Childhood Mental Disorders

Question 1

ADHD

Answer 1

It is a neurodevelopmental disorder characterized by problems of paying attention, excessive activity, and inappropriate behavior for the person’s age. In simple terms, as the name suggests, patients are hyperactive with short spans of attention.

Question 2

ADHD is characterized by three variations in the symptomatic presentation:

Answer 2

1. Inattentive- Deficient attention to activities where a person frequently veers off the tasks he/she engages in. The main problem is a lack of focus and not defiance or incomprehension of instructions.
2. Hyperactivity/impulsiveness- where the patient is restless becomes fidgety and cannot remain still as needed.
3. Combined-A variety of patients have combined hyperactivity and inattentiveness.

Question 3

Risk Factors for Attention-Deficit/Hyperactivity Disorder

Answer 3

1.The risk of developing the disease increases with:

° The presence of a first-degree relative who had a similar disease.

° Exposure to toxins, such as lead in pipes and paints.

° Maternal exposure to drugs, alcohol, and cigarette smoke.

° Premature birth and associated perinatal hypoxic injury.

2 Environmental risk factors:

° Low socioeconomic status

° Parental mental disorder

° Foster care

° Low birth weight or prematurity

Acquired traumatic brain injury

Question 4

Etiology of Attention-Deficit/Hyperactivity Disorder

Answer 4

1. Genetics: The genetic mutations that are incriminated, include genes that encode for dopamine receptors such as DRD4, DRD5, DAT, DRH, 5-HTT, and 5 HTR 1B.
2. Intrauterine toxin exposure to mutation: inducing toxins, such as chemicals in food additives and cigarette smoke taken by the mother, predisposes the fetus to toxin exposure thus leading to DNA damage and possible mutations that cause an alteration in neurobehavioral development.
3. Perinatal hypoxic/ischemic brain injuries: that damage the neurohormonal mechanisms of the brain. Personality factors that naturally predispose some children to suffer from the disease. Toxin exposure at a young age, such as lead in water and soils, leading to neurohumoral brain damage.

Question 5

Attention deficit hyperactive disorder is classified into three major subtypes:

Answer 5

1.Predominantly inattentive:

The patient is deficient in attention to activities where a person is disorganized and veers off the tasks he/she engages in. The main problem is a lack of focus and not defiance or incomprehension of instructions.

2. Predominantly hyperactive/impulsive:

The patient is restless and becomes fidgety with tapping and restlessness. The person cannot remain still. The person bursts into impulses and talks a lot.

3. A variety of patients have combined hyperactivity and inattentiveness: These patients have a variety of symptoms from both inattentiveness and impulsivity.

Question 6

Pathophysiology ADHD

Answer 6

B

Question 7

DIAGNOSTIC CRITERIA (DSM 5)

Answer 7

May be mild, moderate or severe:

° Predominantly inattentive

° Predominantly hyperactive-impulsive, and

°Combined

1. Inattention:(9 symptoms)

° Failing to give close attention to details or making careless mistakes.

° Having difficulty sustaining attention in tasks or play.

° Not listening when spoken to directly.

° Failing to complete tasks or follow through on instructions.

° Often losing things for tasks or activities.

° Often having difficulty organising tasks and activities.

° Being forgetful in daily activities.

° Being easily distracted by extraneous stimuli.

° Avoiding or being reluctant to engage in tasks requiring sustained mental effort.

2. Hyperactivity:(6 symptoms)

° Often fidgeting, squirming or tapping.

° Leaving his/her seat.

° Running or climbing inappropriately.

° Is “on the go”, or behaves as if “driven by a motor”.

° Is unable to play quietly.

° Talking excessively.

3 Impulsivity:(3 symptoms)

° Blurts out answers.

° Has difficulty waiting his/her turn.

° Interrupts or intrudes on others.

° Onset of several symptoms before 12 years.

° Requires 6 symptoms of inattention or hyperactivity/impulsivity.

° Symptoms have persisted for 6 months to a degree inconsistent with their developmental level.

° Symptoms present in two or more settings.

° Interferes with or reduces the quality of social, academic or occupational functioning.

° Exclude psychotic or other psychiatric disorders.

