CAMHS Flashcards
Familial risk factors for behavioural disorders
Angry discord between family members
Parental mental illness, especially maternal depression
Bereavement
Divorce and subsequent loss of parent figure
Intrusive overprotection
Lack of parental authority
Physical/sexual abuse
Emotional rejection
Excessive criticism
Inconsistent, unpredictable discipline
Using child to fill parental emotional needs
Inappropriate responsibility or expectation of the child
Features meal refusal
Child refusing to eat any/much of prepared meals
“mealtimes are a battle”
Child healthy and well-nourished with normal growth
Factors contributing to meal refusal
Past history of force feeding Irregular meals: child is not predictably hungry Unsuitable meals Unreasonably large portions Multiple opportunity for distraction
Mx meal refusal
Offer adequate range of wholesome food Avoid confrontation at mealtimes delevop a relaxed atmosphere Use favourite foods as rewards: use other rewards for compliance at mealtime .e.g. TV Reduce eating between meals
Difficulty settling at night causes
Too much late afternoon sleep Displaced sleep/wake cycle Separation anxiety Overstimulated/overworked in evenings Kept awake by environmental factors Erratic parenting Use of bedroom as punishment Dislike of darkness and silence Chronic physical conditions .e.g. sickle cell crisis
Mx sleeping difficulty
Creating bedtime routine which cues child
Telling child to lie quietly until they sleep
No screen time 1h before sleep
Graded pattern of leaving child
Features night terrors
Occur 1.5hrs after settles Child sitting up in bed, eyes open, seemingly awake Disorientated, confused, distressed Unresponsive to questions or reassurance Child settles within minutes No recollection of episode
Mx toddler disobedience
Ensure demand is reasonable for development of child
Positive instructions not negative instructions
Praise for compliance even when spontaneous
“if you do… we can do…”
Avoid empty threats
Follow through with consequences
Ignore non-significant episodes
Medical factors of poor behaviour
Global or language delay
Hearing impairment
Medication with bronchodilators and anticonvulsants
Mx tantrums
Affect and attention before the tantrum Distraction Avoiding antecedents Ignoring: effective, no surrender Time out from positive reinforcement: walk away, separate from other children Hold firming if risk of danger Star chart 1-2-3 principles: stop-if-consequence
Causes nocturnal enuresis
UTI
Faecal retention reducing bladder volume and causing bladder neck dysfunction
Polyuria from osmotic diuresis/ concentrating disorders
Developmental, attentional and learning difficulty
Ix nightime enuresis
Indicated with recent onset bed wetting, daytime enuresis, UTI, diabetes, ill health
Urinalysis
Normal development nocturnal enuresis
Infrequent bed wetting is common in children
>2 nghts/week present in 6% of 5y and 1.5% 10y
More common in boys
Usually genetically determined delay in sphincter competence
Typically resolves spontaneously
Mx Nocturnal Enuresis
Reassurance and explanation
Ceasing punishment
Excessive fluid intake/ abnormal toileting addressed
Waking and lifting does not promote long term dryness
Star chart for sheet change NOT dry nights
No child blame for wet nights
Enuresis alarm
-1/3 relapse but succeed with second trial of alarm
Desmopressin (ADH synthetic analogue): children >7y
-short term use .e.g. sleepovers and holidays
-sublingual tablet and fluid restriction
-continued for 3-6m
Factors contributing to faecal soiling
Faecal retention and constipation: -pain from fissure -fear of punishment for incontinence -toileting anxiety Urgency of defecation Neuropathic bowel Diarrhoea overwhelming bowel control Mental age below 4y Intentionally as a hostile act
Mx Constipation
Treatment of fissures Emptying rectum: stool softener .e.g. macrogol 2w +/- stimulant laxative Maintenance laxative therapy Regular toileting star charts
Features somatic symptoms
Recurrent medically unexplained symptoms
Aggrevated by dtress
Usually recurrent abdo pain (9y) and headache (12y)
Limb pain, aching muscles, fatigue, neurological signs with increasing age
Pain further away from umbilicus more likely to be organic (Apley’s rule)
Pain may be limited to school days or specific events
Features Tics
Quick, sudden, co-ordinated movement Apparently purposeful Recurrs in the same part of the body Can be suppressed to some extent Typically around face and head: blinking, frowning, head fliching, sniffing, throat clearning, grunting Boys more commonly affeced Average onset 8y, peak at 11y Occur when child is inactive Disappears when concentrating
Gilles de Tourette syndrome features
Multiple motor and vocal tics
Typically persistent
Swearing (coprolalia) is uncommon
Mx severe tics and Tourettes
CBT with habit reversal techniques
Medication .e.g. clonidine or rispiradone
Features chronic tics
Persist more than 12m
Multiple, child is rarely free
Most resolve by adulthood
Reasons for antisocial behaviour
