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Child's Health MBCHB > Mental Health > Flashcards

Mental Health Flashcards

1
Q

When was the attachment theory developed and by who?

A

1960s, Bowlby

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2
Q

What does the attachment theory explain?

A

Infants are evolutionarily primed to form a close, enduring bond on a primary caregiver beginning in the first moment’s of life
Vulnerability of the infant requires that care be provided by the adult and infant’s behaviour and inherent faculties ensure that a bond will be created
Baby has a need -> baby cries -> need met by caregiver -> trust develops -> repeat

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3
Q

What are the stages of attachment?

A

Asocial stage - 0-6 weeks
Indiscriminate attachment 6 weeks to 7 months
Specific attachments - 7-11 months
Multiple attachments

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4
Q

What happens in the asocial stage?

A

Smiling and crying not directed at specific people

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5
Q

What happens in the indiscriminate attachment stage?

A

Attention sought form different individuals

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6
Q

What happens in the specific attachment stage?

A

Strong attachment to one adult
Separation and stranger anxiety

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7
Q

What are the attachment styles?

A

Secure attachment
insecure Ambivalent attachment
insecure Avoidant attachment
Disorganised attachment

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8
Q

What does the secure attachment style show in terms of separation anxiety, stranger anxiety and reunion behaviour?

A

Separation anxiety - distressed when mother leaves
Stranger anxiety - Avoidant of stranger when alone but friendly when mother present
Reunion behaviour - Positive and happy when mother returns

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9
Q

What does the insecure ambivalent attachment style show in terms of separation anxiety, stranger anxiety and reunion behaviour?

A

Separation anxiety - infant shows signs of distress when mother leaves
Stranger anxiety - infant avoids the stranger - shows fear of stranger
Reunion behaviour - Child approaches mother but resists contact, may even push her away

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10
Q

What does the insecure avoidant attachment style show in terms of separation anxiety, stranger anxiety and reunion behaviour?

A

Separation anxiety - infant shows no sign of distress when mother leaves
Stranger anxiety - infant is ok with the stranger and plays normally when stranger present
Reunion behaviour - infant shows little interest when mother returns

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11
Q

What is the view of self and others in insecure avoidant adolescents?

A

Self - unloved, self-reliant
View of others - rejective, controlling, intrusive

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12
Q

What are the characteristic behaviours in insecure-avoidant adolescent?

A
  • Avoid intimacy, dependence, disclosure
  • hard to engage
  • view relationships as unimportant
  • don’t feel a huge need for other people
  • seen as cold - reported as lacking empathy or remorse
  • are indifferent to other’s views - assume others dislike them
  • linked with higher incidence of somatising illness and hard drug use
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13
Q

What is the view of self and others in insecure ambivalent adolescents?

A

Self - low value, ineffective, dependent
Others - insensitivity, unpredictable, unreliable

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14
Q

What are the characteristic behaviours of insecure ambivalent adolescents?

A
  • Disruptive, attention seeking, difficult to manage
  • insecure and coercive
  • can alternate between friendly charm and hostile aggression
  • display antisocial behaviour, impulsivity and poor concentration
  • feel a growing sense of unfairness and injustice - lots of complaining
  • dysregulated emotions
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15
Q

What is secure base?

A

the attachment figure/relationship provides a safe space (literally or symbolically) from which to explore the world

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16
Q

What is a safe haven?

A

the attachment figure/relationship provides a safe space (literally or symbolically) to retreat to at times of danger or anxiety

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17
Q

What is attunement?

A

process between caregiver and infant in which they are able to tune in to each other’s physical and emotional states. Through a process of co-regulation the infant learns to manage stress and anxiety

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18
Q

Where can attunement go wrong?

A

Where the child’s stress is met by a stressed adult who is unable to respond sensitively and effectively to the child’s needs, co-dysregulation may occur in which both caregiver and infant distress escalates.

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19
Q

How is attachment developed?

A
  • infants begin to develop beliefs about themselves, others and the world as a result of their attachment relationships and how effective they experience themselves being
  • These beliefs influence social expectations and beginning to govern interactions with other people and their world in general
  • If a child has mainly adverse and frightening experiences this will be reflected in a distressful and negative working model
  • These models become more resistant to change over time, even if an individuals social and emotional environment undergoes change
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20
Q

What does developmental psychology suggest?

A

that the early relationships with the attachment object causes an infant to form internal working models for relationships that will influence interpersonal relationships throughout life.

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21
Q

What does neuro psychoanalytic perspective suggest?

A

that the affective exchanges between infant and caregiver provides a foundation for neurological development and lead to the creation of neural networks that lead to the creation of neural networks that will influence the infant’s personality and relationships with others throughout life.

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22
Q

How is disorganised attachment shown?

A

confused, indecisive, disorientated behaviour as well as stereotypical signs of distress such as rocking

23
Q

What are the causes of disorganised attachment?