Question 8

Mental status examination (MSE) in ADHD reveals:

Answer 8

° Appearance is one of a fidgety, impulsive, and restless person

° Mood may be elevated with periods of low self-esteem with alternating periods of irritability

° The thought process is usually normal but has a direction towards the goal

° Loud due to hallucinations and delusions

° Loss of concentration and short-term memory

Question 9

Differential Diagnosis of Attention-Deficit/Hyperactivity Disorder

Answer 9

DepressionDue to associated low mood and problems in tolerating frustration

AnxietyThe condition showsa low mood and an inability tocope with expectations

Bipolar disorder– Further investigation to differentiate it from ADHD due to the associated period of low mood.

Tourette syndrome - It can be a cause of new-onset tics

Oppositional defiant disorder- Children suffering from this disorder show negative hostile and defiant behavior towards those in authority such as teachers and parents. They have normal behavior when around their peers.

Antisocial behavior - Due to the inability to cope with friends and the expression of violence and aggression against others

Question 10

GENERAL AND SUPPORTIVE MEASURES for ADHD

Answer 10

Identify and treat co-morbidities such as depressive disorders early, as this may prevent the onset of substance misuse (to ‘self-medicate’) and other risk-taking behaviours during adolescence.

1. Parent counselling:

° Rules and limit-setting

° Positive reinforcement of pro-social behaviour

° Consistent routine

° Restrictive diets and OTC medications are of no proven value

2. Behaviour-based interventions:

° Reward positive behaviour

° Improve social awareness and adjustment

3. Social skills groups.
4. Identify learning difficulties and refer to educational support services.

Question 11

MEDICATION TREATMENT for ADHD

Answer 11

For Children Under The Age Of Six Years:

Refer for diagnostic assessment by a child and adolescent psychiatrist or paediatrician.

For Children Over The Age Of Six Years:

Initiate treatment using the short-acting methylphenidate formulation until effective dosage achieved. Reduce the dose or withdraw methylphenidate if a paradoxical increase in symptoms occurs.

° Methylphenidate, short-acting, oral, 1 mg/kg/day.

° Initial dose: 5 mg, 2–3 times daily, at breakfast, lunch and no later than 14h30 (approximately every 3 to 3½ hours).

° Increase the dose at weekly intervals by 5–10 mg until symptoms are controlled. Use the lowest effective dose.

°Maximum daily dose: 60 mg (adult dose). Any dose greater than 60 mg/day should be prescribed by a child psychiatrist or paediatrician

Question 12

Contraindications To Methylphenidate

Absolute:

Answer 12

° Hyperthyroidism

° Glaucoma

° Concomitant mono-amine oxidase inhibitor therapy

° No absolute contraindication to the concomitant use of methylphenidate with antiepileptic drugs (AEDs) or antiretroviral therapy (ART). However, exercise caution with the prescribed dosages, be aware of potential drug-drug interactions and monitor for adverse effects.

Question 13

Contraindications To Methylphenidate Relative:

Answer 13

° Hypertension

° Cardiac abnormality – need ECG and cardiology assessment

° Anxiety

° Agitation

° Epilepsy

° Tics

Question 14

Conduct disorder (CD) definition

Answer 14

Conduct disorder (CD) is a disruptive disorder that entails a high amount of problematic behaviors and antisocial activities. Children and adolescents with the condition show aggression toward others and willfully destroy property, steal, or lie.

Question 15

Etiology/Risk factors Conduct disorders

Answer 15

No definitive theory owing to multiple risk factors and comorbidities

Risk factors:

1.Personal:

° Uncontrolled infant temperament

° Lower-than-average intelligence, especially verbal IQ

2. Environmental:

°Parental neglect

° Physical/sexual abuse

° Parental criminality

° Rejection by peers

° Exposure to violence and/or substance misuse

3. Genetic and physiologic: higher risk in children with a biologic parent/sibling with other psychiatric comorbidities

Question 16

Zs

Answer 16

Nn

Question 17

Bn

Answer 17

Nn

Question 18

Hh

Answer 18

Bb

Question 19

What role does Effivarenz have in psychiatric illness?

