CAMHS Flashcards
ADHD definition
Neuro-developmental disorder characterised by inattention, hyperactivity + impulsivity.
Chronic: starts in childhood, continues.
Symptoms have to manifest in 2 or more settings to be defined as ADHD (e.g. at home and school, not just at school)
ADHD RFx
- FHx
- MALE
- Low birth weight
- EPILEPSY
- Maternal Antenatal NICOTINE use
- TIC DISORDERS
Psychoscoial adversity
Traumatic brain injury
Severe early deprivation
Lead exposure and Iron deficiency
ADHD presention
- Failure to pay close attention to tasks
- Difficulty maintaining sustained mental effort
- Difficulty organising tasks
- Easily distracted by extraneous stimuli
- Forgetful in daily activities/remembering objects
- Trouble remaining still
- As if ‘Driven by a motor’
- Difficulty being patient (e.g. turn-taking)
Other common Sx:
- Mild mood Sx (dysphoria, mood, irritable, boredom)
- Difficulty in peer interactions
- Low self-esteem
- Impaired working memory
- Impaired processing speed
ADHD Dx
From clinical Hx - taken from multiple sources (parents, teachers, carers etc)
- Behaviour rating scales used to aid (ADHD rating scale, Conner rating scales - 3 forms; most widely accepted)
Can do neuropsychological testing to differentiate from learning disabilities (ADHD kids will have normal cognitive + academic ability but impaired executive function)
ADHD treatment
Ages 4-6:
- Parent Training in Behaviour Management and/or Behavioural classroom intervention + Psychoeduction
- Consider methyphenidate if not responsive/severe
6-18:
- STIMULANT (methylphenidate or amfetamine)
- NON-STIMULANTS (Guanfacine, Clonidine or Atomoxetine) if tic disorder or substance misuse
+ Psychoeduction
Also HEALTHY DIET + EXCERCISE
Asutism Spectrum Disorder
Neurodevelopmental condition characterised by persistantly impaired social interaction and restricted, repetitive and stereotyped patterns of behaviours
Ie impaired social interaction, communication and flexibility of behaviour
When can features of ASD typically be observed by?
3 y/o
Features of ASD relating to social interaction
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
ASD features relating to communication
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
ASD features relating to behaviour
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements - self-stimulating movements
- Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine - Extremely restricted food preferences
Diagnosis of ASD
Clinical diagnosis by specialist - scoring tools to assist (CAST, CARS, Social Communication Questionnaire)
Rule out differentials if suspected
- genetic testing may be offered in general as ASD is associated with a number of genetic variations. (Fragile X syndrome)
ASD Tx
12 months - 5 years (equivalent developmental age)
- Behavioural and Parent-mediated interventions for core features
- Input from early educational services
- Family support + eductaion
Same for older but with additional support for other mental health conditions as required
Requires MDT management:
- CAHMS
- SALT
- Dieticians
- Pediatricians
- Social Workers
- Specially trained educators and school environments
- Charity help potentially
OCD
A disorder characterised by the presence of obsessions and compulsions
These are not something the person enjoys/willingly does. They impact on other areas of life e.g. school, social life
Obsessions
Unwanted, uncontrolled thoughts and images that are difficult to ignore. (intrusive)
E.g. overwhelming fear of contamination, violent/explicit images
Compulsions
Repetitive actions the individual feels they must do, generating anxiety if not done.
Often a way to handle compulsions
In young people particularly, compulsions usually involve family members. May not be able to articulate the resoning behind them.
What is the cycle of repetitive behaviour in OCD
The obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour.
