Child Psych Flashcards
What is autism spectrum disorder (ASD)?
Characterized by impairments in social communication/interaction & restrictive, repetitive behaviors/interests
Combines 4 previously separate disorders (autistic, Asperger’s, childhood disintegrative, pervasive development disorder)
Diagnosis of ASD
Severity depends on degree of impairment:
- Mild
- Moderate
- Severe (severe RBRs)
DEFICITS IN SOCIAL COMMUNICATION & INTERACTION:
Impaired social/emotional reciprocity:
- Can’t hold a conversation (unidirectional)
- Not share (interests, emotions)
- Not check on other person interest
- Lack empathy / understanding
- Screener: understand others emotions?
Deficits in nonverbal communication:
- Eye contact, facial expressions, gestures, body
Relationship / interpersonal challenges:
- Lack of interest in peers
- Not adjust behavior to situation
- Not sharing imaginative play
RESTRICTED, REPETITIVE BEHAVIORS, INTERESTS, & ACTIVITIES (RBRs): Stereotyped repetitive mannerisms (self-stimulating things):
- Motor (hand flapping, circling)
- Speech (No inflection at the right point, breathes at wrong times, emphasis on the wrong part of the syllable, etc.)
Inflexible rituals / routines (rigid thought patterns, sameness):
- Screener questions: trouble w/ transitions (plan to go to dinner, but then decide not to –> outburst)
Intense / peculiar interest:
- Fixated w/ abnormal intensity / focus
Hyper/hypo-reactivity to sensory input:
- Increased (or decreased) - textures, light, sound, pain
If there are no RBRs, it is SOCIAL (PRAGMATIC) COMMUNICATION DISORDER:
- Social use of verbal & nonverbal communication
Not better accounted for by ID or global developmental delay
- When ID & ASD co-occur, social communication is below expectation based on developmental level
Red flags for ASD
Rapid deterioration of social &/or language skills during first 2 years of life
If skills are lost after age 2 or more expansive losses occur (e.g. self-care, motor skills), an extensive medical workup needs to be initiated
Epidemiology of ASD
Recent increase in prevalence: 1% of population
- Could be related to expansion of diagnostic classification and/or increased awareness/recognition
Males to females ratio is 4:1
Symptoms typically recognized between 12-24 months old, but varies based on severity
Etiology of ASD
Multifactorial:
- Prenatal neurological insults:
- Infections
- Drugs
- Advanced paternal age
- Low birth weight
- 15% of cases are associated w/ known genetic mutation:
- Fragile X syndrome (most common known single gene cause of ASD)
- Down’s syndrome
- Rett syndrome
- Tuberous sclerosis
- High comorbidity w/ ID
- Association w/ epilepsy
Known not to cause:
- Maternal temperament & mental illness
- Immunizations
Prognosis of ASD
It is a chronic condition
- Prognosis is variable, but 2 most important predictors of adult outcome:
- Level of intellectual functioning
- Language impairment
- Only minority of patients able to live & work independently in adulthood
No cure, but various treatments are used to help manage symptoms & improve basic social, communicative, & cognitive skills
Treatment of ASD
Early intervention
Remedial education
Behavioral therapy
- Applied Behavioral Analysis
Psychoeducation
Meds:
- Used to reduce disruptive behavior / irritability / aggression associated w/ ASD:
- Low-dose atypical antipsychotic:
- Risperidone (Risperdal)
- Aripiprazole (Abilify)
- Low-dose atypical antipsychotic:
What is intellectual disability (ID)?
