Child Psychiatry Flashcards
1
Q
What is ADHD?
A
A neurodevelopemental disorder associated with inattention, hyperactivity and impulsivity arising before the age of 6 years
2
Q
What is the DSM-V diagnostic criteria for ADHD?
A
- At least 6 symptoms present for at least 6 months
- Must have started between age 6-12 years
- Must be present in 2 different settings (ie home and school)
- Must be an element of developmental delay
- Must exclude all other causes
5 symptoms if >17
3
Q
What are the DSM-5 subtypes of ADHD?
A
- Inattentive type
- Hyperactive/impulsive type
- Both
4
Q
Why do children with ADHD present to clinic?
A
- Poor school performance
- Disruptive behaviour
- Or both
5
Q
What are the S/S of ADHD?
A
Inattention
Difficulty maintaining focus on particular topic/task
- Ignores instructions
- Easily distracted
- Avoids / can’t sustain tasks
- Lacks organisation
- Forgetful in daily activities
- Loses things
- Does not seem to listen when spoken to directly
Hyperactivity
High level of activity that makes it difficult to sit still / keep from acting impulsively
- Loud / talks excessively
- Energetic / runs around
- Doesn’t wait their turn easily
- Will spontaneously leave their seat when expected to sit
- Interruptive / intrusive
- Answers prematurely, before question has been finished
> Particularly pronounced in places like school
6
Q
What is the aetiology/RFs for ADHD?
A
Cause unknown
- Boys > Girls (3: 1)
- FHx
- Sibling with ADHD
- problems during delivery - Prematurity, LBW, lack of oxygen
- Toxins during pregnancy - smoking, alcohol, heroine
- Conduct/mood disorder
- Autism Spectrum Disorder
- Learning disability
- Antisocial behaviour and depression
7
Q
What are the investigations for ADHD?
A
- Do development assessment and full neurological screen
- Assess social/educational impact in context of age (i.e. making friends if young, dangerous driving if older)
- Rating scales – cannot provide a diagnosis
Conner’s Comprehensive Behaviour Rating Scale; age 6-18
Strengths and Difficulties questionnaire
8
Q
What is the initial management of ADHD?
A
MDT-focussed
Paediatrician, psychiatrist, ADHD SNs, mental health and learning disability trusts, CAMHS, parent groups, social care workers, school/college and school nurses
1st line = following presentation, a period of watchful waiting for 10 weeks
- Self-help, simple behavioural management
- See if symptoms change or resolve over time
Refer to specialist if… severe symptoms, or >10w
9
Q
What is the management for ADHD in children <5yrs?
A
[AFTER A 10w WATCH AND WAIT]
1st line: offer ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral
10
Q
What is the management for ADHD in children >5yrs?
A
[AFTER A 10w WATCH AND WAIT]
1st line: ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral and medications if ADHD persists:
- 1st line = methylphenidate (trial for 6 weeks)
- 2nd line (monitor SEs) = lisdexamphetamine (3rd line if side effects)
- 3rd line = dexamphetamine
- 4th line = atomoxetine (NARI) or guanfacine
3rd line: CBT if problems in… social skills, self-control, active listening, dealing with expressing feelings
11
Q
What other medications can be used in ADHD?
A
Clonidine > sleep disturbance, rages or tics
Antipsychotics > aggression and irritability
12
Q
What is a SE of methylphenidate?
A
Stunted growth
13
Q
What needs to be monitored during ADHD treatment?
A
Baseline:
Height, weight, HR, BP and ECG
Monitor:
- Response with symptom rating scales (e.g. Conner’s)
- Development of tics after taking stimulant medication
- Sexual dysfunction, seizures, sleep disturbance and worsening behaviour
- Measure weight every 3m (<10yo) or 6m (>10yo)
- Measure height, HR and BP every 6 months (may suppress appetite and cause growth impairment)
- Include plotting on a growth chart
- If interruptions to growth > referral and a planned break to allow catch-up growth
- Drugs cardiotoxic so refer to cardiologist if concerns
14
Q
What dietary advice should be given to patients with ADHD?
A
n.b. no dietary interventions are particularly evidence-based
- Stress importance of balance diet and regular exercise
- Explore foods that seem to influence behaviour (recommend keeping a food diary)
- Dietician referral if relationship with certain foods is observed in the diary
15
Q
What is the prognosis of ADHD?
