CAMHS Flashcards
What are the core features of ADHD?
Inattention
Impulsivity
Hyperactivity
Examples of hyperactivity symptoms in ADHD
Fidgeting Climbing on furniture Always on the go Talking excessively Interrupting
Examples of inattention in ADHD
Easily distracted Unable to complete tasks Unable to organise Forgetful Losing things Appearing not to listen
Age of onset for hyperkinetic disorder (ICD-10)
Before 5
Age of onset for ADHD in DSM-IV and V
IV: Before 7
V: Before 12
Gender ratio of ADHD in children
3:1 boys:girls
Risk of ADHD in siblings
2-3x increase
Prevalence of ADHD in the UK
ICD-10 criteria: 1-2%
DSM IV criteria: 3-4%
Neuro-imaging aetiology of ADHD
Reduced cerebral blood flow in frontal lobe.
Neutrotransmitter aetiology of ADHD
Dopamine and noradrenaline dysregulation in pre-frontal cortex
Which neurotransmitters do psychostimulants impact for ADHD symptoms?
Release Noradrenaline, Dopamine and Seretonin (which modulates dopamine transmission)
Environmental aetiological factors
Obstetric complications Low birth weight and prematurity Prenatal exposure to alcohol, nicotine and benzos Poor attachment and early deprivation Growing up in institutions
Co-morbid disorders in ADHD
Oppositional defiant disorder (40%) Anxiety disorder (34%) Conduct disorder (14%) Tics (11%) Mood disorder (6%)
How many children with ADHD have a comorbid disorder?
50-80%
How many children with ADHD go on to develop problems with substance misuse?
15-20%
How many children will continue to suffer residual symptoms into adulthood?
50%
What happens to ADHD symptoms as one gets older?
Fewer impulsive-hyperactivity symptoms
Factors that result in poor prognosis for ADHD
Poverty and overcrowding High EE Parental psychopathology Severe symptoms Symptoms predominantly hyperactive-impulsive Conduct disorder Language disorders
Non-pharmacological treatment options for ADHD
Educational/remedial interventions
o Parent training programme for child management skills– based on social learning theory and
behavioural interventions
o Individual/family/group therapies
o CBT methods, especially behavioural, are often effective
o Social skills training
Which medication for ADHD has the most rapid onset?
Methylphenidate - 1-3 hours
What type of medication is Atomoxetine?
NARI
How does Atomoxetine work?
Increases NA in synaptic cleft
Monitoring for methylphenidate
Height & weight, HR and BP at initially 3 then 6 montys
Monitoring for atomoxetine
Height and weight at 3 then 6 months
Signs of depression or suicidality
Adverse effects of Methylphenidate
Appetite and weight loss Insomnia if taken late in day Abdominal cramps in first few weeks Headache BP and HR increase Evening crash Depression Tics Hallucinations - skin crawling, visual Mild growth slowing first two years
Atomoxetine SEs
Appetite and weight loss
GI symptoms; nausea, vomiting, diarrhoea, constipation
Fatigue and dizziness
Diagnostic criteria for conduct disorder for ICD-10
At least one of the following behaviours to be present for at leat 6 months:
- Physical aggression or threats of harm to people, cruelty to people and animals
o Destruction of their own property or that of others
o Theft or acts of deceit
o Frequent and serious violation of age-appropriate rules (Like truanting or running away)
Prevalence of CD in UK
5-7%
M:F ratio of CD
4:1
Environmental aetiological factors for CD
Parental MI Low income Criminality and substance use of father Maternal neurosis Overcrowding & institutional care DV and child abuse Large family size Maternal smoking during pregnancy Early loss and deprivation
Neuroimaging findings in ADHD
Reduced volume of prefrontal area
Neurochemical findings in CD
Deficient seretonergic activity
Autonomic under-arousal
Future risks of child CD
Criminality and ASPD Difficulties in work and education Homelessness and abuse Drug and alcohol dependence Poor physical health Other SMI
Poor prognostic factors for CD
Onset <10 Increased aggression at early age Aggression carried out in isolation Low IQ Low socio-economic status Poor school achievement Attention problems and hyperactivity as a child Poor parenting and family criminality
NICE guidelines for CD <12
Group based parent training/education programmes
Psychological treatment for CD
CBT - social skills and anger management
Family therapy - for 11-18 year olds
Multisystemic therapy
What is multisystemic therapy for CD?
Needs assessed in school and at home, then therapy used to promote strengths of young person within the system.
Therapist responsible to make sure appointments are kept
Feedback on progress from goals from multiple sources including weekly questionnaires from parents and teens
Difference between ODD and CD
Lack of serious violation of societal norms or rights of others
Risk factors for depression in children
FHx of depression Early loss of parent Parental separation Stressful life events History of abuse
Management of mild depression in CAMHS
2 weeks watchful waiting
After 4 weeks: supportive therapy, self help or group CBT
Self help: advice on sleep hygiene, exercise and anxiety management
Management of mod-severe depression in CAMHS
CAMHS review
3/12 of individual CBT, IPT or shorter family therapy
NICE guidance on antidepressants for depression in CAMHS
Fluoxetine (first line)
Sertraline or Citalopram (second line)
What to monitor in use of fluoxetine in CAMHS
Agitation, irritability, suicidality
In what age groups is ECT not recommended?
5-11
How many adolescent deaths are due to suicide?
12% - third most common cause
Prevalence of suicidal ideation in adolescence
Boys 14%
Girls 25%
How many adolescents who attempt suicide repeat within a year?
