Child and Adolescent Psychiatry Flashcards
What is included in the history?
Presentation ‘recently’
- PC
- HPC
Other background history ‘previously’
- Past psychiatric Hx
- Past medical Hx
- Social Hx
- Family Hx, Personal Hx, Developmental Hx
What is included in the examination?
Mental state examination ‘this moment’
- In the room
- School observations
- Video assessment
- One way mirror
How is the patient’s conditions processed and further actioned?
Formulation ‘making sense of it all’
- Hopes for change
- 4Ps grid
Management plan
- More history/questionnaires
- More MSEs
- Treatment
What are the principles of assessment?
- Biopsychosocial approach
- Engagement
- Multiple perspectives and relationships
- Communication
What are the principles of practice?
–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
What spheres contribute to health and illness?
- Psychological
- Social
- Biological
What must be considered when formulating and managing a patient’s condition?
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
What biopsychosocial factors need to be considered?
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.
What are conduct disorders characterised by?
Characterised by repetitive and persistent patterns of antisocial, aggressive of defiant behaviours which violate age-appropriate societal norms
What are those with conduct disorders at increased risk of?
- 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
What is the management of conduct disorders based on?
Based on biopsychosocial assessment and is likely to need multiagency communication and cooperation
What management is there for 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
What are hyperkinetic disorders (ADHD) characterised by?
Characterised by core features of developmentally abnormal inattention, hyperactivity and impulsivity present across time and situations
Why are patients with hyperkinetic disorders highly comorbid?
Highly co-morbid 50-80%
-Specific LD, ASD, CD, tics, motor coordination problems, substance misuse, anxiety, depression
What are hyperkinetic disorders associated with in adulthood?
Majority are symptomatic into adulthood, especially inattention
- Reduced academic and employment success
- Increased criminal activity
- Increased adult mental health problems
How is ADHD managed?
- Psychoeducation
- Medication – stimulants, atomoxetine, guanfacine
- Behavioural interventions e.g. realistic expectations, contingency management
- Parent training - PinC
- School interventions
- Treat comorbidity
- Voluntary organisations
- Benefits
What is the first line pharmacotherapy for ADHD?
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
What is the second line pharmacotherapy for ADHD?
Atomoxetine
-Non stimulant also acts on NAd systems
What is 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.
- Can include self poisoning, cutting and burning
What can self-harm indicate?
Psychiatric disorder or significant psychosocial problems
What is the main risk from self-harm?
Suicide
What mental states are high risk for suicide?
There is a very strong association between depression and suicidality. The combination of mood disorder, substance misuse and conduct disorder is particularly high risk.
What factors increase the risk of suicide?
- 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
How should those at risk of suicide/self harm be managed?
- 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
What is behaviour the product of?
Brain biology
What is developmental psychopathology?
The science underpinning the psychiatry
What do twin studies involve?
- Comparison between DZ and MZ twins
- Calculate % of variance due to environment and % due to genetics
Give examples of psychiatric conditions with a genetic basis.
- ADHD
- Autism
- Depression
- Anxiety
What has been discovered through genome wide association studies?
- 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
What intra-uterine and perinatal factors are there in child mental health?
-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
How does foetal alcohol syndrome present?
Growth retardation including head, body, brain and eyes
Mutiple neuro-developmental effects on:
- Sensorimotor
- Cognitive development
- Executive function
- Language
What is white matter connectivity important for?
Important for functions that require interplay between brain areas e.g. working memory between hippocampus and anterior cingulate
What is low white matter connectivity associated with?
- 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
How does ADD present?
- Distractibility
- Difficulty sustaining attention to tasks that don’t provide high level of stimulation or frequent rewards
- Problems with organisation
How does hyperactivity/ impulsivity syndromes present?
- 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
Give examples of anxiety disorders.
- Panic disorder
- Phobic disorders
- Separation anxiety disorder
- Generalised anxiety disorder
What environmental factors can occur during childhood?
- 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
What is the foundation of attachment theory?
Proximity seeking behaviour such as an infant seeking contact with parent when frightened, injured or ill
What is attachment?
Attachment is described as secure or insecure according to direct observation of behaviour during “Strange situation”.
What is the problem with connecting attachment to mental illness?
-There is little evidence
-Stigmatises mothers and causes unnecessary worry.
Attachment changes across the life span. -Very difficult to disentangle from multiple other influences.
What does our response to stress involve?
Interplay of brain and body
Why is the brain’s response to stress important to mental health?
- 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.
How is head injury linked to mental health?
- Head injuries can influence our behaviours
- Behaviour influence life events
- Some life events increase the probability of head injuries
What concepts have been attributed to psychological development?
