Child Psychiatric Disorders Flashcards
A 10 year old boy with a diagnosis of attention-deficit hyperactivity disorder (ADHD) attends the outpatient psychiatry clinic for review. He was recently started on Methylphenidate to control his symptoms. His behaviour has improved, however, he has developed facial tics which he finds distressing.
Which of the following is the most appropriate drug to switch to for long-term management of his condition?
A. Sertraline
B. Ritalin
C. Melatonin
D. Atomoxetine
E. Risperidone
D. Atomoxetine
In this scenario, the most appropriate drug to switch to for long-term management of ADHD with the development of facial tics would be a non-stimulant medication, such as atomoxetine or guanfacine.
Atomoxetine is a selective norepinephrine reuptake inhibitor that has been approved for the treatment of ADHD. It is effective in reducing the symptoms of ADHD, including hyperactivity, impulsivity, and inattention. It has been shown to have a lower risk of causing tics compared to stimulant medications such as methylphenidate.
Guanfacine is an alpha-2 adrenergic agonist that is also approved for the treatment of ADHD. It has been shown to be effective in reducing symptoms of hyperactivity, impulsivity, and inattention. It is a non-stimulant medication and has been shown to have a lower risk of causing tics compared to stimulant medications.
ADHD triad:
hyperactivity, inattention, impulsivity
DSM-5 criteria for ADHD:
- Inattention - six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level
- Hyperactivity and impulsivity - six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level
In addition to these criteria the following must also be met:
- Several inattentive or hyperactive-impulsive symptoms present before the age of 12 years
- Several symptoms are present in two or more settings
- There is clear evidence that the symptoms interfere with social, school, or work functioning.
- The symptoms are not better explained by another mental disorder
Management of ADHD:
- Conservative:
a) Behavioural techniques
b) Extra support at school. However, ADHD does not generally affect intellectual ability (MDT approach)
-Management should be coordinated by a specialist in ADHD.
-Parental and child education is essential.
-This includes education about parental strategies to manage the child.
-Establishing a healthy diet and exercise can offer significant improvement in symptoms.
-Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician
- Medical:
a) Stimulant medication such as methylphenidate. These medicines have some activity in the frontal lobe thus increasing executive function, attention, and reducing impulsivity.
-Dexamfetamine
-Atomoxetine
what is ADHD?
There is a normal spectrum amongst children and adults in their level of activity throughout the day and night, and their ability to concentrate on a single task for an extended period.
Attention deficit hyperactivity disorder (ADHD) is at the extreme end of “hyperactivity” and inability to concentrate (“attention deficit“). It affects the person’s ability to carry out everyday tasks, develop normal skills and perform well in school.
Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.
ASD mnemonic:
Deficits in BSC:
1. Behaviour
2. Social interactions
C. Communication
ASD features and before what age?
Features vary greatly between individuals along the autistic spectrum. They can be categorised as deficits in social interaction, communication and behaviour. Features are usually observable before the age of 3 years.
- Behaviour
-Greater interest in objects, numbers or patterns than people
-Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
-Intensive and deep interests that are persistent and rigid
-Repetitive behaviour and fixed routines
-Anxiety and distress with experiences outside their normal routine
-Extremely restricted food preferences
- Social Interaction
-Lack of eye contact
-Delay in smiling
-Avoids physical contact
-Unable to read non-verbal cues
-Difficulty establishing friendships
-Not displaying a desire to share attention (i.e. not playing with others)
- Communication
-Delay, absence or regression in language development
-Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
-Difficulty with imaginative or imitative behaviour
-Repetitive use of words or phrases
Diagnosis/management of ASD:
Diagnosis should be made by a specialist in autism. This may be a paediatric psychiatrist or paediatrician with an interest in development and behaviour. A diagnosis can be made before the age of 3 years. It involves a detailed history and assessment of the child’s behaviour and communication.
