Child Psychiatry Flashcards
What is autism?
A pervasive developmental disorder
Characterised by a triad of impairment in social interaction, impairment in communication, and restricted, stereotype interests and behaviours.
What is the prenatal aetiology of autism?
Genetics e.g. chromosome 7
Older parental age
Drugs e.g. sodium valproate
Prenatal viral infections e.g. rubella
What is the antenatal aetiology of autism?
Obstetric complications e.g. hypoxia during childbirth
Decrease GA at birth
Low birthweight
What is the postnatal aetiology of autism?
Toxins such as lead and mercury
Pesticide exposure
No proven link between the MMR vaccine and autism!
What are the risk factors for autism?
Male 4x more likely to be affected Genetics/family history Advanced parental age Parental psychiatric disorders e.g. schizophrenia Prematurity - before 35 weeks Maternal medication e.g. SV
What are the features of autism?
ABC
Asocial - few social gestures, lack of eye contact, social smile, response to name, interest in others.
Behaviour restricted - rocking, twisting, upset at any change of daily routine, same foods, play same games, fascination with sensory aspects
Communication impaired - distorted or delayed speech, echolalia - repetition of words
Onset of autism before age of 3 years. Atypical autism after 3.
intellectual disability can occur, temper tantrums, impulsivity, cognitive impairment.
What other conditions are associated with autism?
Epileptic seizures - 20% Visual impairment Hearing impairment Infections Pica - eating inedible objects Constipation Sleep disorders Underlying medical conditions e.g. PKU, fragile X, CMV, congenital rubella Psychiatric disorders - depression, bipolar, psychosis, OCD
What questions can be asked in a history of autism?
Child ever engage in pretend play alone or with others
Does the child struggle to interact or make friends
Have you noticed them making any abnormal movements e.g. flapping hands, walking on tiptoes
Do they struggle to communicate, is speech monotonous or repetitive
Do you have any concerns about your child’s development
What is the ICD10 criteria for the diagnosis of autism?
A. Presence of abnormal or impaired development before the age of 3
B. Qualitative abnormalities in social interaction
C. Qualitative abnormalities in communication
D. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities.
E. The clinical picture is not attributable to other varieties of pervasive development disorder
What is seen on MSE in autism?
Appearance and Behaviour
Ritualised, clapping, rocking, poor eye contact, lack of facial expression
Speech
Delayed, difficulty initiating and maintaining conversation, repetitive language, unusual rate, rhythm and tone
Mood
Normal or erratic mood changes
Thought
Obsessions and compulsions
Intense preoccupation with special interests
Perception
Sensitive to noise, touch, smell
Cognition
Impaired attention
May concentrate on special interests
Insight
May be poor
May be distressed if aware the don’t fit in
What are the investigations for autism?
Full developmental history FH, pregnancy, birth, PMH Developmental milestones Daily living skills Assessment of communication, interaction and behaviour
Hearing tests if required
Screening tools inc CHAT Checklist for Autism in Toddlers
What are the differentials for autism?
Asperger's Rett's Childhood disintegrative disorder Learning disability Deafness Childhood schizophrenia
What is Asperger’s?
Similar to autism
Abnormalities in social interaction
Restricted stereotyped repetitive interests and behaviours
No impairment in language, cognition or intelligence
IQ normal
More prevalent in boys
What is Rett’s syndrome?
Severe progressive disorder Starts early in life Results in language impairment, repetitive stereotyped hand movements, loss of fine motor skills irregular breathing and seizures Almost exclusively seen in girls
What is Heller’s syndrome?
Childhood disintegrative disorder
Two years of normal development followed by loss of previously learned skills
Associated with repetitive, stereotyped interests and behaviours
Cognitive deterioration
What is the general management of autism?
Diagnosis be specialist
Local autism MDT teams and a key worker to manage
Speech and language, OT, educational psychologists
CBT
Interventions for life skills to support daily living, coping strategies, enable access to education and community facilities e.g. for sport
Address needs of physical, mental health and behaviour
Families offered support
Special schools
Melatonin for sleep disorders
What are the interventions for the core features of autism?
Social-communication intervention - play based strategies.
Do not use pharmacological agents
What are the interventions for challenging behaviour in autism?