Answer 19

1. It can trigger psychiatric disorders
2. Pt’s with known psychiatric disorders:
   ° Effivarenz exacerbates psychotic features
   ° Prolonged side effects of psychotic effect

Question 20

The CNS pathology in HIV/AIDS patients stem from the following factors:

Answer 20

1. Direct viral effects on the brain tissue
2. Opportunistic CNS infections
3. Malignant tumours (Neoplasm)
4. General debilitation
5. Side effects of the drugs

Question 21

Pathophysiology behind HIV related disorders

Answer 21

° Initial systemic HIV infection

° Crosses BBB via infected macrophages

° Viral replication in infected monocytes

° Low grade neuro-inflammatory response

° Neurotoxic effect on brain parenchyma

° Neurologic & psychiatric sequelae

Question 22

Mention 3 stages of which you screen for intellectual disability?

Answer 22

1. Screen during pregnancy
2. Screen before child starts school
3. Screen in early childhood

Question 23

How do to screen for Intellectual disability in early childhood?

Answer 23

1. Screen for developmental milestones
2. Head Circumference (micro/macro)
3. Height (Stunning)
4. Teachers are the ones who first seen the manifestations

Question 24

How would you assess a child with intellectual disabilitiy?

Answer 24

1. Genetic factors
2. Rule out child abuse
3. Screen for Developmental milestones
4. Send to occupational therapy for evaluation

Question 25

Suicidal Risk Assessment

Answer 25

1. Ideation
2. Intent
3. Plan
4. Access to lethal means
5. Hx of past suicide attempts

Question 26

Management for Suicidal Behaviour

Answer 26

???

Question 27

A 59-year old male brought in by his neighbour after 6 hours of unusual behavior. The patient has been wandering around the neighborhood since the afternoon accusing his neighbors of spying on him, which lead to a few physical confrontations. hewas also seen conversing intensely while no one else was around. When asked who he was talking to, the patient said he was talking to a young woman in a red dress. The neighbor states that the patient has been drinking heavily for the past 20 years, but stopped drinking 2 days ago after his family confronted him about his drinking habits. Upon examination, the patient is anxious, irritable, and combative.

a) State the most appropriate medication, including drug name, dosage, and route to administer immediately to this patient. (3)
b) State the most dangerous side effects of the medication just prescribed above (1)

Answer 27

a) Diazepam, IM, 10mg, stat

b) Respiratory depression, cardiac arrest

Question 28

QK a 34-year-old male was rushed by paramedics to A&E, after losing control of the car he was cruising which ended up knocking a big signpost on the roadside. On arrival, he was drunk and had sustained multiple cut wounds on his head. Has a history of drinking alcohol on month-end when he is paid his salary.

a) With at least three supporting evidence state the alcohol use-related mental disorder syndrome which manifested in QK’s scenario above.

Answer 28

1. Alcohol Intoxication:
   • Recent ingestion
   • Incoordination- lost control of the car
   • Impaired judgement- Decided to drive his car while drunk putting his life at risk

Question 29

A 32-year-old single male patient was brought to the ED by friends. He had gotten drunk 3 days ago and lost his temper when a girl at the nightclub declined his attempt to forcefully kiss her. His friends say his wife divorced him 4 years ago as a result of domestic violence that occurred when he was drunk. On physical examination, the patient is visibly malnourished, dehydrated, disoriented, agitated, and displaying signs of delirium tremens

1. Describe 4 of the most important treatment steps for this patient

Answer 29

1. • Ensure adequate hydration
   • Nutritional support
   • Give Diazepam, IV,10 AND Thiamin, oral 300mg
   • Refer to Rehabilitation center to help with recovery of Delirium Tremens

Question 30

2. Once the patient is stable, list the 4 questions to ask to screen this patient for alcohol abuse and/or dependence.

Answer 30

• Have you ever felt you should CUT down on your drinking?
• Have you ever felt ANNOYED when someone talked to you about your drinking tendencies?
• Have you ever felt GUILTY about your drinking?
• Have you ever drank alcohol first thing in the morning as an Eye-Opener to get rid of hangeover?

Question 31

3. Describe 5 important social aspects of alcohol abuse to discuss with the patient

Answer 31

• Violence
• Unemployment
• Crime
• Sexual risk behavior
• Disruption to family life and work

Question 32

A 26-year-old student is brought to emergency D because of violent and abnormal behaviour. According to the family members, the patient’s symptoms started about a year ago, when he started accusing members of his family plotting to kill him. He talks alone, threatens members of his family, and has been unable to continue his studies.
On examination, the patient is agitated, speaks incoherently. He hears the voices of people he cannot see talking about him. He believes his thoughts are being controlled by the TV remote at home.