Formerly mental retardation (this is illegal)
- De-emphasizing IQ scores
- Destigmatize
Characterized by severely impaired cognitive & adaptive/social functioning
- Severity level is based on adaptive functioning, indicating degree of support required
- Single IQ score does not adequately capture this & is no longer used solely to determine ID severity
Diagnosis of ID
FUNCTIONAL DEFICITS Intellectual: - Reasoning - Problem solving - Planning - Abstract thinking - Judgment - Learning (academic & experience) - Confirmed by clinical assessment & standardized intelligence testing (scores at least 2 SDs below the population mean) Adaptive: - Communication - Social participation - Independent living - Require ongoing support in multiple environments
Deficits affect 3 domains:
- Conceptual
- Social
- Practical (being able to live alone)
Onset in developmental period
Severity levels (based on need for support):
- Mild
- Moderate
- Severe
- Profound
Epidemiology of ID
Overall: 1% of population
Etiology of ID
GENETIC:
Down Syndrome (trisomy 21) (most common chromosomal disorder, #1 identifiable cause)
- Epicanthic folds, flat nasal bridge, palmar crease
Fragile X syndrome (FMR-1 gene mutation) (#1 inheritable cause, #2 identifiable cause)
- Macrocephaly, joint hyperlaxity, macroorchidism in post-pubertal males
- Males > females
Others:
- Phenylketonuria
- Familial mental retardation
- Prader-Willi
- Williams
- Angelman
- Tuberous sclerosis
PRENATAL:
TORCH infections
- Toxoplasmosis
- Other (syphilis, HIV/AIDS, alcohol/illicit drugs)
- Fetal alcohol syndrome (FAS) = leading preventable cause of birth defects & ID
- 3 features:
- Growth retardation
- CNS involvement (structural, neurologic, functional)
- Facial dysmorphology (smooth philtrum, short palpebral fissures, thin vermillion border)
- May cause range of developmental disabilities, including ID
- Rubella
- CMV
- HSV
PERINATAL:
- Birth trauma
- Anoxia
- Premature
- Meningitis
- Hyperbilirubinemia
POSTNATAL:
- Hypothyroidism
- Malnutrition
- Toxin exposure
- Trauma
- Psychosocial causes
Idiopathic / unknown = 50%
What is global developmental delay?
Failure to meet expected developmental milestones in several areas of intellectual functioning
Diagnosis reserved for patients <5 years old when severity level can’t be reliably assessed via standardized testing
Patients will need to be reevaluated to clarify the diagnosis at a later time
What are specific learning disorders?
Characterized by delayed cognitive development in a particular academic domain (with normal IQ - it is difficult to say someone has a learning disorder if he/she is not expected to be at a higher level)
- Challenges w/ reading, writing, & arithmetic often co-occur
- Frequently occurs w/ ADHD which can worsen the prognosis
Diagnosis of specific learning disorders
Significantly impaired academic skills which are below expected for chronological age
- Interfere w/ schooling, occupation, or activities of daily living (ADLs)
Begins during school-age, but may become more impairing as demands increase
Affected areas:
- Reading (dyslexia)
- Learning difficulty with accurate/fluent word recognition, poor decoding, & poor spelling
- Writing
- Arithmetic (dyscalculia)
Not better accounted for by ID, visual/auditory deficits, language barriers, or subpar education
Always rule out sensory deficits before diagnosing a specific learning disorder
Epidemiology of specific learning disorders
Prevalence in school-age children: 5-15%
Males > females
Etiology of specific learning disorders
ENVIRONMENTAL:
Increased risk w/ prematurity, very low birth weight, prenatal nicotine use
GENETIC:
Increased risk in first-degree relatives of affected individuals
Comorbidity of specific learning disorders
Commonly co-occurs w/ other neurodevelopmental disorders (e.g. ADHD, communication disorders, developmental coordination disorders, ASD)
Comorbid w/ other mental disorders (e.g. anxiety, depressive, & bipolar disorders)
Treatment of specific learning disorders
Work w/ school
- Develop Individualized Education Plan (IEP) vs. 504 plan
- IEP:
- Have to make sure there are adjustments/accommodations for that particular person so that he/she is able to show that he/she can do that specific thing (give calculator, allow longer time, etc.)
- 504 Plan:
- Only requires “equal access”
- It is a structural thing (ramp access, large doors, allowed to go to school, etc.)
- IEP:
Accommodations:
- Regular classroom
- Special education
Behavioral techniques may be used to improve learning skills
What are communication disorders?
Encompass impaired speech, language, or social communication that are below those expected for chronological age
Begin in the early developmental period
Lead to academic or adaptive issues
What are the types of communication disorders?
