Child and Adolescent Mental Health CAMH Flashcards
What is classed as Depression in Children and Adolescents?
Depression is a disorder that causes persistent feelings of low mood, low energy and reduced interest. It can affect people of all ages, including children and adolescents. It is often triggered by life events, although it can happen without any apparent triggers.
Typical symptoms of depression include:
* Low mood
* Anhedonia, a lack of pleasure in activities
* Low energy
* Anxiety and worry
* Clinginess
* Irritability
* Avoiding social situations (e.g. school)
* Hopelessness about the future
* Poor sleep, particularly early morning waking
* Poor appetite or over eating
* Poor concentration
* Physical symptoms such as abdominal pain
There are key points that need to be considered in assessing children and adolescents with depression. Particular attention needs to be given to the ________________ ____________. It is important to ask question in private as well as taking a history with parents or others present.
There are key points that need to be considered in assessing children and adolescents with depression. Particular attention needs to be given to the psychosocial contributors. It is important to ask question in private as well as taking a history with parents or others present.
Name some psychosocial contributors?
- Potential triggers (e.g. loss of a family member)
- Home environment
- Family relationships
- Relationship with friends
- Sexual relationships
- School situations and pressures
- Bullying
- Drugs and alcohol
- History of self harm
- Thoughts of self harm or suicide
- Family history
- Parental depression
- Parental drug and alcohol use
- History of abuse or neglect
Management for Mild Depression in children/asdolescent?
Mild depression or low mood associated with a single negative event (e.g. loss of a family member) can be managed with watchful waiting and advice about healthy habits, such as healthy diet, exercise and avoiding alcohol and cannabis. Follow up within 2 weeks is advised.
Management for moderate to severe depression?
NICE recommend referral to CAMHS for children with moderate to severe depression. CAMHS can then initiate:
- Full assessment to establish a diagnosis
- Psychological therapy as the first line treatment with cognitive behavioural therapy, non-directive supportive therapy, interpersonal therapy and family therapy
- Fluoxetine is the first line antidepressant in children, starting at 10mg and increasing to a maximum of 20mg
- Sertraline and** citalopram** are second line antidepressants
- When the child responds to medical treatment, it should continue 6 months after remission is achieved
- When they do not respond to medical treatment they may require intensive psychological therapy
Where there is follow up monitoring in secondary care, the mood and feelings questionnaire (MFQ) may be used to assess progress.
Admission may be required where there is high risk of self harm, suicide or self-neglect or where they may be an immediate safeguarding issue.
What is Obsessive compulsive disorder (OCD)?
Obsessive compulsive disorder (OCD) is characterised by obsessions and compulsions.
Name some common examples OCD
Examples of this are an overwhelming fear of contamination with** dirt or germs** or violent or explicit images that keep appearing in their mind.
OCD: What is the difference between obsessions and compulsions?
Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore. Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind.
Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done. Often these compulsions are a way for the person to handle the obsessions. For example, checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. This is a normal behaviour, but in OCD the person may check every plug in the house 10 times before being able to go to sleep or leave.
What is the cycle in OCD?
There is a cycle in** OCD: **The obsessions lead to anxiety, which leads to the compulsive behaviour, which lea ds to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety.
OCD is strongly related to other mental health issues:
- Anxiety
- Depression
- Eating disorders
- Autistic spectrum disorder
- Phobias
Management of OCD
Mild OCD may be managed with education and self help resources.
More significant OCD may require:
- Referral to CAMHS
- Patient and carer education
- Cognitive behavioural therapy
- SSRIs medications (under the guidance of a CAMHS specialist)
What is ASD?
Autistic spectrum disorder refers to the full range of people affected by a deficit in** social interaction, communication and flexible behaviour**
What is Asperger syndrome?
The autistic spectrum has a significant range. On one end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others. This was previously known as **Asperger syndrome. **
Features of ASD can be noticed from the age of?
3
ASD Social Interaction features?
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
ASD Communication features?
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
ASD Behaviour Features?
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
- Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine
- Extremely restricted food preferences
Diagnosis of ASD?
Diagnosis should be made by a specialist in autism. This may be a paediatric psychiatrist or paediatrician with an interest in development and behaviour. A diagnosis can be made before the age of 3 years. It involves a detailed history and assessment of the child’s behaviour and communication.
Management of ASD?
Autism cannot be cured. Management depends on the severity of the child’s condition. Management involves a **multidisciplinary team **to provide the best environment and support for the child and parent:
- Child psychology and child and adolescent psychiatry (CAMHS)
- Speech and language specialists
- Dietician
- Paediatrician
- Social workers
- Specially trained educators and special school environments
- Charities such as the national autistic society
What does ADHD stand for?
Attention Deficit Hyperactivity Disorder
What is ADHD
Attention deficit hyperactivity disorder (ADHD) is at the extreme end of “hyperactivity” and inability to concentrate (“attention deficit“). It affects the person’s ability to carry out everyday tasks, develop normal skills and perform well in school.
ADHD
Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an _____________ _________ rather than an underlying diagnosis
Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis
Features of ADHD?
