Child and adolescent psych Flashcards
How are disorders often characterised in child psychiatry?
- Behavioural
- Neurodevelopmental
- emotional
Although lots of overlap
What ways can you divide children (in terms of age) in child psychiatry ?
Helpful to divide into:
- under 5’s
- childhood
- adolescent ( over 12)
As relates to development
When assessing for child psychiatric disorders what are crucial areas to cover?
- child development (physical, social, emotional, cognitive, moral )
- family relationships
What aspects do you need to cover in the presentation of a child to mental health services, to work out if they have a problem or not?
- age (5 yr old will be different to older child)
- frequency (e.g. panic attacks every day or month)
- severity
- child’s individual characteristics / temperament
- impact on others (e.g. aggressive 14 yr old danger to younger siblings in house safegaurding)
- family / social circumstance (e.g. undiagnosed mental health in parent causing presentation )
What child mental health services are available?
Health services
- specialist services
- universal services
Local authority
- school based services
- community based services
What are the biological factors that can affect children in their emotional development and mental health?
- temperament
- genetic
- neurodevelopemental
- biochemical
What are the development / psychological factors that can affect children in their emotional development and mental health?
- attachment
- learning
- cognitive
- emotional
What are the social / environmental factors that can affect children in their emotional development and mental health?
Acute stressors:
- trauma e.g. war zones
- accident e.g. victim or witnessed
- illness
- death
What are the chronic adversity factors that can affect children in their emotional development and mental health?
- socio economic
- parental mental illness
- parental loss
- family conflict / violence (can lead to modelling of aggressive behaviour)
- parenting ( strict vs relaxed -parental opinion of a naughty child)
- abuse (physical, sexual, emotional)
- exposure to community violence
What are protective factors that children can have to increase their resilience in terms of mental health?
- temperament
- coping strategies (can be learnt / taught)
- self esteem (e.g. have a talent like football )
- problem solving
- stability
- secure relationships
- friends
In thinking of the causes of child mental health problems what are the 3 Ps ?
All about risk vulnerabilities
Predisposing e.g. Neuro development
Precipitating e.g. trauma / death
Perpetuating / maintaining e.g. neglect
causes of childhood mental health are multi factorial, cumulative and interrelated
What elements of history and observation are key in child mental health?
- presenting complaint
- development hx
- family hx
- school (spend 1/3 time at school)
- social hx
- observation of child and child with carers and their interactions
How is the MDT aspect of child mental health central in building up information about a child?
- a lot of ‘outisde’ information obtained for collateral history e.g. school
- different types of assessments from MDT clinicians more common such as:
- Psychometric
- Sensory assessments
- School observations
From occupational therapists, educational psychotherapists, speech and language therapists etc.
What is ADHD?
Characterised by 3 core symptoms of:
- Inattention
- hyperactivity
- impulsivity
Needs to be occur in more than on environment and diagnosis is made after the age of 6
ICD 10 describes these symptoms together as hyperkinetic disorder
ADHD: give examples of inattention
Unable to:
- listen closely to detail leading to carelessness
- to sustain attention for activities
- follow instructions
- finish homework
- organise tasks needing sustained application
- lose / forget things
ADHD give examples of hyperactivity :
- squirming / fidgeting
- ‘on the go all the time ‘
- talks incessantly
- climbs over everything
- restless
- no quiet hobbies
ADHD give examples of impulsivity
- blurts out answers
- interrupts others
- cannot take turns
- intrudes on others
- poor road safety
How common is ADHD?
Which gender more affected ?
3-5% western nations
Boys 2-3 times more common
Is there a genetic link to ADHD?
70- 80% cases genetically inherited
Risk in siblings 2-3 times
Symptoms of ADHD how long should symptoms be present for and where for a diagnosis?
