child/adolescent psychiatry - further clinical topics

Question 1

the out of school matrix

Answer 1

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

Question 2

mental health problems associated w/ being out of school

Answer 2

anxiety 
conduct disorder 
autism 
depression 
OCD

Question 3

effects of mental health problems on school attendance and learning

Answer 3

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

Question 4

anxiety disorders - why do they happen and how do they present

Answer 4

separation anxiety - fear of leaving parents and home, problems on the doorstep

social phobia - fear of joining group, problems at the school gate

Question 5

features of anxiety disorders - 3As

Answer 5

anxious thoughts and feelings

autonomic sx

avoidant behaviour

Question 6

motivational factors affecting school attendance

Answer 6

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)

Question 7

anxiety disorders and amygdala activity

Answer 7

suppressed by R ventrolateral cortex when labelling emotions

reduced connectivity between R ventrolateral cortex and amygdala in generalised anxiety disorders in adolescents

Question 8

feeding fears and escalating problems

Answer 8

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.

Question 9

assessment and management of anxiety

Answer 9

contain anxiety and return to school as soon as possible

Question 10

treatment of anxiety

Answer 10

BEHAVIOURAL: 
learning alternative patterns of behaviour 
desensitisation 
overcoming fear
managing feelings

MEDICATION
SSRI e.g. fluoxetine

Question 11

principle of CBT

Answer 11

thoughts
feelings
behaviour

Question 12

long term effects of successful behavioural treatment for anxiety

Answer 12

challenge
success
self-confidence
resilience

Question 13

long term effects of no behavioural treatment for anxiety

Answer 13

challenge
avoidance
low self-confidence
vulnerability

Question 14

CBT with children and families

Answer 14

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

Question 15

what is psychoeducation

Answer 15

explaining the problem in terms that make sense to everyone

Question 16

importance of goal setting in management of anxiety

Answer 16

choosing reasonable objectives that can be achieved

Question 17

importance of motivating in management of anxiety

Answer 17

getting buy-in so the goals can be achieved

Question 18

what is externalising

Answer 18

taking blame, guilt and anger out of the equation

Question 19

what is autism spectrum disorder

Answer 19

neurodevelopmental disorder

defined as a syndrome of persistent, pervasive and distinctive behavioural abnormalities

often associated with but not defined by low IQ

Question 20

what does pervasive mean

Answer 20

present across the life span (onset <3yrs) and across settings (a feature of brain development and function)

Question 21

how common is ASD

Answer 21

highly heritable

1%

M:F 3:1

Question 22

distinctive social features of ASD

Answer 22

difficulties initiating and maintaining reciprocal conversation

difficulties expressing emotional concern

non-verbal communication - declarative pointing, modulated eye-contact, other gesture, facial expression

Question 23

repetitive behaviour in autism

Answer 23

mannerisms and stereotypes

obsessions, preoccupations and interests

rigid and inflexible patterns of behaviour - routines, rituals, play

Question 24

variable clinical picture of autism

Answer 24

each domain is variable and in addition variation is affected by age and IQ

Question 25

dimensions of clinical features of ASD - decreased/increased

Answer 25

decreased - self-other perspective taking, sharing/divided attention, flexible learning, social understanding

increased - rigidity, sameness, fixed learning patterns, technical understanding

Question 26

dimensions of clinical features of ASD - younger/older

Answer 26

younger/lower IQ - joint attention/attention to others, emotional responses, movements/actions

older/higher IQ - conversation, empathy, interests

Question 27

causes of autism

Answer 27

strongly genetic

co-morbid w/ congenital or genetic disorders - rubella, callosal agenesis, Down’s syndrome, fragile X, tuberous sclerosis

Question 28

genetic causes of autism

Answer 28

GWAS identifying modulators of genetic expression e.g. rbfox1

also epigenetics

Question 29

heritability of autism

Answer 29

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

Question 30

the autism spectrum

Answer 30

Question 31

neurotransmitter dysfunction in autism

Answer 31

many synaptic proteins are implicated

mainly glutaminergic but also GABA

Question 32

common clinical problems in ASD

Answer 32

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

Question 33

principles of management of ASD

Answer 33

recognition, description and acknowledgement of disability

establishing needs

decrease the demands -> reduce stress -> improve coping

psychopharmacology

Question 34

key features of oppositional defiant disorder

Answer 34

refusal to obey adult's request
often argues with adults
often loses temper 
deliberately annoys people
easily annoyed by others
spiteful or vindictive

Question 35

ODD vs ADHD

Answer 35

not straightforward and usually overlap

Question 36

what causes hard to manage children

Answer 36

child - temperament, ADHD, neurodevelopment
parent - overcrowding, poverty, depression

especially lack of +ve experience of being parented

psychosocial adversity and experience of hostility

Question 37

management of H2M children

Answer 37

parent training programmes

multi-systemic therapy attempts to correct all causes

Question 38

outcome risks with H2M children

Answer 38

antisocial behaviour
substance misuse
long term mental health problems

Question 39

what does parent training involve

Answer 39

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