Child & Adolescent Psychiatry Flashcards
Who outlined the mediators of the effect of parental psychiatric disorders on a child?
Rutter
What factors can mediate the effect of parental MI on a child?
Direct impact of exposure
Indirect impact due to altered interpersonal behaviour and parenting capacity
Social adversity, genetic or constitutional factors
Prenatal affects of maternal depression on the child
Poor nutrtition
Higher preterm birth
Low birth weight
Pre-eclampsia
Effect of maternal depression on the infant
Anger and protective style of coping Withdrawal Passivity Reduced attention Lower IQ
Effect of maternal depression on the toddler
Passive noncompliance
Reduced expression of autonomy
Internalising and externalising problems
Reduced social interaction
Effect of maternal depression on school-aged children
Reduced adaptive functioning
Affective, anxiety and conduct disorders
ADHD-like presentation
Effect of maternal depression on adolescents
Affective disorders, anxiety disorders, phobias
Panic disorder
Conduct disorder
Substance and alcohol misuse
What is the most well known epidemiological study into the effect of childhood adversities and first onset of MI?
Survey into 21 countries in the WHO World Mental Health Survey Initiative Kessler et al. 2010
What is the most common childhood adversity?
Parental death
Prevalence of parental death
11-15%
Name some other childhood adversities
Physical abuse
Family violence
Parental MI
Rate of physical abuse in childhood
5.3-10.8%
Rate of family violence in childhood
4.2-7.8%
Rate of parental MI in childhood
5.3-6.7%
Which childhood adversities increase risk of adult psychiatric disorders?
Maladaptive family functioning
What psychiatric disorders are seen in those with a hx of sexual abuse?
Depression PTSD Conduct disorders Somatisation Suicidal behaviour
F:M ratio of childhood sexual abuse
4:1
What % of childhood sexual abusers are male?
90%
What is the average age of children who are the victims of sexual abuse?
9-11
What is the most prevalent form of child maltreatment?
Neglect
How many childhood cases reported are due to neglect?
60%
How many childhood cases are reported for physical abuse?
20%
How many childhood cases reported are due to sexual abuse?
10%
Signs of physical abuse
Unexplained injuries, especially if recurrent
Improbable excuses for injuries
Refusal to discuss injuries
Untreated injuries or delay in presentation
Excessive physical punishment
Signs of possible physical neglect
Constant hunger Poor persona hygiene Constant tiredness Poor state of clothing Frequent lateness or non-attendance at school Untreated medical problems
Signs of possible non-organise failure to thrive
Significant lack of growth
Weight and hair loss
Poor skin or muscle tone and circulatory disorders
Signs of possible emotional abuse
Low self esteem, continuous self-deprecation
Sudden speech disorder
Self-mutilation
Rocking, head-banging or other neurotic behaviour
Behavioural signs of possible sexual abuse
Lack of trust/over-familiarity with adults Fear of a a particular individual Social isolation Sleep disturbances Running away from home Girls taking over mothering role Unusual interest in genitals Expressing affection in inappropriate ways Developmental regression Over-sexualised behaviour
Physical signs of possible sexual abuse
Bruises/scratches in thighs/genital area Itch/soreness/bleeding/discharge from rectum, vagina or penis Pain or passing urine/recurrent UTI Recurrent vaginal infection Venereal disease Stained underwear Discomfort on walking/sitting Pregnancy - particularly when reluctance to name father Higher morning cortisol
Parental risk factors for childhood physical abuse
Poverty Psychosocial stress - especially financial Young age Low IQ Criminal record poor parenting skills Experience of abuse as a child Psychiatric problems
Risk factors in children of physical abuse
Prematurity Congenital malformation Intellectual disability Chronic illness Difficult temparement
In which families is there an increase in child abuse?
Multiple children Poor housing Welfare reliance Single parents Less parental education Underemployment
At what age does physical abuse commonly begin?
adolescence
Relationship between self blame and powerlessness and sexual abuse?
Inverse relationship in children
Most common relationship in childhood sexual abuse?
Stepfather and stepdaughter
Risk factors of childhood sexual abuse?
Alcohol abuse
Overcrowding
Increased physical proximity
Rural isolation
Features of ADHD
Excessive and impairing levels of hyperactivity, inattention and impulsivity that are evident in more than one setting and cause serious impairment.
Exclusion criteria for ADHD
Those with pervasive development disorder, schizophrenia or another psychotic disorder
In what age group of children is hyperactivity more noticeable?
Pre-school
Change in criteria for ADHD in DSM V
Onset changed from before 7 to before 12
Comorbird diagnosis with ASD is now allowed
Sx threshold for adults is now 5 sx
What questionnaire is commonly used for ADHD?
Connor’s questionnaire to obtain information from schoolteachers
What is ADHD called in ICD 10?
Hyperkinetic disorder
Which diagnostic classification has stricter criteria for ADHD?
ICD 10
What is needed to confirm a diagnosis of ADHD?
Impairment from inattention/hyperactivity-impulsivity needs to be observable in at least 2 settings and interfere with developmentally appropriate functioning socially, academically or extracurricularly activities and persist for at least 6 months
Prevalence of ADHD using ICD 10
1-2%
M:F ratio of ADHD?
