CAMHS Flashcards
Differences in childhood/adolescent presentation of common psychiatric disorders: depression
equal sex ratio before puberty
somatic sx e.g. headache, tummyache
irritability, reduced school performance
mx:
1st medication = fluoxetine (prescribed by specialist after MDT discussion)
1st tx (mild, 4 weeks) = CBT
antidepressant medication only offered in combination with psych therapy
prognosis generally good, severe episodes likely to occur
Differences in childhood/adolescent presentation of common psychiatric disorders: anxiety disorders
9-32% period prevalence
equal sex ration
many commence in adolescence
may present with somatic sx
Differences in childhood/adolescent presentation of common psychiatric disorders: self-harm
all <16 y/o who self-harm must be reviewed by a CAMHS specialist before discharge and admitted to a paediatric warm to facilitate this if necessary
Differences in childhood/adolescent presentation of common psychiatric disorders: psychosis
very rare in children before puberty
poor prognosis, disrupted social development
important to exclude ASD and organic causes (e.g. autoimmune disorders)
Differences in childhood/adolescent presentation of common psychiatric disorders: eating disorders
may present with faltering growth/delayed puberty
expect body weight calculations consider sex, age, and height on centile charts
Normal development
developmental delays can be referred to CAMHS
further assessment is always needed when developmental milestone attainment is delayed beyond the upper ;limit, with consideration of risk factors
Separation anxiety disorder
excessive fear of separation from specific attachment figures → significant distress/functional impairment
sx = thoughts of harm coming to their parent, reluctance to attend school/sleep apart, marked distress at separation, and nightmares about separation
threatened/unmourned loss
mx = family support, child’s anxiety with behavioural therapy, gradually increased separation periods
School refusal
Unconcealed school absence
common during transition e.g. new school/sibling
bullying, fear of failure, unsympathetic teacher
may occur in families with so-called precious children (following difficulty conceiving/sibling’s death) or vulnerable parents (experiencing life-threatening illness or agoraphobia)
tummy aches before school (never on weekends or holidays)
mx = family support, school support, rapid return to full attendance is best prognosis, check for parental depression and separation anxiety, get young person to talk separate from parents
Enuresis
repeating voiding of urine into clothing/bed by day/night above age of expected urinary continence (5 y/o) in the absence of organic causes
FHx
primary = toilet training not mastered
secondary = dryness is lost after at least a year’s continence (usually stress-related)
nocturnal enuresis = more common in boys
diurnal enuresis = more common in girls
Enuresis mx
reassure (common and nobody’s fault)
refer organic causes to a paediatrician e.g. epilepsy, UTI, constipation and diabetes
address stressors and review toilet training received so far
restrict fluids before bed
use star charts to celebrate each dry night (positive reinforcement)
Bell and pad ‘underpants alarm’: clips onto pyjamas, waking the child if moisture is detected, to retrain voiding
Medication e.g. imipramine (tricyclic antidepressant) combined with desmopressin (synthetic antidiuretic hormone) may be considered when all other ex’s have failed
Encoparesis: definition and causes
repeated defecation in inappropriate places above 4 years in absence of organic causes, commoner in boys, primary/secondary
mostly due to overflow incontinence due to:
- dehydration
- painful defecation (e.g. anal fissure)
- fear of punishment
- toilet fears (e.g. monsters in the toilet)
- Hirschsprung disease (rare: bowel obstruction due to aganglionic section of the colon)
When constipation absent, incontinence due to:
- diarrhoea
- disorders of intellectual development
- hostility (e.g. angrily defecating in a parents shoe)
Punitive toilet training → strsss → trigger secondary incontinence
Encoparesis: mx
laxatives and stool softeners for constipation
treat physical causes
reassure, address stress, and review toiler training
star charts to reinforce continence
GOOD prognosis 60-90% become continent within a year
Selective mutism: definition, symptoms, tx
consistent selective speech in specific social situations but not others, lasting at least a month, not limited to the first month of school, to the extent of disrupting education
talkative at home but painfully shy and silent elsewhere, tx involves reassurance; stress and behavioural mx
Autism spectrum disorder: epidemiology
masked by imitating socially expected behaviours
- strong genetic basis
- older parental age
- maternal infections in pregnancy
- obstetric complications leading to hypoxia
highly comorbid with other conditions
- disorders of intellectual development
- epilepsy
- tuberous sclerosis = rare genetic condition that causes mainly non-cancerous (benign) tumours to develop in different parts of the body.