Failure to learn when to exercise social restraint Lacking social skills.e.g. negotiation Responding to peer challenge Chronically angry or resentful Overwhelmed by sadness or temptation
Features of conduct disorder
Serious antisocial behaviour infringing on rights of others
Handicap to general functioning
Features oppositional-defiant disorder
Milder form of conduct disorder
Angry defiant behaviour to authority figures
Mx conduct disorder
Parental management training programmes .e.g. Webster Stratton, Triple P
Child individual or group therapy
-problem solving skills and anger management
Mx School Refusal
Advise and support parents and school
Treat underlying emotional disorders
Plan and facilitate early graded return at a pace tolerable to child
Make school more rewarding than home
Address bullying and educational difficulty
Quality of preschool thought
Child is centre of world
Everything has purpose
Inanimate objects are alive
Poor categorisation
Use of magical thinking
Use of sequences or routine rather than time
Use of toys and imaginative play to make sense of world
Adolescent formal operational thought
Ability to form abstract thoughts Comparing implications of hypotheses Thinking about one's own thinking Testing logic that links propositions Manipulating interactive abstract concepts
Features of school refusal
Inability to attend school on account of overwhelming anxiety
Nausea, headache, illness, hyperventilation effects
Disproportional to stress at school .e.g. bullying, attainment
Typical in children until age 11y
May be provoked by adverse life event
Causes of underachievement at school- chronic
Visual problems Hearing problems Dyslexia Generalise learning problems Hyperactivity Anti-education family background Chaotic family background
Causes of underachievement at school- acute
Preoccupations Fatigue Depression Rebellion Unsuspected poor attendance Sexual abuse Drug abuse Prodromal period of psychotic illness Degenerative brain condition
Features Anorexia Nervosa
Self induced weight loss
BMI <17.5/ plotted on centile chart
Distorted perception of body increasing with weight loss
Determined attempt to lose weight by restricting intake or purging behaviour
Halted pubertal development
Need for control
Parental attention may promote features
Denies hunger/problem/hide behaviours
May cook for others and show interest
Character traits: perfectionist, obsessional
Physiological effects of starvation in AN
Low metabolic rate Slow to relax reflexes Reduced peripheral circulation Bradycardia Amenorrhea Fine lanugo hair over trunk and limbs Puberty delayed Low T3 low plasma proteins (ankle oedema) Low non-cyclical LH and FSH
Feature Bulimia
Weight loss attempt by use of purging following binging episodes
Wide fluctuations in weight
Metabolic abnormalities: hypokalaemia, alkalosis
Typically affects older teens
Mx AN
Refeeding to restore body weight -hospital admission and NG if needed Cx: refeeding syndrome Family therapy Individual psychological therapy -challenge cognition
Prognosis Anorexia
50% fail to make full recovery
Poor outcome: low BMI, physical complications, bulimic symptoms, family disturbance, interpersonal difficulty
High mortality
Death by medical complications and suicide
Features Chronic Fatigue Syndrome
Persisting high levels of subjective fatigue
Rapid exhaustion
Commonly depressive symptoms
Myalgia, migratory arthralygia, headache, difficulty sleeping, poor concentration, irritability
Mx Chronic fatigue syndrome
Remits spontaneously, can take years
Continuous rest is unhelpful
Graded exercise therapy and CBT
Features of depression in adolescents
Apathy, boredom, inability to enjoy oneself Separation anxiety reappears Decline in school performace Social withdrawal Hypochondriacal ideas Complaints of chest, abdo, head pain Irritable mood Antisocial behaviour Less commonly: loss of appetite/sleep/libido, slowing thought and movement, delusional ideas
Mx depression in children
Mild depression: primary care -may recover spontaneously (wait 4w) -supportive therapy or guided self help Referral to specialist if symptoms >2-3m CBT, interpersonal and family therapy >6w therapy: consider SSRI .e.g. fluoxetine
Features psychosis
Breakdown of the perception and understanding of reality and lack of awareness they are unwell
Delusional thinking
Odd behaviour
Speech difficult to follow- thought disorder
Hallucinations
Psychotic disorders in adolescents
Schizophrenia
Bipolar effective disorder
Organic psychosis .e.g. delirium, substance induced
Ix Psychosis
Urine drug screen
Exclusion of infection, seizures, thyroid abnormality, sleep disorders, dementia
Behaviours suggestive of heavy drug misuse
intoxication unexplained absence from home or school mixing with known users high rates of spending or stealing money possession of equipment medical complications
Psychological treatment
Explanation and formulation Counselling of child or parents Parenting groups Behavioural therapy Family therapy Cognitive therapy Individual or group dynamic psychotherapy
