Child Psych Flashcards
is this normal or abnormal:
3 year old throwing tantrums, won’t eat or sleep when told, tiring out mother
normal
is this normal or abnormal:
7 year old disrupting class, doesn’t finish school work, blurts out answers too quickly
can be normal or abnormal - ADHD type picture but could be behavioural
is this normal or abnormal:
12 year old, seen 18 times in past 3 months with various physical health issues. Worries a lot about school work.
Abnormal - ?somatisation of anxiety
is this normal or abnormal:
16 year old boy truanting and hanging out with gangs. always angry, drinking alcohol. charged with arson, theft and assault and can’t seem to control his actions
Abnormal
Describe general CAMHS Mx
- emphasis on psychological therapy
- liase with school / family / social services
- less emphasis on medication
medication for hyperkinetic disorder
methylphenidate
medication for OCD
sertraline / SSRIs
medication for depression
fluoxetine
medication for psychoses
atypical anti psychotics
medication for bipolar
mood stabilisers / anti psychotics
describe normal anxiety development in children
9 months-3 years = separation anxiety
3-6 years = animals / darkness / monsters
6-12 years = performance anxiety
12-18 years = social anxiety
adulthood = illness / death
prevalence & typical age of onset of separation anxiety
3%
<6 years
prevalence & typical age of onset of specific phobias
3%
>6 years
prevalence & typical age of onset of social anxiety
5%
11 to 15
prevalence & typical age of onset of generalised anxiety
3%
Increases through teens
prevalence & typical age of onset of panic disorder
5%
late teens
prevalence & typical age of onset of OCD
2%
early childhood or late teens
Mx of anxiety
psycho-education for children / parents / family
CBT
medication 2nd line = SSRIs
liaison with school eg for school phobia
prognosis of childhood anxiety
do not persist into adulthood but most adult anxiety are proceeded by anxiety in adolescence
list remission rates of different anxiety disorders from most likely to remiss to least likely
seperation > phobias > generalised > panic > OCD
when would a child with sadness be classified with depressive disorder
prolonged episode / recurrent episodes
other depressive sx children present with
somatic sx
irritability
social withdrawal / school refusal / change in academic performance
is depression common in prepubertal children? post pubertal?
no
yes - 5%
comorbid conditions that present with depression
anxiety
conduct disorder
hyperkinetic disorders
key mx points of depression
psychoeducation
advice on sleep /exercise / diet
mange environmental stressors - eg work with schools if bullying
mx of mild depression
watchful waiting for 2 weeks by GP / counsellor / social worker
3 months CBT
mx of moderate-severe depression
referral to CAMHS
3 months CBT / family therapy / psychodyanmic psychothgerapy / interpersonal / brief psychosocial intervention
then switch psychological therapy or SSRI
what is the ONLY SSRI approved for tx of depression in children / adolescents
why is it the only one?
fluoxetine
only one with favourable risk:benefit profile
when would you admit a child with depression
LAST RESORT
- high risk
- poor home supervision / support
- intensive assessment required
key side effect to monitor of fluoxetine
increased suicidality (DSH, suicidal thoughts)
how does Mx of depression in children differ from adults
children
- focus on multiple psychotherapy 1st line
- only use fluoxetine
- rarely use fluoxetine alone
- much more intensive monitoring initially
adults
- first line is CBT
- can offer SSRI alone
prognosis of untreated depression
- 1/3 remit in 2 months
- 10% depressed after 1 year
proportion of children with depression who relapse
1/3 relapse
what are children with depression at higher risk of in adulthood
increased long term risk of suicide attempts / bipolar / hospitalisation
what does bipolar diagnosis in children involve
clear manic episode with euphoria over several days
Sx of bipolar
irritability
behavioural problems
impulsivity
disinhibition
grandiosity
paranoia
how do bipolar symptoms overlap with other disorders / normal development
normal teenage behaviour / depression / drugs / conduct = irritability, behavioural problems
ADHD / normal teenage behaviour = impulsivity, disinhibition
ego-centrisim is part of normal childhood development = grandiosity, paranoia
how is bipolar differentiated from ADHD
ADHD is continuous, bipolar is phasic
how does psychosis differ in children from adults
children do not have systematic or complex delusions
children’s delusions may reflect concerns specific to child’s development eg monsters
children might not have vocab to express delusion
DDx of child with first onset psychosis
prodromal phase can look like autism
substance misuse
social isolation
PTSD / trauma
age appropriate experiences / behaviours
what is EIP
Early intervention in psychosis
rationale of EIP
intensive early intervention and treatment of psychosis improves outcome
challenges of EIP
prodromal symptoms can look like other conditions so diagnosis is difficult
younger people are more sensitive to side effects of anti psychotics
how is cannabis related to psychosis
dose dependent relationship between cannabis use and schizophrenia / psychosis
if use skunk/other more potent cannabis, or start younger, or smoke more often or FHx of psychosis with cannabis use (increased susceptibility of psychosis when using cannabis) –> massive increase in psychosis risk
why does cannabis cause psychosis in 15-16 year olds more
