child/adolescent psychiatry - further clinical topics Flashcards
the out of school matrix
fear vs motivation
school refusal vs truancy
- fear of leaving home
- unwilling to leave home
- fear of going to school
- unwilling to go to school
mental health problems associated w/ being out of school
anxiety conduct disorder autism depression OCD
effects of mental health problems on school attendance and learning
Learning difficulties due to poor attention
Co-morbid specific (or general) learning problems
Difficulty controlling emotion e.g. frustration, escalation of anger, frequent conflict.
Anxiety
Lack of energy, motivation
Difficulties joining in – wanting to be alone or unable to make friends (feeling different).
Sensory problems – too noisy
Preoccupation e.g. fear of germs and contamination
Associations between mental health and learning difficulties e.g. dyslexia
anxiety disorders - why do they happen and how do they present
separation anxiety - fear of leaving parents and home, problems on the doorstep
social phobia - fear of joining group, problems at the school gate
features of anxiety disorders - 3As
anxious thoughts and feelings
autonomic sx
avoidant behaviour
motivational factors affecting school attendance
AFFECTING WILLINGNESS TO GO TO SCHOOL
- learning difficulties
- lack of friends and relationships
- bullying
- lack of parental attention or concern e.g. lack of interest in child’s education
ENCOURAGING ONE TO STAY AT HOME
- maternal depression (separation anxiety)
anxiety disorders and amygdala activity
suppressed by R ventrolateral cortex when labelling emotions
reduced connectivity between R ventrolateral cortex and amygdala in generalised anxiety disorders in adolescents
feeding fears and escalating problems
11 year old child starting at new school feels anxious and complains about “sore tummy” on days before school.
Parent feels anxious and asks GP for tests.
GP feels parental anxiety, and does tests
Child stays home from school
Tests are negative
Child has relaxed being off school and fear of school has grown.
Now refuses to return to school
Problem has now become serious.
assessment and management of anxiety
contain anxiety and return to school as soon as possible
treatment of anxiety
BEHAVIOURAL: learning alternative patterns of behaviour desensitisation overcoming fear managing feelings
MEDICATION
SSRI e.g. fluoxetine
principle of CBT
thoughts
feelings
behaviour
long term effects of successful behavioural treatment for anxiety
challenge
success
self-confidence
resilience
long term effects of no behavioural treatment for anxiety
challenge
avoidance
low self-confidence
vulnerability
CBT with children and families
Don’t expect children to have cognitive awareness
Mostly B & T
Parents as collaborators in the team
Step-wise approach: the ladder to success
Externalisation: disorder is not a matter of blame.
Overcoming barriers to change: problem solving
what is psychoeducation
explaining the problem in terms that make sense to everyone
importance of goal setting in management of anxiety
choosing reasonable objectives that can be achieved
importance of motivating in management of anxiety
getting buy-in so the goals can be achieved
what is externalising
taking blame, guilt and anger out of the equation
what is autism spectrum disorder
neurodevelopmental disorder
defined as a syndrome of persistent, pervasive and distinctive behavioural abnormalities
often associated with but not defined by low IQ
what does pervasive mean
present across the life span (onset <3yrs) and across settings (a feature of brain development and function)
how common is ASD
highly heritable
1%
M:F 3:1
distinctive social features of ASD
difficulties initiating and maintaining reciprocal conversation
difficulties expressing emotional concern
non-verbal communication - declarative pointing, modulated eye-contact, other gesture, facial expression
repetitive behaviour in autism
mannerisms and stereotypes
obsessions, preoccupations and interests
rigid and inflexible patterns of behaviour - routines, rituals, play
variable clinical picture of autism
each domain is variable and in addition variation is affected by age and IQ
dimensions of clinical features of ASD - decreased/increased
decreased - self-other perspective taking, sharing/divided attention, flexible learning, social understanding
increased - rigidity, sameness, fixed learning patterns, technical understanding
dimensions of clinical features of ASD - younger/older
younger/lower IQ - joint attention/attention to others, emotional responses, movements/actions
older/higher IQ - conversation, empathy, interests
causes of autism
strongly genetic
co-morbid w/ congenital or genetic disorders - rubella, callosal agenesis, Down’s syndrome, fragile X, tuberous sclerosis
genetic causes of autism
GWAS identifying modulators of genetic expression e.g. rbfox1
also epigenetics
heritability of autism
broader phenotype in siblings and parents:
- increased rates of depression, OCD, anxiety disorders, language impairment
- poor set-shifting ability, increased visuospatial ability, careers in engineering, computing, mathematics
the autism spectrum
neurotransmitter dysfunction in autism
many synaptic proteins are implicated
mainly glutaminergic but also GABA
common clinical problems in ASD
learning disability - mild to severe disturbed sleep and eating habits hyperactivity high levels of anxiety and depression OCD school avoidance aggression temper tantrums self-injury, self-harm suicidal behaviour - 6x
principles of management of ASD
recognition, description and acknowledgement of disability
establishing needs
decrease the demands -> reduce stress -> improve coping
psychopharmacology
key features of oppositional defiant disorder
refusal to obey adult's request often argues with adults often loses temper deliberately annoys people easily annoyed by others spiteful or vindictive
ODD vs ADHD
not straightforward and usually overlap
what causes hard to manage children
child - temperament, ADHD, neurodevelopment
parent - overcrowding, poverty, depression
especially lack of +ve experience of being parented
psychosocial adversity and experience of hostility
management of H2M children
parent training programmes
multi-systemic therapy attempts to correct all causes
outcome risks with H2M children
antisocial behaviour
substance misuse
long term mental health problems
what does parent training involve
group/individual/self-taught
structured - 1-2hrs/wk for 8-12wks
free resources available
informed by social learning theory - modelling behaviour
focus on +ve reinforcement of desired behaviour and developing +ve parent-child relationships
