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Psychiatry > Child & Adolescent Psychiatry > Flashcards

Child & Adolescent Psychiatry Flashcards

1
Q

In the following domains, give some factors that can predispose mental health problems in children: child, family, environment

A 
Child:
• Male
• Sensory impairment
• Physical illness
• Developmental delay
• Genetics
Family:
• Family breakdown/conflict
• Separation/death and loss
• Abuse/neglect, Inconsistent discipline
• Large families >4 children
• Parental psychiatric illness
Environment:
• Inner city
• Overcrowding
• Poor social support
• Criminality
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2
Q

Give the developmental milestones for the following: eye contact/follows face, smiles responsively, reaches for objects, good head control when sitting, turns to a voice

A

Eye contact/follows face
- 1-4 weeks (limit age: 3 months)

Smiles responsively
- 4-6 weeks (limit age: 8 weeks)

Reaches for object
- 4 months (limit age: 6 months)

Good head control when sitting
- 4 months (limit age: 6 months)

Turns to a voice
- 7 months (limit age: 9 months)

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3
Q

Give the developmental milestones for the following: tuneful babble, sits unsupported, pincer grip, walks independently, builds two cubes, first word

A

Tuneful babble
- 5-6 months (limit age: 10 months)

Sits unsupported
- 7-8 months (limit age: 10 months)

Pincer grip
- 9-10 months (limit age: 15 months)

Walks independently
- 11-13 months (limit age: 18 months)

Builds two cubes
- 13-15 months (limit age: 19 months)

First word
- 8-18 months (limit age: 2 years)

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4
Q

Which conditions come under the autism spectrum disorder?

A

It is a developmental disorder which includes: childhood autism, atypical autism, Asperger’s syndrome

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5
Q

Define autism spectrum disorder

A

Developmental disorder with abnormalities in quantitative ( number of responses) and qualitative impairment (how they say things) in:

  1. Reciprocal social interactions
  2. Verbal and nonverbal communication
  3. Restricted and repetitive behaviours or interests
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6
Q

Explain the aetiology of autism spectrum disorder using a bio-psycho-social model

A

Biological:
o Obstetric complications
o Perinatal infection e.g. maternal rubella
o Genetic disorders (e.g tuberous sclerosis, down syndrome, fragile X)

Psychological:
o NOT parenting styles
o Severe psychological deprivation and neglect

Social:
o Parents are both engineers
o Diet and pollutants

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7
Q

Detail the 3 key features of clinical presentation of autism spectrum disorders

A

Reciprocal Social Interaction
• Not interested in people, tend to play alone
• Lack the ability to read the emotional states of others
• Eye contact avoidant

Communication Abnormalities
• Expressive speech and comprehension are delayed or minimal
• Ideas are taken literally (concrete thinking)
• Gestures are usually absent (e.g. pointing, waving goodbye)
• Speech may consist of monologue, interminable questions and echolalia (repeating what has been said)

Restricted Behaviours and Routine
• Characterised by repetitive, stereotypes behaviours and restricted interests (rather than imaginative play)
• Small changes in routine (e.g. using the wrong spoon) can result in intense tantrums

Additionally: children often have learning disabilities, seizures, and overactive behaviour

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8
Q

How does Asperger’s syndrome differ from autism in terms of clinical presentation?

A
  • Poor social skills and restricted interests
  • But NORMAL language and IQ
  • Tendency to literal interpretation of language and difficulty in reading social cues
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9
Q

Give some differentials for autism

A

o Deafness (causing poor language acquisition)
o Asperger’s syndrome
o Specific language disorder (delayed speech with normal IQ and social ability)
o Learning disability (IQ problems but relatively intact social skills)
o Rare disorders (e.g. childhood schizophrenia, Rett’s syndrome)
o Neglect (can lead to language delay and poor socialisation)

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10
Q

Give some investigations for autism spectrum disorders

A
  • Hearing tests
  • Speech and language assessment
  • Neuropsychological testing- assess IQ and confirm diagnosis
  • ADOS: Autism diagnostic observation schedule: Observation of child, set tasks (play based)
  • ADI-R: autistic diagnostic interview revised (questionnaire)
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11
Q

Outline a management plan for autism using a bio-psycho-social model

A

Social
- Support and advice for families (e.g National Autistic Society)

Psychological

  • Behavioural therapies (e.g ABC approach: reinforce positive behaviours)
  • Special education

Biological

  • Treat comorbid problems (e.g epliepsy)
  • Speech and language therapy
  • Antipsychotics or mood stabilisers OCCASIONALLY used for extreme aggression or hyperactivity

Involving parents in the therapy plan and ensuring that they gain an understanding of the disorder and what works best for each child is VITAL

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12
Q

Outline a management plan for asperger’s syndrome

A
  • Advice and support
  • Routine
  • Social skills training
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13
Q

What do you need to particularly look out for when considering depression in children/adolescents?

