Emotional and Behavioural Flashcards
When is attachment to primary care givers most prominent?
6 - 36 months
When does stranger anxiety begin to develop?
9 months
What is the main/only management of anxiety a toddler has?
Seeking proximity to an attachment figure
When is bruising in a baby particularly concerning? at what age?
In non-mobile infants - there is a tiny % when bruising is accidental at this age
What should happen if a baby has a bruise?
Perform a skeletal assessment, full history and examination
When is it more common to see a bruise on a baby?
When they are mobile
If a child has lots of bruising, which blood tests are performed to check for certain disorders?
Von willibrand disorder
What type of bruising is more concerning on children?
Bruising that isn’t on bony prominences; head/face/cheek/inside thigh or arm/genitalia
If the bruising has a shape/pattern - hand, belt
Number of bruises
What are the differential diagnoses for bruising?
- Meningococcal sepsis
- Bleeding disorder
- Drugs
- Birth marks
- Dirt/dyes
Other than abuse/trauma, what are the other causes of fractures in children/babies? (3)
- Premature
- Rickets
- Osteogenesis imperfecta (brittle bones)
What are the features of abuse associated with burns?
- Delayed presentation
2. Saying it didn’t hurt
What are the features of ‘shaken baby syndrome’ now known as non-accidental head injury or abusive head trauma?
- Subdural bleeds (brain)
- Retinal bleeds (eye)
- Rib fractures
- Long bone fractures
- Brain injury
Apart from fractures/burns/bruising, what are other signs/symptoms of abuse/neglect?
- Dental caries
- Severe recurrent nits
- Sunburn
- Leaving child alone
- Overdose Calpol/medication
- Cold/hungry/thin/grubby
What is attachment?
Describes the relationship between a caregiver and a child - it is a process of proximity seeking to an identified attachment figure in situations of perceived distress or alarm for the purpose of survival
What are the features of attachment behaviour?
Proximity seeking to attachment figure, especially when threatened. Permanent separation e.g. bereavement, affects capacity to feel secure and explore.
What are the 4 classifications of attachment style?
- Insecure avoidant
- Secure
- Insecure ambivalent
- Disorganised
What does separation behaviour represent?
Temperament of the child
What does the behaviour upon reunion represent?
The attachment relationship
What will happen with a secure attachment on reunion?
Comforted by the caregiver, seeks proximity with them immediately and distressed beforehand.
How may an insecure ambivalent attachment present?
Seeking proximity but then wriggling away, not reading immediately to caregiver re-entering room
Why might some children have insecure attachments?
They are used to being left alone, learnt that crying does not work. The care provided by the caregiver is unpredictable; sometimes they should care/support but other times not.
This can be influenced by caregivers health and wellbeing - mental health, under the influence of drugs, distractions
What does disorganised attachment refer to?
Children experiencing some form of abuse by their caregiver
What is secure attachment linked to - in terms of outcomes as children get older?
Secure attachment linked to better behavioural and academic outcomes in childhood. Attachment relationships form basis of working models of future relationships. These models can be updated by later experience, but are fairly stable over time.
What is autistic spectrum disorder (ASD)?
A lifelong developmental disorder - three main areas of difficulty.
- Social interaction
- Communication
- Rigidity of thinking (+ sensory processing difficulties)
How many people are affected by ASD?
1 in 100
Which gender is ASD more common in?
Males
From what age must signs/symptoms of ASD be present in order for it to be diagnosed as such?
Before 36 months old
What are the symptoms of ASD? (5)
- No eye contact
- Rarely seek physical contact
- Difficult peer relationships
- Behaviour not modulated by context (e.g. being quiet in a library or in a church - child with ASD can’t emphasise with the situation to alter behaviour appropriately)
- Aloof
What kind of conversation difficulties may people with ASD have? (4)
- Literal understanding of language
- Overly formal conversation
- Talking at length about their own interests
- Find it difficult to use or understand facial expressions or tone of voice, jokes and sarcasm
Is anxiety always a health problem?
No, it is a normal human experience, which can lead to optimal performance sometimes
What are the normal fears and anxieties faced by children and teenagers? (6)
- Stranger anxiety
- Separation
- Dying and death of others
- School anxiety, performance anxiety
- Germs, getting ill, traumatic events, harm to self or others
- Fear of negative evaluation
What is the Yerkes-Dodson curve?