pruning occurring in brain at this age, so has greater affect on perception and psychosis risk
morbidity of substance misuse in teenagers
8% of deaths in 15-19 year olds
Mx for substance misuse
motivational intervention
behavioural disorders in pre school children
difficulty sleeping / eating / continence
what defines a disorder
distress / impairment caused by problem
aetiological factors of behavioural disorders
child - developmental delay, physical disorders
family - poor routine setting / abuse / poor relationships between child and parents / parental psych issues
environment - stress eg social deprivation
1st Mx of behavioural disorder
rule out physical disorder
eg OSA for sleep, reflux for eating, Hirschrpungs for continence
2nd Mx of behavioural disorder
set up conducive enviroment to formation of desirable habit
classical conditioning - child should associate environment with habit
how do preschoolers learn
CONDITIONING
classical conditioning or operant conditioning
when is medication used in behavioural disorder
give 2 examples of medications used
LAST RESORT
- melatonin for sleep / vasopressin for enuresis
what years are the peaceful years
school age
what is the difference between school refusal and truancy
school refusal
- 5 to 12year old
- parents know child is at home
- related to anxiety / fears
truancy
- adolescence
- parents unaware
- conduct disorder
how do you treat truancy vs school refusal
school refusal
- treat underlying psych disorder & anxiety Mx
- early graduated school return / liaison with education welfare officer
truancy
- effective boundary setting by parents / school
- support needs at school, liaise with EWO
contrast aetiology of school refusal vs truancy
school refusal
- anxious temperament
- overprotective family
- health issues / somatisation
- school transitions
- academically able
truancy
- large disorganised family
- limited academic ability
define key features conduct disorder
- repetitive / persistent pattern of defiant behaviour
- freq / severity beyond age appropriate norms
prevalence in boys vs girls
4.5% boys, 2% girls
what do younger children have vs adolescents in terms of conduct issues
younger = ODD - oppositional defiant disorder
older = conduct disorder
list types of conduct disorder
truanting
stealing
initiating fights / mugging / using weapons
destruction of property / arson
list acts consistent with ODD
severe tantrums
active defiance and refusal to comply with rules
frequent anger
Describe progression of conduct disorder
40% of 7-8year olds with CD become recidivist delinquents as teenagers
predictor of antisocial personality disorder
mx of conduct disorder
treat any psychiatric disorder eg ADHD
target modifiable risk factors at a young age - education/social services
parenting programmes
cognitive problem solving skills training / multi system therapy
mentoring
describe parenting skills programmes
variety of books / videos
individual or group training sessions
4 pillars of parenting programmes
house rules be clearly communicated
spend quality time with child
parents to model good behaviour
behavioural management skills using conditioning
4 pillars of parenting programmes
house rules be clearly communicated
spend quality time with child
parents to model good behaviour
behavioural management skills using conditioning
process of behavioural management
antecedent –> behaviour –> consequence
- identify triggers
- increase desired behaviour
- reinforce behaviour
features of reinforcing good behaviour
clear
immediate
consistent
contingent - linked to particular situation, explaining what exactly is right
with attention / praise / stars
how can bad behaviour be discouraged
extinction - undesired acts ignored
time out from positive reinforcement
distraction / misdirection
clear consequences if boundaries reached
triad of ADHD
inattention
hyperactivity
impulsivity
defintiion of ADHD ICD11
> 6 months
inattention and or hyperactivity-impulsivity
pervasive across different situations
onset < 7 years
significant distress or social impairment
prevalence of ADHD
5%
what is hyperkinetic disorder
more severe impairment than ADHD
male to female ratio ADHD
3:1
comorbidity with %s of ADHD
ODD 50% / conduct disorder 25%
anxiety 25% / depression 15%
LDs 30%
describe the ADHD spiral
ADHD symptoms
–>
learning difficulties
oppositional behaviour
–>
failure at school academically / social
–>
low self esteem, isolation, delinquent peer group
–> back to top
pathophysiology of ADHD
prefrontal cortex dysfunction
udnerfunctionung of dopamine system
executive functioning tests for ADHD
Wiconsin card sorting test
stroop test
what is the stroop test
list of colours written in different colours, have to say the colour the word is written in, not what colour is written
non genetic biological aetiology of ADHD
VLBW
prematurity
foetal alcohol syndrome
food additives ?? maybe not
parental factors causing ADHD
critical comments
maltreatment
physical discipline
lack of sensitivity to childs needs
maternal depression
Non drug Mx of ADHD
cognitive assessment
psycho education - no one is at fault, what behaviours are good / bad, support groups
diet - food diary to find sensitivity
parent skills training
when is drug mx of ADHD used
used for persistent significant impairment
2 drug mx options of ADHD
stimulants
- methylphenidate (sustained or immediate release)
non stimulants
- atomoxetine (NA reuptake inhibitor)
how does methylphenidate work
block pre synaptic DAT and agonist at postsynaptic DRD4
side effects of methylphenidate
stunted growth - height and weight
reduced appetite !!