LANGUAGE DISORDER
Difficulty acquiring & using language due to expressive and/or receptive impairment:
- Reduced vocabulary
- Limited sentence structure
- Impairments in discourse
Increased risk in families of affected individuals
SPEECH SOUND DISORDER (phonological disorder)
Difficulty producing articulate, intelligible speech
CHILDHOOD-ONSET FLUENCY DISORDER (stuttering)
Dysfluency & speech motor production issues
Increased risk of stuttering in first-degree relatives of affected individuals
SOCIAL (pragmatic) COMMUNICATION DISORDER
Challenges w/ social use of verbal & nonverbal communication
If restricted/repetitive behaviors, activities, or interests are present –> diagnose ASD
Increased risk w/ family history of communication disorders, ASD, or specific learning disorder
Treatment of specific learning disorders
Speech & language therapy
Family counseling
Tailor education to meet individual’s needs
What is ADHD?
Characterized by persistent inattention, hyperactivity, & impulsivity inconsistent w/ patient’s developmental stage
3 subcategories:
- Predominantly inattentive type
- Predominantly hyperactive/impulsive type
- Combined type
Diagnosis of ADHD
2 symptom domains: inattentiveness & hyperactivity/impulsivity
INATTENTION (at least 6):
- Fails to give close attention to details or makes careless mistakes
- Doesn’t seem to listen when spoken to directly
- Does not follow through on instructions & can’t finish tasks
- Difficulty organizing tasks
- Avoids, dislikes, or reluctant to engage in tasks requiring sustained mental effort
- Distractible
- Loses things needed for tasks
- Forgetful in daily activities
HYPERACTIVITY/ IMPULSIVITY (at least 6):
- Fidgets w/ hands or feet or squirms in chair
- Runs/climbs in inappropriate situations
- Out of seat constantly in situations where remaining seated is expected
- Difficulty playing quietly
- “On the go” or “driven by a motor”
- Talks excessively
- Difficulty awaiting turn
- Interrupts or intrudes upon others
- Blurts out answers before questions have been completed
Symptom onset before age 12, but can be diagnosed retrospectively in adulthood
- 6+ symptoms for more than 6 months present in AT LEAST 2 settings:
- Get collateral info from teachers at school
- Rating scale: Conner’s, Vanderbilt, etc.
- Sources: parents, teacher, student
- Compare progress before & after treatment & before/after changes in meds & dosages
- Symptoms interfere w/ or reduce quality of social/academic/occupational functioning
- Symptoms not due to another mental disorder
Differential diagnosis of ADHD
MEDICAL DISORDERS:
- Vision / hearing impairments
- Seizure disorders
- Lead poisoning
- Iron deficiency anemia
- Thyroid disorders
- Sleep disorder
MEDICATIONS:
- Prescribed medications (e.g. albuterol, steroids)
- Drugs of abuse (e.g. cocaine)
EMOTIONAL / BEHAVIORAL DISORDERS:
- Depression / mood disorders
- Anxiety disorders
ENVIRONMENTAL DISORDERS:
- Child abuse / neglect
- Inadequate parenting
- Inappropriate educational setting
- Stressful home environment
Epidemiology of ADHD
Prevalence:
- 5% of children
- 2.5% of adults
Males to females is 2:1
- Females present more often w/ inattentive symptoms
Etiology of ADHD
Etiology of ADHD is multifactorial:
GENETIC FACTORS:
- Increased rate in first-degree relatives of affected individuals
ENVIRONMENTAL FACTORS:
- Low birth weight
- Smoking during pregnancy
- Childhood abuse/neglect
- Neurotoxin/alcohol exposure
Course/prognosis of ADHD
Stable through adolescence
Many continue to have symptoms as adults (inattentive > hyperactive)
High incidence of comorbid ODD, CD, & specific learning disorder
Treatment of ADHD
Multimodal treatment of ADHD:
- Meds are most effective treatment for decreasing core symptoms, but should be used in conjunction w/ educational & behavioral interactions
MEDS:
- 1st line: stimulants (response rate 94% if both are tried)
- Methylphenidates (Ritalin, Concerta, Focalin)
- Amphetamines (Adderall, Vyvanse, Dexedrine)
- Nonstimulants
- 2nd line: atomoxetine (SSRI)
- Alpha agonists (Guanfacine, Clonidine)
- Other meds
- Bupropion + TCA
THERAPY:
- Behavioral therapy (modification techniques & social skills training)
- Educational interventions (i.e. classroom modifications)
- Parent psychoeducation
What are disruptive, impulse-control, & conduct disorders?
