Child and Adolescent Psychiatry

Question 1

How is depression in children different to depression in adults?

Answer 1

Depression is not dissimilar in children than adults.

• 1-2% of children and 8% of adolescents are affected.
• The sex ratio is equal before puberty, but girls outnumber boys thereafter.

In terms of presentation, it is similar to that of adults, although children are more likely to complain of somatic problems (e.g. headaches and tummy-aches).

Question 2

What is the management of depression in children?

Answer 2

1. Assess risk and refer to appropriate services. Severely depressed children with high risk may require admission.
2. Psychoeducation is very important, to enable the child and family understand what the child is going through, and giving the child language to express their illness.
3. Advice on sleep, exercise, diet etc.
4. Manage environmental stressors such as work with schools to address bullying

For mild depression, the first-line treatment is three months of cognitive behavioural therapy (CBT). This is the same for moderate-severe depression, however they would need to be referred to CAMHS rather than managed by GP. Antidepressants (mainly fluoxetine) are only prescribed by specialists in severe cases. The prognosis is good, but severe episodes are likely to recur.

Question 3

What are the types of childhood anxiety disorders?

Answer 3

Different types of anxiety disorder:

• Separation Anxiety Disorder - characterised by high distress with separation, tries to avoid separation, and affects functioning. In children and young people this is separation from their parent. Some level of separation distress is expected, but it turns into a disorder when this is prolonged and affects functioning.
• Specific phobiais a marked, unreasonable fear for specific objects. Fear is so severe, it results avoidanceand impairment.
• Social Anxiety Disorder is a fear of being perceived as foolish/stupid; focus of attention, eating or talking in public. It becomes a disorder when the person is so self-conscious, that they cannot perform without impairment. Some children even have selective mutism, without an organic cause.
• Generalised Anxiety Disorder (GAD) - characterised by persistent worries of different things. These could be schoolwork, appearance, future, strive for perfection. GAD is strongly related to depression.
• Panic Disorder - repeated experience of unprovoked panic attackscharacterised by intense fearand physical symptoms. If you have repeated panic attacks for a specific reason i.e. public speaking, this is not a disorder.

Question 4

Describe the management of childhood anxiety disorders

Answer 4

1. Psychoeducation is particularly important as children do not have the language nor the ideas to understand their condition. Also useful for the parents and the whole family
2. Psychological therapy and in particular CBT is very effective in managing anxiety disorders. The cognitive aspect of CBT involves monitoring the ‘dysfunctional’ thoughts and associated feelings using diaries and charts. These thoughts are challenged with thought experiments or real-life experiments. The behavioural aspects involves systemic desensitisation and relaxation techniques (breathing exercises, progressive muscular relaxation and creative visualisation). This is hard-work but highly effective.
3. Medication is second-line and is usually sertraline or fluoxetine (for OCD [though OCD is technically not an anxiety disorder]).

Question 5

What is the prognosis of childhood anxiety disorders?

Answer 5

Most child anxiety disorders stay in childhood and do not progress into adulthood. However, most adult anxiety disorders are preceded by an anxiety disorder in childhood.

Question 6

Describe the epidemiology of learning disabilities

Answer 6

Males are affected slight more than females (3:2). Most cases of learning disabilities are mild (prevalence of 2.5%), moderate learning disability is uncommon (0.4%) and severe and profound are rare (0.1% combined).

Question 7

What is the aetiology of learning disability?

Answer 7

Specific causes can be split into antenatal, perinatal and postnatal. Multifactorial cases are common, and may be due to environmental factors with polygenic inheritance.

Question 8

What is the criteria for a diagnosis of learning disability?

Answer 8

All three of the following; significant impairment of:

• Intellectual functioning (I.e. IQ < 70)
• Social or adaptive functioning
• Both of these impairments must be present before age of 18

Question 9

Describe the clinical picture of patients with learning disabilities - including the key differences between mild, moderate, severe and profound.

Answer 9

Mild learning disability:

• Language is usually reasonably good, although its development may have been delayed.
• Problems go undiagnosed, although individuals struggle through school or may be labelled with behavioural problems.
• With appropriate support, many people live and work independently.

Moderate learning disabilities:

• Language and cognitive abilities are less developed
• Reduced self-care and limited motor skills may necessitate support
• May need long-term accommodation in their family home or in a staff-supported group home

Severe learning disabilities:

• Marked impairment of motor function
• Little or no speech during early childhood.
• Simple tasks may be accomplished with support
• Likely to require their family home or 24-h staffed home.

Profound:

• Severely limited language, communication, self-care and mobility
• Significant associated medical problems
• Usually requires higher level of support

People with learning disabilities have increased physical morbidity and mortality, including higher rates of epilepsy. Problems are confounded by less frequent involvement in health screening and preventative interventions. Value judgements by healthcare professionals have been blamed for discriminatory practices, and diagnostic overshadowing is the tendency to attribute everything to the learning disability itself.

