Child psych (Brandt) Flashcards
Psychiatric Disorders in Childhood- epidemiology
5-15% of Children have Psychiatric Disorders
Many adult disorders also occur in childhood.
Must know normal development in order to understand abnormal.
Children are constantly changing. What’s normal at one stage may be abnormal at another.
Early intervention is also important.
Growth & Maturation
You must understand a child’s level of: Emotional maturity Intellectual maturity Strengths / protective components in their life Weaknesses / stressors in their life Gender-specific challenges
Who is the Patient?
Recognize that the one whom you might need to treat may be a parent or other loved one.
Be tactful & non-critical.
Parents and child are usually interviewed together & separately.
Observing the family together in order to gain information about the relationships and communication.
Remember that norms vary widely.
Involve the Family & Others
Parents may need to learn behavioral techniques.
They need emotional support.
They need education.
Assure confidentiality – except when there is danger to self or others.
Try to get the child/teen to tell their parents the real issues.
Involve a whole health care team.
- Psychiatrist
- Social worker / teachers
- Psychologist
Never Forget a Physical Exam
Look for congenital abnormalities – high arched palate, low set ears, webbing of fingers, abnormal genitalia & neuroectodermal /skin lesions.
Get Head CT’s or MRI’s when indicated.
Make sure the child has had an eye exam.
Has the child’s hearing been checked?
Do they need Occupational Therapy or Physical Therapy because of motor skills problems? Can the child walk, skip, hop, or even write well?
Learning Disorders
An inability to achieve in reading, writing, or math at a level consistent with one’s IQ
They are diagnosed with formal educational testing.
These disorders often run in families, can be very handicapping, & often have other problems with them: truancy, school refusal, conduct disorder , ADHD or drug use.
Treatment is remedial instruction (tutoring). Most do well.
3 main types:
Reading disorder – formerly called dyslexia (2-8% of kids)
Ratio in males to females is 2-4:1
Mathematics disorder
Disorder of written expression
Attention Deficit Hyperactivity Disorder
KEY: pattern of extreme inattentiveness and/or restlessness
Occurs in at least two settings for at least 6 months with onset before the age of 7 with at least 6 symptoms
3 types: inattentive type; hyperactive-impulsive type; combined
Symptoms of hyperactivity are usually are very obvious by first grade when children are asked to sit still and focus in class.
Symptoms need to be present before age 7.
Treatment of choice is stimulants such as methylphenidate.
Adults can have difficulties at work and thus may need meds.
Estimates are that 60% of the cases persist until adulthood.
3-10% of young & school age children
Male-female ratio is 4:1
Without treatment there are more arrests, suicide attempts, substance abuse, car accidents and poor school/work performance.
DSM-IV Criteria for ADHD
Inattention – 1A (6 or more)
6 or more of 1B:
Hyperactivity - 1B
Impulsivity – 1B
Symptoms that cause impairment were present before age 7 years.
Impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social, school, or work functioning.
The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Inattention – 1A
Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
Often has trouble organizing activities.
Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
Is often easily distracted.
Is often forgetful in daily activities.
Hyperactivity - 1B
Often fidgets with hands or feet or squirms in seat.
Often gets up from seat when remaining in seat is expected.
Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
Often has trouble playing or enjoying leisure activities quietly.
Is often “on the go” or often acts as if “driven by a motor”.
Often talks excessively
Impulsivity – 1B
Often blurts out answers before questions have been finished.
Often has trouble waiting one’s turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).
three types of ADHD are identified:
ADHD,Combined Type: if both criteria 1A and 1B are met for the past 6 months
ADHD,Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
ADHD,Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.
More ADHD facts
Impairment must be in more than one setting.
- Home AND school or work
Etiology – Probably multi-factorial – genetic, environmental, neurobiological and social
Quantitative MRI show prefrontal cortex, basal ganglia & cerebellar abnormalities
Co-morbid disorders are common, seizures, Conduct D/O, Oppositional Defiant D/O or learning disorders
Clinical Management- ADHD
Stimulants are effective for 80% of patients and are first line treatment.
Methylphenidate or mixed amphetamine salts
- Weight-based dosing. Typical 0.5 – 1 mg/kg/day
- Side Effects: Decreased appetite, irritability, insomnia, weight loss, abdominal pain & misuse, abuse/diversion are concerns – Monitor growth & weight & get feedback from teachers.
Nonstimulants – atomoxetine
Alpha 2 agonists – clonidine, guanfacine
Rarely tricyclics or bupropion
Start at lowest recommended dose and increase slowly, as tolerated and indicated
Treatment with stimulants has decreased risk for substance abuse.
Environmental Supports
Parents
- need to learn behavioral management
- limit-setting
- positive reinforcement techniques
School
- Teachers need to understand the disorder
- Minimize distractions
- Divide work into smaller subsets of problems
- Make sure the student masters one topic before moving to the next
Psychotherapy
- Group therapy for social skills and impulse control