- Reward-based learning
- Executive Function
- Delay-aversion
- Sharing emotion and empathy
- Expressed emotion
What happens in operant conditioning?
Dopamine neurones fire when you associate an action with a subsequent reward
What is the experience of adversity and the reward deficiency model of addiction?
- 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
How is executive and cortical control applied in CBT?
- Taking control over ‘automatic’ and learned behaviours
- Inhibit prepotent responses
- Intentional decision making and forward planning
- Requires self-awareness and capacity to self-monitor
Give an example of delay-aversion and delayed gratification.
A child successfully carrying out the marshmallow test and receiving a second marshmallow
What may delay-aversion explain?
- It is a theory to explain ADHD
- Inability to wait and maintain attention in the absence of immediate reward
What is the social brain?
- Sharing emotion and empathy
- Increasing understanding, reflection and control with age
Give an example of the social brain.
- 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
Theory of mind: Understanding false belief is a true test of…
The ability to represent other’s thoughts as different to one’s own
What may predict the rate of relapse from chronic illness?
Carers negative emotion
How does expressed emotion increase relapse rates?
- 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
What are the 4 components of the out of school matrix?
School refusal
- Fear of leaving home
- Fear of going to school
Truancy
- Unwilling to go to school
- Unwilling to leave home
What mental health problems are associated with being out of school?
- Anxiety
- Conduct disorder
- Autism
- Depression
- Obsessional compulsive disorder
What effects can mental health have on school attendance and learning?
- Learning difficulties (general or due to poor attention)
- Difficulty controlling emotion
- Anxiety
- Lack of energy, motivation
- Difficulties joining in
- Sensory problems
- Preoccupations
Separation anxiety disorder
- Fear of leaving parents and home
- Problems on the doorstep
Social phobia
- Fear of joining group
- Problems at the school age
What are the 3As (features) of anxiety disorders?
- Anxious thoughts and feelings
- Autonomic symptoms
- Avoidant behaviours
What factors can affect child’s willingness to go school?
- Learning difficulties
- Lack of friends and relationships
- Bullying
- Lack of parental attention of concern
- Maternal depression
What is the neurobiology associated with anxiety?
- 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.
What is the treatment for anxiety?
Behavioural
- Learning alternative patterns of behaviour
- Densensitsation
- Overcoming fear
- Managing feelings
Medication
-Serotonin reuptake inhibitor e.g. fluoxetine
How can childhood anxiety be escalated?
- By feeding their fears
- The emotional contagion
What are the principles of CBT?
- Thoughts
- Feelings
- Behaviours
What are the long term effects of successful behavioural treatment?
- Presented with a challenge
- Have success
- Build in self-confidence
- Gain resilience
What are the long term effects of no behavioural treatment?
- Presented with a challenge
- Avoid the challenge
- Low self-confidence
- Become vulnerable
How is CBT carried out for children with their families?
- 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
Give examples of narrative approaches to use with children.
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
What are the general features of Autism spectrum disorder?
- 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
What is the neurobiology behind ASD?
Many synaptic proteins are implicated mainly glutaminergic but also GABA.
How do the poles of ASD differ with increasing severity of neurotransmitter dysfunction?
Autism with normal IQ
-Only effects on synaptic function
Autism with LD
-Effects on synaptic function, neural migration and brain development
What are some distinctive features of ASD?
Social
- Non-verbal communication
- Expressing emotion concern
- Reciprocal conversation
Repetitive behaviour
- Mannerisms and stereotypes
- Obsessions, preoccupations and interests
- Rigid and inflexible patterns of behaviour
How does each case of ASD differ?
The variable clinical picture of autism: each domain (reciprocity, language and obsessions) is variable and in addition variation is affected by age and IQ
What are the clinical features of ASD?
Decreased
- Self-other perspective taking
- Sharing/ divided attention
- Flexible learning
- Social understanding
Increased
- Rigidity
- Sameness
- Fixed learning patterns
- Technical understanding
What clinical problems can people with ASD present with?
- 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
What is the connection between ASD and genetics?
- 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
How is ASD managed?
- 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
What are the 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 is ODD different from ADHD?
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
How is ADHD different from ODD?
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.
Why are some children hard to manage?
- 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
What are the possible outcomes for hard to manage children in the long term?
- Antisocial behaviour
- Substance misuse
- Long term mental health problems
How can H2M children be managed?
- Parent Training programmes are effective (NICE guidance, 2006)
- Multi-Systemic Therapy (MST) attempts to correct all causes.
What is involved in parent training?
- 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.