Person feels they can’t get relief from anxiety if they don’t do compulsions
RFx for OCD
- FHx - esp 1st degree relatives (genetics plays a role as monozygotic twins more likely to exhibit in both)
- AGE (peak onset between 10-21 years)
- Environmental factors like strep infections (PANDAS - aediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
- PREG + POSTNATAL PERIOD (more likely to experience OCD in postpartum than general populace - relating to baby)
Oft associated with psychiatric co-morbidity (Anxiety, Depression, Eating disordes, ASD, phobias, tic disorder)
OCD Dx
Clinical - based on DSM-5
- supported by scoring sytems/interviews
- Particularly CY-BOCS (Children’s Yale-Brown Obsessive Compulsive scale (Y-BOCS = adult one))
Sx need to have lasted 2 weeks to be diagnosed OCD
OCD Tx
1st line = CBT or Pharmacotherapy (SSRI or Tri-cyclic (clomipramine))
- give BOTH if severe/comorbid personality disorder/dissociative symptoms
2nd line = increased dose/combination therapy
3rd = diff drug
4th = specialist evaluation
Seperation anxiety
Normal in < 3 y/o - disorder typically diagnosed between 7-9 y/o
- more common if insecure attachment; if parent ill etc
Crying, nausea, stay while falling asleep, may refuse to go to classes, exacessive worrying about caregivers, nightmares
- typically harder to calm child than in younger kids
Can lead to agrophibia, panic disorder later
Need to differentiate if it is a specific phobia or seperation anxiety
School phobia consists of
- SIgnificant anxiety
- Fear of specific aspect of school
- Avoidance
Selective mutism Dx
Must be mostly mute for most days over the course of at least 6 months
Organic causes to exclude for anxiety
- Hyperthyroid
- Arrhythmias
- Epilepsy
- Phaeochromocytoma
- Asthma
- Non-prescription drugs
Anxiety Mx
- Assess for co-morb (e.g. ASD)
- Anxiety management techniques
- Graded exposure
-
CBT
- Identify/’capture’ scary thought; challange it; re-write it; distract; change behaviour (focus on reality + rationality)
- Thought shifting (e.g. do it scared)
- Worry monster
- Group work
- Medication (SSRIs - Fluoxitine)
Grounding tecniques
- Sensory grounding + distraction
- Isometric muscle contraction
- Other distraction:
- Music
- Items
Things to consider when investigating self-harm
- How at risk are they of suicide
- How severe + is it ongoing
- Make it clear that you may have to disclose particularly concerning stuff
Self harm/suicide epidemiology
4:1 female:male self-harm; males more likely to commit suicide
Leading cause of death in adolescents worldwide (in top 3 causes)
Causes of self-harm
- Depression
- Bullying
- Sexual abuse
- family difficulties
- culture
- drugs
Factors increasing the risk of Completed suicide
_ presence of psych disorder
- Depression, PTSD, psychosis, ED
- Previous suicide attempt
- Alcohol/substance misuse
Things to ask while investigating self harm
- Associated suicide attempts
- Social factors
- Frequency, severity, methods, infection
- Reasons
THings to ask while investigating suicidal ideation/attempt
- Alone or tell anyone
- Planned?
- Letter?
- CONTINUING IDEAS
- Preventing factors
Presisting Thoughts; Frequency of thoughts
- Encourage looking towards future
- Reassurence
Management of Self harm
- Distraction/grounding
- Management of underlying problem e.g. family therapy, bullying at school
- CBT
Managing Suicide
- Manage IMMEDIATE RISK
- Tell parents - support network
- Manage underlying condition
Hosp/intensive home treatment if too severe
Consider social care if parents unable to meet needs/can’t prioritise kid
Anorexia nervosa
Disorder where individual obsessively restricts calorie intake with intention to lose weight
-> failure to thrive
- they feel overweight despite evidence of norm/low body weight
May excessively exercise or use laxatives/diet pills
Features of anorexia nervosa
- Excessive weight loss
- Amenorrhoea
- Lanugo hair (fine, soft, increased body hair)
- Malnutrition
- HypoKALAEMIA (heart risk!!) - HypoTENSION (heart slows)
- HypoTHERMIA (conserving energy)
- Change in moods -> ANXIETY + DEPRESSION; oft co-morb mental health
- Solitude
Complications of Anorexia
- CARDIAC COMPLICATIONS
- ARRHYTHMIAS
- cardiac ATROPHY
- SUDDEN CARDIAC DEATH
Rapid increase in risk of mortality as BMI decreases
Difficulties in assessing anorexia
- Individuals may look and feels well
- Normal blood tests DON’T provide reassurance as they may look normal (even if weight critically low)
Medical Admission Criteria for anorexia
- Significant weight loss (<= 70% of median BMI for age + sex ; OR rapid rate of weight loss)
- Resting BRADYCARDIA <= 50 bpm
- POSTURAL tachycardia >= 35 bpm
- Postural drop in systolic BP >= 20
- HYPOTHERMIA < 35.5 C
- SEVERE Abdo PAIN
- ESCALATING PARENTAL CONCERN
Anorexia Nervosa Ix
- BMI and recent rate of weight loss
- Cardiac status (reduced muscle + impaired reserve on X-ray/CT)
- refeeding can increase risk HF + death - HR <= 50 bpm
- ECG (arrhythmias?; postural hypotension)
- when people stand up the HR can INCREASE over 30 bpm due to systolic BP falling by >= 20 mmHg - CORE TEMP
