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Systems: Psychiatry AB > Child and Adolescent Psychiatry > Flashcards

Child and Adolescent Psychiatry Flashcards

1
Q

What is included in the history?

A

Presentation ‘recently’

  • PC
  • HPC

Other background history ‘previously’

  • Past psychiatric Hx
  • Past medical Hx
  • Social Hx
  • Family Hx, Personal Hx, Developmental Hx
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2
Q

What is included in the examination?

A

Mental state examination ‘this moment’

  • In the room
  • School observations
  • Video assessment
  • One way mirror
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3
Q

How is the patient’s conditions processed and further actioned?

A

Formulation ‘making sense of it all’

  • Hopes for change
  • 4Ps grid

Management plan

  • More history/questionnaires
  • More MSEs
  • Treatment
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4
Q

What are the principles of assessment?

A
  • Biopsychosocial approach
  • Engagement
  • Multiple perspectives and relationships
  • Communication
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5
Q

What are the principles of practice?

A

–Introductions and explanations
-History: problems, family, development, school, social, interests, strengths, what has been tried, hopes.
-Mental state and observations
Individual time
-Other info: collateral history, questionnaires, other assessments

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6
Q

What spheres contribute to health and illness?

A
  • Psychological
  • Social
  • Biological
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7
Q

What must be considered when formulating and managing a patient’s condition?

A

Consider problem in terms of biological, psychological and social aspects and identify predisposing, precipitating, maintaining and protective factors

  • Use along with a risk assessment to formulate a management plan. Aim to actively involve family in this process
  • Consent/ capacity/ legislation
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8
Q

What biopsychosocial factors need to be considered?

A

Biological
-Genetic predispositions; neurodevelopmental insults; illness etc.

Psychological
-Temperament; attachment style; psychological attributes e.g. impulsivity, low self esteem, perfectionism; belief systems etc

Social
-Family relationships; peer relationships; hobbies/ interests; religious faith; neighbourhood; school; rural/ urban; criminality; finances etc.

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9
Q

What are conduct disorders characterised by?

A

Characterised by repetitive and persistent patterns of antisocial, aggressive of defiant behaviours which violate age-appropriate societal norms

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10
Q

What are those with conduct disorders at increased risk of?

A
  • Persistent disorder associated with increased risk of early death (often sudden or violent)
  • Social exclusion
  • Poor school achievement
  • Long-term unemployment
  • Criminal activity
  • Adult mental health problems
  • poor interpersonal relationships including their own children
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11
Q

What is the management of conduct disorders based on?

A

Based on biopsychosocial assessment and is likely to need multiagency communication and cooperation

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12
Q

What management is there for conduct disorders?

A
  • 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
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13
Q

What are hyperkinetic disorders (ADHD) characterised by?

A

Characterised by core features of developmentally abnormal inattention, hyperactivity and impulsivity present across time and situations

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14
Q

Why are patients with hyperkinetic disorders highly comorbid?

A

Highly co-morbid 50-80%

-Specific LD, ASD, CD, tics, motor coordination problems, substance misuse, anxiety, depression

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15
Q

What are hyperkinetic disorders associated with in adulthood?

A

Majority are symptomatic into adulthood, especially inattention

  • Reduced academic and employment success
  • Increased criminal activity
  • Increased adult mental health problems
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16
Q

How is ADHD managed?

A
  • Psychoeducation
  • Medication – stimulants, atomoxetine, guanfacine
  • Behavioural interventions e.g. realistic expectations, contingency management
  • Parent training - PinC
  • School interventions
  • Treat comorbidity
  • Voluntary organisations
  • Benefits
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17
Q

What is the first line pharmacotherapy for ADHD?

A

Methylphenidate

  • Closely related to amphetamine
  • Oral
  • Non-addictive, purely symptomatic treatment, lasts 4 hours and wears off
  • Side effects include appetite, weight and sleep (BP a little)
  • Acts on NAd and DA systems
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18
Q

What is the second line pharmacotherapy for ADHD?

A

Atomoxetine

-Non stimulant also acts on NAd systems

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19
Q

What is self-harm?

A
  • 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.
  • Can include self poisoning, cutting and burning
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20
Q

What can self-harm indicate?

A

Psychiatric disorder or significant psychosocial problems

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21
Q

What is the main risk from self-harm?

A

Suicide

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22
Q

What mental states are high risk for suicide?