A

Presentation is similar to adults, although children mainly present with:

  • Somatic problems (e.g headaches, tummy aches)
  • Deteriorating school performance
  • Changes in social functioning
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14
Q

What is the treatment for depression in children/adolescents?

A

• 1st line: CBT
• Antidepressants are only used in severe cases
o Fluoxetine is the safest option in children

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15
Q

How does anxiety usually present in children/adolescents?

A
  • Separation anxiety disorder

- School refusal

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16
Q

What is the main treatment for anxiety in children/adolescents?

A

Psychological therapies (counselling, CBT)

17
Q

What is enuresis?

A

Involuntary urination, especially at night

Can be primary (toilet training was never mastered) or secondary (dryness achieved for at least 1 year but has been lost)

18
Q

Outline the management for enuresis

A
  • Refer organic causes to paediatricians (e.g. epilepsy, UTI, diabetes)
  • Reassure the family and the child that the problem is common and no one’s fault
  • Address stressors and review toilet training received so far
  • Restrict fluids before bed
  • Star charts to celebrate each dry night (positive reinforcement)
  • Bell and pad (clips onto the pyjamas and wakes the child if the moisture is detected)
  • Medication (e.g. imipramine (TCA) or desmopressin (ADH))
19
Q

What is encopresis?

A

Inappropriate defecation after the age of 4

Most cases relate to constipation (overflow incontinence)

20
Q

Give some causes of constipation causing encopresis

A

o Dehydration
o Painful defecation (e.g. anal fissure)
o Fear of punishment
o Toilet fears (e.g. monsters)
o Hirschsprung’s disease (rare - bowel obstruction due to an aganglionic section of colon)

21
Q

Outline the management for encopresis

A
  • Laxatives (if constipated)
  • Reassure, address stress and review toilet training
  • Star charts
22
Q

Give 2 examples of behavioural disorders

A
  • ADHD (attention deficit hyperactivity disorder)

- Conduct disorder

23
Q

Define ADHD

A

A hyperkinetic disorder, in which problems must be present by the age of SIX, for at least SIX months, being persistent and pervasive across DIFFERENT social situations

24
Q

Outline the clinical triad of ADHD

A 
- Hyperactivity (3+ of):
o Fidgets or squirms
o Leaves seat
o Excess running about
o Unduly noisy
o Excess motor activity (in adults: restlessness)
- Inattention (6+ of):
o Fails to:
o Sustain attention
o Follow-through on instruction/work
o Listen
o Careless errors
o Avoids tasks requiring mental effort
o Lose things
o Easily distracted
o Forgetting, poor planning (esp. adolescents/adults)
- Impulsivity (1+ of)
o Blurts out answers
o Fails to wait in lines/their turn
o Interrupts or intrudes others
o Excess talking
o In adults: poor self-control, risk-taking
25
Q

Explain the aetiology of ADHD using a bio-psycho-social model

A

Biological

  • Genetics
  • Prenatal risk factors (smoking, maternal alcohol, substance misuse)

Psychological

  • Poor parenting
  • Maternal depression

Social

  • Environmental lead
  • Poor support
26
Q

Give some signs of ADHD on cognitive testing and imaging

A

Poor function in:

  • Stroop test of saying colours
  • Wisconsin card sorting test

Imaging (MRI):
• Decreased prefrontal cortex size …but also in non-ADHD sibs
• Decreased volume and blood flow in Basal ganglia and cerebellum on imaging
• Decreased prefrontal cortex blood flow in SPECT…but also in non-ADHD sibs
• Decreased prefrontal cortex activity on fMRI during EF (executive functioning) tasks

