Child & Adolescent Psychiatry Flashcards
1
Q
How do we categorise disorders in child psychiatry?
A
Behavioural, emotional & neurodevelopmental HOWEVER there is often overlap
2
Q
What two key factors are essential to explore in child psychiatric history?
A
- Development
- Family & other relationships
3
Q
What do we mean by resilience?
State soem protective factors for resilience
A
A positive psychological adaption that allows a person to overcome any damaging effects of adversity (i.e. ability to get past difficulty situations)
Protective factors:
- Easy temperament
- High/good self-esteem
- Secure relationships
- High IQ
- Good problem-solving skills
- Faith & sense of meaningn in life
- Humour
- Positive parentingn experiences
4
Q
Define autism
A
Pervasive neurodevelopmental disorder, which manifests before three years of age, characterised by triad of
- impairment in social interaction
- impairment in communication
- restricted steroetyped interests & behaviours
5
Q
Discuss the epidemiology of autism; include prevelance and male to female ratio
A
- 1.1%
- Male to female is 4:1
6
Q
State some risk factors/discuss aetiology of autism; structure your answer as prenatal, antenatal and post natal
A
Prenatal
- Genetics (number of chromosones implicated including 7, increased risk with genetic syndromes likes fragile X, tuberous sclerosis)
- Advancing parental age
- Drugs (e.g. if mum took sodium valporate while pregnant)
- Infection (e.g. rubella)
Antenatal
- Obstetric complications e.g. hypoxia
- Prematurity
- Low birth weight
Postnatal
- Toxins e.g. lead, mercury
- Pesticide exposure
*ALSO, being male and FH of ASD and of psychiatric disorders (e.g. schizophrenia) increase risk
7
Q
Discuss ICD-10 criteria for autism
A
8
Q
Discuss clinical features of autism
HINT: think ABC
A
- *Also for behaviour restricted:*
- may become attached to unusual, non soft objects
9
Q
Alongside features in ICD-10 diagnostic criteria for autism, state some other features which may be present
A
- Fear/phobias
- Sleeping and/or eating disturbances
- Temper tantrums
- Aggression
- Lack creativity
- Self injury (e.g. wrist biting is common)
- Intellectual disability (NOTE: if you include all those on ASD spectrum majority won’t have disability)
10
Q
What age must autism present before/age of onset is before?
A
Age of onset before 3yrs
50% parents recognise something wrong by 12-18 months
11
Q
State some other medical conditions associated with autism
A
12
Q
What screening questionnaire can be used to help identify children aged 18 months to three years who have autism?
A
CHAT (CHecklist for Autism in Toddlers)
13
Q
Example of questions in ASD history
A
14
Q
When screening for autism you must take full history- including all usual aspects- and ensure you find out about pregnancy & birth, developmental milestones, communication, social interaction & stereotypes behaviours in detail.
Discuss some speech & hearing developmental milestones
A
15
Q
When screening for autism you must take full history- including all usual aspects- and ensure you find out about pregnancy & birth, developmental milestones, communication, social interaction & stereotypes behaviours in detail.
Discuss some social behaviour milestones
A
16
Q
Discuss potential MSE of autistic patient
A
17
Q
What investigations may you consider in child who has autism?
A
- Hearing tests
- Eye tests
18
Q
Delays in language & social interaction indicate likely autism but global developmental delay indicates alternative pathology; true or false?