Symptoms should be at developmentally INAPPROPRIATE levels and be present for across time and situation (e.g. home and school) for at least 6 months and start before age of 7
risks for ADHD (atieology) aside from genetic
Rates are higher in :
- low weight babies
- babies born to drug / alcohol / tobacco using mothers
- head injury
- some metabolic disorders
What are some differentials for ADHD.
What are some differentials for ADHD?
- age appropriate active children
- attachement disorder
- hearing disorder
- learning difficulties
- high IQ not stimulated
- behavioural disorder
- anxiety disorder
-substance misuse - medication side effects
- Brian injury
-Personality disorder
What are co-morbidities for ADHD?
50-80 % have another disorder
- learning disorder
- motor coordination problems
- ASD
- tic disorders
- Conduct disorders
- anxiety
- depression
- bipolar
What is involved in making a diagnosis of ADHD?
- hx taking from young person
- collateral hx from parents and teachers
- full developmental and psych hx including mental state
- assessment of behaviours in different domains of life causing psych/ educational or social impairment based on interviews and direct observation
- observation at school (education psychotherapists) and in clinic
- psychometric testing e.g. rating scales such as Conner’s / strengths and difficulties questionnaire
- screen for comorbidity and organic cause
How is ADHD treated?
General :
- psychoeducation for parents and family
- treat any co-morbidity
Mild and moderate:
- parent training and school intervention
E.g. behavioural interventions such as positive reinforcement, reducing distraction, realistic expectations
Severe:
medication is 1st line:
- Methylphenidate - 12 hour long acting preparation
- Atomextine
What type of drug is Methlyphenidate? What does this mean in terms of cautions / monitoring when prescribing it.
It is an amphetamine - a stimulant or “speed”
- it has a street value and can be misused.
- because of this it is a controlled drug.
- need to ensure not being misused
- when prescribing on FP10 form need to specify the quantity in numbers and figures
What advice / info do you need to share with parents about methylphenidate when prescribing?
I.e. when should be taken
- it can suppress growth and appetite
- avoid taking on school holidays and weekends to prevent this
What are side effects of amphetamines such as methlyphenidate ?
Mental health effects:
- anxiety
- rarely cause psychosis
Systemic:
- increase HR (palpitations)
- suppress growth and appetite
What is ICD10 definition of autism (long but gist)
A type of pervasive developmental disorder that is defined by:
- (a) the presence of abnormal or impaired development that is manifest before the age of 3 years
- (b) the characteristic type of abnormal functioning in all the three areas of psychopathology:
- reciprocal social interaction
- communication
- restricted, stereotyped repetitive behaviour.
- a range of other nonspecific problems are common, such as phobias, sleeping and eating disturbances, temper tantrums, and (self-directed) aggressioN
What is autism spectrum disorder?
- Autism is a neurodevelopmental condition characterized by:
- qualitative impairment in social interaction and communication
- repetitive stereotyped behaviour, interests, and activities.
When do symptoms of autism usually present / when do parents notice?
- early childhood
- child not speaking
- speech may be non existant, limited, robotic or have sterotypical answers
How many vocab words might a child of 3 years with autism have compared to a child without ASD?
- child aged 3 years w/o autism might have a vocab of 300-400 words
- child aged 3 WITH autism might have < 50 words or even <10 words in their vocab
According to oxford handbook of clinical specialities what are the core symptoms of autism?
- Persistent deficits in social communication and social interaction ACROSS MULTIPLE contexts
- Restricted, repetitive patterns of behaviour, interests or activities
NOTE:
* symptoms have a significant impariment on social functioning and cannot be put down to another condition such as intellectual impairment or global development delay
What is a major associated co-morbidity / condition in children with ASD?
75% of children with ASD have a learning disability / intellectual impairment
Comment on the epidemiology of ASD
- Recent estimates suggest a prevalence of 1-2%.
- 3-4 x more common in boys than girls
- Around 50% of children with ASD have an intellectual disability (this is passmed but dr Milward said 75% in teaching)
Comment on the cause of ASD
- Genetic - unknown exact genes
- feature of some genetic syndromes: fragile X syndrome, tuberous sclerosis and Angelmann syndrome
- “synaptic pruning theory”
- if one child affected there is a 5-10% chance next sibling will be affected
- associated with epilepsy 30%
- NO association with MMR vaccine!
