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MRCPsych Part B > Child & Adolescent Psychiatry 1.2 > Flashcards

Child & Adolescent Psychiatry 1.2 Flashcards

1
Q

Impairments in children with anxiety

A

Behavioural avoidance
Extreme level of distress compared to peers

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2
Q

Prevalence of anxiety disorders in children

A

5-15%

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3
Q

M:F ratio of anxiety in childhood

A

Equal

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4
Q

Prevalence of anxiety after adolescence in M:F

A

2:1

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5
Q

Prevalence of separation anxiety

A

3.5% in children
0.8% in adults

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6
Q

Prevalence of GAD

A

4$ in adolescence

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7
Q

Prevalence of simple phobia in children

A

10%

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8
Q

Which gender is more likely to have simple phobia?

A

Twice as common in females

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9
Q

Prevalence of social phobia

A

1% in children
5-15% in adolescence

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10
Q

Prevalence of panic disorder in children

A

3-6%

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11
Q

Peak age of onset of panic disorder

A

15-19%

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12
Q

Sx of anxiety in preschool children

A

Tearfulness
Clinging

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13
Q

Sx of anxiety in middle childhood

A

Somatic complaints
Hypochondriacal fretting
Irritability
Aggressive behaviour

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14
Q

Which anxiety disorders occur later in childhood?

A

OCD
Social phobia
Panic disorder

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15
Q

Which children are more likely to have comorbid specific phobia?

A

Children with SAD

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16
Q

Which children are more likely to have comorbid mood disorders?

A

Children with GAD and social phobia

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17
Q

How many young people with GAD have a comorbird diagnosis?

A

90%

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18
Q

Definition of seperation anxiety disorder (SAD)

A

Developmentally inappropriate and excessive anxiety concerning separation from home or from those whom the individual is attached.
Interferes with age-appropriate functioning.

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19
Q

Essential clinical feature of SAD

A

Excessive worry about losing or being permanently separated from major attachment figure

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20
Q

Sx of SAD

A

Anxiety about separation or danger to attachment figure
Sleep disturbances, nightmares about separation
Refusal to go to sleep w/o being near attachment figure
Somatisation - especially on occasions of separation
Refusal to go to school

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21
Q

Duration criteria for SAD

A

At least 4 weeks
Cause clinically significant impairment in social, academic and occupational domains
Age of onset <18 years

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22
Q

What is SAD called if diagnosed in a child <6 years of age?

A

Early onset SAD

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23
Q

Importance of attachment for the child

A

Allows the child to understand their inner world
Foundation for safe separation and development of autonomy

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24
Q

How many children have secure attachment

A

60%

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25
Q

How many children have insecure ambivalent/resistant type attachment?

A

10%

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26
Q

How many children have disorganised/disorientated attachment?

A

15%

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27
Q

Describe secure attachment

A

Child uses carer as secure base to explore freely and go back for comfort if necessary
Carer sensitive to childs cues

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28
Q

Describe insecure, ambivalent/resistant attachment

A

Appears interested in caregiver
Minimal distress at separation
Sometimes ignores/avoids caregiver

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29
Q

Describe disorganised/disorientated attachment

A

Child displays contradictory behaviour patterns
Thought to arise from either the child experiencing the carer as frighting or the carer being frightened themselves.

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30
Q

What was the Romanian Adoptees Study?

A

Data on severe attachment disorders was obtained from follow-up of children from severely deprived institutions in Romania and adopted by families in Canada and the UK.

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31
Q

What did the Romanian adoptees study show?

A

20% had severe disturbances at age of 6.
Duration of exposure to deprivation was strong associated with severe disinhibited behaviour

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32
Q

Who does reactive attachment disorder occur in?

A

Infants
Young children

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33
Q

What happens in reactive attachment disorder?

A

Persistent abnormalities in childs pattern of social relationships associated with emotional disturbance and reactive to changes in environmental circumstances

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34
Q

When is reactive attachment disorder diagnosed?

A

<5 years of age

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35
Q

How can reactive attachment disorder manifest?

A

Inhibited
Disinhibited

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36
Q

Which children is reactive attachment disorder more common in?

A

Poverty-stricken
Socially disrupted environments

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37
Q

Causes of reactive attachment disorder

A

Severe parental neglect, abuse and serious mishandling (direct cause)
Young, isolated, inexperienced and/or depressed carer

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38
Q

Features of reactive attachment disorder

A

Fearfulness
Hypervigilance - does not respond to comforting
Poor social interaction with peers
Aggression towards self or others
Growth failure

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39
Q

What is disinhibited attachment disorder?

