o speech and language therapy
o behavioural modification
o treatment of associated medical and psychiatric conditions
o rarely medication e.g. SSRIs for repetitive behaviour, antipsychotics (respiridone - think JJ from skins) for irritability
may use ADHD meds if overlap of Sx

Question 10

What is aspergers syndrome?

Answer 10

pervasive developmental disorder characterised by:
 Qualitative impairments in social interaction.
 A restricted, stereotyped, and repetitive repertoire of behaviours, interests, and activities.

• Unlike in autism, there is no significant delay in language or cognitive development.
• As intelligence is normal, presentation may be later than in autism.
• Individuals may appear aloof, eccentric, and clumsy.

Question 11

What is conduct disorder?

Answer 11

characterised by a repetitive and persistent pattern of dissocial or aggressive behaviour to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.

• Behaviour that is disturbed far beyond reasonable naughtiness/rebellion
• Duration = over 6 months
• Many progress to antisocial personality disorder, drugs and/or crime
• Usually diagnosed after 7 years old. If earlier or milder, often termed oppositional defiant disorder

Question 12

How common is conduct disorder?

Answer 12

• 5–10% of 8–16-year olds

* M:F = 5:1

Question 13

What are risk factors for conduct disorder?

Answer 13

• Environmental factors such as large families, poor parenting, deprivation, and abuse play an important aetiological role.

Question 14

What should you rule out before diagnosing conduct disorder?

Answer 14

attention-deficit hyperactivity disorder, pervasive developmental disorders such as autism and Asperger’s syndrome (see above), and mood and adjustment disorders.

Question 15

What is Oppositional defiant disorder ?

Answer 15

type of conduct disorder seen in younger children, and is thought to be a milder form of conduct disorder.
o It is defined by the presence of markedly defiant, disobedient, and provocative behaviour in the absence of the more severe dissocial or aggressive acts described above.

Question 16

What are some other subtypes of conduct disorder?

Answer 16

conduct disorder confined to the family, unsocialised conduct disorder, and socialised conduct disorder

Question 17

How should you manage conduct disorders?

Answer 17

family therapy, parenting classes (for the parents), and social skills training (for the child)

Question 18

What are the core features of ADHD?

Answer 18

1 Hyperactivity
2 Poor attention and concentration
3 Impulsivity

Question 19

What are other symptoms in ADHD?

Answer 19

o These features arise in early childhood, are pervasive over situations, and are persistent in time.
• Children are easily distracted, frequently shifting their attention from one task to another and unable to complete any.
o They appear fidgety and they are unable to sit still or be quiet.
• Associated features include impulsive and antisocial behaviour, learning difficulties, and soft neurological signs.

Question 20

What is the epidemiology of ADHD?

Answer 20

common and is diagnosed in 5–8% of school-age children in the USA, although this figure is substantially smaller in the UK (probably) due to more stringent diagnostic criteria and a greater reluctance to make the diagnosis.
• The disorder is three times more common in boys than in girls, but this may at least in part reflect a lesser likelihood of making the diagnosis in girls.

Question 21

What is the aetiology and pathophysiology of ADHD?

Answer 21

• The aetiology of ADHD has a strong genetic component, while environmental factors may modulate the expression of the disorder.
• Pathophysiology is thought to involve a deficiency of dopamine and noradrenaline neurotransmitters in frontal and prefrontal brain areas.

Question 22

What is the biological management of ADHD?

Answer 22

o Medication = psychostimulants (increase dopamine)
 Methylphenidate (Ritalin) first line in ADHD and ADHD with conduct disorder
 Methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
 Atomoxetine if methyphenidate unsuccessful
• (an amphetamine)
 others = Adderall, Modafinil
o Food allergy
 Controversial cause, parents may blame allergy
 Sometimes avoid salicylates or artificial colours/flavours/preservatives
• “FEINGOLD DIET”

Question 23

What is the psychsocial management of ADHD?

Answer 23

o	STRICT adherence to behavioural principles
	Reward good, ignore/discourage bad
	Support and psychoeducation
	Remedial education
	Family therapy

Question 24

Are there affective disorders in children and if so how are they different?

Answer 24

• Other than depressive conduct disorder in ICD-10, neither ICD-10 nor DSM-IV lists any specific childhood affective disorders.
• That having been said, adult- type depressive disorders are recognised to occur in adolescents, prepubertal children, and even preschool children.
• The point prevalence of depressive disorders in adolescents is about 4%, dropping to less than 1% in pre- school children.
• Clinical features are similar to those in adults but recurrence is more common and prognosis is poorer.
• Hypomanic or manic episodes are very rare in prepubertal children, but ‘masked symptoms’ may include irritability, agitation, impulsiveness, and severe temper tantrums.

