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MRCPsych Part B > Child & Adolescent Psychiatry > Flashcards

Child & Adolescent Psychiatry Flashcards

1
Q

Who outlined the mediators of the effect of parental psychiatric disorders on a child?

A

Rutter

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2
Q

What factors can mediate the effect of parental MI on a child?

A

Direct impact of exposure
Indirect impact due to altered interpersonal behaviour and parenting capacity
Social adversity, genetic or constitutional factors

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3
Q

Prenatal affects of maternal depression on the child

A

Poor nutrtition
Higher preterm birth
Low birth weight
Pre-eclampsia

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4
Q

Effect of maternal depression on the infant

A 
Anger and protective style of coping
Withdrawal
Passivity
Reduced attention
Lower IQ
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5
Q

Effect of maternal depression on the toddler

A

Passive noncompliance
Reduced expression of autonomy
Internalising and externalising problems
Reduced social interaction

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6
Q

Effect of maternal depression on school-aged children

A

Reduced adaptive functioning
Affective, anxiety and conduct disorders
ADHD-like presentation

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7
Q

Effect of maternal depression on adolescents

A

Affective disorders, anxiety disorders, phobias
Panic disorder
Conduct disorder
Substance and alcohol misuse

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8
Q

What is the most well known epidemiological study into the effect of childhood adversities and first onset of MI?

A

Survey into 21 countries in the WHO World Mental Health Survey Initiative Kessler et al. 2010

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9
Q

What is the most common childhood adversity?

A

Parental death

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10
Q

Prevalence of parental death

A

11-15%

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11
Q

Name some other childhood adversities

A

Physical abuse
Family violence
Parental MI

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12
Q

Rate of physical abuse in childhood

A

5.3-10.8%

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13
Q

Rate of family violence in childhood

A

4.2-7.8%

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14
Q

Rate of parental MI in childhood

A

5.3-6.7%

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15
Q

Which childhood adversities increase risk of adult psychiatric disorders?

A

Maladaptive family functioning

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16
Q

What psychiatric disorders are seen in those with a hx of sexual abuse?

A 
Depression
PTSD
Conduct disorders
Somatisation
Suicidal behaviour
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17
Q

F:M ratio of childhood sexual abuse

A

4:1

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18
Q

What % of childhood sexual abusers are male?

A

90%

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19
Q

What is the average age of children who are the victims of sexual abuse?

A

9-11

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20
Q

What is the most prevalent form of child maltreatment?

A

Neglect

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21
Q

How many childhood cases reported are due to neglect?

A

60%

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22
Q

How many childhood cases are reported for physical abuse?

A

20%

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23
Q

How many childhood cases reported are due to sexual abuse?

A

10%

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24
Q

Signs of physical abuse

A

Unexplained injuries, especially if recurrent
Improbable excuses for injuries
Refusal to discuss injuries
Untreated injuries or delay in presentation
Excessive physical punishment