A

Pattern of abnormal social functioning during first five years of life

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40
Q

How does disinhibited attachment disorder manifest in the early stages?

A

Clinging
Diffuse non-selectively focused attachment behaviour

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41
Q

How does disinhibited attachment disorder manifest by the age of 4?

A

Diffuse attachment
Attention seeking
Indiscriminately friendly behaviour

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42
Q

Duration criteria for sibling rivalry disorder

A

Onset within 6 months of birth of immediately younger sibling
Duration at least 4 weeks
Emotional disturbance that is abnormal

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43
Q

Sx of sibling rivalry disorder

A

Anxiety, regression, tantrums, dysphoria
Attention seeking with one or both parents
Sleep difficulties
Oppositional behaviour
(2 of these must be present)

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44
Q

How do children with school refusal present?

A

Excessive fearfulness
Temper outbursts
Complaints of feeling ill when faced with school; usually physical

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45
Q

Incidence of school refusal in children

A

1-5%

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46
Q

Sex distribution of school refusal

A

Equal

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47
Q

Main incidence peaks of school refusal by age

A

5-7
11
14

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48
Q

Reason for school refusal at ages 5-7

A

Possible separation anxiety

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49
Q

Reasons for school refusal at age 11

A

Transition to secondary school

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50
Q

Reasons for school refusal at age 14 and older

A

First presentation of depression/anxiety
Bullying
Exam pressure
Specific stressors

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51
Q

Most common age of school refusal

A

11

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52
Q

How many children who refuse school successfully reintegrate?

A

70%

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53
Q

Signs in truants

A

Antisocial sx
FHx of antisocial behaviour
Inconsistent discipline
Poor academic achievement
Large family size
Male
Child is neither at home or school

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54
Q

Characteristics of children who refuse school

A

Emotional sx
FHx of neurosis
Over-protecting parenting
Satisfactory academic achievement
Small family or youngest member
Parents aware of childs absence
No gener difference

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55
Q

What is selective mutism?

A

Persistent failure to speak in specific settings

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56
Q

Onset of selective mutism

A

3-5 years

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57
Q

Which psychiatric disorder is seen in selective mutism commonly?

A

Social phobia

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58
Q

Rate of selective mutism in the UK

A

3-8/10,000

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59
Q

Gender differences in selective mutism

A

More common in girls

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60
Q

Helpful treatment for selective mutism

A

Behavioura approach with positive reinforcement techniques aimed at increasing frequency of talking and decreasing frequency of non-communication
Assert what communication is like at home

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61
Q

What is SAD a risk factor for?

A

Development of panic disorder or agoraphobia in adulthood

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62
Q

What is a temperamental predictor of social phobia?

A

Behavioural inhibition

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63
Q

What does GAD have a close genetic link with?

A

Depression

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64
Q

Which therapy has been found to be helpful for children with anxiety?

A

Individual CBT + family component
Psychoeducation

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65
Q

CBT techniques for anxiety in children

A

Relaxation training
Cognitive restructuring

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66
Q

Which groups of children can group CBT be helpful for?

A

Treatment of socially phobic children

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67
Q

First line medication treatment for anxiety in children

A

SSRI

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68
Q

What anxiety disorders in children are SSRIs efficacious for?

A

Social phobia
SAD
GAD

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69
Q

Changes in DSM V for PTSD in children

A

Diagnostic threshold lowered

Separate PTSD criterion added for children <6

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70
Q

When was PTSD formulated as a diagnosis?

A

1980

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71
Q

How many young people meet the criteria for PTSD?

A

6%

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72
Q

How many children aged 11-15 have PTSD?

A

11-15

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73
Q

M:F ratio of PTSD in children

A

1:2

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74
Q

Most common traumatic exposures in children

A

Physical and sexual abuse
Domestic, school or community violence
Kidnapped
Terrorist attacks
Motor vehicle/household accidents
Natural disasters

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75
Q

What must childs response to trauma require for PTSD diagnosis?

A

Intense fear
Terror
Helplessness
Horror
or Disorganized or agitated behaviour

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76
Q

Classification of childhood trauma

A

Type 1
Type 2

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77
Q

What is type 1 trauma

A

Single, acute, traumatic event

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78
Q

Which type of trauma is more common in children?