problems with mood - irritability / low mood / anxious
problems sleeping
what needs to be monitored with methylphenidate and why
height / weight - can reduce appetite and stunt growth
BP - causes HTN
baseline ECG if high risk - cardiac arrhythmias
tic progression if they had tics prior to starting
who is recommended for methylphenidate
severe / moderate ADHD who have failed to respond to psychosocial intervention
second line mx for ADHD
dexamfetamine (also a stimulants)
non stimulant medication for ADHD
guanfacine (alpha adrenergic receptor agonist)
atomoxetine (NARI)
when can atomoxetine be used
to help with comorbid depression
what needs to be monitored in atomoxetine
liver failure so do LFTs
3 key things to be monitored regularly in methylphenidate
growth & BP
suicidal thoughts
3rd line Tx for ADHD
atomoxetine
prognosis of ADHD
all patients will get better to some degree, but 2/3rd have some symptoms persisting
what % of patients will have ADHD as adults
15% have ADHD as adults
major complication of untreated ADHD
90% conduct disorder if untreated
what is aspergers
ASD without learning difficulties
3 key features of ASD
reciprocal social interaction difficulties
communication difficulties
repetitive / restrictive behaviour
what is reciprocal social interaction difficulties
poor appreciation of social cues
difficulty reciprocating in social interactions - reduced sharing interest/enjoyment with others, reduced proto-declarative pointing
poor non verbal communication - eye contact/social smiling/facial expression range
failure to develop peer relationships
what is proto declarative pointing
pointing at something interesting to share your interest with someone else
what are communication difficulties in ASD
- non verbal: less gestures, variety/spontaneity of pretend play
- verbal: delay in language development, stereotyped/repetitive speech, lack of chit-chat
what are restricted / repetitive behaviour
unusual or repetitive play / use of objects
unusual sensory interests
stereotyped motor mannerisms - eg flapping
adherence to routines / rituals
unusual pre-occupations or circumscribed interests
other difficulties of ASD
lower IQ
fears / phobias / OCD
ADHD / aggression / self injury
epilepsy in 20%
when do ASD symptoms present
they are present in under 3 year olds, but manifestations change as child ages
heritability of ASD
90%
medical conditions causing ASD
Tuberous sclerosis
fragile X
Downs
prevalence of ASD
autism 0.25%, ASD 1%
2 psychological theories of ASD
- executive dysfunction theory
- poor flexibility of behaviour to context - theory of mind
- can’t appreciate that others have thoughts / feelings of their own that may be different to their own
what is the sally anne test
to test theory of mind
Mx of ASD
cognitive assessment
psycho-education - no one is at fault, leaflets
MDT - specialist schools, paeds, SLT, OT
behavioural Mx +/- meds for psych disorder
prognosis of ASD
variable - depending on IQ/language/social skills
10% achieve independent lives / work /relationships
what factors/models must you consider in the development of a mental health condition in children
4Ps
- predisposing
- precipitating
- perpetuating
- protective
3 areas
- individual
- family
- environment
bio-psycho-social model
how can biological processes in the family cause mental health condition
genetics - influence all psych conditions, esp autism / ADHD / schizophrenia / BPAD
genetics of personality / resilience
exposure - alcohol/drugs in utero / childhood
how can psychological processes in the family cause specific mental health conditions (list them related to the psych factor)
parental modelling of:
social boundaries and law - conduct disorder
education - truancy
food - EDs
alcohol / drugs - misuse
poor attachment - anxiety / depression