Management
Autism cannot be cured. Management depends on the severity of the child’s condition. Management involves a multidisciplinary team to provide the best environment and support for the child and parent:
- Child psychology and child and adolescent psychiatry (CAMHS): 1st line: psychosocial play-based intervention (w. play specialists & SALT) eg* E.G. EarlyBird (<5yo), EarlyBird Plus (4-8yo): 3 month programme for parents/carers of autistic children (run by national autism society)
o Applied Behaviour Analysis (ABA) from behavioural nurses
- Speech and language specialists
- Dietician
- Paediatrician
- Social workers
- Specially trained educators and special school environments
- Charities such as the national autistic society
2nd line: pharmacological – used if behaviour making psychosocial training ineffective:
* Antipsychotic medication (review at 3-4 weeks; stop at 6 weeks if no clinical indication)
* Melatonin for sleep difficulties
* Methylphenidate for attention difficulties
* SSRIs for obsessional behaviours
Previous Asperger’s syndrome definition:
(mild): Normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others.
what are the different types of conduct disorder?
- Oppositional-Defiant Disorder (ODD; mild CD, characterised by angry, defiant behaviour to authority)
- Unsocialised CD (significant abnormality with relationships with other children)
- Socialised CD (generally well-integrated into a peer group)
- CD confined to family context
austism screening tools:
ADI-R / Autism Diagnostic Inventory – Revised
ADOS / Autism Diagnostic Observatory Schedule
o Childhood Autism Rating Scale (CARS)
how is chronic sleep-wake cycle disruption treated in those with learning disability?
melatonin (not licensed in <55yr olds, need a psychiatrist prescription)
level of intellectual disability:
o Mild IQ 50-70 ‘20’
o Moderate IQ 35-50 ‘15’
o Severe IQ 20-35 ‘15’
o Profound IQ <20 ‘20’
Investigations for learning disability
o Intellectual impairment:
WAIS III (Wechsler Adult Intelligence Scale) – Verbal IQ + Performance IQ = Full Scale IQ
o Adaptive and social functioning:
ABAS II (Adaptive Behaviour Assessment System)
Clinical interview (leave plenty of time) – establish presence in childhood
Physical examination (sight and hearing)
School reports
A 14 year old girl, who has been doing very well at school and had been physically well, presents to A&E with new onset seizures and her family have noticed that she does not seem to know where she is or what she is doing for some of the days of the last week and she cannot remember simple things. She can switch from crying to laughing within the space of minutes for no apparent reason. She has never had mental health problems and neither has anyone in her family. She has no history of epilepsy or febrile seizures and regains full consciousness between seizures. After full neurological examination and a normal MRI brain, lumbar puncture shows increased lymphocytes in the cerebrospinal fluid. What is the first-line treatment of her condition?
A. Methylprednisolone
B. Plasma exchange
C. Cyclophosphamide
D. Antibiotics
E. Rituximab
A. Methylprednisolone
This girl’s presentation, neuroimaging and lumbar puncture findings are consistent with a diagnosis of autoimmune encephalitis. The first-line treatment of autoimmune encephalitis includes steroids and intravenous immunoglobulin. Plasma exchange can also be used as an adjunctive treatment in those who are not fully responding to steroids or immunoglobulin; it is rarely used alone
viral illness prior to the onset of symptoms, indicative of acute disseminated encephalomyelitis. In this condition, demyelination is a characteristic feature of the illness which develops after any viral illness, or vaccination
Not B: Plasma exchange
The first-line treatment of autoimmune encephalitis includes steroids and intravenous immunoglobulin. Plasma exchange can also be used as an adjunctive treatment in those who are not fully responding to steroids or immunoglobulin; it is rarely used alone
Not C: Cyclophosphamide
The first-line treatment of autoimmune encephalitis includes steroids and intravenous immunoglobulin. Second-line treatment, if patients are not responding within 2 weeks, includes immunosuppressant therapy with agents such as Rituximab and Cyclophosphamide
cyclophosphamide also used for: Churg-Strauss syndrome (eGPA), polyarteritis nodosa, SLE, GVHD, fibrosing lung disease, multiple myeloma