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25
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 ```
26
Signs of possible non-organise failure to thrive
Significant lack of growth Weight and hair loss Poor skin or muscle tone and circulatory disorders
27
Signs of possible emotional abuse
Low self esteem, continuous self-deprecation Sudden speech disorder Self-mutilation Rocking, head-banging or other neurotic behaviour
28
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 ```
29
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 ```
30
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 ```
31
Risk factors in children of physical abuse
``` Prematurity Congenital malformation Intellectual disability Chronic illness Difficult temparement ```
32
In which families is there an increase in child abuse?
``` Multiple children Poor housing Welfare reliance Single parents Less parental education Underemployment ```
33
At what age does physical abuse commonly begin?
adolescence
34
Relationship between self blame and powerlessness and sexual abuse?
Inverse relationship in children
35
Most common relationship in childhood sexual abuse?
Stepfather and stepdaughter
36
Risk factors of childhood sexual abuse?
Alcohol abuse Overcrowding Increased physical proximity Rural isolation
37
Features of ADHD
Excessive and impairing levels of hyperactivity, inattention and impulsivity that are evident in more than one setting and cause serious impairment.
38
Exclusion criteria for ADHD
Those with pervasive development disorder, schizophrenia or another psychotic disorder
39
In what age group of children is hyperactivity more noticeable?
Pre-school
40
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
41
What questionnaire is commonly used for ADHD?
Connor's questionnaire to obtain information from schoolteachers
42
What is ADHD called in ICD 10?
Hyperkinetic disorder
43
Which diagnostic classification has stricter criteria for ADHD?
ICD 10
44
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
45
Prevalence of ADHD using ICD 10
1-2%
46
M:F ratio of ADHD?
3:1
47
In which group of children is ADHD more common?
Boys Areas of social deprivation Children living in institutions
48
Heritability of ADHD
80%
49
ADHD in siblings
Siblings have 2-3x increased risk
50
Concordance % of ADHD in twins?
79% MZ | 32% DZ
51
Which genes are implicated in ADHD?
``` 5 6 11 DAT1 and dopamine D4 gene SNAP-25 gene ```
52
What areas of the brain are affected in ADHD?
Prefrontal cortex Striatum Cerebellum
53
What does PET show in ADHD?
Lower cerebral blood flow and metabolic rates in frontal lobe areas
54
What does PET show in girls with ADHD?
Globally glucose metabolism than both controls and males with ADHD
55
Which neurotransmitters are involved in ADHD?
DA and NA dysregulation in prefrontal cortex
56
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
57
How many patients with ADHD have a HI?
25%
58
Protective factors for ADHD
Relationships within family and at school
59
How many children with ADHD have a comorbird disorder?
50-80%
60
How many children with ADHD have oppositional defiant disorder?
40%
61
How many children with ADHD have anxiety disorder?
34%
62
How many children with ADHD have conduct disorder?
14%
63
How many children with ADHD have tic disorder?
11%
64
How many children with ADHD have mood disorder?
6%
65
How many patients with ADHD continue to meet diagnostic criteria at age of 25?
15%
66
How many people with ADHD will suffer some impairment from residual sx?
50%
67
What are children with hyperkinetic disorder at risk of?
5x risk of antisocial behaviour, substance abuse and other psychiatric disorders
68
How many children with ADHD go on to develop substance misuse problems?
15-20%
69
Which type of ADHD go on to exhibit fewer impulsive-hyperactiver sx as they get older?
ADHD, combined type
70
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
71
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 ```
72
What is the biggest study looking into treatment for ADHD?
Multimodal treatment study of children with ADHD (MAT)
73
Describe the structure of MAT
RCT involving 579 children with ADHD
74
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
75
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.
76
What drugs are licensed for ADHD?
Methylphenidate Atomoxetine Alpha 2 agonists Antipsychotics
77
Onset of Methylphenidate?
1-3 hours
78
Half life of Methylphenidate?
2-3 hours
79
Dose range of Methylphenidate
5-60mg/day
80
Which drug is n longer licensed for ADHD and why?
Pimoline | Causes liver failure
81
How does Atomoxetine work?
NARI | Increases noradrenaline in the synaptic cleft
82
What note did MHRA add to Atomoxetine in Dec 2012?
Can cause increase in BP and HR and therefore should be monitored
83
Monitoring for Methylphenidate
Height, weight, BP and HR initially 3 monthly, then 6 monthly
84
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
85
Which drug has the largest and most rapid effect on ADHD?
Methylphenidate
86
How does Methylphenidate work?
Indirect sympathomimetic by increasing DA and release
87
What sx can Methylphenidate help with?
Comorbid aggression and oppositional defiant disorder | Hyperactivity
88
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 ```
89
Initial dose of Methylphenidate
5-10mg OD
90
How is Methylphenidate dose increased
5-10mg per week
91
Which SE are not found with Atomoxetine?
Insomnia | Tics
92
Which comorbid disorder can Atomoxetine help with in ADHD?
Depression
93
Adverse effects of Atomoxetine
Weight loss GI sx Fatigue, dizziness Mild growth slowing
