Level 2 - Emotional and Behaviour Problems Flashcards
What is anxiety?
- Anxiety is normal human experience to threat or danger
When does anxiety become a problem?
- Mental health issue if response is exaggerated, lasts more than 3 weeks and interferes with daily life
Types of anxiety?
o Separation anxiety disorder (SAD)
o Generalised anxiety disorder (GAD)
o Social anxiety disorder
o OCD
o Panic disorder (+/- agoraphobia)
o Phobias o PTSD
Epidemiology of anxiety?
- 2-5% of children
- SAD and GAD more common
- Women 2:1 Men
Aetiology of anxiety?
o Genetic
o Trauma and adverse life-events
o Stress (work, home, noise)
Risk Factors in anxiety?
o Bullying
o Exams
o House moves
o Physical illness
o Abuse
o Bereavement
o Friendship problem
Psychological symptoms in anxiety?
Agitation
Poor concentration
Insomnia
Repetitive thoughts/activities
Thoughts going around and round
Impending doom
Biological symptoms in anxiety?
Dizziness
Faint
Tachypnoea
Butterflies
Nausea
Sweating
Muscle tension
Heart racing
Palpitations
Tremor
Lump in throat
o Panic Attacks
Social symptoms in anxiety?
Reassurance seeking
Avoidance
Dependent on person
DDx of anxiety?
- Child Abuse Depression
Assessment of anxiety?
MH history
- Assessment of behaviours
o Antecedents, Behaviours, Consequences
Psychoeducation in anxiety?
o Understanding
o Reassurance
o Information leaflet
o Regular exercise
o Meditation
o Relaxation techniques
Management of anxiety?
o CBT (First-line) includes:
Clarity of diagnosis + education to child and parent Helping child face their fears
Identification of unhelpful thinking and practicing more functional thinking
Skills acquisition (progressive muscle relaxation, guided imagery)
Parents as motivators and behavioural coaches
Relapse identification - Medication
o SSRIs (after CBT fails)
What is attachment? When does it develop?
- Describes relationship between caregiver & child
- A process of proximity seeking to an identified attachment figure in situations of perceived distress or alarm for purpose of survival
- Attachment not seen in humans before 6 months – develop stranger anxiety
Importance of attachment?
o Secure attachment linked to better behavioural and academic outcomes in childhood
o Forms basis for working models of future relationships
ICD-10 classification of Reactive attachment disorder?
Abnormal social relationships associated with emotional disturbance due to circumstances
Examples are fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some children
Withdrawn behaviour, with a lack of attachment behaviour towards caregivers
Affected children tend not to seek comfort when distressed and not respond when comfort is offered
ICD-10 definition of disinhibited attachment disorder?
Attention-seeking and indiscriminately friendly behaviour
Attachment is described as diffuse rather than selectively focused and there are poorly modulated peer interactions
Risk factors of attachment disorderS?
o Neglect
o Abuse
o Institutionalism
o Disruption of care
o Separation from primary caregiver
Features of attachment behaviour?
o Proximity seeking to attachment figure
o Secure base
o Separation leads to protest by infant
o Permanent separation e.g. bereavement, affects capacity to feel secure & explore.
o Maximal at 18-36 months.
o Modulated by temperament of child.
DDx of attachment?
Autism spectrum disorder, PTSD, ADHD, anxiety disorders, selective mutism
Classification of attachment - insecure avoidant?
Attachment behaviour is downplayed by these children and they do not give signals regarding need for comfort
Classification of attachment - insecure ambivalent?
Up-regulation of attachment behaviour, with excessive amounts of distress and/or anger at separation from their caregiver and difficulty in calming the child after reunion
Classification of attachment - secure?
Children can be comforted by their primary caregiver and use that person as a safe base from which to explore their environment
Classification of attachment - disorganised?
Behaviour patterns are disorganised. The caregiver may be the source of the stress as well as the supposedly safe base
Advice to give carers and management of attachment?
