Child Psychiatry Flashcards
What are the 4 requirements in the DSM5 for defining Intellectual disabilities [previously MR]?
- deficits in intellectual functioning
- reasoning, problem-solving, planning, abstract, judgement, academics, learning
- determined by clinical assessment and standardized instruments
- scores below 2 SD - deficits in adaptive functioning
- limited function in 1 activity of daily living [communication, social, independent living]
- determined by clinical assessment and standardized instrument - onset must be in the developmental period
- SEVERITY is based on ADAPTIVE, not intellectual scores
What is the overall population prevalence of ID?
What sex is more affected in general?
Which sex is more affected in severe forms?
1% of the population has intellectual disability
Males are affected 1.6 :1
Severe forms M:F is 1.2:1
A child showed no obvious conceptual differences in preschool, but by school age, he needed help to attain academic skills appropriate to age. In adulthood he has impaired abstract thinking, executive function, short-term memory.
His speech is similar to his peers, although a little socially immature. He has difficulty with emotion/behavior regulation and can be very gullible.
He is able to eat, dress, bathe and overall care for himself, but he needs some assistance with shopping, food prep and finances.
He has a job at the grocery store.
Is this mild, moderate, severe, or profound intellectual disability?
Mild
A girl showed slower development in preschool and went to school through low elementary level. She needs assistance for all conceptual tasks of daily life.
Socially, she has less complex speech than peers, but is able to have friendships. She is limited in social judgement skills.
Growing up she struggled, but by adulthood she is able to perform most personal care but needs reminders and teaching. She is able to ride the bus and make purchases on her own.
She sweeps the floor at her church for a job but needed extended training and gets continued support.
Is this mild, moderate, severe or profound ID?
Moderate
A boy has limited understanding of written language and numbers and needs extensive help for all problem-solving.
His speech is restricted to single words and phrases but he is able to communicate desires. He has a close bond with family and familiar individuals.
He requires supervision at all times. Occassionally he has maladaptive behavior and does self-injury.
Is this mild, moderate, severe or profound ID?
Severe
A girl has minimal/no understanding of language/numbers. She cannot understand speech or gestures and expresses desires through non-verbal, non-symbolic communication. She requires supervision at ALL TIMES and needs complete assistance for all self care.
She is soothed by music and likes to watch videos and go to the pool.
Is this mild, moderate, severe, or profound ID?
Profound
James is less than 5 years old and has not met the appropriate developmental milestones in several areas of intellectual functioning. He cannot undergo systematic assessment because he is too young.
What is this classification and what is the next step?
Global developmental delay
- reassess in the future
Sally is 12 with intellectual disabilities. She cannot be adequately assessed because of physical/ sensory impairments.
What is this called and what are the next steps?
Unspecified Intellectual Disability [itellectual development disorder]
This category requires future assessment of the patient
What is a specific learning disorder?
- difficulties in acquiring or using reading, writing, math skills appropriate for age/grade
- symptoms for 6months, despite intervention that target the difficulty
- skills below expected for age that causes interference in functioning, confirmed by standardized achievement measures
- NOT accounted for by ID, lack of education, another mental, neuro, medical disorder
What are the 2 symptom domains of autism spectrum disorders?
- social communication domain
2. restricted interests/repetitive behaviors
For a child to have autism spectrum disorder, he must have deficits in all three of what social communication interactions?
- social-emotional reciprocity = failure for back&forth convo
- nonverbal communicative behaviors for social interaction
- bad eye contact
- poor body language
- not understanding gestures - developing, maintaining, and understanding relationships
Bob is unable to have back in forth conversations in multiple social interactions and settings. He has abnormal eye contact and body language. He has a difficult time making friends because he doesn’t adjust behavior to the social setting.
He is constantly ordering his blocks from smallest to largest. He insists to his mom that he needs to have an apple and peanuts everyday in a green ziploc. He is preoccupied with the train schedules and has them memorized. Sometimes he will stand in the corner and stroke a fleece sweater or will stare at the lights.
These features presented early in development and impair his social interactions at school. He does well on standardized tests.
What does Bob have?
autism spectrum disorder
Alex has difficulty with verbal and non-verbal communication in social settings. He speaks very loudly in the library and doesn’t seem to understand that to be a problem.
He doesn’t adjust communication to match the needs of his listener so he explains things to adults and children in the same way.
