Child and Adolescent Psychiatry Flashcards
Core symptoms of ADHD
Difficulty concentrating
Hyperactivity
Impulsivity (action without foresight)
Pervasive Condition
Core symptoms of OCD
Obsession - thoughts
Compulsion - the behaviour following the thoughts
This results in functional impairment
Core symptoms areas of Autism Spectrum Disorder
Difficulty with social interaction
Language Difficulties
Restrictive and repetitive behaviours
Pervasive condition
How do you want the input from in a presenting complaint of children with mental health problems
Parents
Child
School
What else should be asked about when taking a psychiatric history from a child
Past psychiatric history
Past medical history (temporal lobe epilepsy and head injuries, anaemia, hypothyroidism)
Medications and allergies
Social history and habits (remember to ask about legal highs)
Family history (psychiatric and appropriate medical history)
Personal history (schools, housing, life events, relationships, bullying, abuse)
Developmental History (birth until now)
Biological predisposing factors
Genetic predispositions, neurodevelopmental insults, illness
Psychological predisposing factors
temperament; attachment style; psychological attributes e.g. impulsivity, low self-esteem, perfectionism; belief systems etc.
Social predisposing factors
family relationships; peer relationships; hobbies/ interests; religious faith; neighbourhood; school; rural/ urban; criminality; finances etc.
How are conduct disorders characterised
repetitive and persistent patterns of antisocial, aggressive or defiant behaviours which violate age-appropriate societal norms.
Course of conduct disorders
persistent disorder, associated with increased risk of early death, often by sudden or violent means. Also at increased risk of social exclusion, poor school achievement, long-term unemployment, criminal activity, adult mental health problems, and poor interpersonal relationships including those with their own children.
Management of conduct disorders
Parent training programme (12 or younger) e.g. The Incredible Years
Modification of school environment eg behavioural support
Functional family therapy
Multi-systemic therapy
Child interventions: social skills, problem-solving, anger management, confidence building
Treat comorbidity
Address child protection concerns
Core features of hyperkinetic disorders
developmentally abnormal inattention, hyperactivity and impulsivity present across time and situations.
Symptoms of hyperkinetic disorders
Specific LD, ASD, CD, tics, motor coordination problems, substance misuse, anxiety, depression.
Hyperkinetic disorders are associated with
reduced academic and employment success, increased criminal activity and increased adult mental health problems
Management of ADHD
Psychoeducation Medication – stimulants, atomoxetine, guanfacine Behavioural interventions e.g. realistic expectations, contingency management Parent training - PinC School interventions Treat comorbidity Voluntary organisations Benefits
Medication treatment of ADHD
Methylphenidate (ritilin) which is closely related to amphetamine.
Side effects of methylphenidate
Reduced appetite, weight loss and sleep
Methylphenidate acts on what neurotransmitters
NAd and DA systems
2nd line treatment of ADHD
Atomoxetine – non stimulant also acts on NAd systems
Self Harm
Self injury is a coping mechanism. An individual harms their physical self to deal with emotional pain, or to break feelings of numbness by arousing sensation
What can self harm behaviour indicate
Psychiatric disorder or significant psychosocial problems
Factors increasing the risk of suicide in children
Persistent suicidal ideas Previous suicidal behaviour High lethality of method used High suicidal intent and motivation Ongoing precipitating stresses Mental disorder Poor physical health Impulsivity, neuroticism, low self esteem, hopelessness Parental psychopathology and suicidal behaviour Physical and sexual abuse Disconnection from support systems
Management of suicide in children
Usually admit to age appropriate medical ward after serious attempt for medical treatment and psychosocial assessment.
Mental health and risk assessment by specially trained staff member with ready access to psychiatric opinion.
Confidentiality (with exceptions).
Disorders that are highly heritable
Autism and ADHD
Genetic risk factors for mental health problems
Mostly polygenetic inheritance. Polymorphisms: DAT gene, 5-HTTP, FRAX gene, MAO genes.
Intrauterine and perinatal risk factors for mental health problems
maternal stress - cortisol exposure Substance misuse – alcohol, marijuana Toxins – lead, mercury and PCB’s Drugs - esp psychotropics/antiepileptics (lipid soluble) Epigenetics – folate controlled methylation Endocrine environment – esp androgens Immune environment Premature birth/ Perinatal complications Twinning Impressive levels of resilience
Early experiences
Carer-child relationship Parenting skill Parental mental disorder Marital Harmony Nutrition Discipline
Later experiences that increase the risk of mental health problems in children
Schooling Peer relationships Family functioning Discipline Abuse Life events -
Head injuries are more likely to have problems with
Behaviour, then more likely to experience adverse life events, the more likely they are to get head injuries and exhibit exotic behaviour
Turning points
Changing life-trajectory as a result of life-event e.g. Young person brought up in care developing close confiding relationship.
