Child & Adolescent Psychiatry 1.2 Flashcards
Impairments in children with anxiety
Behavioural avoidance
Extreme level of distress compared to peers
Prevalence of anxiety disorders in children
5-15%
M:F ratio of anxiety in childhood
Equal
Prevalence of anxiety after adolescence in M:F
2:1
Prevalence of separation anxiety
- 5% in children
0. 8% in adults
Prevalence of GAD
4$ in adolescence
Prevalence of simple phobia in children
10%
Which gender is more likely to have simple phobia?
Twice as common in females
Prevalence of social phobia
1% in children
5-15% in adolescence
Prevalence of panic disorder in children
3-6%
Peak age of onset of panic disorder
15-19%
Sx of anxiety in preschool children
Tearfulness
Clinging
Sx of anxiety in middle childhood
Somatic complaints
Hypochondriacal fretting
Irritability
Aggressive behaviour
Which anxiety disorders occur later in childhood?
OCD
Social phobia
Panic disorder
Which children are more likely to have comorbid specific phobia?
Children with SAD
Which children are more likely to have comorbid mood disorders?
Children with GAD and social phobia
How many young people with GAD have a comorbird diagnosis?
90%
Definition of seperation anxiety disorder (SAD)
Developmentally inappropriate and excessive anxiety concerning separation from home or from those whom the individual is attached.
Interferes with age-appropriate functioning.
Essential clinical feature of SAD
Excessive worry about losing or being permanently separated from major attachment figure
Sx of SAD
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
Duration criteria for SAD
At least 4 weeks
Cause clinically significant impairment in social, academic and occupational domains
Age of onset <18 years
What is SAD called if diagnosed in a child <6 years of age?
Early onset SAD
Importance of attachment for the child
Allows the child to understand their inner world
Foundation for safe separation and development of autonomy
How many children have secure attachment
60%
How many children have insecure ambivalent/resistant type attachment?
10%
How many children have disorganised/disorientated attachment?
15%
Describe secure attachment
Child uses carer as secure base to explore freely and go back for comfort if necessary
Carer sensitive to childs cues
Describe insecure, ambivalent/resistant attachment
Appears interested in caregiver
Minimal distress at separation
Sometimes ignores/avoids caregiver
Describe disorganised/disorientated attachment
Child displays contradictory behaviour patterns
Thought to arise from either the child experiencing the carer as frighting or the carer being frightened themselves.
What was the Romanian Adoptees Study?
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.
What did the Romanian adoptees study show?
20% had severe disturbances at age of 6.
Duration of exposure to deprivation was strong associated with severe disinhibited behaviour
Who does reactive attachment disorder occur in?
Infants
Young children
What happens in reactive attachment disorder?
Persistent abnormalities in childs pattern of social relationships associated with emotional disturbance and reactive to changes in environmental circumstances
When is reactive attachment disorder diagnosed?
<5 years of age
How can reactive attachment disorder manifest?
Inhibited
Disinhibited
Which children is reactive attachment disorder more common in?
Poverty-stricken
Socially disrupted environments
Causes of reactive attachment disorder
Severe parental neglect, abuse and serious mishandling (direct cause)
Young, isolated, inexperienced and/or depressed carer
Features of reactive attachment disorder
Fearfulness Hypervigilance - does not respond to comforting Poor social interaction with peers Aggression towards self or others Growth failure
What is disinhibited attachment disorder?
Pattern of abnormal social functioning during first five years of life
How does disinhibited attachment disorder manifest in the early stages?
Clinging
Diffuse non-selectively focused attachment behaviour
How does disinhibited attachment disorder manifest by the age of 4?
Diffuse attachment
Attention seeking
Indiscriminately friendly behaviour
Duration criteria for sibling rivalry disorder
Onset within 6 months of birth of immediately younger sibling
Duration at least 4 weeks
Emotional disturbance that is abnormal
Sx of sibling rivalry disorder
Anxiety, regression, tantrums, dysphoria Attention seeking with one or both parents Sleep difficulties Oppositional behaviour (2 of these must be present)
How do children with school refusal present?
