Psychiatric disorders in children

Question 1

1) What percentage of children may be affected by psychiatric problems at any one time?
2) What 2 main things can mental illness during childhood affect?
3) Who would usually raise concerns about a child’s mental health?
4) What 4 professions will be present in ever CAMHS team?
5) Interactions between what 3 things contribute to the overall risk of childhood mental health problems?

Answer 1

1) 15%
2) There can be devastating effects on social development and education.
3) A parent or a teacher, rarely the child themselves.
4) Psychologist, psychiatrist, specialist nurse and social worker.
5) the child, their family and their environment.

Question 2

Name 6 risk factors for mental health within the child.

Answer 2

1) Male
2) Sensory impairment
3) Physical illness
4) ‘Difficult’ temperament (impulsive, intense negative emotions).
5) Genetic factors

Question 3

Name 7 family risk factors for mental health in a child.

Answer 3

1) Family breakdown/ conflict
2) Separation/ death and loss
3) Abuse/ neglect
4) Inconsistent discipline
5) Hostility
6) Large families (>4)
7) Parental factors (psychiatric illness, physical illness, substance misuse, personality disorder, criminality).

Question 4

Name 7 environmental risk factors for child mental health problems.

Answer 4

1) Inner city
2) Overcrowding
3) Migration
4) Homelessness
5) Trauma
6) Poor social support
7) Peer criminality

Question 5

1) What is the prevalence of Autism?
2) What is the male to female ration for Autism?
3) Name 5 risk factors for Autism.
4) Name 3 investigations you might carry out if you suspect developmental disorders.

Answer 5

1) 1 in 1000.
2) 4:1.
3) obstetric complications, perinatal infection (maternal rubella), genetic disorders (tuberose sclerosis, Down syndrome, fragile X).
4) Hearing tests, speech and language assessment and neuropsychological testing (assess IQ and confirm diagnosis).

Question 6

Name the 3 domains where problems might be noticed in children with Autism.

Answer 6

1) Reciprocal social interaction.
2) Communication abnormalities.
3) Restricted behaviours and routines.

Question 7

Describe 6 areas of abnormality in the reciprocal social interaction domain of children with Autism.

Answer 7

1) Autistic children are not interested in people.
1a) They may appear aloof.
1b) They tend to play alone.
1c) They lack the ability to ‘read’ emotional states in others.
2) Attachments are impoverished without mutuality or warmth (these children do not turn to parents for comfort).
3) Eye contact may be odd, either avoidant or ‘looking through you’.

Question 8

Give 5 communication abnormalities that may arise in people with Autism.

Answer 8

1) Expressive speech and comprehension are delayed or minimal.
2) Ideas are taken literally (concrete thinking).
3) Gestures are usually absent (pointing/ waving goodbye).
4) Later, speech may consist of monologues, interminable questions or echolalia (repeating what has been said), but there is not exchange.
5) Classically, ‘I’ and ‘me’ are confused with ‘you’, ‘he’ and ‘she’ (pronominal reversal).

Question 9

What is autism characterised by with regards to restricted behaviours and routines?

Answer 9

Characterised by repetitive, stereotyped behaviours and restricted interests - rather than imaginative play. Even small changes in routine can results in intense tantrums.

Question 10

1) What do 75% of people with autism also have?

2) What do 25% of people with autism also suffer from?

Answer 10

1) Significant learning disabilities.

2) Seizures.

Question 11

Give 6 differential diagnoses for a patient with suspected Autism.

Answer 11

1) Deafness: causes poor language acquisition.
2) Asperger’s syndrome.
3) Specific language disorder: delayed speech but normal IQ and social ability.
4) Learning disability: IQ problems but relatively intact social skills.
5) Rare disorders: childhood schizophrenia/ Rett’s syndrome.
6) Neglect: can lead to language delay and poor socialisation - reversible unless severe.

Question 12

Give the 6 areas of management for a patient with Autism.

Answer 12

1) Support and advice for families: For example, National Autistic Society.
2) Behaviour therapy: reinforce positive behaviours.
3) Speech and language therapy.
4) Special education.
5) Treat co-morbid problems: for example, epilepsy.
6) Antipsychotics/ mood stabilisers: occasionally used for extreme aggression or hyperactivity.

Question 13

1) What percentage of adults with Autism gain full independence?
2) What are good prognostic indicators for people with Autism?

Answer 13

1) 1-2% of adults Gian full independence, with most needing lifelong support and care.
2) Good prognostic factors: IQ >70 and acquisition of some useful language.

Question 14

1) What is Asperger’s syndrome?
2) What is the male:female ratio for Asperger’s syndrome?
3) Describe the prognosis of Asperger’s syndrome in relation to Autism.