Cause of abdo discomfort in anorexia nervosa
Constipation and bloating due to:
- reduced GASTRIC EMPTYING
- reduced GUT MOTILITY
- Impaired pancreatic + gut ENZYME SECRETION (Decreased)
(trying to keep food in/get as much out of it as possible)
Pathophys of famine oedema
Kidney function impaired so not excreting salt + water well
- water + salt leaks out of vessels
-> reduced intravascular volume
Complications of Anorexia
- Pancreatitis
- Superior mesenteric artery syndrome
- aorta + mesenteric artery compress small intestine due to lack of peritoneal fat -> surgical emergancy
Long term:
- Osteoporosis + risk of Frax (due to reduced oestrogen)
- typically slightly osteoporotic by 18 if AN during adolescence - Growth stunting + pubertal delay
- Neurocognitive impairment
(reduced by timely + effective weight restoration)
What causes hypothermia in anorexia
- Impaired cutaneous vasoconstriction + impaired increase in metabolic rate when in cold
Management of anorexia
- 3 week admission aim (rest, monitor, feed)
- MEAL PLANS (1 = lowest; 8 = highest)
- 3 meals + 3 snacks
- start with restricted meal plans
- Carefully monitor MAGNESIUM, POTASSIUM, PHHOSPHATE, GLUCOSE + FLUID BALANCE
- Supplement electrolytes + vitamins (esp B VITs)
- ECG monitoring may be needed
Refeeding syndrome
In people who have been starved for prolonged periods, their cells have slowed functioning.
Upon refeeding, as cells start processing nutrients again they start RUNNING OUT of MAGNESIUM, POTASSIUM and PHOSPHATE
Also risk of arrhythmias, HF + fluid overload if too much fluid given when they are not used to it/heart atrophied.
Oppertunities and challenge with interacting with families
- Focus on the SYSTEM the child is within
- Interview family TOGETHER (understand relationship + environment)
- Speak to young person individually (e.g. self harm; abuse etc)
Challange = family feels vulnerable + expresses it as anger
Oppertunity = Safety network for young person
Conduct disorder
Description of young person with behavioural presentation eg tantrums, breaking things, disruptive in school , in trouble with police.
Causes of depression in kids
Social:
- Bullying
- Learning Difficulties at school
- Abuse/Neglect
- Domestic violence
Drugs:
- Alcohol (depressent)
- Speed
PHx
Biological:
- Genetic (FHx)
- Thyroid disorder
- Steroids
- Chronic Physical Illness
Low self esteem
Protective factors for depression
Friendships + supportive family environment
Tx for depression
- Info + SAFETY NETTING
- 1ST = CBT
- Community CBT Therapists
- Specialist CBT
- IPT
- Family therapy
- Antidepressants - FLUOXETINE, Sertraline, Citalopram
CBT
- Cognitive: Identify which thoughts influence feelings
- Behavioural: Identify which behaviours influence feelings / mood
‘Realistic thinking’
Depression prognosis
- Adolescent who has had episode of depression – 4x more likely to have further episode
- CBT halves likelihood of further episodes
What is a Traumatic Event
An event which is Life threatening or threatening to the integrity of the self
What are protective factors for a young person with a difficult childhood?
- Positive attachment to a consistent adult
- Education
- Supportive peers
PTSD Sx
- INTRUSIVE THOUGHTS
- Flashbacks
- Intrusive sensations - Sleeplessness / NIGHTMARES
- Anxiety -> Hyperalertness
- AVOIDANCE of Things + thoughts
- Foreshortening of the future
- Poor conc
- Irritable
- Numbing of feelings
- Withdrawal
- Anhedonia
- Depressive Sx
- Suicidal thoughts
What is a flashback
Can affect any sensory modality + feels like it is currently happening
- most commonly nightmares
Common causes of PTSD
- Traumatic accident
- Witnessing/experiencing a serious injury
- Bullying
- Violent crime against you
- Childhood sexual abuse / sexual assult
- Dog bite
- War
- Natural disaster
- Childhood physical abuse
PTSD Tx
- Engagement + grounding
- ABT
- EMDR
- Treat co-morbs BUT things like antidepressents don’t help the PTSD itself
Common co-morbs with PTSD
- Major depression
- Separation anxiety disorder
- Oppositional defiant disorder
- Conduct disorder
- Other anxiety disorders
- SUBSTANCE ABUSE
How is speech affected by a traumatic experience
- Speech area switched off during trauma
- Leads to Lack of verbal memory / fluency
- Declarative memory/’narrative memory’
How can dysfunctional REM sleep affect PTSD
- Woken from REM by nightmare – processing of memory not completed
- Function of REM – Processing and storing of memories
- If tape of Trauma played – R hemis. Limbic function increased and Brocas area function decreased
What improves the outcomes for PTSD
- Support
- Early Tx
- Only a single trauma
(Sexual assult has worse PTSD outcomes)
Types of eating disorder
- Anorexia Nervosa
- Bulimia Nervosa
- Avoidance Restrictive Food Intake Disorder (ARFID)
- Binge Eating Disorder (BED)
- Other specified feeding / eating disorder (similar to anorexia but not got all the Sx to be diagnosed as Anorexia)
Eating disorder definition
mental health conditions that involve an unhealthy relationship with food and eating, and often an intense fear of being overweight.
