Paediatric Psychiatry

Question 1

How does depression present differently in children?

Answer 1

Depression in Children and Adolescents Clinical features are slightly different as they are often more subtle and less constant
• Grumpy or irritated rather than sad and anhedonia, low mood is persistent but not pervasive i.e. low with family but not with friends.
• Thought changes such as loss of self-esteem, confidence and concentration
• Physical changes such as reduced energy, sleep, appetite, and self-harming behaviour – but be careful as this is often normal in children

Question 2

How is the history for a child with suspected depression different?

Answer 2

When assessing/taking histories non verbal clues are much more important as adolescents do not talk much. Collateral from parents and school is helpful. However, ALWAYS ask about drugs and alcohol abuse, suicidal thoughts, abuse, bullying but offer them the option to talk about this in private.

Question 3

How is depression managed in children?

Answer 3

Mild depression – usually best for 4 weeks of watchful waiting along with supportive therapy and guided self-help, if unresponsive then refer to CAMH specialists.
Moderate/Severe – CBT, antidepressant (fluoxetine is only one licensed in under 18s)

Assess how you can help with other problems such as abuse, bullying and sexuality.

In under 18s avoid Citalopram, paroxetine, sertraline, TCAs, venlafaxine, and fluvoxamine.

Question 4

How does GAD present in children?

Answer 4

Free floating anxiety
Fears of death, loss of child or parents
Somatic (nausea, abdominal pain, sickness, headaches, sweating, palpitations)

Question 5

What is separation anxiety?

Answer 5

Anxiety manifests upon separations or threat of it
Somatic manifestations
Nightmares with separation themes
School refusal

Question 6

What are the key features of OCD and PTSD in children?

Answer 6

OCD
Obsessional thoughts – intrusive persisting, awareness of their illogicality and resistance to them. Compulsive actions related to the obsessional thoughts.

PTSD
Persistently re-experiencing trauma
Avoidance of associated stimuli or numbing of responsiveness
Increased arousal – sleep disturbance, irritability, and poor concentration

Question 7

How are anxiety disorders managed in children?

Answer 7

Behaviour therapy – systemic desensitisation, flooding (dropping in the deep end), and response prevention
Psychotherapies – brief psychodynamic, family and CBT
Anxiolytics most commonly fluoxetine

Question 8

Is psychosis normal in children?

Answer 8

Making up imaginary friends and a blurring of reality is a normal part of psychosocial development of children.

Be careful that psychotic symptoms do not actually mean psychosis or schizophrenia.

Question 9

What symptoms would suggest a pathological psychosis in children?

Answer 9

Nonspecific psychotic symptoms – odd beliefs, mistrust of others and magical thinking
Decline in interpersonal skills and school functioning.
Positive family history

Question 10

What hallucinations should you be particularly worried about?

Answer 10

Hallucinations that are of particular worry
Imperative or exciting strong emotions e.g. kill you sister
Any heard unambiguously outside the head
Any referring to ideas that are not their own
Multiple voices at once especially if talking to each other

Question 11

How is psychosis managed in children?

Answer 11

Early diagnosis and prompt interventions
Antipsychotics, named workers and psychoeducational work, psychotherapy and social components. Keep child engaged to encourage compliance.

Question 12

What is conduct disorder?

Answer 12

Intense repetitive and persistent pattern which significantly deviate from age related socially acceptable norms. These causes significant impairment of the child as judged by parent, teachers and others. Isolated acts of aggression, destruction or fire setting can be sufficient to warrant concern.

Question 13

What are the risk factors for conduct disorder?

Answer 13

Lack of clear boundaries and inconsistent parenting
Rejection
Family conflict, especially witnessing violence and aggression
Child abuse
Child temperament
Comorbid learning or developmental difficulties

Question 14

What are the core symptoms of conduct disorder?

Answer 14

Core symptoms
Defiance of will or authority (usually police)
Aggression
Antisocial behaviour

Question 15

What is the diagnostic criteria for conduct disorder?

Answer 15

3 acts exhibited over the last 12 months and at least one in the past 6 months in multiple places.

Question 16

Do all children with conduct disorder go on to develop an antisocial personality disorder?

Answer 16

Most will not progress to antisocial personality disorder although surveying those with antisocial personality disorder as an adult reveal 40% would have met the criteria)

Question 17

What are the two types of conduct disorder?

Answer 17

Can be split into socialised and unsocialised types
Socialised – usually viewed as less serious and tends to be phasic in nature
Unsocialised – conduct disorder is more serious and potentially leads to criminality and later diagnoses of antisocial personality disorder. Lying stealing, taunting, viollece to people and animals.

Question 18

What is oppositional disorder?

Answer 18

Opposition defiance disorder is a subsection of CD with enduring pattern of negative, hostile, and defiant behaviour without serious violation of societal norms or rights of others.

Question 19

How is conduct disorder managed?

Answer 19

Parent training programmes – consistent care and parenting
Individual cognitive therapy for older children
Multisystemic therapy involving young person, family, school and criminal justice system.

Question 20

What are the 3 main parasomnias?

Answer 20

Arousal disorder – sleepwalking, night terror and confusional arousal
Sleep-wake transition disorders – rhythmic head banging disorder
REM sleep – nightmares, sleep paralysis, hallucinations and REM sleep behaviour disorders

Question 21

What advice should be given to parents with children who are having sleep problems?

Answer 21

Self-hypnosis or waking 30 mins before the expected event
Sleep hygiene
Schedule
Limit caffeine, alcohol and nicotine
Eliminate factors that create a hostile environment e.g. noise, light, ventilation and temperature (cooler is better)
Exercise performed during the day but not immediately before bed

Question 22

What treatment can be offered for sleep problems?

Answer 22

Antiparasomniacs – bedtime clonazepam, amitriptyline and carbamazepine
Psychotherapy e.g. CBT