A
True
19
Q
State some potentail differential diagnoses for autism
A
- Asperger’s syndrome
- Rett’s syndrome
- Childhood disintegrative disorder
- Learning disability
- Deafness
- Childhood schizophrenia (age onset <13yrs. VERY rare)
20
Q
We have said the following are differential diagnoses for autism:
- Asperger’s syndrome
- Rett’s syndrome
- Childhood disintegrative disorder (Heller’s syndrome)
… briefly describe each
A
Asperger’s syndrome
- Similar to autism with abnormalities in social interaction and the repetitive stereotyed interests and behaviours but there is NO impairment in communication/language or cognition or intelligence. M >F
Rett’s syndrome
- Severe, progressive disorder resulting in language impairment, repetitive stereotyped hand movements, loss of fine motor skills, irregular breathing & seizures. Almost exclsuive to females
Childhood disintegrative disorder (Heller’s syndrome)
- Two years of normal development followed by loss of previously learned skills in language, social and motor domains. Associated with repetitive, stereotyped interests & behaviours and cognitive deterioraiton.
21
Q
Discuss the management of autism, consider:
- General points in management
- Interventions for core features of autism
- Interventions for challenging behaviours
A
Biological
- Treat co-existing disorders e.g. hyperkinetic disorder
- Melatonin for sleep disorders that persist despite behavioural interventions
- Antipsyschotics for severe challenging behaviour that hasn’t responded to psychosocial interventions
Psychological
- Psychoeducation for families or carers
- CBT if child has verbal & cognitive ability to engage and is motivated
Social
- Modification of enviromental factors (particularly if these initiate or maintain challenging behaviour)
- Social-communication intervention (e.g. play based strategies)
- Special schooling
- Self-help groups for families/carers & child e.g. National Autistic Society
22
Q
What is the first line management of challenging behaviour in autism?
A
- Modification of environmental factors that initiate or challenge behaviour (e.g. lighting, noise, social circumstances)
If has co-existing disorder treat this also. If psychosical interventions insufficient can use antipsychotics for severe behavioural challenges.
23
Q
Who should diagnose autism?
Children with autism are managed by local autism teams; who is involved in these teams?
A
- Specialist by age of 3yrs
- Local autism teams are community based MDTs and include:
- Paediatricians
- Psychiatrists
- Educational pscyhologists
- SALT
- Occupational therapists
ALL those with autism should have a key worker to manage and coordinate treatment
24
Q
What is hyperkinetic disorder also known as?
A
ADHD (attention deficit hyperactivity disorder)
25
Define ADHD/hyperkinetic disorder
Characterised by an **early onset**, **persistent pattern** of **inattention, hyperactivity and impulsivity** that are more frequent and severe than in individuals at a comparable satege of develop AND are **present in more than one situation.**
26
Discuss the epidemiology of ADHD, include:
* Prevelance
* Male to female ratio
* Age of onset
* 3% in UK
* Male to female is 3:1
* Age of onset 3-7yrs
27
State some risk factors/potential causes for ADHD
* Genetic/family history
* Abnormality in dopaminergic pathways
* Neurodevelopmental abnormalities in pre-frontal cortex
* Male
* Social deprivation
* Cannabis use during pregnancy
* Alcohol use during pregnancy
* Low birth weight
* Prematurity
*\*NICE state that alcohol during pregnancy and low birth weight are the most strongly associated environmental risk factors*
28
What genes are thought to play a role in ADHD?
DRD4
DRD5
29
Discuss the ICD-10 criteria for ADHD
* Both inattention & hyperactivity must be evident in more than one situation
* Impulsivity and other associated features do not have to be present
* Duration at least 6 months
* Early onset (usually between 3yrs and 7yrs)
30
State the 3 core features of ADHD
* Inattention
* Hyperactivity
* Impulsivity
31
The three core features of ADHD are inattention, hyperactivity and impulsivity. State some features/behaviours that demonstrate:
* Inattention
* Hyperactivity
* Impulsivity
... in children with ADHD
32
Example of how to ask questions in ADHD history
33
OSCE tips for assessing ADHD
34
Discuss potential MSE for child with ADHD
35
Collateral information from _____ is important is the assessment of ADHD
* School e.g. teachers report
36
What investigations might you consider in children with suspected ADHD?