These disorders involve problematic interactions / inflicting harm on others
- While disruptive behaviors may appear within scope of normal development, they become pathologic when frequency, pervasiveness, & severity impair functioning of individual or of others
What is oppositional defiant disorder (ODD)?
Maladaptive pattern of irritability/anger, defiance, or vindictiveness which causes dysfunction or distress in patient or those affected
- These interpersonal issues involve at least 1 non-sibling
If child has no difficulties getting along w/ peers, but will not comply w/ rules from parents/teachers, consider ODD
What is conduct disorder (CD)?
Includes most serious disruptive behaviors, which violate rights of other humans & animals
- Inflict cruelty & harm through physical & sexual violence
- May lack remorse for committing crimes or lack empathy for victims
Diagnosis of ODD
Need 4+ symptoms in past 6 months (with at least 1 individual who is not a sibling):
- Anger/irritable mood
- Loses temper
- Touchy/easily annoyed
- Often angry / resentful
- Argumentative / defiant behavior:
- Breaks rules
- Argues w/ authority figures
- Deliberately annoys other
- Blames others
- Vindictiveness
- Spiteful at least 2 times in past 6 months
- Disturbance associated w/ distress in individual or others or it impacts negatively on functioning
- Behaviors do not occur exclusively during another mental disorder
Diagnosis of CD
Pattern of recurrently violating basic rights of others or societal norms w/ 3+ symptoms in over the past year w/ at least 1 in the last 6 months:
- Aggression to people & animals
- Bullies/threatens/intimidates others
- Initiates physical fights
- Uses weapon
- Physically cruel to people/animals
- Stolen items while confronting victim
- Forced someone into sexual activity
- Destruction of property
- Engaged in fire setting
- Destroyed property by other means
- Deceitfulness or theft
- Broken into home/car/building
- Lied to obtain goods/favors
- Stolen items without confronting victim
- Serious violations of rules
- Stays out late at night before 13 years
- Runs away from home overnight at least twice
- Often truant from school before 13 years
Epidemiology of ODD
Prevalence: approx. 3%
Onset usually during preschool years - boys before adolescence
Increased incidence of comorbid substance use & ADHD
Although ODD often precedes CD, most do not develop CD
Epidemiology of CD
Lifetime prevalence: 9%
More common in males
- Males: higher risk of fighting, stealing, fire-setting, & vandalism
- Females: higher risk of lying, running away, prostitution, & substance abuse
High incidence of comorbid ADHD & ODD
- Associated w/ antisocial personality disorder
Treatment of ODD & CD
Behavioral modification, conflict management training, & improving problem-solving skills
Parent management training (PMT) can help w/ setting limits & enforcing consistent rules
- Family therapy is the key
Meds (often used to treat comorbid conditions - ADHD)
What is a tic disorder?
Defined as sudden, rapid, repetitive, stereotyped movements or vocalizations
- Although experienced as involuntary, patients can learn to temporarily suppress tics
- Prior to tic, patients may feel premonitory urge (somatic sensation) w/ subsequent tension release after tic
- Anxiety, excitement, & fatigue can be aggravating factors for tics
This is the only psychiatric disorder that can be diagnosed without the requirement of it affecting life
What are the different types of tic disorders?
Simple tic disorders:
- Motor
- Vocal
Complex tic disorders
Diagnosis of tic disorders
PERSISTENT (chronic) MOTOR OR VOCAL TIC DISORDER
Single or multiple motor or vocal tics, but not both
PROVISIONAL TIC DISORDER
Single or multiple motor and/or vocal tics <1 year
TOURETTE SYNDROME
Most severe of tic disorders
Characterized by multiple motor tics & at least 1 vocal tic lasting for at least 1 year
- Vocal tics may appear many years after the motor tics, may wax & wane in frequency
- Coprolalia: utterance of obscene, taboo words as an abrupt, sharp bark, or grunt
- Echolalia: repeating others’ words
Most common motor tics involve face & head (eye blinking, throat clearing)
Onset prior to age 18 year
Not caused by a substance (e.g. cocaine) or another medical condition (e.g. Huntington’s disease)
Epidemiology of tic disorders
Transient tic behaviors: common in children
Tourette’s disorder: 3/1000 school-age children
Prevalence boys > girls
Onset of tic disorders
Usually slow
If fast, think of PANDAS / PANS
Course/prognosis of tic disorders
Onset typically occurs between 4-6 years
- Peak severity between ages 10-12 years
Tics wax & wane & change in type
Symptoms tend to decrease in adolescence & significantly diminish in adulthood
High comorbidity w/ OCD & ADHD
Treatment of tic disorders
Psychoeducation
Behavioral interventions (habit reversal therapy)
Meds (only used if tics become impairing)
- Alpha-agonists
- Guanfacine (first-choice)
- Clonidine (more sedating)
- In severe cases:
- Second generation (atypical) antipsychotics
- Risperidone
- First generation (typical) antipsychotics
- Pimozide
- Second generation (atypical) antipsychotics
What are elimination disorders?