Clinical features of ASD : what are 3 main categories of clinial features ? (before go into each one)
- Impaired reciprocal social interaction
- Impaired imagination (part of abnormal communication)
- Poor range of activities and interests (repetetive behaviours, interests and activites)
Mentioned by Dr Millward:
sensory - sensitive to noise, light, sensation of clothes
Elaborate on the clinical features of ASD which fall under the “Impaired reciprocal social interaction” category
- unawareness of the existence and feelings of others (oblvious to others distress / treat people as furniture
- abnormal response to being hurt i.e. doesnt come for comfort
- impaired imitation e.g. copies actions w/o understanding such as waving goodbye when walking through a door when no one is there
- few friends / play alone / poor empathy
- repetetive play
*awkward interactions with peers
Elaborate on the clinical features of ASD which fall under the “Impaired imagination (part of abnormal communication)” category
- few facial expressions / no gestures / babbling in infancy
- avoids mutual gaze, no smiles on approach, stiffens when held
- no interest in stories / fantasy / pretend play
- odd speech, repetitions, off use of words and pronouns
- odd monotonous voice
- difficulty in initiating or sustaining reciprocol roles in conversations
- awkward posture/body language
Elaborate on the clinical features of ASD which fall under the “poor range of activities and interests” category
- stereotyped movements e.g. hand-flicking, spinning, head banging
- pre-occupation with parts of objects e.g. sniffing or repetitive touching of a particular texture or odd attachment e.g. coal
- marked distress over trivial changes e.g. vase is moved
- insists on following routines in precise detail
- narrow fixations e.g. lining up objects, amassing facts about the weather
How is ASD diagnosed?
- requires a specialist team often including psychiatrist / paedatrician, psychologist, speech and language therapist.
- assessment includes (no indivudal test) detailed hx, collateral hx from school and observation across different settings.
- diagnostic instruments such as Austistic Diagnostic Observation Schedule (ADOS) and ‘developmental, dimensional and diagnostic interview’ (3di) can be used for formal framework of diagnosis - useful to establish severity
Outline non pharmacological treatment for ASD
Early intensive behavioural intervention
* pass med : applied behavioral analysis- ABA
* speech and language therapy
* Special schooling e.g. ASD preschool programme.
Parental training
* increase ASD knowledge (enhances parent child interaction and decrease maternal depression
* psycho-education when diagnosed
Support
* e.g. National Autism society
* sensory sensitivity adaptations
Social skills training
* can help
Benefits
* disability living allowance
What is the broad goal of ASD treatment?
- no cure for ASD
- early diagnosis and early intensive treatment is key
- educational and behavioural management, medical therapy, and family counselling
- increase functional independence and QOL in:
- learning and development, improved social skills, and improved communication
- Decreased disability and comorbidity
- Aid to families
Outline some pharmacological treatments for ASD
drugs have a small role - dont improve communication.
- SSRIs- reduce symptoms e.g. repetitive stereotyped behaviour, anxiety, and aggression
- Antipsychotic e.g. risperidone for aggression, self-injury
- melatonin - sleep
- Methylphenidate: for attention deficit hyperactivity disorder (ADHD).
What age is typical for conduct disorder to present?
Between 11-18
After 18 usually they would be diagnosed as having a personality disorder
Core symptoms of conduct disorder?
1) defiance of will of authority (usually police)
2) Aggression
3) Antisocial behaviour (e.g. property damage, vandalism, theft, truancy)
How do you diagnose conduct disorder?
3 acts relating to the core symptoms (defiance, aggression and antisocial behaviour) must have been exhibited in the last 12 months with at least 1 present in the last 6 months, in multiple places.
What is oppositional defiant disorder?