It shows when anxiety is useful - related to optimal performance, and also when it is detrimental to performance.
What % of children have clinical anxiety?
2-5%
What are the treatments for anxiety?
- CBT - cognitive behavioural therapy (first-line treatment)
- Exposure, response, prevention or flooding - for phobias
- Antidepressants - higher threshold in children; not so commonly prescribed
What are the four P’s in the bio/psycho/social model?
- Predisposing (risk factors for developing mental health problems)
- Precipitating (why now?)
- Perpetuating (what’s keeping it going?)
- Protective (what stops mental health problems/what helps recovery)
What are the risk factors for teenage depression?
- Family discord
- Bullying
- Physical, sexual or emotional abuse
- History of depression in the family
- Ethnic and culture factors
- Homelessness
- Refugee status
How can the presentation of depression in teenagers differ from adults?
Fall in grades at school
Sleeping too much
Gaining/losing weight (more often in adults its just weight loss)
What is the ICD 10 criteria for depression?
- Depressed mood
- Loss of interest or pleasure in activities
- Decreased energy or increased fatigue
- Loss of confidence or self-esteem
- Feelings of guilt
- Thoughts of death or suicide
- Sexual problems
- Previous episodes of self-harm
What is the leading cause of death in 15-24 year olds?
Suicide (alongside road traffic accidents and murder)
Depression is up to how many times more common in females than males?
4 times more common
What are the common characteristics of adolescents who die by suicide?
- Parental separation, divorce of death of parents
- History of mental health problems
- Family history of mental health problems
Why do adolescents self-harm?
- To die
- Relief of tension
- Get back at others to make them feel guilty
- Show desperation to others
- Escape from unbearable situations
What questions need to be asked to assess a young person who has self harmed?
- HOW?
- Conducted in isolation?
- Timed so that intervention is unlikely?
- Precautions to avoid discovery
- Preparations made in anticipation of death e.g. a will or giving things away
- Act had been considered for hours/days beforehand
- Why? - was it impulsive, was it associated with drug/alcohol abuse? what was the intent?
- What? - what needs to change to make them feel better?
9? Who?
What are the alternatives to self-harm?
Hitting a pillow Crying/screaming Going for a walk Holding an ice cube against skin Drawing on skin with red pen
What are the different diagnoses under the criteria of eating disorders?
- Anorexia
- Bulimia
- Binge-eating disorder
- Other
What is the criteria for diagnosis of anorexia?
- Persistent restriction of energy intake leading to significantly low body weight
- Intense fear of gaining weight
- Body dysmorphia
What is the biological factor that can trigger anorexia?
Malnourishment - causes hormonal changes that increase anxiety in response to food. Malnourishment also causes body to restrict energy to vital organs, and this includes restriction to frontal lobe of brain, which means you can’t process others opinions so easily, or logically think through situation - self-perpetuating cycle
Treatment for eating disorders?
FBT - family based treatment (aim is to restore weight before anything else, and then give support if needed once the frontal lobe is processing information better etc.) CBT-E Guided self-help Family therapy Cognitive remediation therapy
What is the weight for height BMI? - used for teenagers?
Actual BMI x 100 / median BMI (less than 95% = underweight)
How is attention deficit hyperactivity disorder defined?
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
For ADHD to be diagnosed, what criteria of symptoms must be met? (5)
- Starts before 12 years of age
- Occurs in two or more settings such as home and school
- Symptoms present for at least 6 months
- Interfere with, or reduce the quality of social, academic or occupational functioning
- Do not occur exclusively during the course of a psychotic disorder and are not better explained by another mental disorder
What are the three components of ADHD?
- Inattention
- Hyperactivity
- Impulsivity
How is inattention described?
It manifests as wandering off task, lacking persistence, having difficulty in sustaining focus and being disorganised
How is hyperactivity described?
It manifests as excessive motor activity when it is not appropriate (such as running around) or by excessive fidgeting, tapping or talkativeness
(In an adult is may be extreme restlessness or wearing others out with their activity)
How does impulsivity manifest itself?