27
Q

Give some differentials for ADHD

A

o Depression/anxiety - can cause agitation
o Mania (RARE)
o Conduct disorder

28
Q

Give some investigations for ADHD

A 
o	Questionnaires (e.g. Conner's Rating Scales)  
Completed by child, parents and teacher

o Classroom observation of the child

o Educational psychology assessments

IMPORTANT: the teachers should be involved in the assessment

29
Q

Generate a management plan for ADHD using a bio-psycho-social model

A

Social

  • Support for teachers: appropriate schooling placement
  • Family education on ADHD, advice on parenting and boundaries

Psychological
- Behavioural management
o Realistic expectations
o Praise/reward including achievable targets being met and being good
o Process: individual sessions, groups, books and media
- Family therapy
- Group parent training programme: will teach various parenting techniques to deal with ADHD and meet other parents in similar situations

Biological
- Stimulant medication: e.g. methylphenidate, dexamphetamine. Increases monoamine pathway activity, improving concentration and allowing learning and maturation.
o SE: decreased appetite/weight/growth (need regular height and weight checks), insomnia
- Atomoxetine: NA reuptake inhibitor. Usually given if substance abuse or treatment resistance.

30
Q

Identify possible complications of ADHD

A
  • Low self-esteem, peer rejection, educational underachievement
  • Risk factor for later dissocial personality disorder, criminality, substance misuse
  • In childhood: risk factor for conduct disorder

Co-morbidities
• Conduct disorder (25-50%)
• Anxiety disorder (25%) / Depressive disorder (15%)
• Learning difficulties (30%)

31
Q

Define conduct disorder (CD)

A
  • Repetitive & persistent (> 6 months) pattern of antisocial, aggressive or defiant behaviour
  • Frequency & severity beyond age appropriate norms.
  • Violate other people’s expectations or rights
32
Q

Give examples of CD behaviour

A
  • Aggression to people or animals
  • Destruction of property
  • Deceitfulness or theft
  • Serious violations of rules
33
Q

Describe the aetiology of conduct disorder using a bio-psycho-social model

A

Biological

  • Genetic – runs in families but no genes have been identified.
  • Substance Misuse
  • Child factors e.g. ADHD
  • Perinatal complications

Psychological

  • Parental criminality
  • Harsh and inconsistent parenting
  • Antisocial behaviour learned from parental or societal models

Social

  • Urban upbringing, neighbourhood
  • Deprivation
  • Schools (run down, poor clarity of rules, deviant friendship groups)
34
Q

Outline some behavioural symptoms of CD

A
  • Touchy or easily annoyed by others
  • Angry or resentful
  • Spiteful or vindictive
  • Blames others for one’s own mistakes or behaviours
  • Actively defies or refuses adults’ requests or rules
35
Q

Often the appropriate investigations for CD is to exclude other diagnoses, give some differentials for CD

A
  • Oppositional defiant disorder: milder form of CD, occurring in children under 10 with provocative, angry and
    disobedient behaviour towards adults. No extreme antisocial behaviour is present.
  • ADHD
  • Depression: some children present with antisocial behaviour.
36
Q

Generate a management plan for CD using a bio-psycho-social model

A

Psychological:
• Family education
o Make the family understand CD and how they may accidentally reinforce the behaviours
• Psychological therapy (CBT, anger management)
o Talk about feelings and thoughts and how these affect behaviour and wellbeing to a therapist
• Parent management training
o Teaches parents to reward good behaviour and deal constructively with negative behaviours
• Family therapy
o Family meets with a skilled therapist to discuss current problems

Social:
• Educational support and interventions at schools

Biological:
• Treat co-morbid problems e.g. ADHD – manage underlying hyperactivity

37
Q

Identify complications of CD

A
  • Criminality
  • Developmental issues
  • Predicts for; unemployment, domestic violence, homelessness, dependance on tobacco/drugs
  • Mental health problems (depression, anxiety, suicide)
38
Q

What are tic disorders?

A

Repetitive, involuntary and purposeless movements or vocal utterences

Categorised into:

  • Simple; e.g blinking, throat-clearing
  • Complex; e.g swearing, self-hitting
39
Q

Outline the management for tic disorders

A
  • Reassurance, education and stress management
  • Clonidine (alpha-2 agonist)
  • Atypical antipsychotics

Psychiatry (14 decks)

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