- Down syndrome
- Rett syndrome = affects brain development
- fragile X syndrome
ASD: clinical presentation
struggle to initiate and sustain reciprocal social interaction and social communication
restricted, repetitive, inflexible interests and behavioural patterns
sx often identified first 3 years of life
severe enough to impact educational/occupational and other functioning
associated with a range of intellectual and language abilities and its functional impact varies across the spectrum
ASD: reciprocal social interaction
struggle to express emotions, ‘read’ other people, understand their feelings and intentions
→ may be interpreted as insensitive/socially awkward, influence ability to make friends
prefer to make their own company, especially when surrounded by people
ASD: communication
difficulty interpreting verbal and non-verbal communication e.g. gestures (pointing), facial expressions, tone of voice
interpret language literally (concrete thinking) including jokes and sarcasm
speech onset often delayed
echolalia = repeat sentences verbatim (echolalia) or speak continuously about their own interests without pausing to hear from others
speech can be monotonous with limited prosody and pronoun reversal (saying I/me to mean you/she)
ASD: repetitive behaviour
world confusing and unpredictable
daily routines, rigid food preferences, school/transport habits but lead to distress or tantrums when can’t be accommodated
play games repetitively/order toys by abstract properties rather than play imaginatively
may develop intense, focused interests from a young age
ASD: associated symptoms
Sensitivity to sound, touch, taste, smell, light colour, temperature → anxiety and discomfort
self-stimulating (e.g. hand flapping) and self-injuring behaviour (e.g. head-banging) are common
ASD: DDx
untreated deafness impairs language acquisition
developmental language disorder → persistent difficulties in language acquisition, understanding, production, or use, disproportionate to intellectual development
disorders of intellectual development → significantly below-average (2 or 3 SD below mean), intellectual functioning and adaptive behaviours, often associated with impairments of complex language acquisition and comprehension, academic skills, self-care, and domestic and practical activities
development syndromes which cause ASD e.g. Rett’s syndrome
neglect can impair language acquisition and socialisation (reversibly, unless it’s particularly severe)
ASD: Ix
- hearing tests for deafness
- SAL assessment
- neuropsychological cognitiv assessment
- specialist ASD assessment incoroporating nursery/school reports, detailed developmental and FHx, observation in several settings, physical examination, and tailored assessment of the child’s cognition, communication, behavioural, and mental state e.g. Autism Diagnostic Interview (ADI), Autism Diagnostic Observation Schedule (ADOS)
- Genetic tests if dysmorphic features, congenital abnormalities, FHx, or comorbid disorder of intellectual development
- EEG if epilepsy is suspected
ASD: Mx
Carer support and advice e.g. National Autistic Society
Behavioural therapy = reinforce positive behaviours and discourages challenging ones
SALT
school support via education, health and care plan (EHC) plan
tx for comorbid physical (e.g. epilepsy) and mental health problems (e.g. depression, anxiety disorders)
antipsychotics and mood stabilisers are occasionally prescribed for severe aggression or hyperactivity not responding to behavioural interactions
ASD: prognosis
lifelong
need skills and strategies for children and families to manage symptoms into adulthood
ADHD: what is it? epidemiology
persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity
early to mid-childhood, outside normal variation, significantly interferes with functioning, in more than one setting
3:1 m:f
75% heritable
unknown cause
comorbid disorders = oppositional defiant disorder (ODD), and conduct/dissocial disorder (CDD), disorders of intellectual development, Tourette syndrome
ADHD: clinical presentation and associated features
hyperactivity = excessive movement/difficulty keeping still in situations requiring behavioural self-control
- boisterous, excessive energy, constantly on the move
Inattention = distractibility, disorganisation, difficulty concentrating on tasks that aren’t exceptionally stimulating, without frequent rewards