1. What is the most likely diagnosis in this patient
2. Give 4 reasons to support the diagnosis

Answer 32

1. Schizophrenia
2. • Delusion of control> 6months
   • Hallucination
   • Disorganised speech and behaviour
   • Function is impaired (social)

Question 33

A 26-year-old student is brought to emergency D because of violent and abnormal behaviour. According to the family members, the patient’s symptoms started about a year ago, when he started accusing members of his family plotting to kill him. He talks alone, threatens members of his family, and has been unable to continue his studies.
On examination, the patient is agitated, speaks incoherently. He hears the voices of people he cannot see talking about him. He believes his thoughts are being controlled by the TV remote at home.

3. List 4 investigations you will carry out in this patient
4. The patient refuses to be admitted and demands to go home Will you admit this patient to the hospital without his consent? Provide reasons for your answer

Answer 33

3. • Urine drug screening
   • CSF: CNS infections
   • FBC: Infection
   • MRI/CT scan: Physical abnormality of brain tissue (loss of cortical tissue volume)
4. Yes, according to the MHCA, you admit a patient who is mentally disturbed who is a anger to himself or others.

Question 34

A 34-year-old male presents at the ED with 30 mins history of tongue protrusion, stiffness and abnormal posture of limbs and trunk without loss of consciousness. He has been diagnosed with Schizophrenia and is currently on Haloperidol.

1. State the MOA of Haloperidol.
2. Mention the name of the side-effect of antipsychotic drugs called

Answer 34

1. Blocking postsynaptic dopamine D2 receptors in the limbic system of the brain, thus reducing the response of the postsynaptic neuron to dopamine excitation.
2. Extra-pyramidal side effects (Dystonia)

Question 35

List 3 ways HIV infection can predispose to mental illness

Answer 35

• Stigma
• Fatality
• Chronicity

Question 36

List 4 mental disorders that can be seen in people living with HIV

Answer 36

• MDD
• Pain syndrome
• Anxiety
• Delirium
• Dementia

Question 37

Outline 5 steps (The 5 A’s) involved in Brief Behavioural change counselling

Answer 37

1. Arrange for follow up
2. Assist with the treatment plan
3. Assess readiness to increase physical activity
4. Advice and encourage physical activity
5. Ask physical activity vital signs

Question 38

What are the side effects of haloperidol?

Answer 38

1. Sedation
2. Dystonia (muscle spasms),
3. Akinesia (loss of voluntary movement),
4. Akathisia (motor restlessness), and tardive
5. Dyskinesia (involuntary oral-facial movements)
6. Dry mouth,
7. Urinary retention,
8. Blurry vision

Question 39

MOA of SSRI’s

Answer 39

The SSRIs act to prevent the reuptake of serotonin from the synaptic cleft, thereby potentiating the effects of serotonin on the postsynaptic receptors.

Question 40

Indication of SSRI’s

Answer 40

1. Major depression,
2. Anxiety disorders,
3. Obsessive-compulsive disorder
4. Bulemia

Question 41

Side effects of SSRI’s

Answer 41

1. Sexual dysfunction
2. Drowsiness;
3. Weight gain
4. Increase suicidal ideation

Question 42

MOA of Carbamazepine

Answer 42

Inhibiting the flow of sodium ions

through sodium channels

Question 43

A 32-year-old single male was brought to an ED. He had gotten drunk, involved in an altercation (fight) and he sustained a number of lacerations. A diagnosis of soft tissue injuries and alcohol intoxication was made.

1. Explain the 2 central nervous systems (CNS) effects of alcohol (effect of alcohol on the CNS) (4 marks)

Answer 43

1. • Impaired judgment: Because the patient is intoxicated he can not properly separate right from wrong (got into a fight)

• Impaired coordination: Due to intoxication there is less coordination, which may lead to falls, injuries

Question 44

Alcohol INTOXICATION

2. State the drug you would use to treat this patient (2 marks)

Answer 44

2. Thiamine, oral, 300mg daily for 14 days
   AND
   Diazepam, oral, 10mg immediately

Question 45

Alcohol INTOXICATION

3. State other supportive management for this patient (2 marks)

Answer 45

??