Answer 14

1) An Autism spectrum disorder.
2) 8:1.
3) Prognosis is much better than for Autism.

Question 15

Give 5 clinical presentations of Asperger’s syndrome.

Answer 15

1) Poor social skills.
2) Restricted interests
3) Normal language and IQ.
4) Tendency to literal interpretation of language.
5) Difficulty in reading social cues.

Question 16

Give the 4 areas of management for Asperger’s syndrome.

Answer 16

1) Advice
2) Support
3) Routine
4) Social skills training.

Question 17

Name 5 emotional disorders which commonly affect children.

Answer 17

1) Depression
2) Anxiety
3) Enuresis
4) Encopresis
5) Elective mutism

Question 18

1) What percentage of children and what percentage of adolescents are affected by depression?
2) Describe the male: female ratio before and after puberty for depression.
3) Briefly describe the presentation of depression in children.
4) What factors may be reported by teachers which could suggest depression in a child.
5) What is first line treatment for depression in children?

Answer 18

1) 1-2% of children, 8% adolescents.
2) Equal before puberty, but more common in girls outnumber boys thereafter.
3) Presentation similar to that in adults, although children are more likely to complain fo somatic problems (headache/ tummy ache).
4) Irritability and deteriorating school performance may be reported by teachers.
5) CBT.

Question 19

1) When are antidepressants prescribed for children?
2) Describe the prognosis for children with depression.
3) Describe the male to female ratio of anxiety in children.
4) What is the presentation of anxiety in children similar to?
5) What are the mainstay of treatment for anxiety in children?

Answer 19

1) Only prescribed by specialists in severe cases.
2) Prognosis is generally good, but severe episodes are likely to recur.
3) Anxiety disorders affect boys and girls equally.
4) Presentation of anxiety in childhood is similar to that of adults.
5) Psychological therapies are the mainstay of treatment.

Question 20

Describe separation anxiety disorder in children.

Answer 20

1) Children present as clingy.
2) Become distressed on separation from parents, often fearing that it will become permanent.
3) History may reveal a threatened or unmourned loss.

Question 21

How can separation anxiety disorder be managed?

Answer 21

The family can be helped while managing the child’s anxiety by increased periods of separation with reunion.

Question 22

1) What is school refusal?
2) When is school refusal common?
3) What 3 factors might be implicated in school refusal?
4) What types of families might school refusal occur in?
5) Describe a typical child with school refusal.

Answer 22

1) `This is unconcealed absence from school.
2) It is common at times of transition (e.g. a new school or a new sibling).
3) Bullying, fear of failure or an unsympathetic teacher may be implicated.
4) May occur in families with ‘precious’ children (death of a sibling/ difficulty conceiving) or vulnerable parents (life-threatening illness/ agoraphobia).
5) The child typically has tummy-ache just before school, but never at weekends or holidays.

Question 23

Describe how to manage a patient with school refusal.

Answer 23

1) First, help the parents tackle the problem, enlisting the schools support to deal with anxiety about performance and for bullying.
2) A rapid return to full attendance carries the best prognosis.
3) Failure to achieve a full return to attendance signals deeper problems (depression/ separation anxiety in the parent or the child).

Question 24

1) What is enuresis?
2) What percentage of 5 year olds and what percentage of adolescents are affected by enuresis?
3) What are the 2 different types of enuresis?
4) Who is more commonly affected by nocturnal enuresis?
5) Who is more commonly affected by diurnal enuresis?

Answer 24

1) Poor bladder control.
2) up to 10% of 5 year olds and 1% of adolescents are affected.
3) Primary (toilet training never mastered) and secondary (dryness was achieved for at least a year but has been lost).
4) Boys are more commonly affected by nocturnal enuresis.
5) Girls are more frequently affected by diurnal enuresis.

Question 25

1) What is primary enuresis normally due to?
2) What else can cause primary enuresis?
3) What usually causes secondary enuresis.

Answer 25

1) Primary enuresis is normally due to delayed maturation of the bladder’s nervous innervation or more generalised developmental delay.
2) Stress and excessively relaxed or strict toilet training can also play a role.
3) Secondary causes are usually stress related, for example, starting a new school.

Question 26

State the 6 steps in management for a child with enuresis.

Answer 26

1) Refer organic causes of enuresis to paediatrics (epilepsy, UTI, constipation, diabetes).
2) Reassure the family and the child that the problem is common and that it is nobody’s fault. Address stressors and review toilet training received so far.
3) Restrict fluids before bed.
4) Star charts to celebrate dry nights (positive reinforcement).
5) Bell and pad: underpants alarm clips into pyjamas and wakes child if moisture is detected, teaching normal voiding.
6) Medication: Imipramine (TCA) and Desmopressin (synthetic ADH).