Treat co-existing physical disorders e.g. epilepsy, constipation, mental health problems, behavioural problems
Modification of environmental factors e.g. lighting, noise, social circumstances
Antipsychotics e.g. risperidone considered when psychosocial interventions insufficient or features are severe
What is the bio-psychosocial management of autism?
Biological
Treat co-existing disorders
Antipsychotics for behaviour
Melatonin
Psychological
Psychoeducation for families
Assessment of behaviour etc
CBT
Social Modification of environmental factors Social-communication intervention Self-help groups Special schooling
What is ADHD characterised by?
Inattention, Hyperactivity and Impulsivity
+
Early onset, persistent, present in >1 situation
+
More frequent and severe than comparable individuals
How common is ADHD?
2.4% prevalence
What can cause ADHD?
Genetic - DRD4/5 gene
Neurochemical - dopaminergic pathway changes
Neurodevelopmental - pre-frontal cortex abnormalities
Social - Drug/alcohol in parents, social deprivation
How is ADHD diagnosed?
Assessment by CAMHS to observe child, talk to parents and teachers and looking at school reports
DIVA test is used to judge symptoms
To be diagnosed, symptoms must interfere with performance
What inattentive signs are typical of ADHD?
Distracted so doesnt finish tasks Avoid tasks that req. concentration for a long time Doesnt listen Lose and forget belongings Trouble organising tasks
What hyperactivity/impulsive signs are typical of ADHD?
Fidget and restless Doesn't engage in quiet activities Temper tantrums and aggression Doesnt wait their turn Talk lots, interrupt others, blurt out answers at school
What is hyperkinetic disorder?
ADHD
Attention deficit hyperactivity disorder
Early onset, persistent pattern of inattention, hyperactivity and impulsivity.
What is the aetiology of ADHD?
Genetic predisposition
Neurochemical - reports of link between hyperkinetic disorder and genes coding for dopaminergic pathways
Neurodevelopment abnormalities in the pre-frontal cortex
Social deprivation, family conflict, parental cannabis and alcohol exposure
What are the risk factors for hyperkinetic disorder?
Male - 3x more likely
Family history
Environmental risk factors such as social deprivation, cannabis and alcohol
What are the three core features of hyperkinetic disorder?
Inattention - not listening, distractable, reluctant to engage, forgetting or regularly losing belongings
Hyperactivity - restless, reckless, running and jumping around inappropriate places, cannot engage in quiet activities, excessive talking
Impulsivity - difficulty waiting turn, interrupting others, blurt out answers, disobedient, temper tantrums
What is the ICD-10 criteria for hyperkinetic disorder?
Abnormality of attention, activity and impulsivity at home.
Also at school or nursery
Directly observed abnormality of attention or activity
Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
Onset before 7
Duration >6 months
IQ above 50
What can be asked in the history of hyperkinetic disorder?
Inattention - reluctant to engage, leaves activities unfinished, loses stuff, does not listen when spoken to
Hyperactivity - constantly fidgeting, jumping, running, cannot sit still
Impulsivity - cannot wait turn, blurts out answers
What is important in an assessment of hyperkinetic disorder?
Observe child - overawed by clinical context, may interrupt parents
Speak to child - do they make eye contact, offer them a toy are they easily distracted
Speak to parents
What is observed on an MSE in hyperkinetic disorder?
Appearance and Behaviour - fidgety, unable to sit still, running, jumping, climbing
Speech - loud, at inappropriate times, makes inexcessive noise
Mood - normal, may be low if co-morbid depressive disorder
No disorders or hallucinations
Poor attention levels, lac of concentration
Poor insight
What are the investigations for hyperkinetic disorder?
Blood tests including TFTs to rule out thyroid disease
Hearing tests - examine middle and inner ear
Rating scales
What are the differentials for hyperkinetic disorder?
Learning disabiltiy, dyslexia Oppositional defiant disorder Conduct disorder Autism Sleep disorders Mood disorders Anxiety disorder Hearing impairment
What is conduct disorder?
A repetitive and severe pattern of antisocial behaviour including aggression, destruction of property, deceitfulness and major violations of age-appropriate expectations.
What are the risk factors for conduct disorder?
Male
Abuse as a child
Poor SE status
Parental psychiatric disorders
What is oppositional defiant disorder?
Defiant and disruptive behaviour against authoritative figures, but less severe than conduct disorder.
Violations of law and physical abuse is less common.
When should those presenting with ADHD symptoms be referred?
