Child and adolescent psychiatry Flashcards
Developmental psychopathology
is an approach or field of study designed to better understand the complexities of human development.
how can child development be affected
by both their immediate family and peers, but also by wider socio-economic and cultural factors.
what is attachment theory
lifespan model of human development emphasizing the central role of caregivers (attachment figures) who provide a sense of safety and security.
Any child under the age of 18 can have an adverse childhood experience. ACEs are more common among:
Girls or children assigned female at birth.
Racial or ethnic groups classified as a minority.
Children who experience socioeconomic challenges.
Children of parents or caregivers who experience stress.
Children who have family members or friends diagnosed with substance use disorder or a mental health condition.
Inattentive symptoms
*Difficulty sustaining attention to tasks that do not provide a high level of stimulation or reward or require sustained mental effort
*Lacking attention to detail
*Making careless mistakes in school or work assignments
*Not completing tasks
*Easily distracted by extraneous stimuli or thoughts not related to the task at hand
*Often does not seem to listen when spoken to directly
*Frequently appears to be daydreaming or to have mind elsewhere
*Loses things
*Is forgetful in daily activities
*Has difficulty remembering to complete upcoming daily tasks or activities
*Difficulty planning, managing, and organizing schoolwork, tasks, and other activities
Hyperactive / impulsive symptoms
*Excessive motor activity
*Leaves seat when expected to sit still
*Often runs about
*Has difficulty sitting still without fidgeting (younger children)
*Feelings of physical restlessness, a sense of discomfort with being quiet or sitting still (adolescents and adults)
*Difficulty engaging in activities quietly
*Talks too much
*Blurts out answers in school, comments at work
*Difficulty waiting turn in conversation, games, or activities
*Interrupts or intrudes on other’s conversations or games
*A tendency to act in response to immediate stimuli without deliberation or consideration of risks and consequences (eg, engaging in behaviors with potential for physical injury; impulsive decisions; reckless driving)
how do you assess inattentive or hyperactive children
History – Developmental, Sleep, School, Family and Social,
From child and parents
Examination
Assessment tools: Vanderbilt’s, Conners Q to P&T
Reports from teachers and other involved adults
Consider the impact of difficulties on child and family
Consider formulation
4P model
how do you treat inattentive / hyperactive children
ADHD focussed Group Parenting Programme – Parents in Control PINC
School adjustments
Assess comorbidities , autism, tics
Medications need to monitor height weight pulse BP. R/o FH of sudden cardiac death or any fatigue/SOB/ Syncope on exercise
Methylphenidate 1st line
Lisdexamfetamine 2nd Line
Atomoxetine/Guanfacine 3rd line
NICE guideline 87 SIGN 145 due update
what are different types of TICS
Motor / Phonic tics : brief repetitive patterned and non rhythmic movements or vocalisations sometimes performed in response to premonitory urges
Simple- blinking , grunting
Complex- gestures, words and phrases
Transient tics are common in childhood ( 5-15% of school age children)
Typically wax and wane
Chronic Motor Tic Disorder
Chronic Phonic Tic Disorder
what is Tourettes syndrome
PANDAS - CDP-2023-0174.pdf
COVID-19 related increase in childhood tics and tic-like attacks. Isobel Heyman, Holan Liang, Tammy Hedderly. https://doi.org/10.1136/archdischild-2021-321748
Tourettes
1% of population
Motor and phonic tics
For at least one year
Commoner in boys 5:1
Onset in the developmental period 4-6 years with peak at 8-12 years
Not manifest by another medical condition or due to effects of substances or medication on CNS
Diminish during sleep and focussing on enjoyable activity and worsen with stress
Premonitary sensation – may not always be possible to elucidate
how do assess individuals with TICS or Tourettes syndrome
Diagnosis based on history – normal examination
Tools include Yale Global Tic Severity Scale.
Investigations are not required
Impact on social, academic, occupational, functioning
Comorbid with ADHD, OCD, depression, anxiety, intellectual disability
Consider environmental events on tic suppression/expression
management of TICs or Tourettes
Careful assessment of tics, impact and co-occurring symptoms
Educating the young person and family
NICE guidelines: For children with a tic disorder that has a significant impact on their quality of life, consider referring according to local pathways, as follows:
referral to mental health services if the tic disorder is associated with symptoms of anxiety or obsessive compulsive behaviour
referral to the neurodevelopmental team if the tic disorder is associated with symptoms suggestive of autism or attention deficit hyperactivity disorder
referral for neurological assessment if the tic disorder is severe
pharmalogical treatments for TICS and Tourettes
Alpha-2- adrenergic agonists, CLONIDINE and GUANFACINE (Intuniv)
Atypical Antipsychotics
Physicians in the United Kingdom can prescribe medications off-label. According to General Medical Council guidance, the physician must be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate safety and efficacy.
Typical antipsychotics
Botulinum toxin
non pharmacological treatments for TICS and Tourettes
Behavioural therapies are an essential component in the treatment of tics. Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication. Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time. Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.
Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.
Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists. However, this type of therapy may not be easily accessible in some communities.
what is ICD-11 autism
1-2% children, M:F 4:1
Essential (Required) Features:
Persistent deficits in initiating and sustaining social communication and reciprocal social interactions that are outside the expected range of typical functioning given the individual’s age and level of intellectual development. Specific manifestations of these deficits vary according to chronological age, verbal and intellectual ability, and disorder severity.
Persistent restricted, repetitive, and inflexible patterns of behaviour, interests, or activities that are clearly atypical or excessive for the individual’s age and sociocultural context.
The onset of the disorder occurs during the developmental period, typically in early childhood, but characteristic symptoms may not become fully manifest until later, when social demands exceed limited capacities.
The symptoms result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
ICD-11 for Mortality and Morbidity Statistics (who.int)
how do you assess individuals with autism
History
Examination
Vanderbilt and SRS2 Questionnaires
School report +/- observations
ADOS 2
management for individuals with TICS or Tourettes
Parent-mediated Intervention Programme CYGNET
National Autistic Society, Autistc Girls Network, Right Click Scottish Autism, Autism and Neurodiversity (North East)
Environmental Adjustment and Behavioural Interventions
Consider co-morbidities sleep disturbance, ADHD, anxiety, depression, intellectual disability
Investigations Microarray and Fragile X, ? Refer to Genetics
Support for Communication SALT
Occupational Therapy
Medication : Melatonin for sleep.
( Management of irritability and aggression Aripriprazole and Risperidone)
SIGN 145 and NICE CG 128
what is the process for referral to CAMHS