- struggle to focus in class, flitting between activities, leaving tasks unfinished
Impulsivity = act IRT immediate stimuli without deliberating or considering risks and consequences
- dangerous (e.g. road safety) and can cause parental concern
Associated features = accident-prone or disobedient (through impulsivity rather than defiance), pay little attention to social conventions
ADHD: Ddx
Organic disorders e.g. hearing impairment, epilepsy
CDD
Agitation in depression or anxiety
Mania (rare in children)
ADHD: Ix
Questionnaires e.g. Conners Rating Scales, completed by the child, parents, and teacher
Clinician observation in a classroom setting
- collateral from teacher
Educational psychologist assessment
ADHD: Mx
Parent training and education programmes
Educational psychologist assessment of child’s classroom needs
Group CBT and social skills training
Social support and self-help for families e.g. the national attention deficit disorder information and support service (ADDISS)
Stimulant medications (improves concentration, facilitate learning) = methylphenidate, dexamftamine, lisdexamfetamine
- not addictive for ADHD
- side effects: nausea, diarrhoea, HTN, tachycardia, appetite suppression, insomnia
- → drug-free weekends and school holidays limit growth restriction s/e
Non-stimulant medication = atomoxetine, guanfacine
ADHD: prognosis
children may experience low self-esteem, peer rejection, educational underachievement, and harsh parenting
sx often improve in adolescents
untreated ADHD is a RF for later dissociality in personality disorder, criminal behaviour, and substance use
Conduct/dissocial disorder CDD: what is it, epidemiology, RFs
Repetitive and persistent pattern (1 year or more) of behaviour violating either basic rights of others, or major age-appropriate societal norms, rules, or laws
- aggression towards people/animals
- destruction of propertu
- deceitfulness or they
- serious rule violations
of sufficient severity to significantly impact the child’s personal, family, social, educational, or occupational functioning
4:1 m:f
RFs: urban upbringing, deprivation, parental criminal activity, harsh and inconsistent parenting, maternal depression, FHx of substance use
Dissocial (antisocial) behaviur is often learned from parental or environmental exposure, and may be reinforced e.g. increased attention
CDD: clinical presentation
persistently dissocial e.g. bullring, stealing, fighting, fire-setting, truancy, cruelty to animals or people
socialised CDD = dissocial behaviour done in a peer group
unsocialised CDD = rejected by other children, making them isolated and hostile
CDD: Ddx
ODD = persistent pattern (6 months or more) of markedly defiant, disobedient, provocative, or spiteful behaviour. Prevailing angry or irritable mood, severe temper outbursts or headstrong, argumentative and defiant behaviour sufficiently severe to impact the child’s functioning
ADHD
Depression
CDD Mx
Support to understand CDD and limit potentially reinforcing responses
Parent management training teaches caregiver to reward good behaviour and respond constructively to undesired behaviour
Education support: close working with teachers is crucial, as children with CDD are at risk of exclusion
Anger management for the child or young person
Treatment of comorbid disorders e.g. ADHD
CDD: prognosis
50% children with CDD develop substance use or dissociality in real life
Psychiatric hospital admission for children reserved in…
Eating diorders
Affective disorders
Psychosis
Severe/complex neurodevelopment disorders
Presentations with severe self-harm
Psychiatric hospital admission for children reserved in…
Eating diorders
Affective disorders
Psychosis
Severe/complex neurodevelopment disorders
Presentations with severe self-harm
Tic disorders: what is it, features, epidemiology, mx
Sudden, rapid, non-rhythmic, involuntary, recurrent movements or vocalisations
may be simple (e.g. blinking, sniffing, tapping, throat-clearing) or complex (e.g. self-hitting, swearing)
recede when distracted
voluntarily suppressed by cost of internal tension → seen on expression
3:1 m:f
OCD/ADHD can be comorbid
stress and stimulant medications worsen tics
Mx = reassurance and stress mx, clonidine (adrenergic agonist) or antipsychotics can help
