Paediatrics CAMHS Flashcards
How does depression present in childhood?
Low mood
Anhedonia
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding school
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms e.g. abdo pain
What psychosocial factors contribute to depression in childhood?
Potential triggers (e.g. loss of a family member)
Home environment
Family relationships
Relationships with friends
Sexual relationships
School situations and pressures
Bullying
Drugs and alcohol
History of self harm
Thoughts of self harm or suicide
FH
Parental depression
Parental drug and alcohol use
History of abuse or neglect
How is mild depression managed in childhood?
Mild depression (associated with single negative event) can be managed by watchful waiting, avoiding alcohol and cannabis) with follow up in 2 weeks
Referral to CAMHS for children with moderate to severe depression
How does CAMHS manage moderate to severe depression?
Full assessment to establish diagnosis
Psychological therapy with CBT, non-directive supportive therapy, interpersonal therapy and family therapy
Fluoxetine (first line in children 10mg to 20mg)
Sertraline and citalopram are second line antidepressants
Continue medical for 6 months after remission
Intensive psychological therapy if no response to medical treatment
How is response to treatment assessed in secondary care?
Mood and feelings questionnaire
When may admission be required for mental health issues in adolescents?
Risk of self harm, suicide or self-neglect or where there may be an immediate safeguarding issue
What is GAD?
Mental health condition causing excessive and disproportional anxiety and worry which negatively impacts the persons every day life
What is the GAD-7 questionnaire?
A questionnaire to help establish the severity of the diagnosis
How to assess a patient presenting with anxiety?
Assess for environmental triggers and contributors, e.g. family, relationships, friendships, bullies, school pressures, alcohol and drug use
What is the management of mild and moderate to severe anxiety?
Mild = watchful waiting and diet, exercise, avoiding alcohol
Moderate = counselling, CBT, medical (SSRI e.g. sertraline)
What are Obsessions and what are Compulsions?
Obsessions = unwanted / uncontrolled thoughts and intrusive images the person finds difficult to ignore e.g. overwhelming fear of contamination with dirt
Compulsions = repetitive actions the person feels that they must do, generating anxiety if they are not done e.g. checking all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down
Describe the ‘cycle’ in OCD?
Obsession leads to anxiety, leads to compulsive behaviour, leading to temporary improvement in anxiety, obsession reappears, cycle continues and becomes more engrained
What is OCD associated with?
- Anxiety
- Depression
- Eating disorders
- Autistic spectrum disorder
- Phobias
How is OCD managed?
Education / self help resources
Referral to CAMHS
Patient and carer education
CBT
SSRIs (under the guidance of CAMHS specialist)
Who does “autism spectrum disorder” apply to?
People affected by a deficit in social interaction, communication and flexible behaviour (grouping Asperger’s and autistic disorder together)
How is Asperger syndrome characterised?
Normal intelligence and function in everyday life but difficulty with reading emotions and responding to others
How does ‘social interaction’ change in autism?
Lack of eye contact
Delay in smiling
Avoid physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not displaying a desire to share attention (i.e. not playing with others)
How does ‘communication’ change in autism?
Delay, absence or regression in language development
Lack of appropriate non-verbal communication e.g. smiling, eye contact, responding to others and sharing interest
Difficultly with imaginative behaviour
Repetitive use of words or phrases
How does ‘behaviour’ change in autism?
General interest in objects, numbers or patterns than people
Self-stimulating movements which are used to comfort themselves e.g. hand flapping or rocking
Intensive and deep interest which are persistent and rigid
Repetitive behaviours and fixed routines
Anxiety and distress with experiences outside their normal routine
Extremely restricted food preferences
How is autism diagnosed?
Detailed history and assessment of the child’s behaviour and communication (diagnosis can be made before 3 years old)
Who is involved in the management of autism?
Child psychology and child and adolescent psychiatry (CAMHS)
Speech and language specialists
Dietician
Paediatrician
Social worker
Charities e.g. national autistic society
What does ADHD stand for?
Attention deficit hyperactivity disorder
What are the features of ADHD?