He has trouble following the rules of conversation and story-telling, not taking turns, rephrasing when misunderstood, or using verbal signals appropriately. He cannot understand what is not explicitly states.
What does he have?
Social [Pragmatic] Communication Disorder
What are the 3 major genetic causes of ID?
Which is the most common genetic cause?
Most common inherited cause?
Most common cause overall?
- Down Syndrome = most common genetic cause, moderate to severe, 1/700
- Fragile X syndrome = most common inherited cause, FMR1 with anticipation on the X chromosome 1/1000 men, 1/2000 women
- FAS - most common cause
What are the prenatal causes of ID?
TORCH Toxo Other [syphilis, AIDs, alcohol/drugs] Rubella CMV Herpes simplex
What are the 3 perinatal causes of ID?
- anoxia
- prematurity
- birth trauma
What are 5 post-natal causes of ID?
- hypothyroidism
- malnutrition
- encephalitis/sepsis
- trauma
- lead poisoning
What are risk factors for ID with unknown etiology?
- low SES, multiple births [2nd or later births]
- low birth weight
- lower maternal education
What percent of ID populations have comorbid psychiatric illnesses? Why are they often missed?
10-40%
Often missed because:
1. symptoms are attributed to ID
2. difficult to diagnose b/c of differences in presentation
3. inability for patient to communicate [esp. severe/profound]
In any child with ID [esp who are non-verbal and more severe] who demonstrates a change in behavior, what must be evaluated?
evaluate for underlying medical illness or pain
What characteristic psychiatric features are associated with prader-willi ID?
Fragile X?
Prader-willi is associated with OCD
Fragile X is associated with attentional/social problems
What 4 common issue with ID have become focuses for treatment?
- self-injury
- aggression
- hyperactivity/impulsivity
- stereotypies [rocking, flapping]
When giving medication to a person with ID, what it is important to consider?
ID population has a higher rate of adverse medication reactions [ex. paradoxical effect to benadryl]
What should be included in the examination of a child with ID?
- Hx and PE [focus on birth hx, FHx, comorbid conditions, and any features on PE that could allude to genetic syndrome]
- genetic testing [CMA, karyotyping, specific tests]
- hearing/speech/vision
- cognitive testing and adaptive skills eval **
- metabolic testing, EEG, neuro imaging if necessary
What is treatment for ID?
- adaptive skills training
- social skills training
- vocational training
- educate the family about how to enhance competency and self-esteem
- Rx to treat aggression, hyperactivity, comorbidities
What drug is used to treat irritability, aggression and self-injury in patients with ID?
risperidone
What drug families are used to treat the following in ID:
- repetitive behaviors
- hyperactivity, impulse, inattention
- aggression, mood lability
- antidepressant
- psychostimulant, a2-agonist [clonidine]
- anticonvulsants
What does IDEA guarantee?
students with disabilities get a free, appropriate public education from ages 3-21.
Students not succeeding in gen ed get a comprehensive eval as requested by teacher, parent, caretaker. Evaluation must be done w/in 60 days of referral
What percent of school-aged children are affected by a specific learning disorder?
What subjects are most common causes?
5-10%
Males>females
Reading and writing are most common disabilities
What are the sequelae of a learning disorder on children?
Low self-esteem, low morale, poor relationships.
1.5x more likely to drop out of school
Difficulties with jobs/social adjustment.
What are 3 common comorbid disorders with specific learning disorder?
- ADHD
- depression
- disruptive behavior disorder
What is the etiology of specific learning disorder?
Multifactorial with:
- genetic, perinatal injury, neurological/medical condition
- environmental [poverty, educ. quality, interactions w/ teachers]
- personal factors [personality, social skills, co-morbid psych conditions]
How is specific learning disorder diagnosed?
- Hx of learning problems [past grades, access to education]
- performance on standardized measures
- assessment of impact of behavioral, emotional, social, medical problems on learning
This info must be obtained from multiple sources including student, caretaker, teacher, tests.
What is the treatment for specific learning disorder?
Remedial education with IEP
How is the prevalence of autism changing?
What 4 factors are thought to contribute to this change?
What sex is more affected?
Prevalence is increasing because
- increased awareness
- changes in case definition
- case substitution [people prior ID are now realized to be autistic]
- actual increase in incidence
Boys are 5x more likely than girls
What is the etiology of autism?