Steeling
Like the bending or stretching of hot soft steel to make it stronger when cold.
Developing social and emotional cognition
Joint-attention and ‘theory of other minds’
Reward-based learning
Controlling emotional responses “emotional regulation”
Effects of adverse experiences on development of threat and reward response mechanisms.
Jont attention (learning to judge what someone else thinks)
Attending to the same thing together, checking and directing another person’s attention.
Motivational aspect:
wanting another person to be interested in what interests you.
Cognitive aspect:
How your brain works out and monitors whether another person is looking at the same thing as you. Checking out that you are both attending to the same thing.
Form of mental state understanding involving action representation.
Experience of adversity and the reward deficiency model of addiction
Early adversity (reduced DA function), decreased reward sensitivity, increased behaviour to elicit reward; increased reward required for satiety, increased tolerance and increased behaviour.
Executive and Cortical Control
This is the taking control over the automatic and learned behaviours. It requires self-awareness and capacity to self-monitor.
Sharing emotion and empathy
Infant mother interaction and emotion contagion.
6 weeks sensorimotor control emerging
24 months - secondary representation, able to recognise and label emotions
School refusal
Fear of leaving home
Fear of going to school
School Truancy
Unwilling to leave home
Unwilling to go to school
Mental health problems associated with being out of school
Anxiety, conduct disorder, autism, depression, OCD
Effects of mental health problems on education
Learning difficulties due to poor concentration Co-morbid specific learning problems Difficulty controlling emotion Anxiety Lack of energy, motivation Difficulties joining in Sensory problems - the classroom may be too noisy Fear of germs and contamination
Separation anxiety
Fear of leaving parents and home. Problems occur on the doorstep of the home or the school
Social phobia
Fear of joining group. The problems occur at the school gate.
Features of anxiety disorder
Anxious thoughts and feelings
Autonomic symptoms
Avoidant behaviour
Medication treatment of anxiety
Serotonin re-uptake inhibitors (fluoxetine)
Behavioural Treatment of Anxiety
Learning alternative patterns of behaviour
Desensitization
Overcoming fear
Managing feelings
What is autistic disorder
Qualitative impairments in reciprocal social interaction. Qualitative impairments in communication. Restricted, repetitive and stereotypes patterns of behaviour, interests and activities.
Onset of autism
Before the age of 3
Clinical features of ASD
Decreased self other perspective sharing, divided attention, flexible learning and social understanding
Increased rigidity, sameness, fixed learning patterns, technical understanding.
Younger/lower IQ symptoms of ASD
Joint attention, reduced emotional responses and movements and actions (diagnostically significant factors)
Older/higher IQ ASD
conversation, empathy, interests
Qualitative impairments in reciprocal social interaction ASD
Failure to appreciate socio-emotional cues
Failure to respond to other’s emotions
No modulation of behaviour according to social situation
Lack of facial expression and social smiling
Failure to direct attention
No seeking to share
Qualitative impairments in communication (ASD)
Poor social use of language e.g. conversation
inflexible of language use e.g. stereotypies and echolalia
Lack of social-imitative and make believe play
Reduced gesture, eye gaze and modulation of tone, rate or volume of speech.
Restricted, repetitive and stereotyped patterns of behaviour, interests and activities
Unusual Preoccupations Circumscribed interests Verbal rituals Adherence to routines, rigid habits and resistance to change. Unusual sensory interests Motor stereotypies
Non-specific feature of ASD
Learning disability – mild to severe Self-injury Aggression Temper tantrums Hyperactivity Disturbed sleep and eating habits Developmental Motor Coordination Disorder.
When is a diagnosis of ASD made
Many symptoms are present
Been there since age 3yrs
Symptoms are pervasive.
Conditions associated with ASD
Learning disability (delayed milestones, poor verbal IQ) Depression Social anxiety Obsessional-compulsive disorder Attention-Deficit-Hyperactivity-Disorder Conduct disorder
Causes of ASD
Can be comorbid with congenital or genetic disorders (rubella, callosal agenesis, Downs, fragile X, Tuberous sclerosis) but mostly are idiopathic genetic
Management of ASD
Main thing is the recognition, description and acknowledgement of disability. This can then be adapted to.
Key features of oppositional defiant disorder
Refusal to obey adults request Often argues with adults Often loses temper Deliberately annoys people Touchy or easily annoyed by others Spiteful or vindictive
How does ODD compare to ADHD
Aggression is intentional (goal-directed) Behaviour is learned Enacted to obtain a desired result May be associated with social modelling More likely to result from impaired parenting
What causes ODD
Lack of positive experience of being parented.
Management of ODD
Parent training programmes and Multi-Systemic Therapy
Parent training
Aggression is intentional (goal-directed) Behaviour is learned Enacted to obtain a desired result May be associated with social modelling More likely to result from impaired parenting