If problems are having adverse impact on development;
Watchful waiting up to 10 weeks
Referral to group based focused support and don’t wait for formal diagnosis
If persist, specialist referral
In adults should refer if evidence began in childhood, persisted throughout life, not explained by other psychiatric diagnoses
What are the general principles of management of ADHD?
Written information about self help, support groups e.g. Mind, AADDUK
Discussion from professional - positives of diagnosis, effects, education, effect on driving, goals, treatment plan and pregerence
Parent-training and education programmes, in school goers - psychoeducation and CBT
What pharmacological management can be offered for ADHD?
Not recommended for pre-school, in school age is reserved if persisting significant impairment
Methylphenidate (Ritalin) offered first line, or lisdexamfetamine, dexamfetamine.
CNS stimulants contribute to impulse control
What is a learning disability?
State of arrested or incomplete development of the mind.
Characterised by impairment of skills manifested during the developmental period.
What triad must exist to constitute a learning disability?
Low intellectual performance, IQ below 70
Onset at birth or during early childhood
Wide range of functional impairment including social handicap due to reduced ability to acquire adaptive skills
What can some of the causes of a learning distability be due to?
Genetic - Down’s, fragile X, prader-willi, hydrocephaly
Antenatal - CMV, infection, nutritional deficiency, physical damage, pre-eclampsia
Perinatal - birth asphyxia, intraventricular haemorrhage, neonatal sepsis
Environmental - malnutrition, non accidental injury, neglect
Psychiatric - autism, Rett’s
What are the clinical features of a mild LD?
Identified at later age at school
Adequate language abilities, social skills and self-care
May be difficulties in academic work
What are the clinical features of moderate lD?
Able to communicate but language is limited
May need supervision for self-care but able to do simple work
What are the clinical features of a severe LD?
Marked degree of motor impairment, little or no speech in early childhood
May eventually use simple communication
May have associated physical disorders
What are the clinical features of profound LD?
Severe motor impairment and severe difficulties in communication
Little or no self care
Freq have physical disorders and require residential care
Presentation of GAD in children
Anxiety
Fears of death of themselves or others
Somatic manidestations - Nausea, abdopain, sickness, headaches, sweating, palpitations, tension
Panic attacks - sudden, extreme fear, physical symptoms, faintness
Presentation of separation anxiety
Fear of or anxiety with separation from attachment figure
Somatic manifestation
Nightmares
School refusal.
Management of anxiety disorders in children
Behaviour - systemic desensitisation, flooding (expose to painful memory (fast systematic densensitization), response prevention
Psychotherapy - brief dynamic, family and cognitive therapy
Anxiolytics (last resort include beta blockers and diazepam)
Management for Depression in children
CBT, Fluoxitine
List 3 child factors that promote resilience
Easy temperament and good nature Female (prior to adolescence) Male (during adolescence) Higher IQ Good social skills Empathetic Humour Self-aware of strengths and limitations
List 3 family factors that promote resilience
Warm and supportive parents
Good parent-child relationship
Parental harmony
Valued social role
List 3 environmental factors that promote resilience
Supportive extended family Successful school experience Valued social role Extracurricular activities Member of faith/religious community
What is the importance of resilience in regards to child mental health?
Enhances formulation
Recognises resources the child/family can use
May prevent or inhibit development of mental disorders
How can child attachments be categorised?
Secure Insecure (avoidant) Insecure (anxious) Insecure (ambivalent) Disorganised
What is the ICD-10 criteria for conduct disorder?
1+ features at a marked level for over 6 months
What routine interventions exist for conduct disorder?
Group parent training programmes - for 3-11years
Functional family therapy
Multi systemic therapy - family-based, including school and community
Child-focused programmes
When are pharmacological interventions to be considered in conduct disorder?
Risperidone is considered for short-term management of severely aggressive behaviour in conduct disorder with explore anger and severe emotional dysregulation.
What are the side effects of Risperidone?
Metabolic: weight gain, diabetes
EPSE: akathisia, dyskinesia, dystonia
CV: QTc prolongation
Hormonal: increased PRL
What are pervasive developmental disorders?
Group of disorders characterised by delays in the development of multiple basic functions including socialisation and communication.
Examples include autism, Asperger’s, Rett syndrome
Autistic spectrum
What is specific developmental disorders?
Classification of disorders characterised by delayed development in one specific area.