A

Type 1

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79
Q

What is type 2 trauma?

A

Longstanding or repeated exposure to extreme external events

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80
Q

Sx of type 1 trauma

A

Full detailed memories
Omens or cognitive reappraisal
Misperceptions

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81
Q

Sx of type 2 trauma

A

Denial and psychic numbing
Self-hypnosis
Depersonalisation
Dissociation and rage
Extreme passivity

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82
Q

Treatment of PTSD in kids

A

Trauma-focused CBT
Crisis intervention
Medications

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83
Q

Should EMDR be used for PTSD in kids?

A

No evidence

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84
Q

Structure of trauma-focused CBT

A

8-12 sessions.

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85
Q

What is crisis intervention?

A

Structured sessions with group leaders discussing trauma to share feelings and knowledge and process it.

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86
Q

NICE guidelines for medication?

A

Should not be routinely prescribed for kids with PTSD

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87
Q

What medication has been reported to be helpful in kids with PTSD?

A

Citalopram 20-40mg OD - trial for 8 weeks

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88
Q

What is OCD?

A

Presence of recurrent intrusive thoughts (obsessions) associated with anxiety or repetitive purposeful mental or physical actions (compulsions) aimed at reducing fear caused by obsessions.

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89
Q

Difference in OCD between adults and children

A

Children do not always demonstrate awareness that their thoughts and behaviours are unreasonable.

Childhood OCD secrecy - they understand their behaviour is unusual so try to hide it.

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90
Q

How many children with OCD do not have obsessive thoughts?

A

40%

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91
Q

How many children with OCD have rituals/habits?

A

2/3

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92
Q

Prevalence of OCD in children

A

0.5%

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93
Q

Mean age of onset of OCD in children

A

10

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94
Q

M:F ratio of childhood OCD

A

2:1

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95
Q

M:F ratio of OCD post-pubertal

A

More common in girls

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96
Q

Heritability findings for OCD

A

Increased incidence in first degree relatives and MZ twins: 80% compared to 40%for DZ

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97
Q

Possible causes of OCD

A

Genetic
Autoimmune
Hyperactive orbitofrontal circuits
Serotonin receptor dysfunction
Dopaminergic dysfunction

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98
Q

What is the autoimmune hypothesis for OCD?

A

Reduced volume of caudate nucleus

99
Q

What leads to the hypothesis of the dopaminergic dysfunction leading to OCD?

A

High dose stimulants increase OCD sx

100
Q

Comorbidity of OCD

A

70% have one other disorder

101
Q

How many patients with OCD have tic disorders

A

17-40%

102
Q

How many children with OCD have depression

A

26%

103
Q

How many children with OCD have specific developmental disabilities?

A

24%

104
Q

Best treatment for OCD in kids

A

Combination of medication and therapy (CBT)

105
Q

What drugs are licensed for OCD in children?

A

Fluoxetine
Sertraline

106
Q

Which children with OCD are recommended to be trialled fluoxetine?

A

Co-morbid depression

107
Q

Structure of CBT for OCD in children

A

Developmentally appropriate exposure to feared stimulus coupled with response prevention

108
Q

Treatment guidelines for children with mild OCD

A

Trial of CBT before medication

109
Q

Treatment for severe OCD in children

A

CBT and SSRI

110
Q

Which studies were conducted into treatment of OCD in children?

A

POTS - Paediatric OCD treatment study

111
Q

What did POTS find?

A

Combination of therapy and medication is superior to either alone

112
Q

What is PANDAS?

A

OCD sx associated with beta haemolytic strep infection

113
Q

What does PANDAS stand for?

A

Paediatric autoimmune neuropsychiatric disorders associated with streptococcus

114
Q

Onset of PANDAS

A

Pre-pubertal

115
Q

How many children with Sydenhams chorea have OCD sx?

A

75%

116
Q

Hypothesis behind PANDAS

A

Exposure to strep bacteria activates autoimmune system leading to inflammation of basal ganglia and disruption of cortico-striatal-thalamo-cortical function

117
Q

Neuroimaging in PANDAS

A

Increased basal ganglia volume
Proportional relationship between size of basal ganglia and severity of sx

118
Q

Duration criteria for enuresis

A

Developmental or chronological age of at least 5 years

119
Q

Duration of enerusis

A

3 months

120
Q

When does voluntary control of micturition begin?