All the features of ADHD can be part of a normal spectrum of childhood behaviour. When many of these features are present and it is adversely affecting the child, ADHD can be considered:
- Very short attention span
- Quickly moving from one activity to another
- Quickly losing interest in a task and not being able to persist with challenging tasks
- Constantly moving or fidgeting
- Impulsive behaviour
- Disruptive or rule breaking
Management of ADHD
A detailed assessment should be carried out by a specialist in childhood behavioural problems before a diagnosis is made. Management should be coordinated by a specialist in ADHD. Parental and child education is essential. This includes education about parental strategies to manage the child.
Establishing a **healthy diet **and **exercise **can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician
Medication is an option after conservative management has failed or in severe cases. This should be coordinated by a specialist. Contrary to what you might think, they are central nervous system stimulants.
Examples of medication used for ADHD?
- Methylphenidate (“Ritalin“)
- Dexamfetamine
- Atomoxetine
Eating Disorders strong correlations?
There is a strong correlation with personality disorders, obsessive compulsive disorder, anxiety and other mental health disorders.
Are Eating disorders more common in girls or boys?
Eating disorders are more common in girls.
Can Eating disorders be genetic?
yes
Personality disorders are thought to result from a combination of ________ and ____________ factors. Patients often have a history of ….
Personality disorders are thought to result from a combination of genetic and environmental factors. Patients often have a history of early childhood trauma and difficult circumstances.
What is personality disorder?
Personality disorder (PD) is an umbrella term that covers a number of variations of maladaptive personality traits that cause significant psychosocial distress and interfere with everyday functioning. It is characterised by patterns of thought, behaviour and emotions that differ from what is normally expected by society. It leads to difficult relationships, reduced quality of life and poor physical health
Personality disorder symptoms?
- Strong, intense emotions
- Emotional instability
- Anger
- Low self esteem
- Impulsive behaviour
- Substance abuse
- Poor sense of identity
- Difficulty maintaining relationships
- Risky behaviour, such as risky sex
- Violence and aggression
- Self harm
- Suicide attempts
There are many different types of personality disorder. The classification is based on the dominant features. They fall under three main categories:
- Anxious
- Suspicious
- Emotional or impulsive
Examples of Anxious Personality Disorders
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive compulsive personality disorder
What is Avoidant personality disorder
Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.
What is Dependent personality disorder
Dependent personality disorder features heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.
What is Obsessive compulsive personality disorder
Obsessive compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen if these expectations are not met.
Examples of Suspicious Personality Disorders
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
What is Paranoid personality disorder
Paranoid personality disorder features difficulty in trusting or revealing personal information to others.
What is Schizoid personality disorder
Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them
What is Schizotypal personality disorder
Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.
Examples of Emotional / Impulsive Personality Disorders
Emotional / Impulsive Personality Disorders
Histrionic personality disorder
Narcissistic personality disorder
What is Borderline personality disorder
Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.
What is Histrionic personality disorder
Histrionic personality disorder features the need to be at the centre of attention and having to perform for others to maintain that attention.
What is Narcissistic personality disorder?
Narcissistic personality disorder features feelings that they are special and need others to recognise this or else they get upset. They put themselves first
Management for personality disorders?
Management of personality disorders can be difficult. The patterns of thinking and behaviours are deeply ingrained and are difficult to change. Patient and carer education is very important to help them understand the condition. Cognitive behavioural therapy (CBT) and psychotherapy is the key management option of choice. Supportive care can be provided during crises to help keep the patient safe.
There are no medical treatments recommended for personality disorders. Personality disorders can co-exist with other psychiatric problems (e.g. depression) where medications may be beneficial.
What is Tourette’s syndrome
Tourette’s syndrome is characterised by the development of tics that are persistent for over a year.
What are Tics?
Tics are involuntary movements or sounds that the child performs repetitively throughout the day. These tics become more prominent when the person is under pressure or excited. The person may describe an overwhelming urge to perform the tic. This urge increases the more they suppress it. They feel they need to complete the tic, often several times, to get relief from that urge. These feelings are called premonitory sensations.
Tics often present around or after 5 years of age. They can be associated with
OCD and ADHD.
Examples of Simple Tics
- Clearing throat
- Blinking
- Head jerking
- Sniffing
- Grunting
- Eye rolling
Management Tourette’s and Tics
Usually tics will improve over time. Mild cases with no signs of underlying disease may only require reassurance and monitoring. Taking measures to reduce stress, anxiety and triggers can be helpful.
More severe or troublesome tics should be referred to a specialist. They may benefit from:
- Habit reversal training
- Exposure with response prevention
- Medications may be tried in very severe cases, usually with antipsychotic medications
Co-morbid conditions such as **OCD and ADHD **may benefit from treatment.
Examples of Complex Tics
- Performing physical movements, such as twirling on the spot or touching objects
- Copropraxia involves making obscene gestures
- Coprolalia involves saying obscene words
- Echolalia involves repeating other people’s words
What are the reactions to trauma in children
- Denial, shock, irritability, anger, fear, isolation, shame
- Avoidance, not talking about it, clamming up vs
preoccupation, nightmares, flashbacks, enacted through play
What is the signs of trauma on a MSE
- Mood, affect, negative thoughts and thoughts of self-harm
- Posture, speech character, facial expression, eye contact
- Psychomotor agitation, retardation, arousa
What is phsyical signs of trauma?