Very short attention span
Quickly moving from one activity to another
Quickly losing interest in a task and not being able to persist
Constantly moving or fidgeting
Impulsive behaviour
Disruptive or rule breaking
Consistent across various settings (if its just at school = environmental problem)
What is the management of ADHD?
Detailed assessment
Parental and child education
Healthy diet and exercise (food diary for links between food and behaviour)
Elimination of these triggers should be done with the assistance of a dietician
Medication - central nervous system stimulants - methylphenidate (“Ritalin”), dexamfetamine, atomoxetine
How does anorexia nervosa present?
Person feels they are overweight despite evidence of normal / low body weight
Obsessively restricting calorie intake
Exercising excessively
Diet pills / laxatives
What are the features of anorexia nervosa?
Excessive weight loss
Amenorrhoea
Lanugo hair (fine soft hair across most of the body)
Hypokalaemia
Hypotension
Hypothermia
Changes in mood, anxiety and depression
Solitude
Cardiac complications - arrhythmia, cardiac atrophy and sudden cardiac death
How does bulimia nervosa present?
Unlike with anorexia, people with bulimia have normal body weight
Fluctuating body weight
Binge eating followed by “purging” by inducing vomiting or taking laxatives
What are the the features of bulimia nervosa?
Alkalosis, due to vomiting HCl from the stomach
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers
GORD
Calluses on the knuckles where they have been scraped along the teeth (RUSSELL’S SIGN)
What are the features of binge eating?
A planned binge involving “binge foods”
Eating very quickly
Unrelated to whether they are hungry or not
Becoming uncomfortably full
Eating in a “dazed state”
What is the management for binge eating?
Patient and career education
Self help resources
Counselling
CBT
Addressing other areas of life, e.g. relationships and past experiences
SSRIs
What is refeeding syndrome?
Occurs in people who have been in a severe nutritional deficit, patients are at higher risk if BMI below 20 and have had little to eat for past 5 days
As starved cells start to process glucose, protein and fats they use up magnesium, potassium and phosphorus, leading to:
Hypomagnesaemia, hypokalaemia, hypophosphataemia
Risk of cardiac arrhythmias, heart failure and fluid overload
What is the management of refeeding syndrome?
Slowly reintroduce food with restricted calories
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balancing monitoring
ECG monitoring in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
What screening questions can be used for bulimia nervosa?
SCOFF
Sick (do you make yourself sick)
Control (do you worry you have lost control over how much you eat)
One stone (weight loss in last 3 months)
Fat (you think you’re fat when others say you are thin?)
Food (dominates your life?)
Answering yes to two or more suggests bulimia nervosa
What other conditions present as eating disorders?
Stress / anxiety / depression
Malignancy (e.g. stomach, pancreatic, lymphoma, bowel cancers)
Chronic infection (TB, HIV, infective endocarditis)
GI causes (Coeliac disease, peptic ulcer disease, other cause of malabsorption)
Metabolic causes (Addison’s, hyperthyroidism, diabetes)
Medications - NSAIDS, anti hypertensives, digoxin)
What questions in an eating disorder history?
How much weight lost and over what period?
Changes to diet?
Appetite?
Clothes become more loose?
General health?
Anxious / stressed / depressed?
Metabolic disorder (thirsty, pass a lot of urine, hot / sweaty, irritable / tremors)
Other causes (Night sweats? Change in bowel habit? Abdo pain? Chronic cough? Medications? Recreational drugs?)
What to look for on examination of a patient with an eating disorder?
Weight, height and BMI
Check teeth for acid damage
Consider abdo examination +/- PR as indicated from history
Check reflexes and examine thyroid gland
What investigations for a patient with an eating disorder?
FBC, U&Es, ESR, CRP, TFTs, LFTs, random blood sugar
CXR
Urinalysis
Faecal occult blood
If indicated:
HIV serology
Endoscopy (upper and or lower bowel)
USS or CT abdo
Specific tumour markers e.g. CEA or ca-125
What are the features of anorexia?
Overestimation of actual weight and body size (pt denys any weight loss)
Phobia of normal body size and weight
Restricting calorie intake, over exercise, use of laxatives, vomiting, diuretics
Very low body weight (<48kg = amenorrhoea)
Obsession and pre-occupation with food and cooking
What are the clinical effects of starvation?
