Child and Adolescent Psychiatry Flashcards
what are genome wide association studies used for?
identifying genetic risk factors for psychiatric disorder
how can GWAS help identify risk factors for psychiatric disorder?
They can indicate
that many genes are implicated, mostly of small effect. Many implicate micro-RNA and epigenetic
modulation. 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
intrauterine and perinatal factors leading to development of psychiatric disorders
- Maternal health – Maternal antibodies, obesity, diabetes
- Substance misuse – alcohol, marijuana (no initial effects but tendency to depression later on)
- 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
how does foetal alcohol syndrome affect growth?
body head brain (inc cerebellum) eyes (small wideset eyes) thin upper lip and absence of philtrum
neurodevelopmental effects of alcohol during pregnancy
sensorimotor
cognitive development
executive function
language
white matter connectivity and ADHD
White matter connections are important for functions that require interplay between brain areas e.g.
working memory between the hippocampus and anterior cingulate. Low connectivity is 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 and distractibility.
Poorer overall integration of function results in cognitive instability.
common outcomes of foetal alcohol syndrome
variable learning difficulties conduct disorders inc oppositional defiant disorder combined ADHD or ADD or hyp-imp subtypes anxiety disorders
conduct disorders associated with foetal alcohol
frequent loss of temper, arguing, becoming easily angered or annoyed, showing vindictive or other negativistic behaviours
what is ADD?
distractibility, sustaining attention to tasks that don’t provide high level of stimulation or frequent rewards, distractibility and problems with organization.
what are hyp-imp subtypes?
difficulties with 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.
anxiety disorders associated with foetal alcohol
panic
phobic
separation
GAD
environmental factors during childhood associated with psychiatric disorders
- Carer - child relationship (attachment)
- Parenting skill and parental mental disorder e.g. post-natal depression, substance misuse
- Marital harmony, family function
- Nutrition, poverty, deprivation
- Abuse, neglect
- Discipline
- Day-care and schooling
- Peer relationships
- Life events
- Physical disability
describe the brains response to stress
The brain responds similarly to physical and mental stress. The response to stress involves interplay
of brain and body. Early life stress influences the function of the limbic circuit including the amygdala.
It determines subsequent patterns of stress response. Early life stress influences mood and patterns
of response to threat including withdrawal and/or aggressive response.
Experience of adversity trains the brain to adapt to a hostile environment:
1. Perceived behaviour and aggression
2. Limbic response and heightened amygdala activity
3. Cortical response and preparation of aggressive response
4. Behavioural response and aggression
concepts in psychological development
reward based learning executive function delay-aversion sharing emotion and empathy expressed emotion
describe executive and cortical control
- Taking control over ‘automatic’ and learned behaviours
- Applied in Cognitive Behavioural Therapy.
- Inhibit prepotent responses
- Intentional decision-making and forward planning.
- Requires self-awareness and capacity to self-monitor.
temporal lobe epilepsy can present as what? why?
psychosis
auditory hallucinations
what are conduct disorders?
Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive, or
defiant behaviours which violate age-appropriate societal norms. Course and outcome: 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.
core symptoms of ADHD
hyperactivity
impulsivity
inattention
management of conduct disorders
based on biopsychosocial assessment
• 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
examples of hyperkinetic disorders
LD ASD CD tics motor coordination problems substance misuse anxiety depression
what are hyperkinetic disorders associated with?
reduced academic and employment success
increased criminal activity
increased adult mental health problems
ADHD management (non pharmacological)
- Psychoeducation
- Medication – stimulants, atomoxetine, guanfacine
- Behavioural interventions e.g. realistic expectations, contingency management
- Parent training - PinC
- School interventions
- Treat comorbidity
- Voluntary organisations
- Benefits
medication for ADHD
methylphenidate
2nd line - atomoxetine nonstimulant
discuss 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. Self-poisoning, cutting, burning etc. Can
indicate psychiatric disorder, or significant psychosocial problems. Many risk factors for self-harm are
shared with those for suicide. Self-harm is not an act of suicide it is a form of release that soothes the
person. Can be a form of self-punishment. It is not a diagnosis.
factors increasing 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
management of a suicidal person
• The safety of the young person is the first priority
• 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
mental health problems associated with being out of school
anxiety conduct disorder autism depression OCD
effects of mental health problems on school attendance and learning
- Learning difficulties due to poor attention
- Co-morbid specific (or general) learning problems
- Difficulty controlling emotion e.g. frustration, escalation of anger, frequent conflict.