Question 25

How are anxiety disorders different in childhood?

Answer 25

• Anxiety disorders of childhood (referred to as ‘emotional disorders’ to distinguish them from anxiety disorders of adulthood) must be distinguished from anxieties that are a normal part of child development by their timing, severity, and effect on social functioning.
• The prevalence of anxiety disorders of childhood is difficult to establish, but is probably around 5–10%. Unlike in adults, males and females are almost equally affected.

Question 26

What is Separation anxiety?

Answer 26

the child fears that harm is going to befall his or her attachment figures and that he or she is going to lose them.

Separation anxiety is part of normal development but is considered a disorder when it persists beyond ~15-18 months.

Question 27

How does separation anxiety present?

Answer 27

commonly presents in preschool or early school years and is characterised by features of anxiety associated with actual or anticipated separation from a particular adult, usually the mother.

distress and physical symptoms on separation, fear of being alone, reluctance to go to school, reluctance to separate at night, and nightmares involving themes of separation.

Question 28

How should you manage separation anxiety?

Answer 28

 Some work with the family is usually indicated, with individual work with the child dependent on age and cognitive development.
 Specific interventions are mostly behavioural and usually involve graded exposure to separation starting in the situations defined by the family as least distressing.
 Separation should be rewarded with positive comment and praise.
 If features re-emerge (as they do at times of transition and stress), cognitive behavioural therapy may be warranted.
 Family work should address parental expectations, anxiety or behaviours which in themselves may exacerbate the anxiety.

Question 29

When does school refusal normally present?

Answer 29

• Presents throughout childhood especially at times of transition (e.g. when starting or changing school).
• Usually peaks during early adolescence, when it may represent a combination of adolescent stress and the revival of an earlier over dependent parent-child relationship.

Question 30

How can school refusal present?

Answer 30

• The unwillingness to go to school is often expressed openly and the young person may say there is a particular student or lesson that they dislike or find anxiety provoking.
• Young children especially may complain of headaches and abdominal pain to avoid school

Question 31

What is the possible cause of school refusal?

Answer 31

• The increased need for independence and autonomy juxtaposed by the demands of secondary school may precipitate an avoidance of school.
• It may sometimes follow difficult experiences at school, such as bullying or being told off by a teacher.

Question 32

What do you have to rule out in school refusal?

Answer 32

Differentiate school refusal (often due to separation anxiety, bullying, social phobia, depression) from truancy

Question 33

Why is school refusal important?

Answer 33

School refusal is not a psychiatric disorder but is frequently attributable to an emotional/anxiety disorder

Question 34

How should you mange school refusal?

Answer 34

 Most appropriately managed by the education welfare service unless anxiety is a key feature.
 There should be a clear and consistent approach to returning young people to school.
 The school should involve the parents and if appropriate, the child, in devising programmes to introduce the child or young person back to school.
 A phased return especially when absence has been prolonged can be a useful way to start the return.
 Parents need to be firm about what is expected of the young person and resist the temptation to accede to the young person’s distress.
 CBT to help with the anxiety may be indicated.
 Tuition at home is unhelpful as it can make the problem worse.

Question 35

What is enuresis?

Answer 35

• Enuresis is the repeated involuntary voiding of urine in the absence of an organic cause after the chronological and mental age of five years.

Question 36

What are organic causes of enuresis?

Answer 36

• Organic causes include constipation, urinary tract infection, structural abnormalities of the urinary tract, diabetes, epilepsy, neurological abnormalities, and drugs such as diuretics.

Question 37

How can you classify enuresis?

Answer 37

• Enuresis can be:
o Nocturnal, diurnal, or both
o Primary (if continence has never been achieved) or secondary (if urinary incontinence has been preceded by a period of continence).

Question 38

how common is enuresis?

Answer 38

• Enuresis (particularly nocturnal enuresis) is common and by age seven years still affects about 7% of boys and 3% of girls.

Question 39

What is the most common cause of enuresis?

Answer 39

• In most cases it probably results from delayed maturation of the nervous system, although psychological factors may also play a role.
• Perhaps unexpectedly, a family history involving a first-degree relative can be found in as many as 70% of cases.

Question 40

What is the management of enuresis?

Answer 40

• Management involves exclusion of organic causes, reassurance and explanation, bladder training, ‘bed and pad’ or enuresis alarms, positive reinforcement systems such as star charts and, if appropriate, drugs such as desmopressin (a synthetic drug that mimics the action of antidiuretic hormone/vasopressin) and imipramine (a tricyclic antidepressant).
• In particular, parents must be explained that the condition is common, that it is rarely intentional, and that no one is to blame for it.
• Prognosis is good.

