Child Psychiatry Flashcards
Nocturnal Enuresis
=Bed Wetting; Infrequent bed wetting is common; More common in boys
• Genetically determined delay in acquiring sphincter continence; 2/3rds have FMHx;
• Small children need freedom from stress and parental approval to learn night-time continence; Emotional stress can interfere and cause Secondary Enuresis
Nocturnal Enuresis: Causes
Most children are Psychologically normal; Treatment relies on symptomatic approach
o Underlying stress, emotional and physical disorder must be corrected
o Organic Causes are uncommon; UTI, Constipation, Polyuria
Nocturnal Enuresis: Investigations
Urinalysis is only indicated if recent onset Bed-wetting, Daytime Enuresis, Features of UTI, DM or general ill health
Nocturnal Enuresis: Management
After 4yrs, Enuresis resolves spontaneously in only 5%/yr; Problem is common, beyond conscious control; Address fluid intake, etc
o Star chart – Praise and star for agreed behaviour (Helping to change the sheets, vs Dry nights); Bed wetting should be treated in matter-of-fact way
o Enuresis Alarm – Sensor which sounds when wet; Wakes the child, goes to toilet
o Desmopressin – Synthetic ADH for children >7yrs if previous management unsuccessful, or Short-term Relief; PO or Sublingual
Daytime Enuresis
Lack of bladder control during day in a child, normally old enough to be continent (3-5yrs); May coexist with Nocturnal Enuresis
Daytime Enuresis: Aetiology
o Lack of attention to Bladder sensation – Manifestation of Developmental or Psychogenic problems; May also occur with preoccupied children
o Anatomical/Functional Issues: Detrusor Instability, Bladder Neck Weakness, Neurogenic Bladder (Failure to empty properly, Irregular thickened wall; Assoc Spinal Bifida, etc), Ectopic Ureter
o Disease States – UTI, Constipation
Neurogenic Bladder
Neurogenic Bladder may have evidence of Distention, Abnormal Perineal Sensation and Anal Tone, Abnormal Leg Reflexes, Gait; S2 – S4 Dermatome Sensory Loss
Daytime Enuresis: Investigation
Urine MC+S, US Bladder, Urodynamic studies, XR Spine, MR Spine
Daytime Enuresis: Management
If non-neurological cause – May benefit from Star Charts, Bladder Training, Pelvic Floor Exercises; Treatment of Constipation; Anticholinergic (e.g. Oxybutynin) can be considered
Secondary Enuresis
Loss of previously achieved Urinary Continence; Most commonly due to Emotional upset; UTI, Polyuria (Osmotic Diuresis e.g. DM, or Renal Concentrating Disorders e.g. SCD, CKD, DI)
Secondary Enuresis: Investigations
Urine Dipstick – Pyuria, Glycosuria, Proteinuria
• Osmolality of Early Morning Urine – Assessment of Urine Concentrating Ability
o Alternatively, Water Deprivation Tests for Central and Nephrogenic DI
• US KUB might be necessary for anatomical defects – E.g. Ectopic Ureter
Encopresis (Faecal soiling)
Abnormal for child to soil after 4yrs – Can be classified as whether Faecal Retention is present; ascertained by Palpation
Causes of faecal soiling
o Some children have sphincter dysfunction, poor coordination or relaxation, hence more prone to developing retention
o Constipation can occur, as a sequela of dehydration
o Inhibition of Defecation due to pain, or fear of punishment, or anxieties
How does retention lead to soiling
- Once retention is established, hard, large bolus of faeces might contribute to retention
- Rectal loading leads to Rectal Dilatation, possibly leading to habituation to distention; Stool might seep out with spontaneous, involuntary contraction
Managing Faecal Retention
Obvious anal pathology should be identified; Stool softeners (E.g. Macrogol) for few weeks, and if failing to shift, stimulant laxatives can be used
o Rarely enema is required to clear faecal bolus
• Once disimpacted, Maintenance Laxative therapy should be maintained
Child encouraged to defecate regularly, Star chart to encourage; Requires time for dilated rectum to return to normal calibre, regular laxatives still required
• Psychological issues – Child can deny problem if humiliating experience; Children can also find involuntary soiling as a measure of control over parents; Requires Psych review
Soiling without retention
- Less common; Some have urgency defecation for apparently constitutional reasons, Neuropathic Bowel (secondary to Occult Spinal Abnormalities, usually associated with Urinary Incontinence), Diarrhoea
- General Learning Disability <4yrs mental age is another cause
- Children may defecate intentionally as a hostile act – Psychiatric referral
School Refusal
=Instability to attend school due to overwhelming anxiety; Might not complain of anxiety but show physical manifestations (E.g. Hyperventilation)
o Disproportionate to stresses at school; Separation Anxiety persisting beyond toddler years, True School Phobia (anxiety provoked by some aspect of school)
o Might be non-specific, Nausea, Headache, Unwellness; Confined to school days clearing up by mid-day
o Can be rational – Bullying or Educational Underachievement ≠ School refusal
Adolescents – Depressive disorder, Anxiety disorder, Longstanding Personality issues
Causes of Child Absence
Child absence can be due to illness, parental choice or truancy; Truancy is often accompanied by other behavioural difficulties
