Child Psychiatry & Eating Disorders Flashcards
Describe the aetiology of child psychiatric problems
- Multifactorial
- Cumulative effect
- Risk (vulnerability / predisposing) factors
- Also: precipitating and maintaining factors
- Inter-related
Biological Factors
• Temperament
• Genetic
• Neurodevelopmental - hardwired into the brain
• Biochemical - cannabis
Development/Psychological
•Attachment
•Learning
•Cognitive
•Emotional
Social/Environmental Factors
Acute stressors: Trauma, Accident, Illness, Death
Chronic Adversity:
•Socio-economic
•Parental mental illness
•Parental loss
•Family conflict –violence. Modeling what they see in the family
•Parenting. Strict style = unruly
•Abuse (physical, sexual, emotional)
•Exposure to community violence
Resilience – Protective factors
- Temperament
- Coping strategies
- Problem-solving
- Self-esteem
- Stability
- Secure relationships
- Friendships
- Achievement
What factors influence interaction with children
Environmental
•Privacy
•Suitability
–Noisy/overstimulating
–Access to toys/materials
–Age appropriate
- Intimidating - Wear casual clothes
- Correct for what is being assessed
Child/adolescent factors
•Feeling safe/secure - see with parents?
•Willingness to engage
•Family or carers present/not present
•Cognitive ability: IQ/processing problems
•Emotional development
Clinician Factors
•Setting enough time
•Appropriate use of language
•Appropriate non-verbal communication - don’t appear formal
•Using the right method for the age of child
•Avoid being patronising/condescending
•Try not to sound rehearsed
•(It is easier if you like children)
What are the important differences to consider when seeing a child
•Consideration of child
–Age
–Cognitive ability
–Emotional understanding
–Communication problems
–Willingness to engage - who sent them?
–What they can say with parents present
•Considering the parent/carer
–Multiple informants: might get very different pictures
–Expectations
–Parental mental health
–Family dynamics i.e divorce
–Engagement
–Ability to leave the child
History and observation
•Certain elements have greater relevance
•Development Hx
•Family Hx
•Social Hx
•School
•Observation of the child/child and carers
•Different types of assessment more common
–Psychometric
–Sensory assessments
–School observations
Describe general and seperation anxieties in children
Generalised Anxiety Disorder
- Free floating anxiety - not just one cause or situation
- Fears of death, loss (of child or parents)
- Somatic manifestations more common (nausea, abdominal pain, sickness, headaches, sweating, palpitations, tension)
- Panic attacks (sudden onset, extreme fear, physical symptoms, faintness)
Seperation Anxiety
- Anxiety manifest upon separation (or threat of separation) from attachment figures (usually parent, particularly mother)
- Somatic manifestations
- Nightmares with separation themes
- School refusal
Treatments
- Behaviour therapy (systemic desensitisation, flooding, response prevention)
- Psychotherapies (brief psychodynamic, family and cognitive therapy)
- Anxiolytics
Describe OCD and PTSD in kids
Obsessive-Compulsive Disorder (OCD
Obsessional thoughts – intrusive persisting, awareness of their illogicality, resistance to them (e.g. counting, urge to wash hands or touch wood a certain number of times) hard to pick up
Compulsive actions – related to the thoughts. This is what you get with the younger children
Treatment must involve the family.
Post-Traumatic Stress Disorder (PTSD)
Persistently re-experiencing trauma Avoidance of associated stimuli or numbing of responsiveness Increased arousal (sleep disturbance, irritability, poor concentration)
Describe behavioural problems in children
Oppositional Disorder (Behavioural Problems) - confined to home and school
- Uncooperative, unwilling to comply with requests, frequent temper tantrums
- Wilful, defiant, may also be aggression
- Unless managed, tends to escalate
- Main treatment is behavioural work
- Important to see if underlying neurodevelopmental or social factors. Need to rule out everything else
Conduct Disorder - involves behavioural problems outside the home
- Prolonged pattern of antisocial behaviours which are outside social norms
- Complex aetiology depending on individual, family and environmental factors
- Associated with other mental health problems including mood problems and substance abuse
Socialised and unsocialised types
Socialised conduct disorder where peer relationships are normal is usually viewed as less serious and tends to be phasic in nature
Unsocialised conduct disorder where the young person has no friends and is rejected by peers is more serious, and potentially leads to criminality and a later diagnosis of antisocial personality disorder
Lying, stealing, truanting, violence to people and animals
Risk Factors
- Lack of clear boundaries, inconsistent parenting
- Rejection
- Family conflict, especially witnessing violence and aggression
- Child abuse
- Child temperament
- Comorbid learning or developmental difficulties
Treatment
Consistent care and parenting
Behavioural therapy
School-based interventions
Community interventions
What are the key features and treatment of ADHD?