Low metabolic rate
Cold peripheries
Bradycardia
Alopecia
Osteopenia
Vitamin deficiencies & electrolyte disturbances
Amenorrhoea
Lanugo hair (fine downy hair which may appear on the body)
Skin changes
Ankle oedema
Urine ( low LH and low FSH)
What are the components to management of anorexia?
Parental counselling (to get across seriousness)
Weight gain (by setting targets - 500g per week)
Drug therapy is not effective (e.g. SSRI)
How are bulimia patients different to anorexic patients?
Usually normal weight
What is refeeding syndrome?
Change from metabolising fats to metabolising carbs causes hypophosphataemia, hypogylcaemia, hypokalaemia
Due to massive cellular uptake of electrolytes
What can a low phosphate cause?
Muscle weakness and diaphragmatic insufficiency
How does refeeding syndrome present?
Confusion, coma, convulsions and death
What is the treatment of refeeding syndrome?
Thiamine and vitamin B complex supplements when feeding resumes in anorexia
Biochemistry monitored and abnormalities in potassium, magnesium and phosphate should be corrected
What is a personality disorder?
Maladaptive personality traits causing significant psychosocial distress and interfere with everyday functioning.
Patterns of thought, behaviour and emotions which differ from what is normally expected by society
Result of genetic and environmental factors
How do personality disorders present?
Strong intense emotions
Emotional instability
Anger
Low self esteem
Impulsive behaviour
Substance abuse
Poor sense of identity
Difficulty maintaining relationships
Risky behaviour
Violence and aggression
Self harm
Suicide attempts
What are the different types of personality disorder?
Anxious
Suspicious
Emotional / impulsive
What is an avoidant personality disorder?
Severe anxiety about rejection or disapproval and avoidance of social situations or relationships
What is dependent personality disorder?
Heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach
What is obsessive compulsive personality disorder?
Unrealistic expectations of how things should be done by themselves and others, catastrophising about what will happen if these expectations are not met
What is paranoid personality disorder?
Difficulty in trusting or revealing personal information to others
What is schizoid personality disorder?
Lack of interest or desire to form relationships with others / feeling that this is of no benefit
What is a schizotypal personality disorder?
Unusual belief, thoughts and behaviours as well a social anxiety which makes forming relationships difficult
What is borderline personality disorder?
Fluctuating strong emotions and difficulties with identity and maintaining healthy relationship
What is histrionic personality disorder?
Need to be at the centre of attention and having to perform for others to maintain that attention
What is narcissistic personality disorder?
Feelings that they are special and need others to recognised this or else they get upset. They put themselves first
What is the management of personality disorders?
CBT
Psychotherapy
No medical treatments specifically
What is Tourette’s syndrome?
Tics which are persistent for over a year
What is a tic?
Involuntary movement or sound which the child performs rapidly throughout the day (more prominent when the person is under pressure or excited) - overwhelming urge to perform, increases more they suppress it, need to get relief by performing (premonitory sensation)
When do tics present?
After 5 years of age (associated with OCD and ADHD)
What are some examples of simple tics?
Clearing of throat
Blinking
Head jerking
Sniffing
Grunting
Eye rolling
What are some examples of complex tics?
Performing physical movements e.g. twirling on the spot / touching objects
Copropaxia- performing obscene movements
Coprolalia - saying obscene words
Echolalia - repeating others words
What is the management of tics?
Usually improve over time (mild cases with no signs of underlying disease may only require reassurance and monitoring)
Measures to reduce stress, anxiety and triggers can be helpful
How can more severe or troublesome tics be managed?
Habit reversal training
Exposure with response prevention
Medications (antipsychotics)
Outline the HEADSSS assessment in adolescence?
Home = e.g who is at home, do you have your own room
Education / Employment = e.g. school / college, subjects you like? Who are your friends? Does anyone bully you?
Activities = spare time? relax? spend time with friends?
Drugs = e.g. some people around your age try smoking, alcohol or drugs? who supplies you?
Sex = are you seeing anyone? have you ever had sex? contaception?
Self harm = how is your mood? sad / depressed? hurting yourself?
Safety and abuse = do you ever feel unsafe?