Separation Anxiety
Typical of children <11yrs, May be provoked by adverse life event; Child unable to tolerate separation from attachment figure
• Treatment aims to gently promote separation from parents (e.g. Staying overnight with relatives or friends), arranging early return from school
Child Protection
Protecting children from harm is the duty of all healthcare professionals; Abuse can range from Physical and Sexual abuse to include Neglect, Emotional abuse, Sexual Exploitation, Fabricated Illness and Genital Mutilation
o Often complex and difficult cases requiring MDT approach by specialists
UN Convention of the Rights of the Child
Right to be protected from Maltreatment both physical and mental; Governments are responsible to ensure children are properly cared for
o Right to life and Basic Needs, Right to Achieve Full Potential, Right to Protection and Right to take an Active Role in their communities and nations
Presentation of Child Abuse
- Physical and Psychological Signs and Symptoms
- Concerning interaction observed between child and carer
- Child might have told someone about abuse, or abuse witnessed by others
- Fractures in non-mobile, Rib and Multiple fractures (unless significant accidental trauma),
- Bruising in the shape of hand or object, Strangulation bruising, Ligature marks,
- Burn in child who is non-mobile, Burn in shape of implement (cigarette burns, iron marks), glove or stocking distribution, Adult-sized Bite marks
- Less likely if bruises on shins of mobile child, or burn with splash marks
What factors should be considered in presenting child abuse and neglect
Factors to consider – Age, Developmental progress, Plausibility of injury, Delay in reporting injury, Inconsistent history, Inappropriate reactions from carers e.g. Evasiveness, Lack of concern, Aggression
Management of NAI: Fractures
Fractures might not be easily detectable and require X rays; Full skeletal survey with rib oblique views if suspected abuse
Management of NAI: Coagulation disorders
Mongolian blue spots on back or thighs mistaken for bruises, Osteogenesis Imperfecta in fractures; bullous impetigo or scalded skin syndrome can be mistaken for burns
Management of NAI: Brain Injury
If brain injury suspected – CT head immediately, following by MR Head; Skeletal survey to exclude fractures; Expert Ophthalmology opinion to identify Retinal Haemorrhage, Coagulation screen
Management of NAI: Assessing Child
• Good practice to speak to the child with chaperone present without parents; Full history and examination, recording all injuries or medical findings and photographed with consent; Growth plotted on centile chart, Interactions between parent and child noted.
Management of NAI: Suspected or confirmed abuse
If abuse suspected or confirmed, whether protection for further harm is immediately needed – Admission, or engaging police; placement with foster carers if no medical concerns
o Also consider safety of other siblings and children at home
o Strategy Meeting and Child Protection Conference (Parents present); Whether Child Protection Plan is required, whether Application to the Court for Protection is needed, and follow ups
Other types of Child Abuse and Neglect
Abuse and Neglect are both forms of Maltreatment; Can either be Inflicting harm, or failing to act to Prevent Harm; Typically abuse occurs by someone known to them
Emotional Abuse
Persistent Emotional Maltreatment resulting in Severe and Persistent adverse effects; May involve conveying that children are worthless/unloved, inadequate, or valued only to meet the needs of another person
• May include developmentally inappropriate expectations – E.g. Interaction beyond developmental capacity; Overprotection and Abnormal Social Interaction
• May involve witnessing ill treatment of others; Intimate partner violence Is a form of abuse
• Can also involve serious bullying that cases children to feel frightened or in danger
Sexual Abuse and Exploitation
• Child might tell someone about abuse, be pregnant (definitively abuse if <13yrs), STI without clear explanation (non-transplacental)
• Involves forcing or enticing child to take part in sexual activities, including prostitution, whether the child is aware of what is happening
• May involve physical contact, or even non-contact activities such as involving children watching or producing pornography, or witnessing sexual activities or encouraging children to behave in sexually inappropriate ways
• Sexual Exploitation – Exploitation for money, power or status; Children might to be deceived into believe they are part of loving, consensual relationship
o Might involve element of Human Trafficking
Child Neglect
Consider when regularly misses appointments, immunisation, hungry, dirty, inadequate clothing, abusing drug and ETOH;
• Neglect is the persistent failure to need basic Physical and Psychological needs, likely resulting in serious impairment of child’s health of development
o Food, clothing, shelter, protection from harm or danger, supervision and access to appropriate medical care or treatment
Fabricated or Induced Illness
Broad term – Behaviours by Parents or Carers, but usually the mother which fulfils their needs