Specific speech articulation
Receptive language disorder
Expressive language disorder
Specific reading or spelling disorder
What occurs in methylphenidate toxicity?
Those similar to acute amphetamine intoxication
Euphoria, delirium, confusion, toxic psychosis
Hallucinations
Name 3 side effects of atomoxetine
Anorexia Dry mouth NaV Headache Fatigue
What is the indication for atomoxetine?
ADHD
What skills may be impaired in someone with a learning disability?
Cognition
Language
Motor skills
Social skills
Differentiate between impairment, disability, and handicap
Impairment: Any loss/abnormality of psychological, physiological or anatomical structure or function.
Disability: Any restriction/lack of ability to perform an action in a normal manner or range.
Handicap: A disadvantage for a given individual, resulting from impairment or disability that limits/prevents the normal fulfilment of a role.
List three physical associated problems of learning disabilities
Motor and mobility problems Speech, hearing and visual impairment Epilepsy Urinary and faecal incontinence Increased risk of obesity and fractures Poor oral health Poor diet, constipation, GORD Sleep disorders Premature death
Name 3 common comorbid psychiatric disorders seen in people with learning disabilities
Schizophrenia Anxiety disorders Depressive disorders Bipolar affective disorder Personality disorders Early-onset dementia Autism ADHD
How does schizophrenia present differently in people with learning disabilities?
Prevalence is 3x greater
Earlier age of onset (23yr)
More commonly associated with epilepsy, negative symptoms, and impaired episodic memory
What additional symptoms may present in schizophrenia of severe learning disability?
Unexplained aggression
Bizarre behaviour
Mood lability
Increased mannerisms and stereotypes
How does bipolar affective disorder present differently in people with Learning disabilities?
Prevalence is greater (2-12%)
More difficult to diagnose if severe LD also present
How does depressive disorder present differently in people with Learning disabilities?
Commonly missed
More marked biological features, with diurnal variation
Suicidal ideation is less frequent in severe LD
List five associated behavioural problems alongside learning disabilities
Difficulty accessing care and support
Poor self-care: hygiene, diet, exercise, physical and mental health
Lack of supportive social network
Lack of regular employment and income
Boredom
Harmless behaviour interpreted as aggression
Temper tantrums
Criminal activity due to challenging behaviour or misunderstanding
Challenging behaviour
Communication difficulties, ASD, sensory impairment
What types of behavioural disorders are seen in the LD population?
Aggression and antisocial Social withdrawal Stereotypic behaviours Hyperactive disruptive behaviours Repetitive communication disturbance Anxiety/fearfulness
Name 3 interventions can be used in behavioural disorders
Educational and social intervention
Facilitating communicate needs - e.g. hearing aid
Behavioural intervention - reinforcement
Psychotherapy
Pharmacological treatment for comorbidities
Physical intervention - protect individual and others
Outline the co-occurrence of epilepsy and LD
Epilepsy is more in patients with LD of various causes. May be due to shared aetiologies. Frequent epileptic seizures may lead to (or worsen) permanent loss of intellectual functioning. Therefore, early diagnosis and treatment is essential to prevent fatal progression.
What problem arises in the management of epilepsy if severe LD is present?
A person with a severe learning disability is more likely to have side-effects than someone with a milder learning disability.
Describe the cautions of using pharmacological treatment in people with LD
Presence of any comorbid physical disorders (e.g. epilepsy, constipation, cerebral palsy) increase the likelihood of side effects.
Atypical responses are more common ➔ advise lower doses and gradual increases in medication. Evidence base is lacking in LD population
What are the indications for antipsychotics in people with LD?
Comorbid psychiatric disorders (e.g. schizophrenia)
Acute behavioural disturbances
What are the indications for antidepressants in people with LD?
Depression
OCD
Anxiety disorders
Violence, self-injury, and non-specific distress
What are the indications for Lithium in people with LD?
Bipolar affective disorder
Augmentation of antidepressant therapy
Some effect in reducing aggressive outbursts
How should cognitive therapies and CBT be delivered to the LD population?
Borderline/mild/moderate LD: Cognitive approaches may be adapted to level of intellectual impairment.
What is the aim of behavioural treatments in learning disabilities?
Teach basic skills: feeding, dressing
Establish normal behaviour patterns: sleep
Teach more complex skills: social skills, relaxation
Alter maladaptive pattens of behaviour: phobias, disinhibition etc.
