Child and adolescent psychiatry Flashcards
What innteruterine nad perinatal factors cause psychiatric problems in children and adolescents?
○ Maternal health – Maternal antibodies, obesity, diabetes
○ 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
○ Foetal alcohol syndrome
What are the common outcomes of foetal alcohol syndrome?
□ Alcohol has a non-specific effect of the foetal brain and so the outcomes are quite variable
□ Learning difficulties
□ Conduct disorders including oppositional defiant disorder (ODD)
® frequent loss of temper, arguing, becoming easily angered or annoyed, showing vindictive or other negativistic behaviours.
□ Combined ADHD or ADD or Hyp-Imp subtypes
® ADD: distractibility, sustaining attention to tasks that don’t provide high level of stimulation or frequent rewards, distractibility and problems with organization
® Hyp/Imp: 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: e.g. panic disorder, phobic disorders, separation anxiety disorder or generalized anxiety disorder
What environmental factors can increase the chances of a child or adolescent developing a psychoatric disorder?
○ 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
Explain carer-child relationship (attachment)
- Proximity-seeking behaviour-
□ The infant seeking contact with parent when frightened, injured or ill
□ Foundation of attachment theory - Attachment is described as secure or insecure according to direct observation of behaviour during “Strange situation”
- Much variability of mental health has been attributed to early attachment patterns “lack of bonding”.
□ Little evidence for this - Stigmatises mothers and causes unnecessary worry
- Attachment changes across the life span. Very difficult to disentangle from multiple other influences
How does the brain respond to stress?
- Brain responds similarly to physical and mental stress
- Response to stress involves interplay or brain and body
- 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
What are the features of an anxiety disorder in children?
- Anxious thoughts and feelings (e.g. impending doom)
- Autonomic symptoms
□ Tingling in fingers
□ Churning in the stomach
□ Need to go to the toilet
□ Heart palpitations
□ Quick breathing - Avoidant behaviour
What are the behavioural treatment of anxiety in children?
□ Learning alternative patterns of behaviour
□ Desensitization
□ Overcoming fear
□ Managing feelings
What are the medical treatments of anxiety in children?
Serotonin reuptake inhibitors e.g. fluoxetine
Describe CBT in children with anxiety
- CBT with parents and children
□ Don’t expect children to have cognitive awareness
□ Mostly B & T
□ Parents as collaborators in the team
□ Step-wise approach: the ladder to success
□ Externalisation: disorder is not a matter of blame
□ Overcoming barriers to change: problem solving
□ Psychoeducation – explaining the problem in terms that make sense to everyone
□ Goal-setting – choosing reasonable objectives that can be achieved
□ Motivating: getting buy-in so the goals can be achieved
□ Externalising: taking blame, guilt and anger out of the equation
What is autism spectum disorder?
○ 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
What are the distinctive features of autism spectrum disorder?
- Social: reciprocal and communication □ Reciprocal conversation □ Expressing emotional concern □ Non-verbal communication □ Declarative pointing □ Modulated eye-contact □ Other gesture □ Facial expression - Repetitive behaviour □ Mannerisms and stereotypies □ Obsessions, preoccupations and interests □ Rigid and inflexible patterns of behaviour ® Routines ® Rituals ® Play
What clinical problems might a child with autistic spectum disorder have?
- 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)
What are the causes of autistic spectrum disorder?
○ Strongly genetic
- 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:
□ increased rates of depression, OCD, anxiety disorders, language impairment
□ Poor set-shifting ability, increased visuospatial ability, careers in engineering, computing or mathematics
How is autistic spectum disorder managed?
- Recognition, description and acknowledgement of disability
- Establishing needs
- Appreciating the can’t and the won’t
- The broken leg metaphor
- Decrease the demands -> reduce stress ->improve coping
- Psychopharmacology
Talk about oppositional defience 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 ○ 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