Question 27

1) What is Encopresis.
2) Who is more commonly affected by Encopresis?
3) What are the 2 types of Encopresis?
4) What are most cases of Encopresis related to?

Answer 27

1) Inappropriate defecation after age 4 when bowel control is normally expected.
2) Boys.
3) Can be primary or secondary.
4) Most cases relate to constipation (‘overflow incontinence’).

Question 28

Give the 5 reasons that constipation might be due to as a cause of Encopresis.

Answer 28

1) Dehydration
2) Painful defecation (for example, anal fissure)
3) Fear of punishment
4) Toilet fears (for example, thinking there are monsters in the toilet).
5) Hirschprung’s disease (rare - bowel obstruction due to an ganglionic section of colon).

Question 29

Name 3 reasons for encopresis when constipation is not the cause.

Answer 29

1) Diarrhoea
2) Learning disabilities
3) Hostility (angrily defecating in mum’s shoe)

Question 30

Name the 3 steps in management of encopresis.

Answer 30

1) Laxatives and stool softeners for constipation: also treat other physical causes.
2) Reassure, address stress and review toilet training.
3) Star charts.

Question 31

1) What is the success rate of management of encopresis?
2) Briefly describe a child with elective mutism.
3) How many children are affected by elective mutism?
4) Who is more commonly affected by elective mutism?
5) When does elective mutism often start?

Answer 31

1) 60-90% become continent within a year.
2) An electively mute child can speak, but doesn’t in certain situations, for example, at school.
3) 4 in 1000.
4) Girls are slightly more affected than boys.
5) Often begins around the time of starting school.

Question 32

What 3 things does treatment of elective mutism involve?

Answer 32

1) Reassurance
2) Reducing stress
3) Behavioural management (sometimes)

Question 33

1) Name the 2 main behavioural disorders.
2) What percentage of children in the UK are affected by ADHD?
3) Who is more commonly affected by ADHD?
4) What 3 factors are implicated as possible causes of ADHD?
5) When should problems caused by ADHD present by?

Answer 33

1) ADHD and conduct disorder.
2) 2% UK children.
3) ADHD is 3 times more common in boys.
4) Dopamine deficiency, Noradrenaline deficiency and frontal lobe abnormalities.
5) Problems caused by ADHD should present by the age of 6.

Question 34

1) In order to be diagnosed, what must ADHD be?

2) What are the 3 domains of ADHD?

Answer 34

1) Must be persistent and pervasive across different situations.
2) Hyperactivity, inattention and impulsivity.

Question 35

Give 4 presentations associated with hyperactivity.

Answer 35

1) Children are boisterous with excessive energy.
2) Child is constantly on the move; running, jumping and climbing.
3) Children are unable to sit still for any length of time without fidgeting, squirming or wandering about.
4) Usually noisy and garrulous.

Question 36

Give 3 factors associated with inattention.

Answer 36

1) Children are distractible and unable to concentrate.
2) Flit chaotically between activities.
3) Often leave tasks unfinished.

Question 37

Give 4 features associated with impulsivity.

Answer 37

1) Children are impulsive and reckless, rarely stopping to consider the consequences of their actions.
2) Risky behaviour such as poor road safety.
3) They tend to be clumsy and accident prone.
4) May be disobedient (normally through impulsivity rather than deliberate naughtiness).

Question 38

Except from features associated with hyperactivity, inattention and impulsivity, give 2 other features of ADHD.

Answer 38

1) Children are often socially disinhibited and pay little attention to normal social conventions.
2) Often interrupt others and find it hard to take their turn.

Question 39

1) What other 2 conditions are associated with ADHD?
2) Give 3 differential diagnoses for patients presenting with features of ADHD.
3) Why are teachers good to get a collateral history from for patients with suspected ADHD?
4) What 4 negative experiences might a child with ADHD suffer going forwards?

Answer 39

1) Learning disabilities and conduct disorders.
2) Depression/ anxiety, mania (extremely rare in childhood) and conduct disorder.
3) Because they understand the range of ‘normal’ behaviours for particular age ranges.
4) low self-esteem, peer rejection, educational under-achievement and harsh parenting.

Question 40

Describe 3 investigations you might do for a child with suspected ADHD.

Answer 40

1) Questionnaires such as Conner’s rating scales, completed by the child, parents and teacher to rate ADHD related behaviours.
2) Classroom observation of the child by the clinician.
3) Educational psychology assessments.

