Childhood Psychiatry Flashcards
What are the 4 P’s, which are especially important in childhood psychiatric disorders? What are some protective/resilience factors?
Predisposing - i.e. genetics, chronic illness, childhood trauma
Precipitating - “why now”, starting school/divorce
Perpetuating factors - consistently unstable household
Protective factors = time together as family, regular exercise and sleep, no bullying
What is ADHD and how may it present?
ICD10 - type of hyperkinetic disorder where there is persistent and severe impairment of psychological development.
- > Impaired attention and overactivity (restlessness, talkativeness, fidgeting)
- > Present before 6-7 y of age and lasting at least 6m
- > Impairment must be present in multiple settings i.e. home, school
- > [Exclude organic causes]
Note: don’t need to have both inattention and hyperactivity but usually both present
What is the aetiology of ADHD and some RFs?
Caused by dysfunction of dopamine transmission in the prefrontal cortex, controlling self monitoring/regulation
- boys> girls (3:1), 2.5% prevalence
Bio - FHx (60-70% genetic link), prematurity, LBW, FAS, conduct or mood disorder, ASD, learning disability, Fragile X
How would you investigate suspected ADHD?
Ix:
- Full psych history and collateral Hx (school?)
- Assess social/educational impact in context of age
- Rating scales such as ‘Conner’s comprehensive behaviour rating scale’ (age 6-18) and ‘Strengths and difficulties” questionnaire
How would you manage ADHD?
MDT focussed approach - paediatrician, psychiatrist, ADHD SNs, MHTs, CAMHS, social care workers, schools
1st line in all cases [if negative impact on child’s development or family life]
= up to 10w watchful waiting w self-help and simple behavioural management
= group based ADHD focused support for parents
= refer to specialist if severe symptoms >10w
Children <5y [after 10w watchful wait]
1st = offer ADHD-focussed group parent training programme for parents and careers which gives education on ADHD, parent strategies and environmental changes
2nd = specialist service referral
Children >5y [after 10w watchful wait]
1st = offer ADHD-focussed group parent training programme
2nd = specialist service referral and medications if ADHD persists
- 1st line drugs = 6w trial of methylphenidate (CNS stimulant - SE = abdomen pain, nausea, dyspepsia)
- 2nd line = lisdexamphetamine
- 3rd line = dexamphetamine
- 4th line = atomoxetine (NARI) or guanfacine
SEs = appetite loss, mood changes, palpitations and tics
3rd line = CBT
- if problems in social skills, self control, active listening and dealing with expressing feelings
Other meds include clonidine (sleep disturbance, rage, tics) and antipsychotics (for aggression and irritability)
MONITORING is required:
- Baseline height, weight, HR, BP and ECG + then checked at appts
- Appointments every 3m if <10y and 6m if >10y
- Monitor response with symptom rating scales (Conner’s test), development of tics, growth on growth chart, sleep disturbance/seizures/sexual dysfunction
What are some key points about ADHD prognosis?
ADHD manifestation will change in the child as they get older - hyperactivity becomes less of a problem whereas inattention becomes more pronounces as they tasks they face get more complex
- Some kids grow out of it
- 90% kids get conduct disorder if UNTREATED
- 15% have ADHD as an adult
What are some RF/associations for autism spectrum disorder and its prevalence/presentation (ASD)?
1.1.% in the UK
Presents at around 3y (2-4) when language and social skills normally rapidly expand
75% boys»_space; girls
Most have decreased IQ
RFs = sibling with ASD, parent psychotic/affective disorder, birth CNS defect, prematurity (<35w), sodium valproate, LD, chromosomal disorders such as T21, genetic disorders like Fragile X, ADHD, HIE
Associations = fragile X, tuberous sclerosis, neurofibromatosis, Di-george
What are some of the autism spectrum disorders?
Autism - 1.4 per 1000
Asperger syndrome - no delay in language or cognitive development (0.3 per 1000) (psychosis in adult life, marked clumsiness)
Rett syndrome - medical disorder, X-linked, affecting girls more than boys (sudden deterioration after 2y old)
Childhood disintegrative disorder (CDD)
Pervasive developmental disorder not otherwise specified (PDD-NOS)
-> most common ASD
What is the ICD-10 criteria for diagnosis of ASD?