Excessive fearfulness
Temper outbursts
Complaints of feeling ill when faced with school; usually physical
Incidence of school refusal in children
1-5%
Sex distribution of school refusal
Equal
Main incidence peaks of school refusal by age
5-7
11
14
Reason for school refusal at ages 5-7
Possible separation anxiety
Reasons for school refusal at age 11
Transition to secondary school
Reasons for school refusal at age 14 and older
First presentation of depression/anxiety
Bullying
Exam pressure
Specific stressors
Most common age of school refusal
11
How many children who refuse school successfully reintegrate?
70%
Signs in truants
Antisocial sx FHx of antisocial behaviour Inconsistent discipline Poor academic achievement Large family size Male Child is neither at home or school
Characteristics of children who refuse school
Emotional sx FHx of neurosis Over-protecting parenting Satisfactory academic achievement Small family or youngest member Parents aware of childs absence No gener difference
What is selective mutism?
Persistent failure to speak in specific settings
Onset of selective mutism
3-5 years
Which psychiatric disorder is seen in selective mutism commonly?
Social phobia
Rate of selective mutism in the UK
3-8/10,000
Gender differences in selective mutism
More common in girls
Helpful treatment for selective mutism
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
What is SAD a risk factor for?
Development of panic disorder or agoraphobia in adulthood
What is a temperamental predictor of social phobia?
Behavioural inhibition
What does GAD have a close genetic link with?
Depression
Which therapy has been found to be helpful for children with anxiety?
Individual CBT + family component
Psychoeducation
CBT techniques for anxiety in children
Relaxation training
Cognitive restructuring
Which groups of children can group CBT be helpful for?
Treatment of socially phobic children
First line medication treatment for anxiety in children
SSRI
What anxiety disorders in children are SSRIs efficacious for?
Social phobia
SAD
GAD
Changes in DSM V for PTSD in children
Diagnostic threshold lowered
Separate PTSD criterion added for children <6
When was PTSD formulated as a diagnosis?
1980
How many young people meet the criteria for PTSD?
6%
How many children aged 11-15 have PTSD?
11-15
M:F ratio of PTSD in children
1:2
Most common traumatic exposures in children
Physical and sexual abuse Domestic, school or community violence Kidnapped Terrorist attacks Motor vehicle/household accidents Natural disasters
What must childs response to trauma require for PTSD diagnosis?
Intense fear Terror Helplessness Horror or Disorganized or agitated behaviour
Classification of childhood trauma
Type 1
Type 2
What is type 1 trauma
Single, acute, traumatic event
Which type of trauma is more common in children?
Type 1
What is type 2 trauma?
Longstanding or repeated exposure to extreme external events
Sx of type 1 trauma
Full detailed memories
Omens or cognitive reappraisal
Misperceptions
Sx of type 2 trauma
Denial and psychic numbing Self-hypnosis Depersonalisation Dissociation and rage Extreme passivity
Treatment of PTSD in kids
Trauma-focused CBT
Crisis intervention
Medications
Should EMDR be used for PTSD in kids?
No evidence
Structure of trauma-focused CBT
8-12 sessions.
What is crisis intervention?
Structured sessions with group leaders discussing trauma to share feelings and knowledge and process it.
NICE guidelines for medication?
Should not be routinely prescribed for kids with PTSD
What medication has been reported to be helpful in kids with PTSD?
Citalopram 20-40mg OD - trial for 8 weeks
What is OCD?
Presence of recurrent intrusive thoughts (obsessions) associated with anxiety or repetitive purposeful mental or physical actions (compulsions) aimed at reducing fear caused by obsessions.
Difference in OCD between adults and children
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.
How many children with OCD do not have obsessive thoughts?
40%
How many children with OCD have rituals/habits?
2/3
Prevalence of OCD in children
0.5%
Mean age of onset of OCD in children
10
M:F ratio of childhood OCD
2:1
M:F ratio of OCD post-pubertal
More common in girls
Heritability findings for OCD
Increased incidence in first degree relatives and MZ twins: 80% compared to 40%for DZ
Possible causes of OCD
Genetic Autoimmune Hyperactive orbitofrontal circuits Serotonin receptor dysfunction Dopaminergic dysfunction