Characterized by developmentally inappropriate elimination of urine / feces
Though typically involuntary, this may be intentional
Course may be primary (never established continence) or secondary (continence achieved for period & then lost)
Can cause significant distress / impair social / other areas of functioning
Diagnosis of elimination disorders
ENURESIS
Recurrent urination into clothes / bed-wetting
Occurs 2x/week for 3+ consecutive months or results in clinical distress or marked impairment
5+ years old developmentally
Can occur during sleep (nocturnal), waking hours (diurnal), or both
Not due to substance (e.g. diuretic) or another medical condition (e.g. UTI, neurogenic bladder, diabetes)
ENCOPRESIS
Recurrent defecation into inappropriate places (e.g. clothes, floor)
Occurs 1+/month for 3+ months
4+ years old developmentally
Not due to substance (e.g. laxatives), or another medical condition (e.g. hypothyroidism, anal fissure, spinal bifida)
Epidemiology of elimination disorders
Prevalence of enuresis decreases w/ age:
- 5-15% of 5 year old
- 3-5% of 10 year old
- 1% of >15 years
Nocturnal enuresis more common in boys
Diurnal enuresis more common in girls
Prevalence of encopresis: 1% of 5 year old children, boys > girls
Etiology of elimination disorders
Genetic predisposition for nocturnal enuresis:
- About 4x increase risk if maternal
- About 10 x increase if paternal
Psychosocial stressors may contribute to secondary causes
Encopresis: often related to constipation / impaction w/ overflow incontinence
Treatment of elimination disorders
Take into account the high spontaneous remission rates (5-15% per year)
Psychoeducation is key
Only treat symptoms if they are distressing & impairing
PMT for managing intentional elimination
Enuresis:
- Limit fluid intake & caffeine at night
- Behavioral program w/ monitoring & reward system
- Meds (used if above methods are ineffective or for diurnal enuresis):
- Desmopressin (DDAVP) (first-line) (antidiuretic hormone analogue)
- Imipramine (TCA)
Encopresis without constipation:
- Comprehensive behavioral program (“bowel training”) for appropriate elimination
Encopresis due to constipation:
- Initial bowel cleaning followed by stool softeners, high-fiber diet, & toileting routine in conjunction w/ behavioral program
What is child abuse?
Encompasses physical, sexual, emotional, and neglect
Toxic stress may result when children endure prolonged, severe trauma & adversity without buffer of supportive caregivers
Can disrupt child’s development & lead to spectrum of pathologic sequelae
About 1 million cases of child maltreatment in US
- Up to 2500 deaths/year caused by abuse in US
What are the different types of child abuse?
Physical abuse
Sexual abuse
Psychological abuse
Neglect
What is physical abuse?
Any act that results in nonaccidental injury & may be result of severe corporal punishment committed by individual w/ responsibility for the child
Physical exam & x-rays demonstrate multiple, concerning injuries not consistent w/ child’s developmental age
Most common perpetrator is first-degree caregiver (e.g. parent, guardian, mother’s boyfriend)
Red flags for physical abuse
Delayed medical care for injury
Inconsistent explanation of injury
Multiple injuries in various stages of healing
Spiral bone fractures
Bruising patterns consistent w/ hand/belt
Cigarette burns
Head injuries
What is sexual abuse?