A
- Manifestation of ADHD will change as the child gets older
- Hyperactivity tends to become less of a problem
- Inattention becomes more pronounced as the tasks they face become more complex
Outcome:
- Some may grow out of it
- 90% get conduct disorder if untreated
- 15% have ADHD as an adult
16
Q
What is autism spectrum disorder (ASD)?
A
A neurodevelopmental condition characterised by deficits in… (evident when <3yo):
- Verbal and non-verbal communication
- Reciprocal social interaction
- Restrictive or repetitive behaviours/interests
17
Q
What is the epidemiology of ASD?
A
- Presents at 2-4yo (when language and social skills normally rapidly expand)
- Most have decreased IQ (savant syndrome is very rare)
- May occur in association with any level of general intellectual/learning disability
- Ranges from subtle problems of understanding and impaired social function to severe disabilities
- M > F
18
Q
What are the RFs for ASD?
A
- Genetics (chromosomal abnormalities e.g. Down’s / gene defects e.g. Fragile X)
- M > F (75% - 25%)
- Sibling with ASD
- Birth CNS defect
- Premature
- Parental psychotic/affective disorder
- Sodium valproate
- Learning disability
- ADHD
- HIE
- Older parents
19
Q
What is the diagnostic criteria for ASD?
A
(A) Abnormal / impaired development evident ≤3yrs
- Receptive or expressive language
- Development of selective social attachments or of reciprocal social interaction
- Functional or symbolic play
(B) ≥6 symptoms:
(1) Impairment in social interaction (≥2)
- Failure adequately to use eye-to-eye gaze
- Failure to develop peer relationships
- Lack of socio-emotional reciprocity
- Lack of spontaneous seeking to share enjoyment, interests, etc. with other people
(2) Abnormalities in communication (≥1); e.g.
- Delay in or total lack of, development of spoken language (no attempt to compensate)
- Relative failure to initiate or sustain conversation
- Stereotyped and repetitive use of language or idiosyncratic use of words or phrases;
- Lack of varied spontaneous make-believe play
- Echolalia
(3) Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities (≥1); e.g.
- Preoccupation with stereotyped and restricted patterns of interest
- Apparently compulsive adherence to specific routines or rituals e.g. same meal each day
- Repetitive motor mannerisms involving hand, finger flapping and whole-body movements
- Preoccupations with non-functional elements of play materials (such as their odour)
(C) The clinical picture is not better described by other medical disorder
20
Q
What are the investigations for ASD?
A
Specialist diagnosis required > Refer to specialist (CAMHS, developmental paediatrician)
- History from parent
- History from nursery
- Physical exam to exclude physical causes and establish baseline
Autism diagnosis and assessment – GOLD-STANDARD
- ADI-R (Autism Diagnostic Inventory – Revised)
- ADOS (Autism Diagnostic Observation Schedule)
- Childhood Autism Rating Scale (CARS)
Learning difficulties assessment:
- Wechsler Intelligence Scale for Children (WISC) or Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
- Conner’s rating scale (6-18yrs)
21
Q
What is the management for ASD?
A
MDT / Patient-Centred care is key
- A spectrum, so everyone is different > individualise management plan
- MDT: paediatrician, child, adolescent psychiatrist, educational or clinical psychologist, SALT, OT, specialist health visitor / social worker, specialist nurse (SN)
Early education and behavioural interventions:
- Applied behavioural analysis (ABA) - therapy that helps kids with autism lessen problematic behaviour
- Early Start Denver Model (ESDM) - play based therapy for kids aged 12-48 months to help develop communication skills, play skills, language skills
- More Than Words - for parents to learn techniques how to encourage kids to communicate
- Adjust the social and physical environment to suit the child (i.e. lighting, noise levels, visual support)
Family Interventions:
- Support
- Parental education
- Involving parents in therapy plan
- Discuss need for education, health and care (EHC) plan assessment with nursery/school/GP/community paeditrician
22
Q
What pharmacological management can be used for ASD?
A
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
23
Q
What is conduct disorder?
A
Disorder of childhood or adolescence (below age of 18) characterized by a repetitive and persistent pattern of antisocial behaviours, which violate the basic right of others and are out of keeping with age-appropriate social norms.
24
Q
What is the aetiology of conduct disorder?
A
Exact unknown. Theories suggested include the following:
Parental
- Violence
- Failure to set rules
- Alcoholism
- Antisocial PD
- Divorce
- Rejection
Child
- Difficult temperament
- Low IQ
- Neurological impairment
- ADHD
- Substance misuse
- In the care system
- Deprived area
25
What are the different types of conduct disorder?
