Children and Adolescent Psychiatry Flashcards
When do mental health problems start?
Childhood
Pre-conception factors influencing mental health
Genetics
Which mental health problems are highly genetic?
ADHD
autism
Which mental health problems are substantially genetic?
Depression
Anxiety
Post conception factors influencing mental health
Maternal health
- antibodies
- obesity
- DM
Substance misuse (alcohol, marijuana)
Toxins (lead, mercury)
Drugs (esp psychotropics, antiepileptics)
Epigenetics (folate controlled methylation)
Endocrine environment - especially androgens
Immune environment
Premature birth / perinatal complications
Twinning
What substance is linked to depression later on in childhood?
marijuana
In an androgen environment, what is more likely to develop?
Autism
ADHD in boys
What is premature birth / perinatal complications related to?
impaired development of attention and cognition - those being associated with ADHD
Presentation of foetal alcohol syndrome
Growth retardation (body, head, brain (inc. cerebellum), eyes Sensorimotor effects cognitive development effects executive function effects language effects characteristic appearance - short palpebral fissure length in eyes - thin upper lip - smooth / absent philtrum Grey matter gyrification - increased cortical complexity
Outcomes of foetal alcohol syndrome
Highly variable clinical picture Learning difficulties Conduct disorders (ODD) Combined ADHD or ADD or hyp-imp subtypes Anxiety disorders
What does ODD stand for?
Oppositional defiant disorder
Presentation of ODD
Frequent loss of temper Arguing becoming easily angered or annoyed showing vindictive, spiteful or other negativistic behaviours Behaviour is learned - enacted to obtain a desired result Oppositional defiance Refused to obey adults request Deliberately annoys people Touch of easily annoyed by others
Presentation of ADHD
Distractibility sustaining attention to tasks that provide high level of stimulation or frequent rewards problems with organisation Impulsive aggression Poor cognition often remorseful resistant to pure behaviour management
Presentation of Hyp-imp subtypes disorders
Difficulties with remaining still - more evident in situations that require behavioural self control
Impulsivity
What is white matter connectivity important for?
Functions that require interplay between brain areas e.g. working memory between hippocampus and anterior cingulate
What is low connectivity of white matter associated with?
More ‘neural noise’ in the system
cognitive instability
Poor integration of function
===»> ADHD
Environmental factors during childhood influencing mental health
Carer-child relationship (attachment) Parenting skills Parental mental disorder Marital harmony / family function Abuse / neglect Discipline (too much is associated with mental health problems) Day care and schooling Peer relationships life events physical disability
What does early life stress influence in the brain?
The function of the limbic circuit including amygdala and determines the subsequent patterns of stress response (resilient or flight)
mood and patterns of response to threat including withdrawl and/or aggressive response
What does experience of adversity do?
Trains the brain to adapt to a hostile environment
- limbic response and heightened amyglada activity
- cortical response and preparation of aggressive response
- behavioural response and aggression
What happens in reward based learning?
Dopamine neurones fire when you associate an action with a subsequent reward
Association between early adversity and reward based learning
early adversity decreases DA response - so have to behave a bit more to get the reward = the hypoactive reward response
What does the hypoactive reward response underpin?
underpins a variety of conditions e.g. addiction (obesity, drugs, alcohol, gambling, porn) and increases delay aversion
Features of executive function and cortical control
Taking control over automatic and learned behaviours
inhibit prepotent responses
intentional decision making and forward planning
requires self awareness and capacity to self monitor
Delay aversion and ADHD
Inability to wait and maintain attention in the absence of an immediate reward
What does the social brain reflect?
Increased understanding, reflection and control with age
What does carers negative emotion in the clinical predict?
Rates of relapse of chronic illness
Mental health issues associated with school
Fear of leaving home
Fear of going to school
Unwilling to go to school
Unwilling to leave home
Mental health problems associated with being out of school
Anxiety Conduct disorder Autism Depression OCD
Mental health problems affecting school attendance and learning
Learning difficulties due to poor attention
co-morbid specific or general learning problems
difficulty controlling emotion (escalation of anger, frequent conflict)
Anxiety
lack of motivation / energy
difficulties joining in
sensory problems - too noisy / lots of people
preoccupation - fear of germs/contamination etc
Associations between mental health and learning difficulties e.g. dyslexia
Motivational factors affecting school attendance
affecting willingness to go to school - learning difficulties - lack of friendships and relationships - bullying - lack or parental attention / concern Encouraging one to stay at home - maternal depression / maternal psychiatric disorder making them concerned something will happen to the child once they leave the house - separation anxiety - social factors e.g. helping parents make money
What is separation anxiety?
Fear of leaving parents and home
What is social phobia?