Considered a subsection of CD
Enduring pattern of negatie, hostile and defiant behaviour WITHOUT serious violation of societal norms or rights of other
May only be present in one environment
More evident in interactions with familiar adults or peers
What is the treatment for conduct disorder?
3 empirically supported treatments:
1) Parent training programmes ( Triple P or Webster Stratton courses)
2) Individual cognitive therapy for older children
3) Multisystemic therapy (e.g. with family, school, criminal justice system)
How is conduct disorder and antisocial personality disorder related?
Most children with CD will not progress to antisocial personality disorder
CD infers higher risk of other mental health problems, substance misuse, criminal activity, and early death often by violent and sudden means
Epidemiology of depression in children and adolescents?
Affects around 3% of children
5.6% of adolescents
How can we consider the aetiology of depression in young people?
Stress-vulnerability model
Vulnerability (endocrine, genes) interact with stress to cause depression at times of life stress
Clinical features of depression in young people?
Often more subtle and less constant in adults
* Mood changes: grumpy or irritable, anhedonia
* Thought changes: loss of self- esteen, confidence and concentration
* Physical changes: reduced energy, sleep, appertite, self-harming behaviour
* Resulting in functional impairment e.g. missing school and social life
How do you investigate depression in young people?
Pick up on non-verbal communication
Use silences to give space
Collateral from parents and school
Ask directly about alcohol and drug use, bullying abuse and suicidal thoughts- offer oppurtunity to discuss these issues initially in private
Treatment of depression in young people?
Mild: up to 4 weeks of watchful waiting followed by non-directive supportive therapy or guided self-help. If unresponsive refer to CAMH specialists
Moderate/severe depression: antidepressants- only FLUOXETINE is licensed and psychological therapy may be started concurrently. If combined treatment not effective within further 6 sessions, review formulation in MDT
Antidepressants used CAUTIOUSLY in children aged 5-11.
Social treatment for depression in young people?
Address any sources of distress e.g. bullying
Remove oppurtunities for self harm (e.g. no paracetamol at home)
Improve sense of belonging esp if they feel like an outsider (e.g. sexuality)
If criminality and gang culture involved, peer mentorship may help
What antidepressants should you avoid in under 18s?
As per BNF
Citalopram, paroxetine, sertraline. Also tricyclics, venlafaxine, and fluvoxamine
use fluoextine!
Epidemiology of anxiety disorders in children?
Among the most common psych disorders in youth
Prevalence from 5-15%
Separation anxiety and specific phobie usually have onset in early childhood and GAD is across all ages
OCD, social phobia, agoraphobia and panic- later childhood and adolesence
Risk factors for anxiety disorders in childhood?
Genetic vulnerability, specific temperament (timidity, shyness and emotional restraint with unfamiliar people or situations), insecure attachment, stressful or traumatic life events, high social adversity, over-protective/ciritcal/ punitive parenting
Presentation of anxiety in children and adolescents?
Hard to get a history! Somatic symptoms are often the only one they’ll describe
Behavioural presenations incl over-activity, inattention, sleep disturbance, separation difficulty, regression, school refusal, social withdrawal, aggression, ritualistic behaviours and somatization
General principles of management of anxiety in children?
Use ABC approach to help the child and family understand what happens when the child feels anxious
Show how others reactions are influencing anxiety
Stress reduction incl relaxation
Psychoeducation regarding anxiety
Age appropriate CBT approaches
What is the ABC approach in child psych?
Antecedents, behaviour, consequence
Used for the assessment and formulation of problem behaviours
A- Antecedents- identify the triggers for a behaviour by monitoring environmental and internal circumstances
B-Behaviour- what does the above lead to
C-conseuqnece of the behaviour
What is separation anxiety disorder in young people?
Characterized by increased and inappropriate anxiety around separation from attachment figures or home which is developmentally abnormal and results in impaired functioning
Causes of separation anxiety?