A

There is a very strong association between depression and suicidality. The combination of mood disorder, substance misuse and conduct disorder is particularly high risk.

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23
Q

What factors increase the risk of suicide?

A
  • 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
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24
Q

How should those at risk of suicide/self harm be managed?

A
  • Safety of the young person is priority so take it seriously
  • 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).
  • Further referral to agencies as appropriate e.g. CAMHS, child protection
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25
Q

What is behaviour the product of?

A

Brain biology

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26
Q

What is developmental psychopathology?

A

The science underpinning the psychiatry

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27
Q

What do twin studies involve?

A
  • Comparison between DZ and MZ twins

- Calculate % of variance due to environment and % due to genetics

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28
Q

Give examples of psychiatric conditions with a genetic basis.

A
  • ADHD
  • Autism
  • Depression
  • Anxiety
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29
Q

What has been discovered through genome wide association studies?

A
  • Used to identify risk factors for psychiatric disorder
  • Indicate many genes are implicated
  • Mircro-RNA and epigenetic modulation implicated
  • Genetic factors serving modulation of gene expression are likely to be important
  • They control influence of environmental factors on genetic expression
  • Inflammatory and autoimmune mechanisms are being implicated as well as genes controlling synapse formation, neurotransmission and modification
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30
Q

What intra-uterine and perinatal factors are there in child mental health?

A

-Maternal health:Maternal antibodies, obesity, diabetes
-Substance misuse (alcohol, marijuana)
-Toxins (lead, mercury and PCB’s)
-Drugs( especially psychotropics/ antiepileptics (lipid soluble))
-Epigenetics: folate controlled methylation
-Endocrine environment (especially androgens)
Immune environment
-Premature birth/ Perinatal complications
-Twinning
-Impressive levels of resilience

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31
Q

How does foetal alcohol syndrome present?

A

Growth retardation including head, body, brain and eyes

Mutiple neuro-developmental effects on:

  • Sensorimotor
  • Cognitive development
  • Executive function
  • Language
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32
Q

What is white matter connectivity important for?

A

Important for functions that require interplay between brain areas e.g. working memory between hippocampus and anterior cingulate

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33
Q

What is low white matter connectivity associated with?

A
  • Low connectivity associated with more neural ‘noise’ in the system, intra-individual variability and ‘cognitive instability’.
  • In developing brains this is typically associated with ADHD- poor concentration, distractibility
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34
Q

How does ADD present?

A
  • Distractibility
  • Difficulty sustaining attention to tasks that don’t provide high level of stimulation or frequent rewards
  • Problems with organisation
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35
Q

How does hyperactivity/ impulsivity syndromes present?

A
  • Difficulties remaining still
  • Most evident in situations that require behavioural self-control
  • Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences
36
Q

Give examples of anxiety disorders.

A
  • Panic disorder
  • Phobic disorders
  • Separation anxiety disorder
  • Generalised anxiety disorder
37
Q

What environmental factors can occur during childhood?

A
  • Carer child relationship
  • Parenting skill and parental mental disorder e.g. post-natal depression, substance misuse
  • Marital harmony and family function
  • Nutrition, poverty and deprivation
  • Abuse or neglect
  • Discipline
  • Day-care or schooling
  • Peer relationships
  • Life events
  • Physical disability
38
Q

What is the foundation of attachment theory?

A

Proximity seeking behaviour such as an infant seeking contact with parent when frightened, injured or ill

39
Q

What is attachment?

A

Attachment is described as secure or insecure according to direct observation of behaviour during “Strange situation”.

40
Q

What is the problem with connecting attachment to mental illness?

A

-There is little evidence
-Stigmatises mothers and causes unnecessary worry.
Attachment changes across the life span. -Very difficult to disentangle from multiple other influences.

41
Q

What does our response to stress involve?

A

Interplay of brain and body

42
Q

Why is the brain’s response to stress important to mental health?

A
  • Early life stress influences function of limbic circuit including amygdala
  • Determines subsequent patterns of stress response.
  • Early life stress influences mood and patterns of response to threat including withdrawal and/or aggressive response.
43
Q

How is head injury linked to mental health?

A
  • Head injuries can influence our behaviours
  • Behaviour influence life events
  • Some life events increase the probability of head injuries
44
Q

What concepts have been attributed to psychological development?

A
  • Reward-based learning
  • Executive Function
  • Delay-aversion
  • Sharing emotion and empathy
  • Expressed emotion
45
Q

What happens in operant conditioning?

