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**Y4 CBLs edited > Paeds: Mental Health (1) > Flashcards

Paeds: Mental Health (1) Flashcards

1
Q

Prevalence of mental health problems among children and adolescent

A
  • 10% of children aged 5-16 years has a clinically diagnosable mental health disorder
  • 50% of those with mental health problems in adulthood first experience symptoms by the age of 14
  • 75% before their mid-20s
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2
Q

Consent to treatment in children

A
  • patients less than 16 years old may consent to treatment if they are deemed to be competent, but cannot refuse treatment which may be deemed in their best interest
  • between the ages of 16-18 years it is presumed patients are competent to give consent to treatment
  • patients 18 years or older may consent to treatment or refuse treatment
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3
Q

Requirements for provision of contraceptives in under 16 years old

A

Fraser Guidelines state that all the following requirements should be fulfilled:

  • the young person understands the professional’s advice
  • the young person cannot be persuaded to inform their parents
  • the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
  • unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
  • the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
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4
Q

GMC guidelines on obtaining consent in children

A

The General Medical Council have produced guidelines on obtaining consent in children:

  • at 16 years or older a young person can be treated as an adult and can be presumed to have capacity to decide
  • under the age of 16 years children may have capacity to decide, depending on their ability to understand what is involved
  • where a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment which is in the child’s best interests
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5
Q

Intrinsic aetiology/ causative factors for mental health disorders in children

A
  • Genes
  • chromosomal abnormalities
  • Gender
  • IQ
  • Temperament
  • Chronic physical illness
  • Brain disorders
  • Hearing & visual impairments
  • Language disorders
  • Specific & global developmental disorders
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6
Q

Family factors influencing aetiology for mental health disorders in children

A
  • Size/siblings
  • Parental mental health (nature/nurture)
  • Traumas/losses
  • Marital discord
  • Domestic violence
  • Parenting styles
  • Single parenthood
  • Divorce/separation
  • Deprivation
  • Step-families
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7
Q

Societal/cultural factors influencing aetiology for mental health disorders in children

A
  • Socioeconomic disadvantage
  • Wider social supports
  • Neighbourhood cohesion/violence
  • Child related policies/legislation
  • Child rearing practices
  • Alternative care provision
  • Racism
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8
Q

School/peer/relationships factors influencing aetiology for the development of mental health problems in children and adolescent

A
  • Bullying
  • Transitions
  • Academic failure
  • Deviant peer groups
  • Sexual identity
  • Group identity
  • School ethos/expectations
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9
Q

MDT members within CAMHS

A
  • C&A Psychiatry
  • Clinical psychology
  • Family therapy
  • Child psychotherapy
  • CAMHS nursing
  • Social worker
  • Primary mental health worker
  • Trainees – psychiatry/clinical psychology/nursing/paediatrics
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10
Q

Epidemiology of anorexia nervosa

A
  • 90% of patients are female
  • predominately affects teenage and young-adult females
  • prevalence of between 1:100 and 1:200
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11
Q

Diagnosis of anorexia nervosa

A

Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned:

  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
  2. Intense fear of gaining weight or becoming fat, even though underweight.

3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

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12
Q

Management of anorexia nervosa

A

In children and young people:

  • anorexia focused family therapy as the first-line treatment
  • CBT as second-line treatment

For adults with anorexia nervosa:

  • individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
  • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
  • specialist supportive clinical management (SSCM)

The prognosis of patients with anorexia nervosa remains poor. Up to 10% of patients will eventually die because of the disorder.

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13
Q

Clinical/physiological signs of anorexia nervosa

A
  • reduced body mass index
  • bradycardia
  • hypotension
  • enlarged salivary glands

Physiological abnormalities

  • hypokalaemia
  • low FSH, LH, oestrogens and testosterone
  • raised cortisol and growth hormone
  • impaired glucose tolerance
  • hypercholesterolaemia
  • hypercarotinaemia
  • low T3
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14
Q

Features in patients with anorexia nervosa that may suggest a high risk of needing an intervention

A

Signs / symptoms suggestive of being high risk without intervention:

  • blackouts
  • dehydration
  • confusion
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15
Q

Physiological signs and symptoms of low food intake

A
  • constipation
  • feeling cold
  • weakness
  • dizziness
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16
Q

What else (specific to ask) in a Hx from a patient with suspected anorexia nervosa?