* Hearing tests *(check inattentiveness behaviour not due to impaired hearing)*
* Sight tests *(check inattentiveness not due to impaired sight)*
* TFTs *(rule out hyperthyroidism)*
* Rating scales *(e.g. Conner's rating scale and the Strengths & Difficulties questionniare)*
37
State some differential diagnoses for ADHD
* Learning disability/dyslexia
* Conduct disorder
* Oppositional defiant disorder
* Hearing impairment
* Autism
* Mood disorders (particularly bipolar)
* Anxiety disorder
38
Many people (~70%) with ADHD have co-morbid conditions; state some common co-morbidities
* Learning difficulties (e.g. dyslexia)
* Conduct disorder (present in 50% pts with ADHD)
* Tourette's syndrome
* Dyspraxia
* Mood disorder
* Anxiety disorders
* ASD
* Oppositional defiant disorder
* Sleep disorders
39
Who can diagnose ADHD?
Needs to be diangosed by specialist in childhood behavioural problems and management is coordinated in specialist in ADHD
40
What is conduct disorder?
* Characterized by a **repetitive and persistent** pattern of **dissocial, aggressive, defiant conduct** which is agains the age-appropriate social expectations for that child.
They can be further categorised as:
* Socialised: beahavioiurs are viewed as normal within the peer group or family
* Unsocialised: behaviours are viewed as solitary with peer & parental rejection
41
Discuss the management of ADHD
_General management for all_
* Advise about support groups e.g. ADDISS (for child, parents & teachers)
* Avoidance of certain foods if these are found to trigger symptoms *(if unsure advise to keep food diary)*
* Psychoeducation
_Pre-school/young children_
* Parent training *(help parents to reinforce positive behaviour and find alternative ways of managing disruptive behaviour)*
_School/older children_
* CBT and/or social skills training
* If ADHD is severe, drug treatment is first line:
* Methylphenidate (Ritalin)
* If fails, try atomoxetine
* If fails, try dexamfetamine
42
The drugs used to treat ADHD are CNS stimulants; state some side effects of CNS stimulants
* Headache
* Insomnia
* Loss of appetite & weight loss
* GI upset: indigestion, stomach ache, nausea
43
When are ADHD drugs given?
Modified release 1 tablet in morning
Not modified release 2-3 times per day (morning, midday and maybe late afternoon)
44
What two conditions does **conduct disorders** include?
* Conduct disorder
* Oppositionaal defiant disorder
45
What is oppositional defiant disorder?
**Subtype & milder version of conduct disorder.** It is defined by the presence of markedly **defiant, disobedient, provocative behaviour** and by the **absence of more severe dissocial or aggressive acts** that violate the law or the rights of others. Usualy seen in children younger than 10yrs.
46
State some risk factors for conduct disorder
* Male
* Low socioeconomic satus
* Childhood abuse (physical or sexual)
* Genetics
* Being bullied
* Witnessing domestic violence
47
State some examples of behaviours consistent with conduct disorder
MUST be repetitive, not just one off:
* Fighting and/or bullying.
* Cruelty to animals or people.
* Destructiveness to property.
* Setting fires.
* Stealing.
* Repeated lying.
* Truancy from school.
* Running away from home.
* Unusually severe temper tantrums.
* Defiant provocative behaviour.
* Persistent severe disobedience.
48
State some exampels of behaviour consistent with oppositional defiant disorder
MUST be repetitive:
* Often feeling angry, spiteful or resentful.
* Annoying others and being easily annoyed.
* Blaming others for mistakes or misbehaviour.
* Ignoring or rebelling against rules, at home or at school.
* Arguing with adults.
* Unusually quick loss of temper.
49
What questionnaire can be used to help aid diagnosis of conduct disorders?
Strengths & difficulties questionnaire
50
Discuss the DSM V criteria for ADHD
51
State some comorbid conditios associated with conduct disorders
* ADHD
* Learning or developmental disorders
* Low self-esteem
52
What do we mean by attachment in childhood?