A

15-18 months

121
Q

By what age re children dry by day

A

18 months

122
Q

By age 5 how many children have daytime wetting

A

1%

123
Q

By 2 years how many children are dry at night

A

50%

124
Q

By 3 years how many children are dry at night

A

75%

125
Q

How many boys have nocturnal enerusis at age of 7?

A

22%

126
Q

By age of 7 how many girls have nocturnal enerusis?

A

7-15%

127
Q

M:F ratio of nocturnal enerusis

A

2:1

128
Q

Types of enuresis

A

Primary
Secondary
Nocturnal
Diurnal
Mixed

129
Q

Prevalence of enuresis in school-aged children

A

2-5%

130
Q

Most important predictor of primary nocturnl enuresis

A

FHx of enuresis

131
Q

What predicts secondary enuresis?

A

Delay in control over bedwetting
High rate of adverse life events
Reduced sensitivity to vasopressin in kidneys
Sexual abuse

132
Q

What is daytime enuresis likely to be due to?

A

Structural abnormalities

133
Q

Medical causes of enuresis

A

UTI
Obstruction
Genitourinary pathology
Neurological conditions e.g. spina bifida occulta
Diabetes

134
Q

What factors is enuresis associated with?

A

Stressful life events
UTI
Constipation
Low socioeconomic background
Large families
Overcrowded conditions

135
Q

Psychiatric sx of children with enuresis

A

Poor self-image
Low self-esteem
Social embarrassment and restriction
Intrafamilial conflict

136
Q

What psychiatric disorder do children with enuresis have higher risk of?

A

ADHD

137
Q

Treatment of enuresis

A

R/o medical cause
Psychoeducation - avoid punishment
Record keeping - can be a reinforcer
Behavioural interventions
Medications

138
Q

First line treatment of enuresis

A

Behavioural interventions

139
Q

Name some behavioural interventions for enuresis

A

Bell and Pad (most effective)
Enuresis Alarm
Star chart

140
Q

Effectiveness of Bell and Pad?

A

60%

141
Q

Medications for childhood enuresis?

A

Imipramine
Desmopressin
Rebocetine
Oxybutynin

142
Q

What age must a child be for a diagnosis of encopresis?

A

4 years or older (mental age)

143
Q

M:F ratio of encopresis?

A

6:1

144
Q

How many children over 4 will have encopresis?

A

5%

145
Q

How many children with encopresis show evidence of chronic constipation?

A

75%

146
Q

What organic causes can cause encopresis?

A

Hirschprungs
Anorectal pathology
Neurological problems
Nutritional disorders
Medication SEs

147
Q

What is encopresis associated with?

A

Sexual abuse
Psychiatric disturbances
Maternal hostility
Harsh/punitive parenting

148
Q

What is secondary encopresis?

A

Emerging after a period of normal bowel habits

149
Q

Factors associated with secondary encopresis?

A

Unhappy child in family with ongoing difficulties
Recent acute stress in family
Over-tolerant parents

150
Q

Treatment of encopresis

A

Paediatric assessment
Psychoeducatino
Behavioural approach
Family support

151
Q

How is family support used for encopresis?

A

Reduce family tensions about the sx and establish a non-punitive atmosphere.

152
Q

When does most encopresis stop by?

A

Age of 16

153
Q

What is pica?

A

> 1 month of eating of non-nutritive substances at a developmentally inappropriate age (>1 year) at least twice a week

154
Q

When does pica typically occur?

A

2-3 years of age

155
Q

What psychiatric disorder is pica common in?

A

Developmental disability

156
Q

Consequenecs of pica

A

Toxicity
Infection
GIT ulceration/obstruction

157
Q

Hypothesised causes of pica

A

Hunger
Malnutrition
Nutritional deficiencies
Psychosocial stressors
Brain disorders e.g. lesion in hypothalamus

158
Q

What are pervasive developmental disorders (PDD)?

A

Several disorders characterised by impaired reciprocal social interactions, communication difficulties, aberrant language development and restricted behavioural repertoire.

159
Q

Onset of PDD

A

<3 years of age

160
Q

What does PDD include?

A

Childhood autism
Aspergers
Retts

161
Q

Triad of PDD

A

Deficits in social skills, communication/language and behaviour

162
Q

what does DSM IV categorise PDD as?