- interactions between multiple genes
- high concordance btwn monozygotic
- microduplications or deletions
- monogenic [tuberous sclerosis, fragile x]
- maternal/paternal age increase the risk - environmental modifiers
- prenatal neuro insults
- metabolic or mitochondrial disorders [rare]
What percent of children with autism spectrum disorder also have ID?
40-60%
When are social deficits noticed by the parents of an autistic child?
not until about 12-18months but usually before 3 years
What are the usual 3 ways to evaluate for autism?
- screening by PCP
- ADI [research setting interview with parents about autistic symptoms] and ADOS [assessment of social interaction, play, communication, imaginative use of materials]
- referral to geneticist is ASD is confirmed
- CMA has highest yield 7-10% clinically significant findings
What is treatment for autism?
Which part has the highest efficacy for ASD?
- optimize social/daily living skills
- treat/manage psychiatric symptoms/problem behavior
- medications ONLY if necessary bc
- smaller response rate, higher adverse effects
- resperidone for irritability, aggression, self-harm
- psychostimulants, a2ag, antipsych for hyperactivity
- SSRI for repetitive behaviors/rigidity - Applied Behavior analysis
- discrete trial training with operant conditioning [give the kid candy when they follow directions]
- teaches social behaviors and adaptive behaviors
- HIGHEST EFFICACY
What predicts the outcome of ASD in terms of ability to develop better eye contact, joint attention, and affective reciprocity?
1 cognitive level
2. language ability
What is required for the diagnosis of ADHD?
6 symptoms of inattentiveness, hyperactivity, or both that have persisted for at least 6 months with an onset before the age of 12, behavior inconsistent with age/development and present in at least 2 settings
If a child under 12 has problems listening, concentrating, paying attention to details, organizing tasks, and is easily distracted, forgetful and loses items at home and school what is the diagnosis?
ADHD - inattentiveness
If a child under 12 is blurting out, interrupting, fidgeting, leaving his seat, talking excessively, can’t wait his turn, can’t wait his turn quietly, and runs/climbs excessively at home and at school, what is the diagnosis?
ADHD- hyperactive/impulsive symptoms
What percent of children are affected by ADHD? Is it more common in boys or girls?
How do the types differ by sex?
5%
It is more common in boys than girls
Girls are more likely to have inattentive type which delays diagnosis
What disorders are comorbid with ADHD?
- mood disorders
- conduct disorder
- oppositional defiant disorder
- learning disorders
- substance abuse
- anxiety
7 tic disorders - autistic spectrum disorder
What is the treatment for ADHD?
- pharmacotherapy
- CNS stimulants like methylphenidate, dextroamphetamine are the gold standard
- atomoxitine and a-adrenergic agonists for tics - psychological program based on behavior therapy [hard and not good results]
- parental counseling
- group therapy - social skills training
- addressing comorbidities- learning disorders, disruptive, mood, esteem, social skill
What is the criteria for diagnosing oppositional defiant disorder?
6 months with at least 4 of the following:
- loses temper
- easily annoyed
- angry/resentful
- argues with adults
- defies or refuses requests
- deliberately annoys others
- blames others for mistakes
- spiteful and vindictive
It cannot be during a mood, psychotic or substance use disorder
What percent of children develop ODD? What is the sex preference? What is the usual age of onset? What % remit? If they do not remit, what does it progress to?
1-11 with mean of 3.3%
Males> females
typical age of onset is 8yrs
25% remit, but those that don’t can progress to conduct disorder
What 2 psychological disorders are kids with ODD at risk for?
What comorbid conditions have increased incidence?
At risk for anxiety and depression
Comorbid with ADHD and substance abuse
What is the definition of a conduct disorder?
What are the 2 main specifiers?
repetitive and persistent pattern of violating the basic rights of others for at least 12 months including three of the following:
- aggression toward humans and animals
- destruction of property
- deceitfulness or theft
- serious violation of rules
Specify if childhood or adolescent onset Specify if it is with Limited prosocial emotions meaning 2 of the following: -lack of remorse/guilt - callous lack of empathy - unconcerned about performance - shallow or deficient affect
A child has been killing frogs in the neighborhood, drawing with permanent marker on neighbors houses, breaking rules in school and lying to his grandmother about going to football practice.
When confronted he shows no remorse or guilt. His grandmother starts crying and he shows callous lack of empathy. His affect shallow and he is unconcerned about what he has been doing.
What is the diagnosis and appropriate specifier?
Conduct disorder with limited prosocial emotions
What are the risks and prognostic factors that lead to conduct disorder?