* **Relationship/bond between a child/young person and their primary care giver.**
* This bond is formed in the **early years** and has a **long-term impact** on a child’s **sense of self, development, learning, growth and future relationships** with others.
53
Discuss the management of depression in children
* If mild may try **watchful waiting with review in two weeks**
* If above not worked or moderate-severe try **low intensity psychosocial interventions** e.g. computerised CBT, group CBT
* If moderate to severe try **high intensity psychosocial interventions** e.g. individual CBT, family therapy (younger children)
* **SSRI (fluoxetine)**- ONLY prescribed by child & adolescent psychiatrist
54
State some differential diagnoses for conduct disorders
* ADHD
* Adjustment reaction to external stressor
* ASD
* Bipolar
55
Discuss the management of conduct disorder
* **Parent training programmes** *(group or individual programmes designed to help parents understand their and child's emotions & behaviours, improve communication with child and improve behavioural management)*
* **Cognitive behavioural and social skills therapy** *(usually offered to children aged 9-14)*
* **Medication may be used CAUTIOUSLY if problems are severe e.g.:**
* Atypical antispyshcotics (e.g. risperidone) to reduce aggressive behaviour
* SSRIs to reduced impulsivity, irritability & lability of mood
56
Discuss the prognosis of conduct disorder
Compare this to oppositional defiant disorder
Up to 50% go on to develop antisocial personality disorder *(adolescent onset, \>10yrs, has better prognosis)*
Oppositional defiant disorder has better prognosis
57
State some emotional disorders seen in children & adolescents
* **Separation anxiety disorder** *(severe anxiety about being separated from major attachment figures which is beyond norm)*
* **Sibling rivalry disorder** *(emotinal disturbance in months following birth of younger sibling- this may persist for some time. Can range from reuluctance to share to phsycial trauma to other child)*
* **GAD**
* **Phobic anxiety disorders**
* **OCD *(more superstitious like)***
* **PTSD**
* **Depression**
58
In children with depressive illness the low modo may not be pervasive; true or false?
TRUE- very importnat to remember
*Other notes: in boys it can be masked by anger*
59
NOTE: management of many emotional disorders in children are same as those in adults with additional details such as:
* Family therpy a good option for younger children
* Not as keen/give medication cautiously
60
There are the different types of attachment; state and describe the different types
* **Secure:** child values relationships and is confident within themselves. Infant knows they can venture out and explore and always be welcomed back by primary care giver who is also there for them in times of distress.
* **Insecure:** Develops if early interactions are negative, inconsistent, abusive, neglectful or inappropriate. May behave in ways to promote survival e.g. struggle to ask for help, make friendships, manage emotions, concentrate. Differnet subtypes:
* **Insecure avoidant:** does not value relationships & is independent
* **Insecure anxious:** values relationships but sees them as unreliable
* **Disorganised:** does not value relationships & not confident in themselves
61
State some risk factors for insecure attachment
* Abuse
* Trauma
* Parental mental health difficulties
* Parental substance misuse
* Multiple care placements
* Parents being separated from their baby just after birth, for example if the baby is receiving neonatal care
* Stress such as having a low income, being a single parent, or being a young parent
* Bereavement or loss of another caregiver that a child had an attachment with
62
State some signs of insecure attachement
* being fearful or avoidant of a parent or carer
* becoming extremely distressed when their carer leaves them, even for a short amount of time
* rejecting their caregiver’s efforts to calm, soothe, and connect with them
* not seeming to notice or care when their caregiver leaves the room or when they return
* being passive or non-responsive to their carer
* seeming to be depressed or angry
* not being interested in playing with toys or exploring their environment
63
State some potential effects of insecure attachment
In childhood:
* ADHD
* Conduct disorder
* Learning impaired
As they grow older:
* Poor self-esteem
* Difficulty forming healthy relationships
* Depression
* Anxiety
* Substance misuse
* Antisocial behaviour