•Affects 3-5% of children
- Poor attention and concentration
- Physical overactivity
- Impulsivity
- Needs to occur in more than one environment
- Diagnosis after 6 years, but symptoms present before
- Diagnosis made on history and observation in different settings, rarely made before 6yrs
- Symptoms persist into adulthood in approximately 2/3 of cases
•Mild and moderate: consider parenting and school interventions first
•Severe: medication first line
–Methylphenidate: short or long-acting stimulant
–Atomoxetine: little known abuse potential but less effective
•Treat co-morbidity
What are the key features and treatment of autism?
Affects approximately 1% of children
•Core features make up the triad of impairments
- Social difficulties
- Communication difficulties
- Lack of flexibility of thinking
- Needs to occur in more than one environment
- Symptoms must be present before 3 years of age
- Diagnosis is made on history and clinical observation +/- structured appraisals
- Associated with a number of co-morbid conditions
Treatment
•There is no definitive treatment
•Approaches
–Psycho-education
–Stress reduction
–Environmental changes
–Treat co-morbidities
Describe mood and eating disorders in children
Mood Disorders
•Mood disorders become more common with increasing age
•In Depressive illness is persistent but not necessarily pervasive, anhedonia/ lower levels of enjoyment. I.E. might be ok in short periods
- The biological symptoms are not consistent
- Assessment of low mood can be difficult
- Psychological therapies form the first line of treatment
- Fluoxetine is the main pharmacological treatment and has to be initiated by a specialist
- Managing the underlying or comorbid problems
Eating Disorders
•Rare in the pre-adolescent period but onset of anorexia commonly in adolescent age group
•The majority of cases are female
•Anorexia and bulimia have similar symptoms to adult cases
•Puberty and growth can be affected by eating disorders
•Treatment is complex and includes intensive interdisciplinary interventions typically involving the whole family
•Prognosis worse if younger or male
Describe psychosis in children
Psychosis
•Rare in pre-adolescent age group
•Incidence rises steadily through adolescence to reach a peak in early adulthood
- Hearing voices etc does not always mean psychosis in children
- Antipsychotics are the typical treatments but have a higher incidence of side effects
- Psychosocial interventions are important part of treatment
- Presentation of schizophrenia in adolescence is associated with a poorer long term outcome
- Hallucinations
- Delusions
- Thought disorder
- Need to consider substance misuse
What are the types of anorexia nervosa?
What are the typical behaviours?
- Restrictive type - restricts their diet to the point of starvation
- Binge eating/ purging type - combination of both Anorexia and Bulimia. A person will restrict their diet for long period of time and on resuming their intake will eat huge amounts of high carbohydrate, high sugar foods
- Refusal to maintain or achieve normal body weight BMI <17.5
- Intense fear of gaining weight or becoming fat
- Body shape disturbance
- Undue influence weight & shape on self-evaluation
- Amenorrhoea
- Many emotions and physiological states experienced as “feeling fat” such as feeling full
- Constant comparisons with others
- Body checking and avoidance
Compensatory behaviours
Purging behaviours:
•Self induced vomiting (can be after binges or even small amounts of food)
•Laxatives even though no impact on calorie intake
Medications
Diuretics
•Slimming aids / fat blockers etc
•Amphetamine like drugs
Describe bulimia nervosa
- A. Recurrent episodes of overeating (binges)
- B. Persistent preoccupation with eating and a strong desire to eat (craving).
- C. The patient attempts to counteract the fattening effects of food by compensatory behaviours
- D. A self-perception of being too fat, with an intrusive dread of fatness.