A

Autism
Aspergers
Retts
Childhood disintegrative disorder
PDD-NOS

163
Q

What is different in DSM V re PDD?

A

Autism Spectrum disorder is a new description that includes autism, aspergers, childhood disintegrative disorder and PDD-NOS as a single category

164
Q

What characterises ASD?

A

Deficits in social communication and interaction
Restricted repetitive behaviours, interests and activities

165
Q

If there is a deficit in social communication but no repetitive behaviour, what diagnosis is given?

A

Social communication disorder

166
Q

What characterises childhood autism?

A

Qualitative impairment in social interaction
Impairment in communication
restricted repetitive and stereotyped patterns of behaviour or interests

167
Q

Onset of childhood autism by definition?

A

<3 years of age

168
Q

M:F ratio of autism

A

4:1

169
Q

Recurrence rate of ASD in siblings

A

2-8%

170
Q

Risk of ASD in sibling of 2 autistic children

A

25-30%

171
Q

Heritability of ASD

A

90%

172
Q

MZ vs DZ rates of ASD

A

36% vs 0%

173
Q

Genes involved in ASD

A

2
4
7
13
15
16
17
19
NRXN1
NLGN3

174
Q

Which genetic disorder is associated with ASD?

A

Fragile X
Tuberous sclerosis

175
Q

How many children with ASD have Fragile X?

A

1-4%

176
Q

How many children with ASD have Tuberous Sclerosis?

A

2%

177
Q

Which neurological conditions is associated with ASD?

A

Congenital Rubella and Phenylketonuria

178
Q

How many children with ASD have a medical conditino?

A

10%

179
Q

How many children with ASD have a LD?

A

80%

180
Q

How many children with ASD have mild to moderate intellectual disability?

A

33%

181
Q

MRI findings in ASD

A

Larger brain volumes
Early acceleration in brain growth
Increase in size of lateral and 4th ventricles, frontal lobe and cerebellar abnormalities:
hypoplasia of cerebellar vermal lobules VI and VII

182
Q

Where is the greatest increase in brain size in ASD?

A

Occipital, parietal and temporal lobes

183
Q

Hypotheses around increased brain sizes in ASD

A

Increased neurogenesis
Decreased neuronal death
Increased production of non-neuronal brain tissue such as glial cells and blood vessels

184
Q

Cerebellar pathology in ASD

A

Abnormal purkinje cells in cerebellar vermis
Abnormal limbic architecture

185
Q

Neurotransmitter findings in ASD

A

33% have high plasma serotonin concentrations
Some have high concentration of homovanillic acid in CSD

186
Q

Prenatal associative factors with ASD

A

Congenital rubella infection during pregnancy - mainly first trimester exposure

187
Q

Predictors of good prognosis of ASD

A

Communicative speech by age of 6
IQ >50
Skill consistent with secure employment

188
Q

How many people with ASD will be unable to lead an independent life?

A

60%

189
Q

How many people with ASD have a very good outcome?

A

12%

190
Q

How many people with ASD have a good outcome?

A

10%

191
Q

How many people with ASD have a fair outcome?

A

19%

192
Q

How many people with ASD have a poor outcome?

A

46%

193
Q

How many people with ASD have a very poor outcome?

A

12%

194
Q

Which skills are impaired most in ASD in adulthood?

A

Communication
Reading
Spelling

195
Q

Intervention programmes for ASD

A

Applied behavioural analysis
TEACCH

196
Q

Describe aplpied behavioural analysis for ASD

A

Intense program - 40 hours a week for 3 years
Based on operant conditioning, imitation and reinforcement

197
Q

What does TEACCH stand for?

A

Treatment and Education for Autistic and related Communication Handicapped Children

198
Q

What is TEACCH?

A

Based on belief that children are motivated to learn language.

199
Q

What is TEACCH good at?

A

Reducing self-injurious behaviour
Enhancing llife skills

200
Q

What are SSRIs used to treat in ASD?

A

Repetitive behaviour

201
Q

Dose of SSRIs for repetitive behaviour in ASD?

A

Lower than antidepressant dose

202
Q

First line pharmacological treatment for children with ASD and associated irritability?

A

Atypical antipsychotics

203
Q

Licensed antipsychotic for ASD in children?

A

Risperidone

204
Q

What is Risperidone indicated for in children with ASD?