This refers to hasty actions that occur in the moment without fore through and that have high potential for harm for the individual (for example darting into the street without looking). Impulsive behaviour may manifest as social intrusiveness (for example interrupting others excessively) and/or making important decisions without considering the long-term consequences
Which environmental factors are most strongly associated with ADHD?
- Low birth weight
- Maternal smoking during pregnancy
- Preterm delivery
- Alcohol exposure during pregnancy
- Epilepsy
- Acquired brain injury
(first two are most strongly associated, others are risks)
What are the three different subtypes of ADHD and which is most common?
- Inattentive subtype (accounts for 20-30%)
- Hyperactive-impulsive subtype (15%)
- Combined subtype (50-75%)
In which gender is ADHD more common?
Boys - some populations studies show rates as high as 10:1
Why is it thought more boys are diagnosed with ADHD than girls?
Due to the fact boys tend to present more often with disruptive behaviour that prompts referral, whereas girls more commonly have inattentive subtype.
For children with ADHD, in follow up studies by the age of 25 years, how many approximately will still have the full ADHD diagnosis?
15%
For children with ADHD, by the age of 25, how many will be in ‘partial remission’ i.e. the persistence of some symptoms?
65%
As ADHD progresses, which symptoms tend to persist and which tend to recede?
The inattentive symptoms persist and the hyperactive-impulsive symptoms recede
Which psychiatric/learning and development disorders is ADHD associated with/does someone with ADHD have a higher risk of developing? (7)
- Oppositional defiant disorder
- Conduct disorder
- Substance abuse
- Depression/mania
- ASD
- Dyslexia
- Dyspraxia
How many symptoms of both inattention and hyperactivity-impulsivity must there be for someone to be diagnosed with ADHD?
Six of each
What are the inattention symptoms someone with ADHD may present with? (9) …good luck with that
- Failing to give close attention to detail or making careless mistakes in schoolwork, work or other activities
- Difficulty in maintaining concentration when performing tasks or play activities
- Appearing not to listen to what is being said, as if their mind if elsewhere, without any obvious distraction
- Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand)
- Difficulty in organising tasks and activities
- Reluctance, dislike or avoidance of tasks that require sustained mental effort
- Losing items necessary for tasks or activities such as pencils, mobile phones or wallets
- Easy distraction by extraneous stimuli
- Forgetfulness with regards to daily activities
What are the symptoms of hyperactivity-impulsivity? (9)
- Fidgeting with or tapping hands or feet or squirming when seated
- Leaving the seat where remaining seat is expected (i.e. in a classroom)
- Running about or climbing, in situations wheres this is inappropriate.
- An inability to play or engage in leisure activities quietly
- Being ‘on the go’ or acting as if driven by a motor.
- Talking excessively
- Blurting out an answer being a question has been completed
- Difficulty waiting his or her turn
- Interrupting or intruding on others
What are the differentials for ADHD? (7)
- Anxiety disorders
- Depressive disorders
- ASD
- Personality disorder
- Oppositional defiant disorder
- Specific learning disorder
- Bipolar disorder
In children, how is the severity of ADHD assessed?
Based upon the social and educational impact..
- Self-care i.e. eating, hygiene
- Travelling independently
- Making and keeping friends
- Achieving in school
- Forming positive relationships with family members
- Positive self-image
- Avoiding criminal behaviour
- Avoiding substance misuse
What can a GP offer to a young person/their family who has ADHD and they are struggling to manage their behaviour?
Offer referral to group-based ADHD-focussed support
If a childs ADHD symptoms are severe, and a period of watchful waiting is not acceptable to see how behaviour develops, what referral can be made?
A referral to CAMHS/specialist paediatrician/child psychiatrist
Which websites are a useful resource to families/adolescents with ADHD? (4)
- Adders.org
- www.addiss.co.uk
- www.aadduk.org
- Mind
Which drug is usually offered to children as first-line medication for ADHD?
Methyphenidate
In addition to group-based support, and medication, what else is offered to school-age children with ADHD?
CBT
What are the most common adverse effects of methylphenidate in the treatment of ADHD? (4)
- GI disturbance - abdo pain, vomiting, diarrhoea, dry mouth, anorexia
- Cardiovascular effects - tachycardia, palpitations, arrhythmias
- CNS disturbance such as insomnia, nervousness, depression
- Dermatological effects including pruritus, rash