Common causes of death in Anorexia
sudden cardiac death assoc with ventricular arrhythmias and suicide
- very little heart reserve so can decompensate very quickly (can go down to 1/2 wight of heart)
Common co-morbs with Eating disorders
- Depression
- Anxiety
- ASD
- OCD
- Gender dysphoria
- Attachment disorder / Emerging Emotionally Unstable Personality Disorder (EUPD)
RFx for Eating disorder
- Low self-esteem / lack of confidence
- complex family dynamics (eg overprotective, critical)
- loss/ bereavement / trauma
- pressures of education + transitions – school, exams, puberty
- social pressures – size 0, peers, media + social media
- genetic risk/ environmental risk
- abuse
- perfectionist / obsessive personality traits
- Co-morbidities
Bulimia Nervosa
Characterised by recurrent BINGE-EATING followed by INAPPROPRIATE compensatory behaviours to prevent weight gain
These must occur at least ONCE A WEEK for at least 1 MONTHS
Why should people not brush their teeth if purging
- Acid softens enamel
- Toothbrush scrubs it off
Better to use anti-acid mouth wash
Compensatory behaviours in bulimia
- Self induced vomiting
- Laxatives
- Diuretics
- Fasting
- Exessive exercise
Bulimia epid
- Most commonly in adolescents + young adults
- Female:Male = ~10:1 (tho ~10% of men can experience it but just don’t tend to report)
Bulimia Sx
Psych:
- Binge eating
- Purging
- Body image Distortion
Pysical:
- Dental erosion
- Parotid Gland swelling
- Russell’s sign
- Amenorrhoea
- Excessive vomiting (Boerhaave syndrome or Mallory-Weiss tear)
DDx for bulimia
- Anorexia Nervosa (AN)
- Kleine-Levin Syndrome: Characterized by hypersomnia, hypersexuality, and hyperphagia.
- Kluver-Bucy Syndrome: Involves compulsive eating, associated with bilateral medial temporal lobe lesions.
Bulimia Dx
- Detailed medical history for binge eating and compensatory behaviors.
- Comprehensive physical examination for physical signs.
- Psychological assessments for associated conditions and body image distortion.
Bulimia Mx
- Bulimia Nervosa Focused Family Therapy: First-line for children.
- High-Dose Fluoxetine: Considered in some cases. (uncommon)
Complications of eating disorders
Short term:
- Malnutrition + Dehydration
Weight loss - Dry Skin
- Hair loss
- Dizziness/fainting
- Weakness
- Low Blood Pressure + Heart Rate
- Low body temperature
Long term:
- Severe dehydration –Kidney failure
- Cardiac problems- leading to death
- Infertility
- Fragile Bones - osteoporosis
- Depression, Anxiety
- Risk of relapse post recovery
Psychological effects of starvation
- Anxiety + agitation
- Apathy
- Depression + fluctuating mood
- Obsessions about food
- Behavioural rigidity
- Poor concentration + comprehension
- Poor sleep
- Decreased social reciprocity
General Tx of eating disorders
- Admission for medical stabilisation + re-feeding (if medically unstable)
- MEAL PLAN
- Reviwed by SEDATT before discharge + 1 wk after then continuing on
What are the phases of Family Based Therapy for Anorexia / Bulimia
1 - Acknowledging state of starvation, focus on refeeding, emphasis on parental control
2 – Continued focus on weight gain, starting to shift responsibility (parent to YP)
3 – Weight maintenance, focus on family relationships, develop family strengths
4 – Relapse prevention, endings