A
  • Unplanned pregnancy
  • Consideration of termination
  • Post-natal depression/psychosis
  • Physical/emotional neglect or abuse
  • Separation from primary caregiver
  • Paternal conflict
  • Maternal substance abuse
  • Frequent moves or placements
  • Traumatic experiences
  • Unresponsive baby
  • Undiagnosed, painful illnesses e.g., ear infections, colic
  • Caregiver and child not being attuned
  • Poor parenting skills
  • Parental difficulties with attachment
24
Q

What are the consequences of disorganised attachment on development? (behavioural)

A

Behavioural signs include lack of self-control, self-destructive behaviours and aggression towards others

25
Q

What are the consequences of disorganised attachment on development? (impaired cognitive functioning)

A

Impaired cognitive functioning e.g., lack of cause and effect thinking, language disorders, learning disorders, ‘all or nothing’ thinking - due to lack of a secure base from which the child can explore and learn

26
Q

What are the consequences of disorganised attachment on development? (Impaired emotional functioning)

A

core emotions are intense feelings of fear, pain and shame, mood swings are common, child will struggle to express emotions

27
Q

What are the consequences of disorganised attachment on development (Impaired social functioning)

A

superficially engaging but lacks genuine trust and intimacy, lack of peer relationships, blames others for mistakes

28
Q

What are the consequences of disorganised attachment on development? (Physical aspects)

A

Physical aspects include poor hygiene, chronic body tension, accident prone.

29
Q

How can disorganised attachment impact on delivery of care?

A
  • Staff may find it difficult to accept patient responding in a non-therapeutic manner
  • May lead to different approaches regarding how the young person should be managed - more or less restrictions, more immediate rewards, different mediation, more 1:1 time, more time with peers, discharge if inpatient care is making the young person worse.
30
Q

How is disorganised attachment managed?

A
  • Clear assessment of both attachment and family system and their relevance to current problems and concerns
  • The young person needs to be able to make sense of their history and current functioning.
31
Q

What is temperament?

A

the basic foundation of personality, usually assumed to be biologically determined and present early in life, including such characteristics as energy level, emotional responsiveness, demeanour, mood, response tempo, behavioural inhibition and willingness to explore.

32
Q

What is easy temperament?

A
  • Readily approach and easily adapt to new situations
  • React mildly to things
  • Regular in their sleep/wake and eating routines
  • Overall positive mood
33
Q

What is difficult temperament?

A
  • Withdraw from or are slow to adapt to new situations
  • Intense reactions
  • Irregular reactions
  • Irregular routines
  • Negative mood
  • Long and frequent crying episodes
34
Q

What is slow to warm up temperament?

A
  • Withdraw from or are slow to adapt to new things
  • Low level of activity
  • Show a lot of negative mood
  • Thought of as shy or sensitive
35
Q

What is reactive attachment disorder?

A

Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before 5 years.

36
Q

What causes RAD?

A
  • Associated with grossly pathological care
    • Persistent disregard for the child’s emotional needs for comfort, stimulation and affection
    • Persistent disregard for the child’s physical needs
    • Repeated changes of the primary caregivers
  • As a result of this the child has difficulty forming lasting, loving, intimate relationships
  • Accounts for 1% of all children under 5, about 20% of Looked after Children
37
Q

What risk factors are linked to RAD?

A
  • ACEs - abuse, neglect, household dysfunction
  • Increased likelihood of child is orphaned at a young age
38
Q

What is inhibited RAD?

A
  • refers to children who continually fail to initiate and respond to social interactions in a developmentally appropriate way
  • Interactions are often met with a variety of approaches - avoidance, resisting comfort, hypervigilant or highly ambivalent
  • Example: a child or infant that does not seek comfort from a parent or caregiver during times of threat, alarm, or distress
39
Q

What is disinhibited RAD?

A
  • Refers to a child who has an inability to display appropriate selective attachments
  • Also known as Disinhibited Social Engagement Disorder (DSED)
  • More enduring over time than inhibited subtype
  • Example: a child who displays excessive familiarity with strangers, indiscriminate sociability or lack of selectivity in their choices of attachment figure
40
Q

What is the neurobiology related to RAD?

A
  • Childhood experiences interact with genetics to change the structure of the brain and cause behavioural change
  • Life experiences can dramatically alter the number of neurons, increase or decrease the dendritic branches and the number of synapses
  • In particular, experiences can determine how emotional centres of the brain communicate with the cortex and its higher functioning
41
Q

What are some co-morbidities of RAD?

A

About 50% of children with RAD meet the criteria for one or more co-morbid disorders - emotional disorders, ADHD, behavioural disorders

42
Q

What is the typical presentation of RAD?

A
  • Noticeable neglectful behaviour by the primary caregiver
    • Not comforting baby or child in distress
    • Not responding to needs e.g. hunger, dirty nappy
  • Inappropriate interaction noticed between the baby or child and the primary caregiver
  • Lack of smiling or responsiveness in the baby or child
    • Does not seek attention or comfort, or resorts to extreme measures to gain attention
    • Rejection of demonstrations of comfort
    • Avoidance of touch or gestures of affection
  • Lack of distress in situations which would be expected to cause distress
  • Indiscriminate, excessive friendliness towards healthcare workers
  • Inconsolable crying
  • Emotional and behavioural difficulties
  • Medical signs can include: malnutrition, growth delay, evidence of physical abuse, vitamin deficiencies, or infectious diseases
43
Q

What are the potential differentials in RAD?