- Attachment styles can change if care-giver environment changes for the child
o Improve child-carer relationship
o Parenting programmes
o CBT
Impact of attachment on adult attachment?
o Adult romantic relationships.
o Narrative capacity about our own childhood.
o Attachment style with our own children
What is ADHD? Pathology behind it?
- Triad of inattention, hyperkinesis and impulsivity
- Pathology – frontal lobe under-activity using dopamine
Prevalence, sex preference in ADHD?
- Prevalence 3-5%
- Boys 3:1 Girls
- Presents early
Aetiologies of ADHD?
o Genetic
o Influence of parenting
o Temperamental differences
Symptoms of inattention in ADHD?
o Poor attention to tasks
o Appears not to listen
o Poorly organised
o Easily distracted
o Does not finish tasks
o Forgetful
Symptoms of hyperkinesis in ADHD?
o Fidgets and squirms
o Leaves seat in class or meals
o Runs and climbs rather than walks
o Noisy – cannot play or work quietly
o Not moderated by social demands
Symptoms of impulsivity in ADHD?
o Blurts out answers
o Fails to wait turn
o Interrupts
o Talks excessively
o Short tempers, form poor relationships
DDX of ADHD?
- Developmentally appropriate
- Boisterous personality
- Conduct Disorder
- Attachment disorder
- Anxious inattentiveness
- ASD, Bipolar
- Drugs (steroids)
Diagnosis of ADHD?
o Problems in all areas:
Excessive compared with norms of age
Present from early age
In more than 1 social setting
Assessment in child with ADHD?
o Family background
o Social situation
o Development
o Associated behaviours
o Medical history
Psychological treatment in ADHD?
o Information to parent and child
o Family support
o Behavioural management
o Structured tasks
o Simple instructions
o Time-outs
o School intervention programmes
Encourage quiet self-occupation
Drug treatment in ADHD? Effects, SE?
o Methylphenidate (Ritalin)
Effects last a few hours (slow release preparations available)
Does not cure disorder
Improves some symptoms
May need to continue for years
SE: anorexia, slowed growth, tics, poor sleep, abdominal pain
o Atomoxetine
Works over 24 hours, but takes 4 weeks to onset
What is deliberate self-harm?
- Varies from little actual harm, where there is a wish to communicate distress or escape from situation, to suicide
- DSH - self-poisoning or injury, irrespective of the apparent purpose of the act
What is suicide?
- Suicide - intentionally taking of one’s life
Epidemiology of self-harm?
- 10% of children self-harm
- Females 4:1 Males
Most common DSH admissions?
o Overdoses (90%)
o Laceration (8%)
Risk factors of DSH?
o FHx of DSH, learned ‘copycat’ behaviour
o Abnormalities in endorphin response and serotonin implicated
o Poor early care, abuse, neglect, bullying
o Identity problems (cultural, sexual, body image)
o Conduct disorder, drug misuse
Common methods of suicide?
o Overdose
o Inhalation of car exhaust fumes
o Hanging
o Suffocation
o Shooting
Common methods of DSH>?
o Overdose, cutting
Common reasons to DSH?
o Communicate message
o Emotional immaturity
o Inability to cope with stress
o Maladaptive coping strategy – short-term feel effective and can become addictive
Assessment in a DSH episode?
- Assess capacity and MHA if needed
- Assessment o Injuries to self
o Potential effects of ingestion of substance
o Childs capacity to consent or refuse treatment
o Presence or absence of mental illness
o Risk of further DSH episodes
Management of DSH?
- Psychiatric assessment urgently (CAMHS)
- Social services
- Counselling and support for person and family
What is anorexia?
- Weight loss, leading to at least 15% below expected
- Self-induced avoidance of fattening foods
- Self-perception of being too fat, with fear of fatness
- Amenorrhoea
Epidemiology of anorexia and bullaemia?