Question 41

State and describe 5 management techniques for a child with ADHD.

Answer 41

1) Family: education on ADHD and advice on parenting and boundaries.
2) Behavioural management.
3) Support for teachers: appropriate schooling placement.
4) Family therapy.
5) Stimulant medication (methylphenidate/ dexamphetamine).

Question 42

1) What percentage of children with ADHD experience ongoing problems in adulthood?
2) What percentage of people diagnosed with ADHD in childhood retain the diagnosis as an adult?
3) Untreated ADHD is a risk factor for what 3 disorders?

Answer 42

1) 50% of adults have ongoing problems.
2) 30% retain the diagnosis.
3) later dissocial personality disorder, criminality and substance abuse.

Question 43

1) How does stimulant medication for ADHD work?
2) What are the 3 main adverse effects of stimulant medication?
3) What is done to try and limit growth retardation?
4) Are stimulant medications addictive in ADHD?

Answer 43

1) Increases monoamine pathway activity, improving concentration and allowing learning and maturation.
2) Appetite suppression, insomnia and growth retardation.
3) ‘Drug holidays’ on weekends and school holidays limit growth retardation to 1cm overall.
4) No, they are not addictive in ADHD.

Question 44

1) What percentage of 10 year olds are affected by conduct disorder?
2) Who is conduct disorder more common in and by how much?
3) Give 5 risk factors for conduct disorder.
4) Whereis antisocial behaviour in conduct disorder often learned and how is it reinforced?

Answer 44

1) CD affects 10% of 10 year olds.
2) 4 times more common in boys.
3) urban upbringing, deprivation, parental criminality, harsh and inconsistent parenting, maternal depression and a FHx of substance misuse.
4) Antisocial behaviour is often learned from parental or social methods and may be rewarded (for example, by increased attention) and thus reinforced.

Question 45

1) Briefly describe the behaviour of a child with conduct disorder.
2) What are the 2 types of conduct disorder?

Answer 45

1) Behaviour is persistently antisocial, not merely ‘rebellious’, involving bullying, stealing, fighting, truancy, cruelty to animals or people and fire-setting.
2) Socialised and unsocialised.

Question 46

1) Describe socialised conduct disorder.

2) Describe unsocialised conduct disorder.

Answer 46

1) The child has a peer group who often share in the antisocial behaviour.
2) Children with unsocialised CD are rejected by other children, which often makes them more isolated and hostile.

Question 47

Describe 3 differential diagnoses for a child with suspected conduct disorder.

Answer 47

1) Oppositional defiant disorder: milder form of CD occurring in children <10 with provocative, angry and disobedient behaviour towards adults. No extreme antisocial behaviour is present.
2) ADHD
3) Depression: some children present with antisocial behaviour.

Question 48

Describe 6 steps of management that could be used for a child with conduct disorder.

Answer 48

1) Family education: family members need to understand CD and recognise that they may reinforce problems.
2) Parent management training: teaches parents to reward good behaviour and deal constructively with negative behaviours.
3) Family therapy: family meets with a skilled therapist to discuss current problems. They are helped to cooperate in problem solving.
4) Educational support.
5) Anger management for the child.
6) Treat co-morbid problems such as ADHD.

Question 49

1) What percentage of children with conduct disorder develop substance misuse problems or dissocial personality disorder as an adult?
2) Which children is inpatient admission for conduct disorder reserved for?
3) What are tic disorders?
4) What are tic disorders categorised as?
5) Transient simple tics affects what percentage of children?

Answer 49

1) 50%
2) Reserved for children with complex or risky presentations.
3) Repetitive, involuntary and purposeless movements or vocal utterances.
4) Simple (blinking/ throat-clearing) and complex (self-hitting/swearing).
5) Affect 10% of children

Question 50

1) Who are simple tics more common in?
2) What disorder is commonly comorbid with tic disorders?
3) What 2 factors can usually worsen tics?
4) When do tics usually recede?

Answer 50

1) 3 times more common in boys.
2) Often a FHx of problems and is commonly comorbid with OCD.
3) Worsended by stress or stimulant medication.
4) When the sufferer is concentrating on something else. They can be voluntarily suppressed at the cost of internal tension, which is relieved by their expression.

Question 51

Describe some of the useful treatments for tic disorders.

Answer 51

1) Reassurance and stress management are effective treatments.
2) Clonidine (adrenergic agonist) or haloperidol (antipsychotic) are also useful.

Question 52

What occurs in Gilles de la Tourette syndrome?

Answer 52

There are multiple motor tics with at least 1 vocal tic. It tends to worsen in adolescence and persist into adulthood.