3:1
In which group of children is ADHD more common?
Boys
Areas of social deprivation
Children living in institutions
Heritability of ADHD
80%
ADHD in siblings
Siblings have 2-3x increased risk
Concordance % of ADHD in twins?
79% MZ
32% DZ
Which genes are implicated in ADHD?
5 6 11 DAT1 and dopamine D4 gene SNAP-25 gene
What areas of the brain are affected in ADHD?
Prefrontal cortex
Striatum
Cerebellum
What does PET show in ADHD?
Lower cerebral blood flow and metabolic rates in frontal lobe areas
What does PET show in girls with ADHD?
Globally glucose metabolism than both controls and males with ADHD
Which neurotransmitters are involved in ADHD?
DA and NA dysregulation in prefrontal cortex
Environmental factors of ADHD
Prenatal and perinatal obstetric complications
Low birth weight and prematurity
Prenatal exposure to EtOH, nictine and benzos
Poor attachment and severe early deprivation
Institutional rearing
How many patients with ADHD have a HI?
25%
Protective factors for ADHD
Relationships within family and at school
How many children with ADHD have a comorbird disorder?
50-80%
How many children with ADHD have oppositional defiant disorder?
40%
How many children with ADHD have anxiety disorder?
34%
How many children with ADHD have conduct disorder?
14%
How many children with ADHD have tic disorder?
11%
How many children with ADHD have mood disorder?
6%
How many patients with ADHD continue to meet diagnostic criteria at age of 25?
15%
How many people with ADHD will suffer some impairment from residual sx?
50%
What are children with hyperkinetic disorder at risk of?
5x risk of antisocial behaviour, substance abuse and other psychiatric disorders
How many children with ADHD go on to develop substance misuse problems?
15-20%
Which type of ADHD go on to exhibit fewer impulsive-hyperactiver sx as they get older?
ADHD, combined type
What factors are linked with poor prognosis for ADHD?
Early stressful life experiences such as poverty, overcrowding, expressed emotions and parental psychopathology
Severe sx
Predominantly hyperactive-impulsive in nature
Association with conduct, language or LD
First line treatment of ADHD
Educational interventions Family training programme based on social learning theory and behavioural interventions Individual/family therapy CBT - especially behavioural Social skills training
What is the biggest study looking into treatment for ADHD?
Multimodal treatment study of children with ADHD (MAT)
Describe the structure of MAT
RCT involving 579 children with ADHD
Results of MAT
Confirmed effectiveness of medication management in children + adolescents
Intensive behavioural therapy involving child, family & teachers added little benefit
Psychological interventions were important for families who did not wish to use medication
How do stimulants work in management of ADHD?
Release NA, dopamine and seretonin, increasing extracellular dopamine and inhibiting impulses, helping persistence in motor and cognitive functions.
What drugs are licensed for ADHD?
Methylphenidate
Atomoxetine
Alpha 2 agonists
Antipsychotics
Onset of Methylphenidate?
1-3 hours
Half life of Methylphenidate?
2-3 hours
Dose range of Methylphenidate
5-60mg/day
Which drug is n longer licensed for ADHD and why?
Pimoline
Causes liver failure
How does Atomoxetine work?
NARI
Increases noradrenaline in the synaptic cleft
What note did MHRA add to Atomoxetine in Dec 2012?
Can cause increase in BP and HR and therefore should be monitored
Monitoring for Methylphenidate
Height, weight, BP and HR initially 3 monthly, then 6 monthly
What does MHRA advise patients on Atomoxetine should be monitored for?
BP, HR
Signs of depression, suicidal thoughts and behaviour
Height & weight
3 monthly, then 6 monthly
Which drug has the largest and most rapid effect on ADHD?
Methylphenidate
How does Methylphenidate work?
Indirect sympathomimetic by increasing DA and release
What sx can Methylphenidate help with?
Comorbid aggression and oppositional defiant disorder
Hyperactivity
Adverse effects of Methylphenidate
Weight loss Sleep disturbance Cramps/headaches Mild BP and HR increase Emotional blunting Evening crash Depression Tics Hallucinations Mild growth slowing for 2 yearss
Initial dose of Methylphenidate
5-10mg OD
How is Methylphenidate dose increased
5-10mg per week
Which SE are not found with Atomoxetine?
Insomnia
Tics
Which comorbid disorder can Atomoxetine help with in ADHD?
Depression
Adverse effects of Atomoxetine
Weight loss
GI sx
Fatigue, dizziness
Mild growth slowing
Which antidepressants can be used for ADHD
TCAs
Adverse effects of TCAs
Sedation BP changes Dizziness on standing Dry mouth Cardiac conduction block: need ECG monitoring
What sx do alpha 2 agonists treat in ADHD?
Hyperactivity-Impulsiveness
Tic disorders
Aggression
Which patients are alpha 2 agonists good for in ADHD?
Overaroused
Comorbid anxiety
Adverse effects of alpha 2 agonists for ADHD
Response delayed Sedation Postural hypotension Dry mouth Hypertensive rebound if dose missed