94
Which antidepressants can be used for ADHD
TCAs
95
Adverse effects of TCAs
``` Sedation BP changes Dizziness on standing Dry mouth Cardiac conduction block: need ECG monitoring ```
96
What sx do alpha 2 agonists treat in ADHD?
Hyperactivity-Impulsiveness Tic disorders Aggression
97
Which patients are alpha 2 agonists good for in ADHD?
Overaroused | Comorbid anxiety
98
Adverse effects of alpha 2 agonists for ADHD
``` Response delayed Sedation Postural hypotension Dry mouth Hypertensive rebound if dose missed ```
99
When are antipsychotics helpful for ADHD?
If stimulants or atomoxetine does not help Comorbird anxiety or aggression Tic disorder Bipolar disorder
100
Adverse effects of antipsychotics
``` Sedation EPSEs Endocrine effects TD Akathisia Weight gain Riskiest drug - last resort for ADHD ```
101
What are the disorders of childhood conduct?
Conduct disorder | Oppositional defiant disorder
102
What characterises conduct disorder?
Severe and persistent pattern of antisocial, aggressive or defiant behaviours that defy age-appropriate societal norms
103
What is the difference between ODD and conduct disorder?
In ODD the behaviour does not defy age-appropriate societal norms to the extent as CD
104
How are CD and ODD classified in the ICD 10?
ODD is a subtype of CD
105
How are CD and ODD classified in DSM V?
DSM V excludes ODD if CD is present
106
Diagnostic criteria for CD under ICD 1
At least one behaviour present for 6 months: physical aggression or threats to harm people, cruelty to people or animals Destruction of own property or others Theft or acts of deceit Frequent and serious violent of age-appropriate rules
107
DSM V criteria for CD
At least 3 of 15 behaviours should begin before 13 years for a period of 12 months.
108
What has DSM V added to diagnostic criteria of CD?
Limited prosocial emotions specifier for children who do not meet full criteria but present with limited prosocial emotions.
109
In which group of children is CD increased?
Children of parents with antisocial PD and alcohol dependence
110
Prevalence of CD in the UK
5-7%
111
M:F ratio of CD
4:1
112
Significant risk factors for CD according to the Ontario Child Health Survey (1987)
Family dysfunction Parental MI Low income
113
Risk factors for CD according to Rutter (1978)
``` Low socioeconomic status Criminality of father Overcrowding Maternal neurosis Institutional care Chronic maternal discord ```
114
Biological risk factors for CD
More common in families Temperament of 'callous-unemotional' Brain injury Low IQ
115
Neuroimaging in CD
Prefrontal regions may have reduced volumes
116
Neurochemical findings in CD
Low CSF seretonin and deficient serotonergic activity seen in those with early onset and more aggressive behaviour. Autonomic under-arousal.
117
Psychosocial risk factors of CD
``` Maternal smoking during pregnancy Parental criminality and substance abuse Harsh and inconsistent parenting Lack of warm parental relationship Domestic violence and child abuse Large family size Low family income Early loss and deprivation School failure Social isolation ```
118
What does CD increase risk of in the future?
``` Criminality and antisocial PD Difficulties in education, work and finances Homelessness and abuse Drug and alcohol dependence Poor physical health MI and suicidal behaviour ```
119
How many children with CD go on to have severe antisocial problems in adulthood?
<50%
120
Protective factors of CD
``` Female High IQ Resilient temperament Good parenting Warm relationship with key adult Commitment to social values Increased economic equality ```
121
Poor prognostic factors of CD
``` Onset <10 years Increased aggression at earlier age Aggression carried out in isolation rather than groups Low IQ Low socioeconomic status Poor school achievement Attentional problems and hyperactivity in childhood Poor parenting Family criminality ```
122
Treatment of CD
Psychological therapies | Parent management training
123
NICE recommendations for treatment of CD and ODD <12 years
Group based parent training programmes
124
What does CBT for CD include?
Social skills training | Anger management
125
Targets of CBT for CD?
Aggressive behaviour Social interactions Self-evaluation Emotional dysregulation
126
Best therapies for CD?
Functional family therapy | Multisystemic therapy
127
Target age for functional family therapy?
11-18
128
Structure of functional family therapy?
8-12 1 hour sessions in family home to overcome attendance problems
129
Phases of treatment of functional family therapy
Engagement Motivation Behavioural Change Generalisation
130
Aim of functional family therapy
Keep family in treatment and only then move on to finding what they want Therapist must understand parents goals first
131
What does functional family therapy aim to address?
Family processes such as improving communication between parent and child, reducing interparental inconsistency, supervision and monitoring and rules and sanctions.
132
Does functional family therapy reduce rates of reoffending?
Yes - by 50%
133
Structure of multisystemic therapy
Team available 24 hours | Treatment given over 3 months
134
What happens in multisystemic therapy?
Patient and families needs assessed in the home and in context of school Intervention used to address difficulties and promote strengths Regular written feedback from parents and patient
135
Responsibility of therapist in multisystemic therapy
Ensuring appointments are kept and for making change happen
136
What characterises ODD?