Fear of joining the group
Features of anxiety disorders - THE 3 AS
Anxious thoughts and feelings (e.g. impending doom)
Autonomic symptoms
Avoidant behaviour
Brain affects in anxiety disorders
Amygdala activity suppressed and reduced connectivity between right ventrolateral cortex and amygdala
Treatment of anxiety disorders
Behavioural - learning alternative patterns of behaviour - desensitisation - overcoming fear - manging feelings CBT Medication - Serotonin reuptake inhibitors (SSRIs) e.g. fluoxetine Narrative approaches - e.g. tell child "monster inside head"
Management of child refusing to go to school because of anxiety
Contain anxiety
RETURN TO SCHOOL ASAP
Principles of management of anxiety
Psychoeducation
- explaining the problem in terms that make sense to everyone
Goal setting
- choosing reasonable objectives that can be achieved
Motivation
- getting buy in so the goals can be achieved
Externalisation
- taking blame, guilt and anger out of the equation
Principles of CBT
Thoughts
Feelings
Behaviour
CBT in children
Mostly B and T
Dont expect children to have cognitive awareness
Long term effects of CBT in respect to children and school
Successing the challenge (i.e. going to a day of school) will allow some self confidence and resilience and so will allow them to go and tackle the next thing
When does ASD present?
Under 3 years
What does ASD stand for?
Autistic Spectrum Disorder
Who gets ASD?
M > F 3:1
The autistic spectrum
Autistic - normal IQ
- only effects on the synaptic function
AS SEVERITY OF NEUROTRANSMITTER DYSFUNCTION INCREASES
Autism with LD
- effects on synaptic function, neural migration and brain development
Presentation of ASD (varies with age and IQ)
Social - defects in
- reciprocal conversation
- expressing emotional concern
- non verbal communication (eye contact, facial expression, gestures, declarative pointing)
Repetitive behaviour
- mannerisms
- obsessions, preoccupations and interests
- rigid and inflexible patterns of behaviour (routines, rituals, play)
Learning disability - mild to severe Disturbed sleep and eating habits Hyperactivity High levels of anxiety and depression OCD School avoidance Aggression Temper tantrums Self injury / self harm Suicidal behaviour (6x)
Features of play in ASD
Repetitive
Lined up
Same thing
Presentation of ASD in young / lower IQ
Joint attention / attention to others
Emotional responses
Movements / actions e.g. flapping
Presentation of ASD in older / higher IQ
Conversation
Empathy
Interests
What congenital or genetic disorders is ASD associated with?
Rubella
Downs syndrome
Fragile X
Increased rates of what in ASD?
Depression
OCD
Anxiety disorders
language impairment
Management of ASD
Recognition, description and acknowledgement of disability
establishing needs
decreased demands -> reduce stress -> improve coping
Psychopharmacology
What is ODD associated with?
Impaired parenting
Adversity
What does a mental state examination represent?
A psychiatric stethoscope at the exact time, not the history
A snapshot of the current moment
What are conduct disorders characterised by?
Repetitive and persistent patterns of antisocial, aggressive or defiant behaviours, which violate age appropriate societal norms
Conduct disorders are associated with increased risk of…..
Early death often by sudden or violent means
Social exclusion
poor school achievement
long term unemployment
criminal activity
adult mental health problems
poor interpersonal relationships including with own children
Treatment of conduct disorders
Parental training programme (12 or younger) Modification of school environment e.g. behavioural support Functional family therapy Multi systemic therapy Child interventions - social skills - problem solving - anger management - confidence building treat comorbidity address child protection concerns
What are the hyperkinetic disorders?
ADHD
HKD
Pathology of ADHD
Your limbic system is asleep
Core features of ADHD
Developmentally abnormal inattention
Hyperactivity
impulsivity
Present across time and situations
Symptom pattern in ADHD
Majority are symptomatic into adulthood, especially inattention
Associations of ADHD
Specific LD ASD CD tics motor coordination problems substance misuse anxiety reduced academic and employment success increased criminal activity increased adult mental health problems
Management of ADHD
Psychoeducation Medication - stimulants, atomoxetine, guanfacine - methylphenidate Behavioural interventions - e.g. realistic expectation Parent training Treat comorbidity school interventions
Features of medicine management for ADHD
Non addictive purely symptomatic closely related to amphetamines taken orally acts on And and DA systems
Side effects of ADHD medications
Appetite
weight
sleep
BP slightly
Why is self harm carried out?
As a coping mechanism - harms them selves to deal with emotional pain or to break feelings of numbness by arousing sensation. it soothes the person that is doing it
Modes of self harming
Self poisoning
cutting
burning
Factors increasing risk of suicide
Persistent suicidal ideas Previous suicidal behaviour Highly Lethality of method used High suicidal intent and motivation Ongoing precipitating stresses Mental disorder Poor physical health Impulsivity, neuroticism, low self esteem hopelessness Parental psychopathology or suicidal behaviour Physical and sexual abuse Disconnection from support system
Treatment of attempted suicide
Usually admit to age appropriate medical ward after serious attempt for medical treatment and psychosocial assessment
Mental health and risk assessment
Further referral to agencies as appropriate e.g. child protection