**<10yo**
- Oppositional-Defiant Disorder (ODD; mild CD, characterised by angry, defiant behaviour to authority)
**>10yo**
- Unsocialised CD (significant abnormality with relationships with other children)
- Socialised CD (generally well-integrated into a peer group)
- CD confined to family context
26
What are the S/S of conduct disorder?
**Repetitive and persistent (>6 months) pattern of dissocial, aggressive, or defiant conduct**, e.g.
- Excessive levels of fighting or bullying
- Cruelty to other people or animals
- Severe destructiveness of property
- Fire-setting
More severe than ordinary childish mischief or adolescent rebelliousness
In the absence of features suggestive of another medical diagnosis (i.e. ADHD)
27
What are the investigations for conduct disorder?
- Reports from parents, teachers, etc.
- Developmental assessment
28
What is the management of conduct disorder?
(no medication is used in the UK)
**1st line = parent management training programmes** (e.g. Webster-Stratton, Triple-P)
- Needs strong parental cooperation and motivation
- If weak outcome due to lack of parental engagement, move to 2nd line
**2nd line = child individual or group interventions focussed on problem-solving and anger management**
- Often, affected children do not have the motivation to engage with these well
**Also:**
- Remedial educational teaching (for missed school)
- Alternative peer activities
29
What is the prognosis of conduct disorder?
*50% develop antisocial personality disorder*
**Poorer prognosis:**
- Early onset
- Low IQ
- Co-morbidities
- Family criminal record
- Low socio-economic status
- Poor parenting
30
What is a learning disability?
Impairment of the CNS originating during the developmental period, which usually presents during early childhood with a below-average intellectual performance and reduced ability to acquire life/adaptive skills resulting in social handicap.
- IQ <70
- Impaired social / adaptive functioning
- Onset in childhood
N.B. psychiatric and physical illness may present atypically in people with learning disability since they may have sensory, communication and cognitive problems
31
What are the different types of learning problem?
**Impairment** = any loss or abnormality of psychological, physiological or anatomical structure or function
**Disability** = any restriction or lack of ability (from impairment) to perform an activity considered normal
**Handicap** = a disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal
32
What are the severities of learning disability?
**Mild**
- IQ = 50-69
- Onset = school age
- Features = limited in school work, but able to live alone and maintain some form of paid employment later in life
- Cause = often no specific cause
**Moderate**
- IQ = 35-49
- Onset = 3-5yrs
- Features = Able to do simple work with support, needs guidance or support in daily living
**Severe**
- IQ = 20-34
- Onset = <2yrs
- Features = requires help with daily tasks and capable of only simple speech
- Cause = specific cause (brain damage, genetics)
**Profound**
- IQ = <20
- Onset = <2yrs
- Features = very disabled in all aspects
33
What is the aetiology of a learning disability?
- Genetics - Down's > Fragile X
- Structural developmental abnormalities - Hydrocephalus
- Secondary to brain damage
Antenatal (infection, toxic, hypoxic, maternal disease)
Perinatal (birth asphyxia, intracranial bleed)
Postnatal (infection, injury, epilepsy, hypothyroidism)
34
What are the S/S of Fragile X?
- High forehead
- Low set ears
35
What are the associations/RFs of a learning disability?
- Social and educational deprivation
- Low parental intellect
- Co-morbid conditions include: epilepsy, autism, cerebral palsy, hearing, visual and physical impairments, psychiatric disorder
36
How can learning disability be prevented?
- Parental Education (e.g. risks of alcohol during pregnancy)
- Improved antenatal/perinatal care
- Genetic counselling
- Early detection and treatment of reversible causes (e.g. excluding phenylalanine in babies with PKU)
37
What are the S/S of a learning disability?
**Children**
- Delay in usual development (e.g sitting up, walking, speaking, toilet training)
- Difficulty in managing school work as well as other children
- Behavioural problems
- Poor sleep-wake cycle
**Adolescents**
- Difficulties with peers, leading to social isolation
- Inappropriate sexual behaviour
- Difficulty in making the transition to adulthood
**Adults**
- Difficulties in everyday functioning, require extra support (e.g. cooking and cleaning, filling in forms, handling money)
- Problems with normal social development and establishing an independent life in adulthood (e.g. finding work, marriage, child-rearing)
38
What are the investigations for a learning disability?