Question 41

What is encopresis?

Answer 41

repeated involuntary passage of faeces into places not appropriate for that purpose … the event must take place for at least three months, the chronological age and mental age of the child must be at least four years

Question 42

What are the different types of encopresis and what causes them?

Answer 42

• Retentive encopresis is more common than non-retentive encopresis and results from both physical and psychological causes.
• Non-retentive encopresis, if it is primary, typically results from poor social training.
• If it is secondary, that is, preceded by a period of faecal continence of one year or more, it typically results from emotional stress or defiance.
• Secondary non-retentive encopresis is therefore more commonly situational and/or accompanied by other regressive behaviours.

Question 43

How common is encopresis?

Answer 43

Encopresis affects 1–2% of children under the age of 10 and is much more common in boys.

Question 44

How do you manage encopresis?

Answer 44

involves the exclusion of physical causes such as anal fissure, diarrhoea, constipation, and Hirschsprung’s disease; explanation and reassurance; and, if appropriate, removal of stressors and retraining.
• Of particular note is the fact that children with encopresis are likely to suffer from hostile attitudes and behaviours on the part of parents and teachers, and as a result may come to feel undesired.

Question 45

What is elective mutism?

Answer 45

the child is unable to speak in certain defined situations (most commonly at school) but is able to do so normally in others.
• The child may also limit his or her participation in non-verbal activities such as playing.

Question 46

How common is elective mutism and who does it affect?

Answer 46

affects about one child in 1000 and is slightly more common in girls.
• Onset is usually at the time of entering school.
• Children tend to have an overprotective mother and to be confident and talkative inside the home but shy, anxious, and isolated outside.
• Other anxiety disorders and behavioural disorders are common.

Question 47

How do you manage elctive mutism?

Answer 47

• Parents and teachers need to be educated about the problem and reassured that, although it may last for months or years, it has a good longer-term prognosis.

Question 48

What is a tic?

Answer 48

repetitive, stereotyped, and purposeless movements or vocalisations.
• They can be voluntarily suppressed, but this then leads to a build-up in tension and anxiety (in this respect they are rather like compulsions).

Question 49

How common are tics?

Answer 49

affect up to 20% of all children in the first decade of life and are three times more frequent in boys

Question 50

What are the commonest tics?

Answer 50

simple motor tics that involve a group of functionally related muscles, e.g. blinking, grimacing, and shoulder shrugging

Question 51

What else can tics be?

Answer 51

complex motor tics such as jumping, hitting oneself, and gesturing obscenities (copropraxia); simple vocal tics such as throat-clearing, sniffing, and barking; and complex vocal tics such as repeating one’s utterances (palilalia), repeating others’ utterances (echolalia), or shouting out obscenities (coprolalia).

Question 52

How do you manage tics?

Answer 52

• Tics are exacerbated by stress and attenuated by sustained concentration.
• Their differential diagnosis is essentially from other disorders of movement. In most cases they are mild and transient and do not require any treatment.

Question 53

What is transient tic disorder?

Answer 53

single or multiple motor and/or vocal tics last for less than 12 months

Question 54

What is chronic motor or vocal tic disorder?

Answer 54

If single or multiple motor or vocal tics (but not both) last for more than 12 months

Question 55

How do you diagnose Giles de la Tourettes?

Answer 55

Multiple motor tics + at least 1 vocal tic

Question 56

What is the pathophysiology of Tourettes?

Answer 56

result from dysfunction in the frontal cortex, thalamus, and basal ganglia

Question 57

What can mimic tourettes?

Answer 57

stroke, encephalitis, and carbon monoxide poisoning; and by drugs such as stimulants, levodopa, and carbamazepine (‘tourettism’)

Question 58

How common is tourettes and who gets it?

Answer 58

1 in 2000, but boys are more frequently affected than girls by a ratio of 3–4 : 1.
• Onset is before age 18 (mean 7 years for motor tics and 11 years for vocal tics).

Question 59

What is the management for tourettes?

Answer 59

o education of the patient and family
o pharmacological treatment of the tic disorder if indicated
 (e.g. by CLONIDINE, RISPERIDONE or SULRPIDE), and treatment of co-morbid conditions such as OCD and ADHD.
 I saw a young boy treated with ARIPIPRAZOLE
• Note that the use of stimulants (e.g. in the treatment in comorbid ADHD is likely to aggravate any tic disorder.