A
  • mental state and risk assessment
  • are there cognitions suggestive of an eating disorder → fear of fatness, drive for thinness, distorted body image
  • is she doing anything to keep her weight low → food restriction, purging, exercise, laxative or weight loss medication
  • is she experiencing any physical effects of low food intake → constipation, feeling cold, weakness, dizziness)
  • does she have signs / symptoms suggestive of being high risk without intervention → blackouts, dehydration, confusion?
17
Q

What tests can we do in a patient with suspected anorexia nervosa?

A
  • Muscle power (e.g. sit up from lying or squat)
  • ECG
  • full routine bloods, including TFTs and coeliac screen

*Beware normal bloods though. Can still be high risk.

18
Q

Prognosis in anorexia nervosa

A
  • significant morbidity
  • the highest mortality of all psychiatric disorders due to physical complications and suicide
  • Prognosis is variable. 50% are thought to make a full recovery; 33% improve and 20% remain chronically unwell
  • mortality has been found to be 2.8% over 11 years and higher over longer follow up
19
Q

Risks of treatments for anorexia nervosa (2)

A

There is a risk of:

  • refeeding syndrome if chronically starved and suddenly fed full portions
  • deterioration in mood, anxiety and heightened risk of self-harm and suicide as weight increases
20
Q

What’s Refeeding syndrome?

A

Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvation.

It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism.

21
Q

Metabolic consequences in refeeding syndrome

A
  • hypophosphataemia
  • hypokalaemia
  • hypomagnesaemia: may predispose to torsades de pointes
  • abnormal fluid balance
22
Q

Risk factors for developing refeeding syndrome

A

Patients are considered high-risk if one or more of the following:

  • BMI < 16 kg/m2
  • unintentional weight loss >15% over 3-6 months
  • little nutritional intake > 10 days
  • hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

If two or more of the following:

  • BMI < 18.5 kg/m2
  • unintentional weight loss > 10% over 3-6 months
  • little nutritional intake > 5 days
  • history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
23
Q

Prevention of refeeding syndrome

A

If a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days

24
Q

Definition of ADHD

A

ADHD as a condition incorporating features:

  • inattention and/or hyperactivity/impulsivity
  • these features are persistent
  • there has to be an element of developmental delay
25
Q

Diagnosis of ADHD

A

Features of ADHD:

  • up to the age of 16 years, six of these features have to be present
  • in those aged 17 or over, the threshold is five features
26
Q

Epidemiology of ADHD in the UK

A
  • ADHD has a UK prevalence of 2.4%, about twice that of autism, and is more common in boys than in girls (M:F 4:1)
  • Most children are diagnosed between the ages of 3 and 7
  • There is a possible genetic component
27
Q

Referral process in suspected ADHD

A

Following presentation:

  • a ten-week ‘watch and wait’ period should follow to observe whether symptoms change or resolve
  • if they persist → referral to secondary care

Secondary care = a paediatrician with a special interest in behavioural disorders, or to the local Child and Adolescent Mental Health Service (CAMHS)

28
Q

1st line management of ADHD in children

A
  • mild/moderate symptoms → parents attending education and training programmes
  • for those who fail to respond, or whose symptoms are severe, pharmacotherapy

(drug therapy should be seen as a last resort and is only available to those aged 5 years or more)

29
Q

Drug therapy ADHD (children)

A

Drug therapy should be seen as a last resort and is only available to those aged 5 years or more.

For those who fail to respond to educational and training programme, or whose symptoms are severe, pharmacotherapy can be considered:

  • Methylphenidate is first line in children and should initially be given on a six-week trial basis
  • If there is inadequate response, switch to lisdexamfetamine
  • Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects
30
Q

Methylphenidate

  • class
  • MoA
  • SEs
  • monitoring
A

Methylphenidate

Class and MoA: CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor

SEs: abdominal pain, nausea and dyspepsia

Monitoring: weight and height should be monitored every 6 months (in children)

31
Q

First-line pharmacological options for ADHD in adults

A
  • Methylphenidate or lisdexamfetamine are first-line options
  • Switch between these drugs if no benefit is seen after a trial of the other
32
Q

What else (apart from weight and growth measurement) do we need to do before prescribing drugs for ADHD?

A

All of these drugs are potentially cardiotoxic

  • perform a baseline ECG before starting treatment
  • refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity
33
Q

Are there any structural changes in the brain of a person with ADHD?

A

Yes - brain imaging shows developmental abnormalities in:

  • frontal, temporal and parietal cortical regions
  • basal ganglia
  • cortico-straito-thalamo-cortical network
  • callosal areas
  • cerebellum
34
Q

Neurochemical abnormalities in ADHD

A
35
Q

Environmental risk factors for ADHD

A

**Y4 CBLs edited (32 decks)

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