Any sexual act involving child intended to provide sexual gratification to individual who has responsibility for child
Sexual abuse is most invasive form of abuse & results in detrimental lifetime effects on victim
Approx. 25% of girls & 9% of boys exposed to sexual abuse
Victim of sexual abuse is typically female
- Perpetrator is usually male & known to victim
Children are most at risk during preadolescence
If child ever reports sexual abuse, it should be taken seriously as it is rarely unfounded
Red flags for sexual abuse
STDs
Recurrent UTIs
Prepubertal vaginal bleeding
Pregnancy
Trauma/bruising/inflammation of genitals/anus
Developmentally inappropriate sexual knowledge / behaviors should raise suspicion
What is psychological abuse
Nonaccidental verbal / symbolic acts that result in psychological damage
What is neglect?
Failure to provide child w/ adequate food, shelter, supervision, medical care, education, and/or affection
Victims of neglect may exhibit poor hygiene, malnutrition, stunted growth, developmental delay, & failure to thrive
Severe deprivation can result in death (infants)
Neglect accounts for majority of cases
Treatment & sequelae of physical abuse
Treatment: early intervention
Sequelae:
- Increased risk of developing PTSD, anxiety, depression, dissociative disorders, self-destructive behaviors, & substance use disorders
- Alcohol is most common drug of abuse by adolescents, followed by cannabis
- Increased risk of continuing abuse cycle w/ their own children
Causes of attachment disorders
Extreme insufficient care
- Primary caregiver
- Neglect
- Emotional needs not met
- Changes in caregivers
What are the types of attachment disorders?
REACTIVE ATTACHMENT DISORDER
Not interested in caregiver (aggressive / irritable)
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
Overly friendly to everyone
What are different mood disorders seen in children?
Depression
Disruptive mood dysregulation disorder
- Bipolar is hardly seen in children
Presentation of depression in children
Irritability is common
Treatment of depression in children
MEDS: SSRIs - Fluoxetine (Prozac) - 8 year old - Escitalopram (Lexapro) - 12 year old TCAs
Presentation of bipolar disorder in children
More frequent mood episodes of shorter duration are more common
Bipolar disorder is harder to stabilize & has more chronic course w/ frequent relapses
VERY hard for child to meet bipolar criteria
What is disruptive mood dysreuglation disorder (DMDD)?
Temper outbursts 3 or more times a week (verbal / physical)
Between outbursts: persistent irritability / anger
DSM-V new diagnosis:
- Constantly irritable mood w/ severe temper outbursts are more likely to develop MDD or GAD later in life, but not Bipolar disorder
- Prevent over diagnosis of Bipolar disorder in children who don’t actually meet full criteria of BPAD
Treatment of bipolar disorder in children
MEDS: Mood stabilizers: - Lithium (FDA approved) - Therapeutic levels: 0.6-1.2 - Valproic acid - Therapeutic levels: 60-120 (100x greater than lithium) - Order blood levels early in the morning (want to see the levels during the trough) - Lamotrigine - Trileptal
Second generation antipsychotics (all FDA approved)
- Aripiprazole (Abilify)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Olanzapine (Zyprexa)
- Asenapine (Saphris)
Combo approach may be required (mood stabilizer + antipsychotic)
What are the types of anxiety related disorders?
GAD
Panic
PTSD
Social anxiety disorder
How do anxiety related disorders present in children?
Usually presents w/ irritability
Treatment of anxiety related disorders in children
THERAPY:
Mainstay of treatment
MEDS: SSRIs - Used most commonly - Not as helpful in PTSD in kids - Fluoxetine (Prozac) - Sertraline (Zoloft) - Fluvoxamine (Luvox) - Duloxetine (Cymbalta)
TCAs or MAOIs
- Less commonly prescribed due to safety issues
- Risk of overdose & serious side effects
- Except for clomipramine (Anafranil) - TCA which is FDA approved in OD & often used if treatment failure w/ SSRI
Benzodiazepines
- Not commonly used due to concerns for abuse potential & impairments in cognitive functioning / memory which could affect learning
- Diazepam (Valium)
How do psychotic disorders present in children?
Common causes of psychotic symptoms include anxiety & meds / drugs
Schizophrenia is rare
Mania of Bipolar disorder often presents suddenly & hallucinations
Treatment of psychotic disorders in children
Atypical antipsychotics
- Used most commonly
Typical antipsychotics
- Less commonly prescribed due to concern for movement disorders / EPS
