child and adolescent - mentor & more 1 Flashcards
Children under 5: ADHD
* First-line
ADHD-focused group parent-training
Children under 5: ADHD
* If first-line fails
obtain advice from a specialist ADHD service (tertiary service)
medication for ADHD for any child under 5years
Do not offer medication without a second specialist opinion from an ADHD service
Children and young people (5-18): ADHD
- Provide educational advice and support (1-2 sessions possible)
- Offer ADHD parent training in groups
- Consider medication if significant impairment persists after environmental changes
- Suggest cognitive behavioural therapy (CBT) for young people still significantly impaired despite medication
NICE stance about elimination diet for ADHD
it is against it
when to refer ADHD to cardiology before medicaitons?
- Suggestive cardiac symptoms (fainting, breathlessness, palpitations).
- Sudden death of a first-degree relative under 40 years.
Medication in children and young people (5-18): ADHD
First line
- Methylphenidate or lisdexamfetamine is first-line (try for 6 weeks)
- If above ineffective, consider switching to to the alternative first-line option
- Consider dexamfetamine for those responding to lisdexamfetamine but who cannot tolerate the longer effect profile
Medication in children and young people (5-18): ADHD
Second line
- Offer atomoxetine or guanfacine for those who can’t tolerate methylphenidate or lisdexamfetamine
medication NOT to offer for ADHD without advice from a tertiary ADHD service
- Clonidine treats ADHD in children experiencing sleep disturbances, rages, or tics.
- Atypical antipsychotics may assist ADHD patients with aggression or irritability.
what to do in patients on ADHD Drugs and develop Mania or psychosis
stop ADHD treatment until the episode has resolved
If a person taking stimulants develops tics then what:
- Continuing the medication
- Reducing medication
- Stopping medication
- Swapping to guanfacine , atomoxetine, or clonidine
when to cont. the medication in patients on stimulants who develop tics?
if benefit outweighs risk
when to give guanfacine in patients on stimulants who develop tics?
in children aged 5years and over and young people only
why A drug holiday in ADHD children?
To address concerns about growth restriction
NICE Review on ADHD Drug holiday
Withdrawal from treatment was associated with a risk of symptom exacerbation.
NICE conclusion for drug holiday in ahdd?
- Consider treatment breaks during school holidays for children affected by medications.
- Stimulants can cause minor growth restriction (1-2 cm).
- Growth often normalizes during breaks.
- Monitor for potential larger effects in some cases.
Monitoring of ADHD (children): Weight
- Weight: Every 3 months (under 10 years); every 6 months thereafter.
Monitoring of ADHD (children): Height
- Height: Every 6 months (children and young people).
Monitoring of ADHD (children): Blood pressure
- Blood Pressure & Pulse: Before/after dose change, then every 6 months once stabilized.
Stimulants example in ADHD
METHYLPHENIDATE
LISDEXAMFETAMINE
NON-STIMULANT examples in adhd
Atomoxetine
Guanfacine
Clonidine
Dexamfetamine : Mechanism (hypothesised)
Inhibiting DA (dopamine) and NA (noradrenaline) reuptake
Methylphenidate : Mechanism (hypothesised)
Inhibiting DA and NA reuptake
Lisdexamfetamine: Mechanism (hypothesised)
Prodrug, absorbed by GI tract, converted to dexamfetamine which inhibits the reuptake of NA and DA. Converted by enzymes in red blood cells into dexamfetamine and L-lysine (amino acid). The activation of the prodrug results in longer action and a reduced abuse potential
Atomoxetine: Mechanism (hypothesised)
Targets the NET (noradrenaline transporter), inhibiting the reuptake of NA, therefore increasing NA levels in the synaptic cleft. Selective NA reuptake inhibitor
Guanfacine: Mechanism (hypothesised)
Selective agonist of α2A-adrenergic receptors. Binds to postsynaptic α2A-adrenergic receptors, mimicking NA
Clonidine: Mechanism (hypothesised)
Agonist of α2-adrenergic receptors, mimic NA
Dexamfetamine very common side effect
- decreased appetite
- reduced weight gain and weight loss during prolonged use in children
- insomnia
- nervousness
Methylphenidate every common side effect >1/10
- decreased appetite
- insomnia
- nervousness
- headache
- nausea
- dry mouth
Atomoxetine every common side effect >1/10
- appetite decreased
- headache
- somnolence
- abdominal pain (includes epigastric discomfort)
- vomiting
- nausea
- blood pressure increased
- heart rate increased
Clonidine every common side effect >1/10
- dizziness
- sedation
- orthostatic hypotension
- dry mouth
Antipsychotics (in young people): rate of side effect
Higher in young people
Clozapine in young people
- uniquely beneficial second-line agent for treating children with refractory schizophrenia
- some argue for its early use in first-episode psychosis
difference between fear and anxiety?
fear represents a reaction to perceived imminent threat in the present,
anxiety is more future-oriented, referring to perceived anticipated threats.
Anxiety or Fear-Related Disorders in (ICD-11)
- Generalized Anxiety Disorder
- Panic Disorder
- Agoraphobia
- Specific Phobia
- Social Anxiety Disorder
- Separation Anxiety Disorder
- Selective Mutism
Generalised anxiety disorder:
essential features
- Symptoms of free-floating apprehension and worry lasting for months.