A

Dopamine neurones fire when you associate an action with a subsequent reward

46
Q

What is the experience of adversity and the reward deficiency model of addiction?

A
  • Early adversity leads to reduced DA function
  • Decreased reward sensitivity
  • increase behaviour required to elicit reward and increased reward required for satiety
  • Increased tolerance
  • Increased behaviour
  • Decreased reward sensitivity
47
Q

How is executive and cortical control applied in CBT?

A
  • Taking control over ‘automatic’ and learned behaviours
  • Inhibit prepotent responses
  • Intentional decision making and forward planning
  • Requires self-awareness and capacity to self-monitor
48
Q

Give an example of delay-aversion and delayed gratification.

A

A child successfully carrying out the marshmallow test and receiving a second marshmallow

49
Q

What may delay-aversion explain?

A
  • It is a theory to explain ADHD

- Inability to wait and maintain attention in the absence of immediate reward

50
Q

What is the social brain?

A
  • Sharing emotion and empathy

- Increasing understanding, reflection and control with age

51
Q

Give an example of the social brain.

A
  • Infant mother interaction. Emotion contagion. Infant picks up emotions from mother
  • 6 weeks sensorimotor control emerging and infant smiles intentionally
  • 24months secondary representation. Infant able to recognised and label emotions
  • 3-4 years: metarepresentation. Self-awareness of emotion, able to deceive, understands and feels. Understanding motive and context
52
Q

Theory of mind: Understanding false belief is a true test of…

A

The ability to represent other’s thoughts as different to one’s own

53
Q

What may predict the rate of relapse from chronic illness?

A

Carers negative emotion

54
Q

How does expressed emotion increase relapse rates?

A
  • Carers negative emotion to chronic illness
  • Illness causes worry and stress
  • More severe= more worry and stress
  • Worry and stress leads to negativity in relationships at home
  • impact upon the patient, increasing relapse rate
55
Q

What are the 4 components of the out of school matrix?

A

School refusal

  • Fear of leaving home
  • Fear of going to school

Truancy

  • Unwilling to go to school
  • Unwilling to leave home
56
Q

What mental health problems are associated with being out of school?

A
  • Anxiety
  • Conduct disorder
  • Autism
  • Depression
  • Obsessional compulsive disorder
57
Q

What effects can mental health have on school attendance and learning?

A
  • Learning difficulties (general or due to poor attention)
  • Difficulty controlling emotion
  • Anxiety
  • Lack of energy, motivation
  • Difficulties joining in
  • Sensory problems
  • Preoccupations
58
Q

Separation anxiety disorder

A
  • Fear of leaving parents and home

- Problems on the doorstep

59
Q

Social phobia

A
  • Fear of joining group

- Problems at the school age

60
Q

What are the 3As (features) of anxiety disorders?

A
  • Anxious thoughts and feelings
  • Autonomic symptoms
  • Avoidant behaviours
61
Q

What factors can affect child’s willingness to go school?

A
  • Learning difficulties
  • Lack of friends and relationships
  • Bullying
  • Lack of parental attention of concern
  • Maternal depression
62
Q

What is the neurobiology associated with anxiety?

A
  • Amygdala activity is supressed by right ventrolateral amygdala when labelling emotions.
  • Reduced connectivity between right ventrolateral cortex and amygdala in generalised anxiety disorders in adolescents.
63
Q

What is the treatment for anxiety?

A

Behavioural

  • Learning alternative patterns of behaviour
  • Densensitsation
  • Overcoming fear
  • Managing feelings

Medication
-Serotonin reuptake inhibitor e.g. fluoxetine

64
Q

How can childhood anxiety be escalated?

A
  • By feeding their fears

- The emotional contagion

65
Q

What are the principles of CBT?

A
  • Thoughts
  • Feelings
  • Behaviours
66
Q

What are the long term effects of successful behavioural treatment?

A
  • Presented with a challenge
  • Have success
  • Build in self-confidence
  • Gain resilience
67
Q

What are the long term effects of no behavioural treatment?

A
  • Presented with a challenge
  • Avoid the challenge
  • Low self-confidence
  • Become vulnerable
68
Q

How is CBT carried out for children with their families?

A
  • Children may not have cognitive awareness
  • Mostly B and T
  • Parents are collaborators
  • Step-wise approach
  • Disorder is not a matter of blame= externalisation
  • Overcoming barriers to change to problem solve
69
Q

Give examples of narrative approaches to use with children.