Enduring pattern of negative, hostile, disobedient and defiant behaviour w/o serious violation of societal norms or rights of others.
137
Duration criteria for ODD
Sx must be persistent and evident for 6 months
138
Sx of ODD
Temper outbursts Active refusal to comply Tendency to blame others Spiteful behaviours
139
Age of onset between ODD and CD
Earlier in ODD
140
When does ODD tend to begin?
8 years of age
141
Prevalence of ODD
2-5%
142
Males vs females in diagnosis of ODD?
Before puberty more in boys | After puberty equal in boys and girls
143
How many children with ODD show no sx in adulthood?
25%
144
Aetiology of ODD
Temperamental factors - sick/traumatised child | Power struggle between child and parent
145
Which psychiatric problem is an early predictor of ODD and CD in later life?
ADHD
146
Poor prognostic factors of ODD
Early onset of sx Longer duration of sx Co-morbid anxiety, impulse control and substance misuse Development of CD
147
Primary treatment of ODD
Family intervention using both direct training of parents in child management skills and assessment of family interactions
148
What do behaviour therapists focus on with parents of children with ODD?
How to alter their behaviour to discourage childs oppositional behaviour and encourage appropriate behaviour
149
Prevalence of depression in pre-puberty
1%
150
Sex difference in depression pre-puberty
None
151
Prevalence of depression post-puberty
3%
152
Sex difference in depression post-puberty
More common in females
153
How many young people with depression continue to remain depressed after one year?
50%
154
How many people with adolescent depression will have a recurrence in 5 years?
30%
155
Why is clinical picture of depression more often seen in adolescence?
Cognitive changes such as formal operational thought allow hopelessness to be experienced
156
When should depression in children only be diagnosed?
If there is impairment of social role functioning or sx lead to significant suffering or psychopathy e.g. suicidality
157
Sx of depression in young children
``` Poor feeding Failure to thrive Tantrums/irritability Separation anxiety Hyperactivity Regressed behaviour ```
158
Sx of depression in older children
``` Somatisation (headache) or hypochondriacal ideas School refusal Poor academic achievement Decline in school work Sleep disturbance Antisocial behaviour ```
159
Sx of depression in adolescents
``` Anhedonia Social withdrawal Low self-esteem Biological sx Suicidal acts Behavioural problems Substance misuse ```
160
What is dysthymic disorder?
Chronic condition with fewer sx than depression but lasts a minimum on of one year
161
How many children with depression have longstanding psychosocial difficulties?
95%
162
Risk factors for depression in children
``` FHx of depression Early loss of parent Parental separation Stressful life events Hx of abuse ```
163
Maintaining factors of depression in children
``` Persistence of subthreshold sx Scarring Personality, temperament, cognitive abilities Persisting advesity Comorbidity ```
164
What is scarring?
First episode of depression sensitizes people to further episodes
165
How many children with depression have a comorbidity?
50-80%
166
How many children with depression also have anxiety?
50-80%
167
How many children with depression have CD?
25%
168
How many children with depression have OCD?
15%
169
How many children with depression have an ED?
5%
170
Treatment for mild depression in children
Watchful waiting for 4 weeks | Then supportive therapy, self help or group CBT
171
Treatment for moderate to severe depression in children
CAMHS review | 3 months of individual CBT, IPT or shorter term family therapy
172
Evidence for CBT vs other therapies for childhood depression
CBT reduces duration of illness compared to other therapies
173
NICE guidance for moderate to severe depression
Consider psychotherapy before medication
174
When should combination treatment be considered in childhood depression?
In all cases of moderate to severe depression
175
First line medication for childhood depression
Fluoxetine
176
Second line medication for childhood depression
Sertraline | Citalopram
177
Which medication has FDA and MHRA approval for childhood depression?
Fluoxetine only
178
What needs to be monitored when using Fluoxetine in children at initiation and dose changes?
Agitation Irritability Unusual changes in behaviour Emergence of suicidality
179
Which study compared medication with therapy for childhood depression?
Treatment of Adolescents with Depression Study (TADS)
180
Structure of TADS
439 children given either CBT, fluoxetine, a combination or placebo
181
Results of TADS
CBT not superior to placebo Combination and Fluoxetine alone were superior to both CBT and placebo Combination showed faster recovery Fluoxetine had more favourable outcomes for severe depression Combined treatment superior to fluoxetine alone for remission
182
ECT in children?
Not recommended in 5-11 year olds
183
How common is suicide as cause of death in adolescents?
Third; following accidents and homicides
184
How many adolescent deaths are due to suicide?
12%
185
Suicidal ideation in adolescents?
14% in boys | 25% in girls
186
Most common cause of suicide in boys
Hanging
187
Most common cause of suicide in girls
OD | Jumping from heights
188
How many adolescents who attempt suicide repeat within a year?
10%
189
How many adolescents who complete suicide will have made a previous attempt?
40%
190
Incidence of completed suicide in children
Declining until recently
191
Incidence of non fatal DSH in children
Rising
192
Social class of those who complete suicide