- Genetic vulnerability
- Anxious
- Inconsistent or over-involved parenting
- regression during periods of stress
- illness
- abandonment
Symptoms of separation anxiety?
Anxiety about actual or anticipated separation from, or danger to, attachment figure
Sleep disturbances and nightmares
somatization
School refusal
Symptoms of separation anxiety?
Anxiety about actual or anticipated separation from, or danger to, attachment figure
Sleep disturbances and nightmares
somatization
School refusal
Management of separation anxiety?
Psychological approach with emphasis on relaxation and managing anxiety using an age- appropriate CBT approach
How does ASD presentation differ in girls?
- girls may be able to mask some of their difficulties through learned responses, behaviour and imitation
- special interests can be typical of their age, but the intensity is different
- girls have a greater sense of imagination and fantasy play than boys their age
What are the emotional disorders of childhood and adolescence?
What are the features of GAD in children / adolescants?
- Present for at least 1 month
- Excessive worry
- restlessness
- irritability
- fatigue
- poor concentration / sleep disturbances
- muscle tension.
In children: somatic symptoms:
* headache; stomach pains or ‘irritable bowel’; rapid heartbeat; shortness of breath;
* nail biting and hair pulling
* school refusal.
Management of Anxiety disorders in children / adolescants ?
Bio:
Anxioltyics : if very severe SSRI e.g. fluoextine
(Benzo rare as dependance)
Psych
* LECTURE: Behavioural therapy (systemic desensitisation, flooding, response prevention
* LECTURE: psyhcotherapies e.g. CBT individual, group or family based.
* Psychoeducation for pt and family
What is separation anxiety? How does separation anxiety manifest in children?
- anxiety starts with separation (or threat of) from attachment figure. (usually mum as primary care giver)
Features:
* somatic manifestations
* nighmares with separationt hemes
* school refusal (ALWAYS rule out other causes e.g. bullying / learnign deficits and shame of being behind)
What are features of post-traumatic stress disorder in children?
- Persistently re-experiencing trauma
- avoidance of associated stimuli or numbing of responsiveness e.g. avoiding street they were mugged on
- increased arousal (hyper alert) - sleep disturbance, irritability, poor concentration
Is psychosis common in children ?
No - rare in pre-adolescant group
risk rised steadily throughout adolescence to early adulthood
What is the prognosis for developing schizophrenia in adolescence?
Poorer long term outcome if early onset (adolescence)
What are key features of psychotic illness?
Psychotic symptoms do not always mean psychosis or schizophrenia in young people. Give examples of causes of transient pyschotic symptoms
- Sleeplessness
- drugs
- cultural norms - ‘seeing ghosts’
young children:
* fantasy play involving imaginary friends and blurring of reality and fact is important state of neurodevleopment.
How is early onset schizophrenia diagnosed in adolescants?
In many places with the same criteria as adult schizophrenia as continuous with later forms
sustained psychosis = >4 weeks
What are some examples of non-specific psychotic symptoms an adolescant might present with?
- odd beliefs
- mistrust of others
- magical thinking
These overvalued ideas will lead to decline in interpersonal and school functioning - frank psychosis develops in 40% of pts within 12 months
- FHX, marked functional impairment and evolving psychotic symptoms is biggest risk factors for psychotic illness
What are some differencials for ‘odd ideas’ (non specific psychotic symptoms) in children and adolescants ?
- substance misues
- Schizophrenia
- anxiety
- depression
- hypomania
- head injury
- epileptic aura
- anti- MDMA recpetor antibody encephalitis
- Alice in wonderland syndrome
Management of psychotic illness in children / adolescants
Bio:
* sometimes antipsychotics (second gen) choice ifluenced by SE and closely monitored
Psych:
* psychoeducation for children and family
* psychotherapy e.g. CBT individually and with family
Social:
* Educational/vocational input, e.g. reintegration package to school, specialist education provision, supported college/work placements
* advice with benefits and other support
* voluntary sector e.g. Mind charity
