Child & Adolescent Psychiatry

Question 1

top reasons for presentation to psych clinics - children & adolescents

Answer 1

*disruptive behavior disorders
*anxiety disorders
*depressive disorders
*neurodevelopmental disorders

Question 2

interview techniques for children and adolescents

Answer 2

*children - draw, play, emotions, etc
*ask about school (grades, fav subjects, friends, bullying, getting in trouble)
*adolescents - confidentiality, friends, interests, dating, substances, trauma, why do you think your parents brought you in?
*parents - externalizing behaviors, developmental hx, family hx

Question 3

major depressive disorder (kids & teens) - dx criteria

Answer 3

*same DSM-5 as adults, with 2 exceptions: (1) irritability may be predominant instead of sad mood; (2) failure to gain appropriate weight instead of weight loss

Question 4

major depressive disorder (kids & teens) - epidemiology

Answer 4

*point prevalence: 2% of children; 4-8% of adolescents
*lifetime prevalence by age 18yo: 10-20%
*more common in females
*genetic loading: 40-60% heritable

Question 5

major depressive disorder (kids & teens) - first line treatment

Answer 5

psychotherapy +/- meds:
*meds: SSRIs (fluoxetine, escitalopram)
*therapy: CBT or interpersonal psychotherapy (IPT)

Question 6

bipolar disorder (kids & teens)

Answer 6

*same DSM-5 criteria as adults
*controversial in kids and teens
*competing approaches to dx
*narrow phenotype
*broad phenotype (severe mood dysregulation)

Question 7

bipolar disorder (kids & teens) - first line treatment

Answer 7

meds:
*lithium: 12+ yo
*atypical antipsychotics (aripiprazole, risperidone, quetiapine, lurasidone, asenapine)

Question 8

children “diagnosed with bipolar disorder” are most likely to meet criteria for which disorder in adulthood?

Answer 8

generalized anxiety disorder

Question 9

disruptive mood dysregulation disorder (DMDD) (kids & teens)

Answer 9

*severe, recurrent TEMPER OUTBURST (inconsistent with developmental level, outbursts > 3 weeks)
*mood between outbursts is predominantly angry or irritable + observable by others
*present > 12 months, no period of 3 months without meeting criteria
*present in at least 2 settings, severe in as least 1
*onset usually by age 10 (must be dx b/w 6-18)

Question 10

disruptive mood dysregulation disorder (DMDD) (kids & teens) - treatment

Answer 10

meds:
-stimulants to target impulsive components of disorder
-SSRIs for irritability/anger as depression equivalent
-antipsychotics if warranted for aggression and emotion dysregulation symptoms

Question 11

separation anxiety (kids & teens) - diagnosis

Answer 11

*developmentally inappropriate and excessive fear/anxiety about separation from attachment figures
*associated features - thinking something catastrophic will happen upon separation

Question 12

separation anxiety (kids & teens) - epidemiology

Answer 12

*prevalence: 4% in children, 1.5% in adolescents
*highly heritable (73% concordance in twins)
*risk factors: sudden attachment disruption, intrusive/overprotective parenting

Question 13

selective mutism (kids & teens) - diagnosis

Answer 13

*failure to speak in social situations that have expectation for speaking
*interferes w/ educational achievement or social function
*duration at least 1 month
*not attributable to lack of knowing/comfort with language
*not attributable to communication disorder, ASD, or psychosis

Question 14

selective mutism (kids & teens) - epidemiology

Answer 14

*prevalence 0.03-1%
*no differences w/ gender or ethnicity
*highly comorbid with social anxiety disorder

Question 15

social anxiety (kids & teens) - diagnosis

Answer 15

dx differences from adults:
*anxiety must occur with peers, not just adults
*fear/anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, failing to speak

Question 16

social anxiety (kids & teens) - epidemiology

Answer 16

*2-7% 12-month prevalence
*female predominance (2:1), maybe even higher in adolescents

Question 17

PTSD (kids & teens)

Answer 17

*<6 yo: may not show distress with intrusions, reenactments
*exposure to trauma not just through media
*intrusive memories or dissociations (flashbacks) may be through repetitive play reenactments
*nightmares may be frightening without discernment of actual content/themes

Question 18

treatment of anxiety and trauma disorders - kids & teens

Answer 18

*CBT:
-for separation anxiety, selective mutism: exposure-based CBT
-for PTSD: trauma, focused CBT
*meds: SSRIs (fluoxetine, sertraline)
*also, for PTSD, prazosin (peripheral alpha-1 adrenergic antagonist) can be effective for reducing nightmares

Question 19

obsessive compulsive disorder (kids & teens) - diagnosis

Answer 19

*key difference from adults: kids may NOT be able to explain the aims/goals of compulsions

Question 20

obsessive compulsive disorder (kids & teens) - epidemiology

Answer 20

*approx 1-2% of population
*males w/ earlier age of onset, 25% by age 10
*heritable: 2x higher risk if 1st degree relative with OCD, 10x higher risk if relative’s onset was in childhood
*highly comorbid with Tourette’s disorder

Question 21

obsessive compulsive disorder (kids & teens) - first line treatment

Answer 21

*CBT (exposure & response prevention)
*meds: SSRIs (fluoxetine and sertraline); TCA (clomipramine)

Question 22

disruptive behavior disorders (kids & teens)

Answer 22

*oppositional defiant disorder (6% prevalence)
*conduct disorder (4% prevalence)
*M:F = 1.4:1 until adolescence

Question 23

oppositional defiant disorder (kids & teens)

Answer 23

*angry/irritable mood: often loses temper, touchy/easily annoyed, angry/resentful
*argumentative/defiant behavior:
-argues with authority figures
-defies/refuses to comply with rules/requests
-deliberately annoys others
-blames others for mistakes
*spiteful or vindictive (at least 2x in past 6 months)

Question 24

conduct disorder (kids & teens)

Answer 24

*aggression to people and animals (physical fights, weapons, physically cruel, steals)
*destruction of property (fire-setting with intention of causing damage, deliberately destroying others’ property)
*deceitfulness/theft
*serios violation of rules

Question 25

overlap between oppositional defiant disorder and ADHD

Answer 25

80% of kids who meet criteria for ODD have ADHD

Question 26

treatment for disruptive behavior disorders

Answer 26

*PARENT TRAINING: give effective commands, improve positive attention and overall monitoring, implement immediate & fair & consistent consequences
*individual therapy (+/-)
*meds: stimulants, SGAs

Question 27

general differences in med use in kids & teens

Answer 27

*start lower but get to same dose
*sometimes split dosing/give meds more frequently
*increased risk in suicidality in kids taking antidepressants is only 1% increase