**Assessment:**
- Collateral history from family/carer is essential
- Enquire about problems antenatally/perinatally/postnatally
- Ask about family history of LD
- Take thorough childhood history, including developmental milestones
- Assessment of functioning and life skills
- Neuropsychological assessment including IQ testing
- Consider associated problems (epilepsy, neurological and physical disabilities)
**Intellectual impairment:**
- IQ test - WICS-V and Full Scale Intelligence Quotient (FSIQ)
**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
**Check for other conditions and disorders:**
- Poor diet and obesity
- Epilepsy
- Sensory impairment
- Schizophrenia - 3% prevalence
- Mood disorders - 4x more likely to have depression
- Autism - 75% of ASD have a learning disability
39
What is the management of a LD?
*Biopsychosocial MDT (psychiatrist, OT, SALT, specialist nurse, educational support, social support)*
**General help:**
- Scheduling board (wake up, clean teeth, etc.)
- Self-help board (steps to get dressed)
- Communication aids
**Treat physical / psychiatric comorbidity**
- Annual physical health checks should be offered
- Mental health problems can be difficult to diagnose because of cognitive, language and communication difficulties
- Patients may be particularly sensitive to medications so slower dose titration and careful monitoring maybe required
**Educational Support**
- Statement of Special Educational Needs allow appropriate support
- This may be in mainstream or specialised schools
- The aim is to maximise the child's potential
**Psychological Therapy**
- May include counselling, group therapy and modified CBT
- Behavioural therapy - helps improve unhelpful behaviour patterns
**Medications** – start low, go slow
- Melatonin – helps with poor sleep-wake cycles
**Other support**
- Support network is needed to provide specific help with daily living, housing, employment and finances
- Assess carers' needs
- Information to family and carers about support groups – depends on cause of LD, i.e. CP:
SCOPE disability charity
www.cerebralpalsy.org.uk
Reasonable Adjustment (disability act, 1995)
40
What are the complications of a LD?
- Higher prevalence of psychological symptoms than general population
- Difficulty diagnosing other psychological conditions due to language difficulties and atypical presentations (i.e. schizophrenia may present with simple repetitive hallucinations and persecutory delusions)
- Prognosis – chronic problems but handicap can be modified by social support
- More likely to have poor diet and be obese
41
What is bullying?
Unwanted, aggressive behaviour, involving real/perceived social power imbalance
Repeated behaviour, purposeful actions intended to hurt or make the victim feel uncomfortable
42
What are the S/S of being bullied?
- Injuries or illness without plausible explanation
- Lost or damaged belongings – books, clothes
- Somatic symptoms – changes in habit, nightmares
- Avoidance of school or social situations
- Feeling of helplessness or decreased self-esteem
- Self-harm or suicide intent
43
What are the investigations for bullying?
- Recognise the problem to the child and identify bullying interactions at an early stage
- Assess risk and protective factors (i.e. depression, suicide risk, sources of internal and external resilience)
44
What is the management of bullying?
- Prevention is the best intervention
- Multistep process to address the bullying – teach children not to bully, improve supervision
- Engage the victim – assure child that bullying is not their fault, work with the school, ask to include parents
- Engage the bully – explore the behaviour (don’t label as bully), understand viewpoints, set boundaries
- Team approach – parents involved, family therapy, school anti-bully policy
45
What are complications of bullying?
- Perpetual isolation, general mistrust of people, self-harm
- Can have long-term psychological impact
46
What is the management of depression in children?
- 1st line: CBT or other psychological therapies
- Antidepressants are only used in severe cases
- Fluoxetine is the safest option in children
- Good prognosis
47
What is the management of anxiety disorders in children?
Psychological therapies are the mainstay of treatment e.g. Counselling and CBT
48
What is chronic insomnia?
Defined as difficulty getting to sleep or maintaining sleep on 3 or more nights of the week for 3 months
49
What are the investigations for chronic insomnia?
- Sleep diary and actigraphy
- Identify potential causes (e.g. depression and anxiety)
50
What is the management of chronic insomnia?
1. **Advice** - sleep hygiene, don't drive when tired
2. **Hypnotics** (only if impairment is severe)
- Recommended hypnotics include short-acting BZN (e.g. temazepam) or non-BZN (e.g. zopiclone)
- Use lowest effective dose for shortest duration
- Review after 2 weeks and consider referral for CBT
3. **CBT-I** for insomnia
51
What are the SEs of methylphenidate?
Abdominal pain, nausea, dyspepsia
52
What are the SEs of sleeping pills?
- Daytime sedation
- Poor motor coordination
- Cognitive impairment
- Addiction
53
How is WISC-V interpreted
130 = extremely high
120-129 = very high
110-119 = high average
90-109 = average
80-89 = low average
70-79 = very low
<69 = extremely low