- Anxiety
- Lack of energy, motivation
- Difficulties joining in – wanting to be alone or unable to make friends (feeling different).
- Sensory problems – too noisy
- Preoccupation e.g. fear of germs and contamination
- Associations between mental health and learning difficulties e.g. dyslexia
2 common anxiety disorders in children
separation anxiety
social phobia
3As of anxiety disorders
o Anxious thoughts and feelings (e.g. impending doom)
o Autonomic symptoms
o Avoidant behaviour
motivational factors affecting school attendence
affecting willingness to go to school
encouraging one to stay at home
what factors affect willingness to go to school?
learning difficulties
lack of friends
bullying
lack of parental attention or concern
what may encourage a child to stay ay home?
maternal depression of psychiatric disorder inc separation
treatment of anxiety in children
• Behavioural
o Learning alternative patterns of behaviour
o Desensitisation
o Overcoming fear
o Managing feelings
• Medication
o Serotonin reuptake inhibitors e.g. fluoxetine
discuss ASD
• Defined as a syndrome of distinctive behavioural abnormalities.
• Often associated with Low IQ but not defined by low IQ.
• Pervasive: present across the life span (onset <3yrs) and across settings (a feature of brain
development and function)
• Highly heritable.
• Now thought to affect 1%
• Male: female ratio 3:1
• Girls less likely to present: likely to superficially feign emotion
social reciprocity and communication in ASD
reciprocal conversation
expressing emotional concern
non-verbal communication
(declaritive pointing, modulated eye-contact, facial expression, others)
repetitive behaviour in ASD
mannerisms and stereotypes
• Obsessions, preoccupations and interests
• Rigid and inflexible patterns of behaviour
o Routines
o Rituals
o Play
what is decreased in ASD?
self-other perspective taking
sharing/divided attention
flexible learning
social understanding
what is increased in ASD?
rigidity
sameness
fixed learning patterns
technical understanding
lower IQ in ASD is associated with?
joint attention/attention to others
emotional responses
movements/actions
higher IQ in ASD is associated with?
conversation
empathy
interests
what clinical problems are associated with ASD?
- 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 (6 x)
causes of ASD?
congenital/genetic co-morbid disorders: rubella Callosal agenesis Down's syndrome Fragile X Tuberous sclerosis
broader phenotype in siblings and parents of ASD people is associated with?
increased rates of depression, OCD, anxiety disorders, language impairment
poor set-shifting ability, increased visuospatial ability, careers in engineering, computing or mathmatics
management of ASD
- Recognition, description and acknowledgement of disability
- Establishing needs
- Appreciating the can’t and the won’t.
- The broken leg metaphor
- Decrease the demands à reduce stress à improve coping
- Psychopharmacology
key features of ODD
- Refusal to obey adults request
- Often argues with adults
- Often loses temper
- Deliberately annoys people
- Touchy or easily annoyed by others
- Spiteful or vindictive
ODD vs ADHD
• ODD:
o Relates to temperament – irritable and ‘headstrong’
o Behaviour is learned
o Enacted to obtain a desired result
§ More likely to result from impaired parenting
o Associated with adversity
• ADHD:
o Aggression is impulsive, (and aggression may not be a feature).
o Poor cognitive control and ability to sustain a goal
o Often remorseful
o Resistant to pure behavioural management
o Stronger genetic component.