A
  • Conduct disorder - children with CD are able to form some satisfying relationships with peers and adults
  • Depression - depressed children are often able to form appropriate social relations with those who reach out to them
  • ASD - children with ASD present historical and pervasive difficulties, while children with RAD are more able to adapt based on what they get out of certain relationships
    • There is considerable overlap between RAD and ASD - the Coventry Grid can be used to help differentiate between the two
  • ADHD - children with ADHD are more able to initiate and maintain relationships
44
Q

What investigations can be conducted for RAD?

A
  • Strange Situation - 1-2 years
  • Modified Strange Situation - 2-4 years
  • Attachment Q-sort - 1-4 years
    • Children observed in a number of set environment
  • Story Stem Attachment Profile - 4-7 years
    • Stories with stressful scenarios involving a child and their parents and the children complete them verbally or using toys to enact the story
  • Child Attachment Interview (7-15 years) or Adult Attachment Interview (15 years +) - child asked to describe their relationship with caregivers in various situations
45
Q

What is the preschool management of RAD?

A
  • Video feedback programme for parents, foster carers, guardians or adoptive parents
  • Parental sensitivity and behaviour therapy
  • Home visiting programmes
  • Parent-child psychotherapy for those who have been or are at risk of maltreatment
46
Q

What is the school age management of RAD?

A
  • Parental sensitivity and behaviour training
  • Intensive training and support for foster carers, guardians and adoptive parents
  • Group play sessions - children of primary school age
  • Group-based educational sessions for caregivers and children/young people - late primary school or early secondary school age
  • Trauma-based CBT for those who have been maltreated
47
Q

What is the prognosis of RAD?

A
  • Onset can be detected as early as 2 months - considerable improvement or remission is possible if the child experiences an appropriately supportive environment
  • If not dealt with early:
    • Developmental delay
    • Reduction in academic achievement - withdrawal, disruptive behaviour, difficulties with relationships
    • Increased risk of contact with youth justice
48
Q

What is conduct disorder?

A

Repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms or rules are violated; to a lesser degree, it is called Oppositional Defiant Disorder (ODD) in younger children

49
Q

What influences conduct disorder?

A

Genetic

  • Some evidence in twin studies

**Brain Injury**

  • Intrauterine or post-natal CNS trauma
  • Antisocial behaviour in general is more common in children with neurological conditions

**Environmental**

  • Individual child problem - difficult temperament
  • Family circumstances
    • Families with parents with mental illness and intellectual difficulties
    • Drug and alcohol problems
    • Domestic violence
    • Single parent families
  • Parenting style
    • Lack of house rules - no set routine
    • Lack of clarity as to how children are to behave
    • Inconsistent responses to undersired behaviour with failure to follow through on consequences or with rewards
    • Lack of techniques to deal with crises or resolve conflict within the family
    • Lack of supervision
50
Q

What are the types of conduct disorder?

A
  • Mild-moderate - restricted to family environment
  • Severe
    • Unsocialised - predominantly violent behaviour and more likely to be dealt within the criminal justice system
    • Socialised - more covertly antisocial acts or better ability to avoid getting involved with the criminal justice system
51
Q

What are the co-morbidities of conduct disorder?

A

ADHD

  • ADHD characterised by inattention, hyperactivity, and impulsivity
  • Frequently co-occurs with difficulty in self-regulation
  • Symptoms of ADHD are developmentally inappropriate, impair function, pervasive across settings, and longstanding from age 5
  • It is possible to misdiagnose ADHD in children with HD as they present similarly but also are highly co-morbid
  • However, ADHD (on its own) and ADHD with CD appear to be subtypes
  • While the short-term response to stimulant medication is the same in these two groups, children with ADHD and CD have higher rates of antisocial personality as adults

**Others**

  • RAD
  • Reading and other learning difficulties
  • Depression
  • Substance misuse
  • Deviant sexual behaviour
52
Q

What is the typical presentation of conduct disorder?

A

The presence of three or more of the following criteria in the past 12 months with at least one criterion present in the past 6 months:

  • Aggression to people or animals
  • Destruction of property
  • Deceitfulness or theft
  • Serious violation of rules
53
Q

What is the management of conduct disorder in children with no co-morbidities?

A
  • Parent/foster training when child is under 11
  • Child-focused programmes where child is aged between 9 and 14
  • Multimodal interventions for young people aged between 11 and 17 years
54
Q

What is the pharmacological management for conduct disorder?

A
  • Medication is not main line but in extreme cases can help with impulsivity and aggressive behaviour - in these cases risperidone (atypical antipsychotic) is the drug of choice
  • Stimulant medication for co-existing ADHD
  • SSRIs for co-existing depression

Child's Health MBCHB (8 decks)

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