- Pain, lethargy, continence, appetite, sleep
- Every system - somatisation / conversion
Name some biopsychosocial impacts from trauma?
- Individual
- Development and neurobiology
- Peer relationships (interpersonal relationships)
- Educational disruption (school refusal)
- Financial / employment
- Distress in others (family, professionals)
- Compensatory behaviours in others
What is ACEs
Adverse Child Experiences
* = experiences that harm children’s developing brains and lead to changing
how they respond to stress and damaging their immune systems so
profoundly that the effects show up decades later. ACEs cause much of our
burden of chronic disease, most mental illness, and are at the root of most
violence. (CDC.gov
Give an example of ACE situation?
loss of a parent, household substance abuse or mental illness, divorce
Explain the ACE pyramid
What is attachment?
- An affectionate bond between two people that endures
through time and space and connects them emotionally - Attachment is the base from which children explore
- Early attachment experiences form their concepts of self,
others and the world - Through positive two-way relationships children learn to
regulate their mood and responses, soothe themselves and relate to others
Name the different types of attachement?
Secure attachment
Disordered attachment
Insecure attachment (avoidant)
Insecure attachment (ambivalent)
Disorganised attachment
hat is meant by “neurodevelopmental?”
Neurodevelopmental disorders are a group of disorders
that affect the development of the nervous system, leading to
abnormal brain function which may affect emotion,
learning ability, self-control, and memory. The effects of
neurodevelopmental disorders tend to last for a person’s
lifetime
Can you name some neurodevelopment disorders?
- Intellectual disability (ID) or intellectual and developmental disability, previously called mental
retardation - Specific learning disorders: dyslexia or dyscalculia.
- Autism spectrum disorders
- Motor disorders including developmental coordination disorder and stereotypic movement disorder
- Tic disorders including Tourette’s syndrome
- Traumatic brain injury (including congenital injuries such as those that cause cerebral palsy)
- Communication, speech and language disorders
- Genetic disorders, such as fragile-X syndrome, Down syndrome, *schizophrenia, *
schizotypal disorder, - Disorders due to neurotoxicants like fetal alcohol spectrum disorder, Minamata disease caused by
mercury; behavioral disorders caused by other heavy metals, such as lead, chromium, platinum - Attention Deficit Hyperactivity Disorder (Wiki - *NB not consensus on all included here)
WHat are the core features of ASD
Deficits in:
* Social interaction
* Social communication
* Flexibility and imaginative thinking
Pervasive and manifest in first three years of life
Associated features:
* Sensory sensitivities
* Stereotypies / mannerisms
* Special skill
What do we mean by lack of social interaction?
- Lack of social interest
- Lack of reciprocity
- Socially “odd”
- Reduced capacity for social interaction
- Poor understanding of principles of social interaction
- Difficulty reading social cues
What do we mean by lack of communication in ASD
- Speech delay
- Echolalia
- Lack of non-verbal: gesture, facial expression
- Subtle peculiarities of intonation
- Pedantic, formal speech - “little professor
What do we mean by flexibility and imagination in ASD?
- Restricted range of interests
- Preoccupations
- Fixed daily routines
- Poor tolerance of change and transition
- Reduced pretend play
- Repetitive
How do we diagnose ASD
- Full history, including developmental
- Structured observation (ADOS)
- Unstructured observation: school, home, clinic
- Structured assessment tools and questionnaires
- Multidisciplinary
- Community Paediatrics
- SALT and Educational Psychology
- Psychology / Psychiatry / MHP
- O.T
Management for ASD
Supporting education
* Suitable environment / adequately supported inclusion
* Autism understanding amongst staff
* Transition planning
* Vocational support / training
Social care
* Respite and family support
Medical Care
* Treatment of physical disabilities - hearing, vision, other
* Dental care
* Associated medical conditions
Treatment of child’s deficits:
* Behavioural / communication problems
* Behavioural analysis and interventions
* Communication aids - PECS, symbols, visual timetables
* Social Skills
* Social skills groups
* Social stories
**Psychopharmacology **- MPD, antipsychotic, SSRI, melatonin
If you have ASD what are you more likely to get?
- ADHD
- Depression
- Anxiety
- Learning difficulty (including specific, e.g. dyslexia /
dyspraxia) - Tics
- Similarities and differences between OCD and ASD
- Similarities with disordered attachment
Trauma can lead to ____ later on in life
ADHD
What should you also consider which a person with ASD?
- Retts
- Childhood disintegrative disorder
- Neurodegenerative conditions
- Fragile X
- Severe early deprivation
- NF1 / tuberous sclerosis
- Fetal alcohol syndrome
- Williams syndrome, Rubella enbryopathy
What are the three componenets of ADHD
Inattention, impulsivity, hyperactivity
ADHD medications?
- Methylphenidate
- Guanfacine
- Atomoxetine
What mimics ADHD?
Brain injury and attachment