- Girls 7:1 Boys
- Mortality 5-20%
- Bulimia more common (40%), Anorexia (10%), ED-NOS (50%)
Aetiology of eating disorders? Anorexia and bullaemia?
o No single cause
o Biological
Genetics (twin studies), malnourishment
o Psychological
Perfectionism, reaction to stress, tendency to anxiety and depression, worry
o Environmental
Puberty, stressful life event, bereavement, abuse, stresses
Diagnostic criteria for anorexia nervosa?
• Dietary restriction (may be accompanied by vomiting, exercise, laxative abuse, or other weight control methods)
significant and unhealthy self-induced weight loss. BMI of <17.5)
- Intense fear of gaining weight even when severely underweight
- Body image distortion with dread of fatness
- Amenorrhoea
Complications in anorexia? CNS, hair, heart, blood, muscles, kidneys, electrolytes, GI, hormones, skin?
o CNS - Can’t think right, depression, dizziness, fear of gaining weight, sad, moody, irritable
o Hair – thin and brittle
o Heart – Hypotension, bradycardia, palpitations, heart failure
o Blood – Anaemia
o Muscles and Joints – Weakness, swollen joints, fractures, osteoporosis
o Kidneys – Stones, failure
o Electrolytes – Low potassium, magnesium, sodium
o GI – Constipation, bloating
o Hormones – Amenorrhoea, bone loss, growing problems
o Skin – bruise easily, dry skin, fine hair all over body, cold easily, brittle nails
Diagnostic criteria for bullaemia?
Recurrent episodes of overeating (binges). ≥ 2 per week for 3 months
Strong desire or compulsion to eat (craving)
Attempts to counteract the “fattening” effects of food by one or more of:
- Self-induced vomiting
- Self-induced purging
- Alternating periods of starvation
- Use of drugs such as appetite suppressants, diuretics or thyroid preparations
Self-perception of being too fat, with fear of fatness
• NB can be normal or overweight – atypical bulimia nervosa
Complications in bullaemia? CNS, cheeks, mouth, throat, muscles, stomach, skin, hormones, GI, electrolytes, heart , blood?
o CNS – depression, fear of gaining weight, anxiety, dizziness
o Cheeks – Swelling, soreness
o Mouth – Cavities, tooth erosion, sensitivity
o Throat – Sore, irritated, torn
o Muscles – Fatigue
o Stomach – Ulcers, pain
o Skin – Abrasion of knuckles, dry skin
o Hormones – Irregular periods
o GI – Constipation, bloating, diarrhoea, cramps
o Electrolytes – Dehydration, low K, Mg, Na
o Heart – Arrhythmias, heart failure, low BP, HR
o Blood - Anaemia
When to suspect an eating disorder?
o Weight loss, disordered thoughts about food/image, others concerned, socially withdrawn, physical symptoms
What is the SCOFF questionnaire? when to use it?
- SCOFF Questionnaire (General practise)
o Do you make yourself Sick because you’re uncomfortably full?
o Do you worry you’ve lost Control over how much you eat?
o Have you recently lost more than One stone in a 3-month period?
o Do you believe yourself to be Fat when others say you are too thin?
o Would you say that Food dominates your life?
o Score of 2 or more suggests likely AN or BN
Investigations in eating disorders?
o Height/Weight/BMI (mBMI; <95% is underweight, >120% is overweight)
o BP lying/standing, HR, temp
o Bloods
General advice in eating disorders?
o Challenge not collusion
o Food is medicine
o Restore weight before psychological
What nutritional management is important in eating disorders?
o Weight gain – 0.5kg/week in community (Anorexia Nervosa)
o May need NG tubes
o Multivitamin supplementation
what psychological management important in eating disorderS?
o CBT, Motivational enhancement therapy (MET)
o Family therapy
o Cognitive remediation therapy – groups that run to help affected people
What is the prognosis of eating disorders in children?
o 50% recover
o 30% improve
o 20% chronic illness