A

Autism with aggressive behaviour

205
Q

What must be monitored in children on Risperidone?

A

Weight gain
Somnolence
Hyperglycaemia

206
Q

Difference between Aspergers and ASD

A

Aspergers shows no significant delays in relation to language development, cognitive development or age-appropriate self-help skills

207
Q

Prevalence of Aspergers?

A

6 in 10,000

208
Q

Factors associated with good prognosis of Aspergers?

A

Normal IQ
High level social skills

209
Q

Which psychiatric disorders are common with Aspergers?

A

Depression
Bipolar
Schizophrenia

210
Q

What is Retts?

A

X linked dominant disorder of arrested neurodevelopment

211
Q

What mutation is Retts associated with?

A

MeCP2 gene

212
Q

Gender impact of Retts?

A

Almost exclusively in females

213
Q

Sx of Retts

A

Deceleration of head growth between 6-18 months
Loss of purposeful hand movements, replaced by stereotypic motions
Loss of previously acquired speech
Psychomotor retardatino
Ataxia

214
Q

What skills plateau in Retts by 1 year?

A

REceptive and expressive communication
Social skills

215
Q

How many children with Retts develop seizures?

A

75%

216
Q

EEG in Retts in young children

A

Epileptiform discharges

217
Q

Breathing sx of Retts

A

Irregular respiration - episodes of hyperventilation and apnoea
Particularly when awake

218
Q

What is another name for Childhood disintegrative disorder (CDD)?

A

Hellers disease
Disintegrative psychosis

219
Q

What happens in CDD?

A

Marked regression in several areas of functioning after at least 2 years of normal development

220
Q

What sills are lost in CDD and by what age?

A

Loss of acquired motor, language and social skills between ages 3-4

221
Q

What is required for diagnosis of CDD?

A

Loss of skills in 2 of: language, social or adaptive behaviour; bowel or bladder control; play; or motor skills.
Abnormalities must be present in at least 2 of: reciprocal social interaction, communication skills, and stereotyped or restricted behaviour.

222
Q

Main neurological feature of CDD

A

Seizures

223
Q

Gender ratio of CDD

A

Male predominance

224
Q

What diagnostic categories of learning disorders are there in DSM IV

A

Reading disorder
Mathematics disorder
Disorder of written expression
Learning disorder not specified

225
Q

What can contribute to learning disorders?

A

Genetic predisposition
Perinatal injury
Neurological conditions
Other medical conditions

226
Q

How many school-aged children have a learning disorder?

A

5%

227
Q

What psychiatric disorders are associated with learning disorders?

A

ADHD
Communication disorders
Conduct disorders
Depression

228
Q

DSM IV groups together learning disorders based on sharing which features?

A

Performance significantly below expected for IQ or age
Discrete developmental disability in absence of learning disability
Commonly present as emotional or behavioural problems
50% have comorbid psychiatric disorder
Most show strong evidence of heritability

229
Q

Most common disorders in childhood?

A

Communication

230
Q

What do communication disorders include?

A

Expressive and mixed receptive-expressive language disorders
Phonological disorder
Stuttering

231
Q

How many children have reading disorder/dyslexia?

A

75%

232
Q

What characterises dyslexia?

A

Impaired ability to recognise words
Slow and inaccurate reading
Poor comprehension

233
Q

When can dyslexia be identified?

A

By age of 7

234
Q

What are reading errors in dyslexia characterised by?

A

Omissions
Additions
Distortions of words

235
Q

What do children with dyslexia have difficult with?

A

Distinguishing between printed letter characters and sizes, especially those that differ only in spatial orientation and length of line

236
Q

How many school-aged children have dyslexia?

A

4%

237
Q

M:F ratio of dyslexia

A

4:1

238
Q

How many children with dyslexia have CD or ADHD

A

20%

239
Q

How many children with ADHD have a learning disorder?

A

15-30%

240
Q

What can be used to measure reading ability?

A

WORD
TOWRE
WISC

241
Q

What is WORD?

A

Weschler Objective Reading Dimension
Single word reading test

242
Q

What is TOWRE?

A

Test of word reading efficiency
Measures word reading rate and accuracy

243
Q

What is WISC

A

Wescler intelligence scale for children

Measures overal cognitive ability

244
Q

Management of dyslexia

A

1: remedial teaching
Parental involvement

MRCPsych Part B (64 decks)

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