- Purging Type: Self induced vomiting and laxative abuse most common
- Non-purging Type - Exercise / pasting
Recurrent binge episodes
- Subjective loss of control
- Large amounts, typically calories laden, “forbidden” foods
- “I just cant stop”
- Feel “in a bubble”
- Associated guilt afterwards
- Secretive
- Alone
- Hiding the evidence
Describe the psychological mechanisms involved in eating disorders
AN
- Preoccupation with food
- Fear of loss of control
- Restriction
- Further preoccupation
BN
- Preoccupation with Size and weight
Overvaluation of size linking to self esteem - Restriction and Rules
Forbidden foods - Do not manage to continue restriction: Binge eating
Vomiting
Over exercising - Guilt and return to preoccupation
What are the risk factors for eating disorders?
- Genetics
- Biological vulnerability
- Biological stress
- Psychological
- vulnerability
- Psychological stress
- Social/ cutural
Thinking styles: (cognitively rigid, all or nothing thinking, can’t see bigger picture etc)
Interpersonal styles: (struggle to recognise cues and emotional state of others)
Emotional processing: difficulty recognising own emotional state expressing emotions etc
Personality traits: perfectionistic, obsessional
Social / interpersonal factors
•Issues of control
•Managing relationships
•(friendship, family. Intimate)
•Managing / avoiding emotions
•Separation / individuation
Cultural
Eating disorders are seen as western industrialised society disorders but increasing seen in Asia and India and Africa. May be due to effects of Media Images and Globalisation. Is the mediating factor dieting?
What predicts Good outcome
•Motivation to change
•Short duration of illness
•Level of Severity
•Onset during adolescence
•Good family function
•Lack of comorbid conditions
What are the physical effects of ED’s
Biological adaptations to low weight. The body adjusts its free T4 to reduce its metabolic requirements….
sick euthyroid syndrome: Reduced resting metabolic rate , reduced body temperature and bradycardia.
With time and weight loss multiple systems are unable to adapt and start to show the negative consequences of starvation causing medical complications of Anorexia Nervosa:
Blood: bone marrow suppresson
Electrolyte & nutritional deficiencies: Potassium, Sodium,Calcium, Phosphate, Zinc, Thiamine, Magnesium
Skeletal: osteopenia / osteoporosis, fractures
Cardiovascular: myocardial thinnning, bradycardia, hypotension, arrthymias cardiomyopathy, mitral prolapse heart failure
GI complications: delayed gut motility/ delayed gastric empytying, constiaption, Mallory Weis tears, Hepatitis, pancreatitis, PUD
Endocrine: Amennorhoea (due to ghrelin and low leptin reducing GnRH amplitude), sick euthyroid syndrome (low T4 normal TSH), impaired glucose tolerance.
Neurological: Siezures, peripheral neuropathy, autonomic dysfunction
Renal: Renal failure, stones
Describe the treatment of eating disorders
What is the important danger?
•Bulimia Nervosa
–Guided self help for milder cases
–CBT
RELATIVELY EASY TO TREAT
•Regular eating
•Binge analysis (what triggers binges)
•Mood management
•Interpersonal issues
•Working self esteem
50% -70% recover completely. Relapsing and remitting
Trial of fluoxitine at high dose 60mg can reduce frequency.
May need to treat medical complication of repeated comiting, e.g. potassium replacement
Anorexia nervosa
•Manualised treatments: CBT and MANTRA, SSCM, (second line focussed psychodynamically informed therapy)
Very difficult to treat: Because unlike most psychiatric illnesses its “ego syntonic”…. It feels right
- 30%-75% recover completely (best chance in first 3 years, outcome poor post 10 years)
- up to 25% still anorectic
- 40-80% partially recover
- Mortality rate around 6% overall and 0.5% per year 50% DEATHS DUE TO SUICIDE
Refeeding syndrome
•Very low weight, malnourished patients are at greatest risk
- High carbohydrate feeding most risky
- As the body rushes to rebuild itself it quickly runs of trace elements /vitamins and the deficiencies of Phosphate, K and magnesium are most dangerous, potentially fatal
- Refeeding requires specialist management
- Close blood monitoring (daily bloods)
- Oral supplements and maybe ivs
- Low PO4 can result in heart failure and multi organ failure