- difficult infant temperament, slow resting HR and reduce autonomic fear
- low verbal IQ
- chaotic home life, inconsistent parenting, harsh discipline, substance abuse by parents, lack of positive role models, poverty
- delinquent peer group, neighborhood violence
What percent of children are likely to develop conduct disorder?
Of those that do, what percent will have antisocial personality disorder in adulthood?
4% will have conduct disorder and 40% of them will progress to antisocial personality disorder
What are the comorbid conditions associated with conduct disorder?
** objective 4
- Bipolar
- ADHD
- Depression
- substance abuse
- psychosis
- learning disorder
“BAD SPeLl”
What is required to make the diagnosis of Tourette’s syndrome?
- multiple motor AND one or more verbal tics [verbal appears first]
- motor = wink, shrug, grimace
- vocal = throat clear, echolalia, copralalia, cough - must occur many times a day for most days for more than 1 year [with no tic-free periods of over 3 months]
- onset before 18
What 2 conditions tend to be comorbid with Tourettes?
What is the typical age of onset?
What is the lifetime prevalence?
OCD and ADHD
Onset: 7 years old [boys>girls]
lifetime = 1/2000
What is the etiology of Tourette’s?
How does this affect the psychopharmacologic treatment?
It is genetic and is due to impaired regulation of dopamine in the caudate.
Pharm:
- high potency dopamine antagonists like haliperidol
- alpha-agonists
- atypical antipsychotics
Other:
- behavioral technique of habit reversal [counter tic]
- relaxation
- supportive psychotherapy to improve social, academic and vocational outcomes via self-esteem improvement
What is enuresis?
What are the 2 classifications?
What medical conditions must be ruled out prior to diagnosis?
It is urinary incontinence over the age of 5 that occurs 2x a week for 3 months.
- nocturnal - boys
- diurnal - girls
Rule out: diabetes, seizures, UTI
What is the etiology of enuresis?
What are primary and secondary?
What is the hypothesis for why enuresis occurs?
Genetic:
75% have 1st degree relative with the same thing
Primary- never est. continence by 5yrs
Secondary- 5 to 8
Hypothesis is:
- circadian rhythm of urine production isn’t established
- abnormal central vasopressin receptor sensitivity
What is encopresis?
What must be ruled out before the diagnosis can be made?
- intentional or involuntary passage of feces in inappropriate places after age 4
- once a month for 3 months
Rule out:
hypothyroidism, IBD, intestine abnormality, diet
Encopresis without constipation is more likely associated with what disorder?
ODD
What are the 3 key features of depression in children?
- separation anxiety
- somatic complaints
- behavior problems
What are key features of depression in adolescents?
- anhedonia
- suicidal ideation
- irritable, aggressive
- withdraw from social relationships and stop putting effort into their appearance or school work
- substance abuse
What are key features of depression in adults?
Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicidal ideation
*with depressed mood or anhedonia
What is separation anxiety disorder and how long does it last in children? adults?
It is inappropriate and excessive anxiety concerning separation from an attachment figure.
Children - 4 weeks
Adults - 6months
A child tends to get excessively distressed when having to leave for school. He constantly worries about losing his mom and harm coming to her. He never wants to be alone and refuses to sleep away from home. He has nightmares where his house is on fire and he is separated from his parents. When his parents leave him at grandmas to go on vacation, he gets a really bad stomachache.
What does this boy likely have?
separation anxiety disorder
A 6 year old girl fails to speak in social situations, but her mom says she is always talking at home.
Her teacher complains that the child never speaks and it is affecting her education and social communication. In the first month of school the teacher thought it was normal and she was adjusting, but this has been going on for 3 months.
What does this child have?
What is treatment?
Selective mutism
-treated with SSRI and behavioral therapy
A 5 year old boy is in his third foster home. He has had insufficient care.
When he falls on the playground and gets a big gash in his knee, he does not seek or respond to comfort. He seems sad and irritable and interacts with the new foster family minimally. He does not have the repetitive movements and social communication characteristics of ASD.
What does he likely have?
Reactive attachment disorder
A 4 year old boy is in his 3rd foster home. He has had insufficient care in instances of social neglect and deprivation.
He actively approaches and interacts with unfamiliar adults in a familiar verbal/physical behavior. He does not check back when venturing away from his caregiver.
He is willing to walk off with strangers with no hesitation.
What is the likely diagnosis?
Disinhibited social engagement disorder