A

Psychoeducation
-Explain the problem in terms that make sense to everyone

Goal-setting
-Choosing reasonable objectives that can be achieved

Motivating
-Getting child to buy in so the goals can be achieved

Externalising
-Taking blame, guilt and anger out of the equation

70
Q

What are the general features of Autism spectrum disorder?

A
  • A syndrome of distinctive behavioural abnormalities
  • Often associated with low IQ but not defined by it
  • Pervasive: persistent across lifespan and settings
  • Highly heritable
  • 1% affected
  • M:F 3:1
71
Q

What is the neurobiology behind ASD?

A

Many synaptic proteins are implicated mainly glutaminergic but also GABA.

72
Q

How do the poles of ASD differ with increasing severity of neurotransmitter dysfunction?

A

Autism with normal IQ
-Only effects on synaptic function

Autism with LD
-Effects on synaptic function, neural migration and brain development

73
Q

What are some distinctive features of ASD?

A

Social

  • Non-verbal communication
  • Expressing emotion concern
  • Reciprocal conversation

Repetitive behaviour

  • Mannerisms and stereotypes
  • Obsessions, preoccupations and interests
  • Rigid and inflexible patterns of behaviour
74
Q

How does each case of ASD differ?

A

The variable clinical picture of autism: each domain (reciprocity, language and obsessions) is variable and in addition variation is affected by age and IQ

75
Q

What are the clinical features of ASD?

A

Decreased

  • Self-other perspective taking
  • Sharing/ divided attention
  • Flexible learning
  • Social understanding

Increased

  • Rigidity
  • Sameness
  • Fixed learning patterns
  • Technical understanding
76
Q

What clinical problems can people with ASD present with?

A
  • Learning disability – mild to severe
  • Disturbed sleep and eating habits
  • Hyperactivity
  • High levels of anxiety and depression
  • Obsessional compulsive disorder
  • School avoidance
  • Aggression
  • Temper tantrums
  • Self-injury, self-harm
  • Suicidal behaviour
77
Q

What is the connection between ASD and genetics?

A
  • Co-morbid with congenital or genetic disorders: e.g Rubella, Callosal agenesis, Down’s syndrome, Fragile X, Tuberous sclerosis.
  • GWAS identifying genetic modulators
  • Broader phenotype in siblings and parents
78
Q

How is ASD managed?

A
  • Recognition, description and acknowledgement of disability
  • Establishing needs
  • Appreciating the can’t and the won’t.
  • Psychotherapy
  • Decrease demands o reduce stress and improve coping
79
Q

What are the key features of oppositional defiant disorder?

A
  • Refusal to obey adults request
  • Often argues with adults
  • Often loses temper
  • Deliberately annoys people
  • Touchy or easily annoyed by others
  • Spiteful or vindictive
80
Q

How is ODD different from ADHD?

A

ODD

  • Relates to temperament – irritable and ‘headstrong’
  • Behaviour is learned
  • Enacted to obtain a desired result
  • More likely to result from impaired parenting
  • Associated with adversity
81
Q

How is ADHD different from ODD?

A

ADHD

  • Aggression is impulsive, (and aggression may not be a feature).
  • Poor cognitive control and ability to sustain a goal
  • Often remorseful
  • Resistant to pure behavioural management
  • Stronger genetic component.
82
Q

Why are some children hard to manage?

A
  • Caused by many factors: in child (e.g. temperament, ADHD, neurodevelopment) and parent (e.g. overcrowding, poverty, depression)
  • Especially lack of positive experience of being parented.
  • effects of psychosocial adversity and experience of hostility
83
Q

What are the possible outcomes for hard to manage children in the long term?

A
  • Antisocial behaviour
  • Substance misuse
  • Long term mental health problems
84
Q

How can H2M children be managed?

A
  • Parent Training programmes are effective (NICE guidance, 2006)
  • Multi-Systemic Therapy (MST) attempts to correct all causes.
85
Q

What is involved in parent training?

A
  • Groups, individuals or self-taught (e.g. DVD packages)
  • 1-2hrs/wk for 8-12 weeks
  • Structured
  • Informed by social-learning theory e.g modelling behaviour.
  • Focus on positive reinforcement of desired behaviour and developing positive parent-child relationships.

Systems: Psychiatry AB (18 decks)

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