Question 10

Describe the investigations/assessment of learning disability

Answer 10

1. People aged 16 and above should be assumed to have capacity, but it is important to assess the patient’s capacity on a decision-to-decision basis.
2. Detailed developmental history from patients, carers, school etc.
3. Blood tests such as FBC, U&E, LFTs, TFTs to exclude reversible disturbances.
4. Assess the level of learning disability taking into account skills, strengths, weaknesses and day-to-day living and help requirements.
5. Genetic testing may be appropriate.

PRN also mentions to perform an IQ test for global intellectual impairment, and investigations for associated physical illnesses such as an EEG for epilepsy.

Intellectual impairment can be assessed using the WAIS III test (Wechsler Adult Intelligence Scale) (IQ scale), and adaptive social functioning established via ABAS II (Adaptive Behaviour Assessment System)

Question 11

Describe the management of learning disability

Answer 11

Management requires an MDT approach involving a comprehensive individualised support network to provide help with daily living, housing, employment, and finances. This usually involves:

• Assessment and care co-ordinator
• Community nursing
• Independent supported living
• Psychiatry services
• Specialist occupational therapy
• Speech and language therapy

A carer’s needs assessment should also be performed, and support for parents and families should be provided.

Safeguarding concerns should be assessed if there are concerns regarding maltreatment or exploitation.

When suspecting a diagnosis:

1. Refer to local learning disability service or child development centre to confirm the diagnosis and for general management. They will organise the multi-disciplinary team.
2. Referral to clinical psychologist may be necessary to access benefits etc.
3. If the patient also has mental health problems, refer to mental health services.

Arrange for annual health checks.

Question 12

What is the epidemiology of conduct disorder?

Answer 12

Conduct disorder affects 10% of 10-year-olds and is four times more common in boys.

Question 13

What are the risk factors for conduct disorders?

Answer 13

It runs in families, although no genetic factors have been identified. Risk factors include:

• Urban upbringing
• Parental criminality
• Socioeconomic depravity
• Harsh and inconsistent punishment
• Maternal depression
• Family history of substance misuse.

Question 14

What are the clinical features of conduct disorders?

Answer 14

The child exhibits very antisocial behaviour- not only rebellious, but is often involved in fights, theft, fire-setting, truancy and cruelty to animals and people.

Socialised CD is when the child has a peer group that share the antisocial behaviour. Unsocialised CD is when the child is rejected by other children making them more isolated and hostile.

Question 15

What are the differential diagnoses for conduct disorders?

Answer 15

1. Oppositional Defiant Disorder (ODD) is a milder form of CD, occurring in children under 10, with provocative, angry and disobedient behaviour towards adults. No extreme antisocial behaviour is present.
2. ADHD
3. Depression: some children may present with antisocial behaviour

Question 16

Describe the management of conduct disorder

Answer 16

1. Assess risk to self and others
2. Screen for substance use and refer to local Young People’s Drug and Alcohol Service.
3. Refer to CAMHS and inform other agencies that may be involved in the child’s care such as social services.
4. Also refer directly to psychological intervention:
   
   1. Parental training programmes are recommended for children aged 3-11. Parents attend 16 group sessions lasting up to two hours. Teaches parents to reward good behaviour and deal constructively with negative behaviours. Also available for foster or guardian training.
   2. Child focused programmes are usually offered when the child is aged 9-14. These sessions involve using a cognitive-behavioural problem solving model as well as rehearsal and feedback to improve behaviour.
   3. Multimodal interventions are usually offered to young people aged 11-17. This is usually multisystemic therapy, where a specially trained case manager designated professional provides intensive support to the young person and their family. Interventions are provided to the young person, the family, at school, at the criminal justice system and in the community. Usually these sessions consist of three to four meetings each week for up to five months.
5. Seek permission from Gillick competent young people and parents before passing information to schools for further information.

Question 17

What is the prognosis of conduct disorder?

Answer 17

Up to 50% develop substance misuse problems or dissocial personality disorders as adults.

Question 18

What should you screen for if suspecting somatisation in a child? (i.e. recurrent abdominal pain or headaches)

Answer 18

Important to screen for psychiatric co-morbidities (two main disorders):

• Anxiety disorders: Markedly increased in children with RAP (75%).
  
  • Can be generalised anxiety disorder (GAD)
  • Restricted to specific environments or objects (e.g. separation anxiety from parents, social phobia, specific phobias).
• Depression. Can present as persistent low mood, anhedonia, social withdrawal, lethargy, reduced sleep and appetite.

Question 19

What is the management of somatisation in children?

Answer 19

• Explanation/education: Frequency of RAP in general population, and good prognosis.
• Acknowledge symptoms as genuine: child is not putting it on!
• Analogy of tension headache in adults.
• Pain management involves relaxation, distraction techniques.
• Address contributory factors involving decreasing attention by parents to the symptoms (decreasing reinforcement), setting up non-pain based shared activities, seek to reduce stresses in school/peer interactions.
• Treat co-morbid anxiety/depression
• Persistent problems: consider family CBT (cognitive behavioural treatment)

Question 20

Describe the degree of learning disability based on IQ score

Answer 20

70, 50, 35, 20