Upper and Lower
193
Social class of those who DSH
Lower
194
Childhood of those who complete suicide
Death of parent
195
Childhood of those who DSH
Broken home
196
Precipitants of children who complete suicide
Guilt | Hopelessness
197
Precipitants of DSH in children
Situational crises
198
FHx of children who complete suicide
2-4 times more likely to have a first degree relative who committed suicide
199
Sx of mania in children
``` Increased energy Distractibility Pressured speech Grandiosity Racing thoughts Euphoria Decreased sleep Flight of ideas Poor judgement ```
200
How do children with mania typically present?
Atypical or mixed features characterised by irritability, labile mood and behavioural problems
201
Prevalence of bipolar disorder in adolesence
1%
202
M:F of bipolar in childhood
M>F
203
M:F of bipolar in adolescence
M=F
204
How many adults with bipolar had onset of mood sx before the age of 20?
60%
205
How many children with bipolar have ADHD?
70%
206
How many children with bipolar have ODD?
40%
207
How many children with bipolar have anxiety?
30%
208
How many children with bipolar have substance misuse?
40%
209
How many children with bipolar have Tourette's?
8%
210
How many children with Bipolar have bulimia?
3%
211
Outcome of early onset bipolar?
50% show long-term decline in function
212
How many adolescents wit depression go on to experience a manic episode by adulthood?
20%
213
What features of a depressive episode in adolescence predict development of mania
Rapid onset of episode with psychomotor features Depressive episode with psychosis FHx of mania History of mania/hypomania following antidepressant treatment
214
Suicide risk of children with bipolar
10%
215
NICE recommendation for treatment of bipolar in children
Same medication as for adults but at lower doses
216
First line treatment for acute mania in children
Atypical antipsychotics: Olanzapine, Risperidone | Followed by Valproate/Lithium
217
Why are higher doses of lithium needed in children?
Children have higher renal filtration rate and higher proportion of body water
218
Which SEs of lithium are more common in children?
Tremors Drowsiness Ataxia Confusion
219
What defines childhood onset schizophrenia?
Onset of psychotic sx by 18 years of age
220
Which children are at risk of childhood onset schizophrenia?
Increased heritability aetiology
221
What defines very early onset schizophrenia?
Psychosis before 13 years of age
222
Prevalence of schizophrenia in adolescence
1-2 per 1,000
223
M:F ratio of <13
2:1
224
What characterises childhood schizophrenia?
More negative sx Disorganised behaviour Greater disorganisation both of thought and sense of self Fewer systematized or persecutory delusions More chronic course
225
Common features of children with childhood onset schizophrenia before development of the disorder
Delays in language, reading, bladder control and social functioning
226
Neuropsychological deficits found in children who go on to have childhood onset schizophrenia
Attention Working memory Premorbid IQ
227
Characteristics of children who develop childhood onset schizophrenia
Socially rejected, clingy Limited social skills Hx of delayed motor and verbal milestones Poorly in school
228
What type of hallucinations can present in childhood onset schizophrenia?
Visual
229
How many children with childhood onset schizophrenia have delusions?
>50%
230
What do delusions in childhood onset schizophrenia increase with?
Age
231
Which clinical sx of childhood onset schizophrenia are associated with poor premorbid function?
Illogical thinking Poverty of thought Formal thought disorder
232
Heritability of schizophrenia
82%
233
Risk of schizophrenia amongst first degree relatives with and without the disease
With the disease: 5-10% Without the disease: 0.2-0.6%
234
Neuroimaging findings in childhood onset schizophrenia
Enlarged lateral ventricles Grey matter loss starting in parietal region and proceeding frontally to dorsolateral prefrontal cortex and temporal cortices including superior temporal gyri
235
What is correlated with relapse rates in childhood onset schizophrenia?
High expressed emotion
236
What predicts development of schizophrenia in high risk individuals?
Early attentional deficits Deficits in social functioning Deficits in organisational ability Lower intellectual ability
237
Course and outcome of childhood onset schizophrenia
Responds less to medication | Poor prognosis
238
Predictors of course and outcome of early onset schizophrenia
Childs level of functioning before disease Age of onset IQ Duration of episode Duration of untreated psychosis Presence of negative sx Response to pharmacological interventions How much functioning the child regained after first episode Support available from family
239
Risk of premature death in childhood onset schizophrenia
8.5%
240
Risk of suicide or accidental death from psychotic sx in childhood onset schizophrenia?
5%
241
Treatment of childhood onset schizophrenia
Same as adults
242
Which side effects are more common from antipsychotics in children?
Metabolic EPSEs Acute dystonia
243
What do trials show re efficacy of antipsychotics in children
Olanzapine and Risperidone are effective
244
Which antipsychotics should be avoided in children?
Depot | Sedating drugs
245
Psychosocial interventions for childhood onset schizophrenia?
``` Family work Focus on psychoeducation Social skills Problem solving strategies CBT ```
246
Typical or atypical antipsychotics in children?
Atypical

MRCPsych Part B (64 decks)

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