10%
Risk of suicide in adolescent who has first degree relative who has committed suicide
2-4 times higher
Features of early onset bipolar
Poor outcome - 50% have long term decline in function
Chronic and less responsive to treatment
Atypical and rapid-cycling
Prevalence of early onset Bipolar in adolescence?
1%
How many adolescents with episode of depression go on to experience a manic episode in adulthood?
20%
What depressive sx in adolescents predict mania?
Depression with psychosis
Rapid onset with psychomotor features
FHx of mania
Hx of hypo/mania following antidepressants
Suicide risk in early onset bipolar
10%
NICE guidelines for early onset bipolar
Same as adults but lower doses
First line are olanzapine and risperidone in acute mania followed by valproate or lithium.
What needs to be kept in mind when giving children lithium?
Higher renal filtration and higher proportion of body water so higher doses needed to reach therapeutic range.
In younger children, neurological SEs more common
Age of onset for childhood onset schizophrenia
Onset of psychotic symptoms by age 12
What does early onset SCZ refer to?
Onset before 18
What does very early onset SCZ refer to?
Onset before 13
Prevalence of SCZ in adolescence
1-2 per 1000
M:F ratio in very early onset SCZ (<13)
2:1
What symptoms are more common in child onset SCZ?
Negative sx Frightening visual hallucinations Disorganised behaviour Disorganised thought >50% have delusions, increase with age Blunted affect - almost universal More chronic Insidious onset
Common premorbidities in early onset SCZ
Delay in language, reading, bladder control and social functioning
Reduced attention, working memory and IQ
Greater genetic component
Physical health problems to r/o in child onset SCZ
TLE
Thyroid disease
Brain tumour
Wilsons disease
How much more prevalent is SCZ in those with first degree relatives with the disease?
8x more
Risk of SCZ with those with first degree relative with the disease in %
5-10%
Antipsychotic SEs more common in children
EPSEs
M:F ratio of anxiety in childhood
1:1
M:F ratio of anxiety in adolescence
2:1
% of children and adolescence who have anxiety in the general population
5-15%
% of GAD in adolescence
4%
% of social phobia in children
%
% of social phobia in adolescence
5-15%
Common comorbid disorders with GAD in young people
Other anxiety disorders
CD
Substance use
How much more common is depression in children with an anxiety disorder?
8.2x more
Duration for diagnosis of separation anxiety disorder
4 weeks
Criteria for sibling rivalry disorder
Within 6 months of birth of sibling
Duration of 4 weeks
Sx of sibling rivalry disorder
Regression Tantrums Dysphoria Insomnia ODD/attention seeking from parents
What characterises disinhibited attachment disorder or childhood?
Pattern of abnormal
social functioning that arises during the first 5 years of life.
How does disinhibited attachment disorder manifest?
Early - clinging, non-selective attachment
By age of 4 - clinging, indiscriminately friendly
Late - emotional and behavioural disturbance
What characterises reactive attachment disorder?
Persistent abnormalities in
the child’s pattern of social relationships, which are associated with emotional disturbance and
reactive to changes in environmental circumstances.
Age of onset of attachment disorders
<5
In which environments is reactive attachment disorder most common
Poverty
Socially disrupted
Neglect and abuse
Young, isolated, inexperienced or depressed caretaker
Features or reactive attachment disorder
Fearfulness and hypervigilance that do not respond to comforting are characteristic. Poor social interaction with peers Aggression towards self & others Growth failure occurs in some cases.
Typical age of onset of selective mutism
3-5, after normal speech has been acquired
Which psychiatric disorder is common in selective mutism?
Social phobia
Prevalence of selective mutism in UK
3-8 per 10,000
Prevalence of persistent mutism
1 per 1000 children
Which gender is selective more common in?
Girls
Treatment for selective mutism
A behavioural approach with positive reinforcement techniques aimed at increasing the
frequency of talking and decreasing the frequency of non-communication will be helpful.
It is
important to ascertain what communication is like at home.
Which mental illnesses is separation anxiety disorder a risk factor for in adulthood?
Panic disorder
Agoraphobia
Treatment of anxiety disorders in children
CBT - modified for developmental model
Psychoeducation
Parent training
What does CBT for CAMHS anxiety involve?
Relaxation training
Cognitive restructuring
Which CAMHS anxiety disorders respond to SSRIs?
GAD
SAD
Social phobia
Specific phobias
M:F ratio for PTSD in children
1:2
Treatment for PTSD in CAMHS
Treatment-focused CBT - 8-12 sessions
Family involvement where appropriate
Prevalence of OCD in children and adolescence
0.5%
Mean age of onset of OCD in CAMHS
10
M:F ratio of childhood onset OCD?
2:1
In which gender is post-pubertal OCD onset more common?
Girls
How many children and adolescence with OCD have another disorder?
70%
Common comorbid disorders with childhood OCD
Tics 17-40% Depression 26% Developmental disabilities 24% Other anxiety disorders ASD
Treatment for childhood OCD
Combination of medication and CBT + ERP
Medications licensed for OCD in children and adolescent
Fluoxetine
Sertraline
Treatment for mild OCD in CAMHS
CBT
What does PANDAS stand for?
Paediatric
autoimmune neuropsychiatric disorders associated with streptococcus?
What is PANDAS?
Children who develop obsessive-compulsive symptoms associated with beta haemolytic streptococcal
infection and this presentation represents a minority of OCD cases in this population.
In which viral illness is OCD common
Sydenhams chorea (in rheumatic fever) - 75% of children and young people have OCD
Neuroimaging in PANDAS
Increased basal ganglia volume