A. Abnormal or impaired development evident at 3/<3 years old in:
- Receptive or expressive language
- Development of selective social attachments or reciprocal social interaction
- Functional or symbolic play
B. A total of at least 6/+ symptoms from [1], [2] and [3] with at least 2/+ from [1] and at least 1/+ from [2] and [3]
[1] Qualitative impairment to SOCIAL INTERACTION
- Failure of adequate 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] Qualitative abnormalities in COMMUNICATION
- Delay in or total lack of development of spoken language (no attempt to compensate)
- Relative failure to initiate or sustain conversation
- Stereotyped and receptive use of language or idiosyncratic use of words or phrases
- Lack of varied spontaneous make-believe play
[3] Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities
- Apparently compulsive adherence to specific routines or rituals
- Repetitive motor mannerisms involving hand, finger flapping and whole-body movements
- Preoccupations with non-functional elements of play materials (such as their odour)
c. Clinical picture not better described by other medical disorder
What Ix would you do in a child with suspected ASD?
Ix:
- Hearing, speech and language assessment
- Cognitive assessment (WISC, WPPSI)
- AUTISM SCREENING TEST such as CAST or CARS
- Autism diagnosis and assessment is the gold standard
- -> ADOS and ADIR
How would you manage ASD in a child?
MDT and Patient centred care approach
MDT = paediatrician, child adolescent psychiatrist, SALT, OT, SN, social worker, educational or clinical psychologist
1st line
= Psychosocial play-based intervention (behavioural and parent mediated)
- Increase attention, engagement (play specialists) and reciprocal communication (SALT)
- Increase carers and teachers understanding of patients communication/interaction pattern e.g. EarlyBird <5y and Earlybird+ 4-8y
- Include techniques to expand childs communication, interactive play and social routines
Applied behaviour analysis from behavioural nurses - focuses on improving specific behaviours e.g. social skills, communication, reading as well as adaptive motor skills
Challenging behaviour:
1st line = psychosocial assessment (anticipate and reduce factors which may increase behaviour
- Reduce impairment in communication
- Other physical disorders e.g. otitis media
- Co-existing MH problems
- Physical environment (lighting, noise)
- Reduce unintentional reinforcement of behaviour
Other:
- Adjust social and physical environment e.g. noise levels, lighting and visual support
- Reasonable adjustment law
- Assessment of family needs if needed - plan future of child and extra support e.g. educational and social
- Transition to adult services when 16/+ (CPA approach)
What is conduct disorder? Who does it affect and what are some RFs? What are the different types?
CD is a childhood/adolescent disorder where there is a repetitive and persistent pattern of antisocial behaviour which violates the basic rights of others and that are not in line with age appropriate norms
Affects 7% boys and 3% girls aged 5-10 and 8% boys and 5% girls aged 11-16
Aetiology - unknown, may be parental (violence, failure of rule setting) or child (low IQ, CNS impairment factors)
RFs
- bio = ADHD!! (untreated especially), male
- psychosocial = substance misuse, low socioeconomic status, deprived status, in care
Types:
- <10yo = ODD (mild CD, angry and defiant behaviour to authority)
- > 10yo = unsocialised CD (significant abnormality in relationships with other children), socialised CD (generally well-integrated into a peer group), CD confined to family context
How do children with CD present? How would you Ix them?
Repetitive and persistent (>6m) pattern of dissociate, aggressive or defiant conduct e.g.:
- > Excessive fighting or bullying
- > Cruelty to other people or animals
- > Severe destructiveness of property
- > Fire setting
Ix:
- > Hx from collaterals (school, parents)
- > Developmental assessment
How would you manage conduct disorder? What is the prognosis for it?
Mx:
1st line –> parent management training programmes (Webster-Stratton, triple P)
- requires strong parental cooperation and motivation
- if weak outcome due to poor parental engagement then move to 2nd line
2nd line –> child individual or group interventions focussed on anger management and problem solving (but often child doesn’t have motivation to engage well)
- > Remedial educational teaching
- > Alternative peer activities
Prognosis:
- 50% develop antisocial personality disorder
- Poorer prognosis if early onset, low IQ, comorbidities, poor parenting, family criminal record and low socioeconomic status
How would you differentiate between learning disability, impairment and handicap? How would you define LD?
Impairment = any loss or abnormality in psychological, physiological and 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
Defined as:
- IQ <70
- Impaired social/adaptive functioning
- Childhood onset