- More common in late adolescence; uncommon in children under 5.
- Girls show earlier symptom onset than boys.
- Children may:
- Be overly concerned with rules.
- Have a strong desire to please others.
- Get upset by peers’ disobedience or rule-breaking.
Panic disorder:
essential features
- Recurrent panic attacks
- Intense fear episodes (P.A.N.I.C.):
- P: Palpitations
- A: Anxiety (sweating, trembling)
- N: Nausea (shortness of breath)
- I: Inability to breathe (chest pain)
- C: Chills/hot flushes
- Persistent avoidance of triggers.
Agoraphobia:
essential features
- Fear/anxiety: Transport, Crowds, Alone
- Responses: Avoidance, Support, Endurance
- Symptoms: Months
Acronym: PACE (Transport, Avoidance, Support, Endurance)
Specific phobia:
essential features
Intense, irrational fear or anxiety about specific objects or situations (e.g., animals, flying, heights) that leads to avoidance or extreme distress. Symptoms last for several months.
Social anxiety disorder:
essential features
Intense fear or anxiety in social situations (e.g., conversations, eating, performing) leads to avoidance or distress. Individuals fear negative evaluation by others, and symptoms last for several months.
Separation anxiety disorder:
essential features
Separation anxiety involves intense fear or anxiety about being away from specific attachment figures, typically caregivers or family members, which exceeds normal developmental levels.
Normal separation anxiety peaks between 9 and 18 months and lessens by age 3.
Symptoms persist for several months. The focus of the anxiety is the separation itself, not specific situations.
Separation anxiety disorder:
symptoms
- Thoughts of harm to the attachment figure
- Reluctance to go to school or work
- Distress upon separation
- Refusal to sleep away from the attachment figure
- Nightmares about separation
Separation anxiety disorder:
Common issues:
- School refusal (1-5% of children)
- Nightmares about separation
- Physical symptoms during separations
School refusal differs from truancy and is not a formal diagnosis.
Truancy
- No emotional distress about school
- Parents unaware of absences
- Often exhibits antisocial behavior
- Not home or at school during hours
- Little interest in school work
School refusal
Severe distress about school (tantrums, somatic symptoms).
Parents aware of absences.
No antisocial behavior.
Child mostly home during school hours.
Desires to do schoolwork at home.
Anxiety disorder in children:
1st ______ of Rx
Cognitive Behavioural Therapy (CBT).
social anxiety disorder in children:
1st __________of Rx
- NICE recommends CBT (individual/group) for 8-12 sessions.
- Do not routinely offer pharmacological treatments.
- Mindfulness should not be routinely offered.
specific phobiasin children:
1st __________of Rx
CBT in the form of exposure therapy (or systematic desensitisation)
Where CBT is either ineffective or not appropriate then SSRIs are the treatment of choice.
Attachment disorders :
common belief of DSM-5 and ICD-11
“Two disorders from poor caregiving in childhood.”
“Listed with PTSD under stress conditions.”
Attachment disorders : forms
Reactive attachment disorder
Disinhibited social engagement disorder
Reactive attachment disorder
social withdrawal and unusual attachment behavior, failing to seek or respond to comfort
Disinhibited social engagement disorder
characterized by disinhibited behavior in unfamiliar situations and with strangers
Can a reactive attachment disorder be diagnosed in the context of ASD according to the DSM-5 and ICD-11?
No
Fill in the blank: A reactive attachment disorder cannot be diagnosed in the context of _______.
ASD
how to differentiate Reactive attachment disorder with ASD
they do not exhibit social communication deficits or the persistently restrictive, repetitive, and stereotyped patterns of behaviour, interests
what is ‘quasi-autism’
Affected individuals show improved autism-like features in nurturing environments.
ICD 11- Essential features of Reactive attachment disorder:
- RAD involves abnormal attachment behaviours.
- Linked to inadequate childcare (neglect, maltreatment).
- Children with RAD avoid seeking comfort.
- Diagnosis evident in children under 5.
- Cannot be diagnosed before age 1.
- Distinction from Autism Spectrum Disorder.
ICD 11- Required features of Reactive attachment disorder:
history of grossly insufficient care that my include:
- Lack of emotional support.
- Neglect of physical needs.
- Frequent caregiver changes.
- Unstable living environments.
- Maltreatment.
Reactive attachment disorder:
Abnormal attachment behaviors in a child toward adult caregivers, marked by:
- Minimal seeking of comfort when distressed.
- Rare response to offered comfort.
DSM-11 - Essential features of Reactive attachment disorder:
A. Consistent withdrawn behavior towards caregivers, shown by:
- Rarely seeks comfort when distressed.
- Rarely responds to comfort when distressed.
B. Persistent social/emotional disturbance, shown by:
- Minimal responsiveness to others.
- Limited positive emotions.
- Unexplained irritability, sadness, or fear during nonthreatening interactions.
C. History of insufficient care, shown by:
- Lack of emotional support from caregivers.
- Frequent changes of primary caregivers.
- Unusual settings limiting attachment opportunities.
D. Care issues in C are connected to disturbed behavior in A.
E. Criteria not met for autism spectrum disorder.
F. Disturbance evident before age 5.
G. Child has at least a 9-month developmental age.
