Psychiatry- Child Psychiatric Disorders

Question 1

Diagnostic criteria of ADHD

Answer 1

• Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:
◦ Duration of at least 6 months
◦ In at least 2 settings (e.g. home, school, clinic)
◦ Not explained by other disorders

Question 2

Risk factors for ADHD

Answer 2

RISK FACTORS:
• Boys
• Family history
• Obstetric (prematurity, low birth weight)
• Conduct disorder
• Autism
• Learning disability

Question 3

Inattention symptoms in ADHD

Answer 3

Inattention:
‣ Struggles holding attention
‣ Struggles organising tasks/activities
‣ Does not listen when directly spoken to
‣ Does not follow instructions
‣ Fails to complete tasks
‣ Easily distracted
‣ Forgetful + loses things

Question 4

Hyperactivity/impulsivity symptoms in ADHD

Answer 4

Hyperactivity/Impulsivity:
‣ Unable to play quietly
‣ Talks excessively
‣ Does not wait their turn
‣ Interruptive or intrusive
‣ Spontaneously leaves their seat
‣ Fidgeting

Question 5

Investigations for ADHD

Answer 5

• Collateral history (parents, teachers)

Question 6

General management of ADHD

Answer 6

• MDT-focused: paediatricians, psychiatrist, ADHD nurses, CAMHS, parent groups, school/college

1) Watch and Wait (10 weeks):
• Consider for all patients
• Offer self-help and simple behavioural management

2) ADHD-focused group parent-training programme:
◦ 10-16 meetings
◦ After 10 week wait
◦ Education on ADHD, parenting strategies, environmental changes, dietary advice

Question 7

If parent training programme fails, what to do for children <5yo with ADHD

Answer 7

Children <5 years old:
3) Refer to specialist ADHD Service:
• If parent training programme fails, refer here for advice

Question 8

If parent training programme fails, what to do for children >5yo with ADHD

Answer 8

3) Refer to specialist ADHD service + offer Medication:
• Pharmacotherapy ONLY for those >5 years old
• 1) Methylphenidate (Ritalin) 6 week trial

					• 2) Lisdexamphetamine

Question 9

Mechanism of action of methylphenidate

Answer 9

◦ Inhibits dopamine + noradrenaline reuptake

Question 10

Side effects of methylphenidate

Answer 10

abdo pain, nausea, dyspepsia, STUNTED growth

Question 11

Monitoring for methylphenidate

Answer 11

◦ Monitor height and weight EVERY 6 MONTHS (every 3 months if <10yo)- plot growth chart
◦ Measure HR + BP every 6 months
◦ Baseline ECG as cardiotoxic

Question 12

Prognosis of ADHD

Answer 12

• As child gets older, hyperactivity reduces and inattention becomes more pronounced
• 90% get conduct disorder if untreated

Question 13

What is ASD

Answer 13

Neurodevelopmental condition characterised by qualitative impairment in social interaction + communication and repetitive stereotyped behaviour, interests and activities

Question 14

Risk factors for ASD

Answer 14

• RISK FACTORS:
• Male
• Family history
• Chromosomal abnormalities (Fragile X syndrome, Down’s syndrome)
• Prematurity or Low birth weight

Question 15

Typical associations with ASD

Answer 15

• Most have decreased IQ
• ASD children likely have ADHD and epilepsy

Question 16

When does ASD present

Answer 16

• Typically present at 2-4 years old: when language and social skills normally rapidly develop

Question 17

What is Asperger’s syndrome

Answer 17

Type of ASD where there is NO delay in communication/language or cognitive abilities

(Still have repetitive behaviours and issues with social interaction)

Question 18

Diagnostic triad of ASD

Answer 18

Diagnostic Triad:
• Verbal and non-verbal communication impairment:
◦ Struggles with non-verbal cues
◦ Difficulty in expressing emotion
◦ Delay or lack of development of spoken language
◦ Failure to initiate or sustain conversation
◦ Echolalia: involuntary repetition of words/phrases said by someone else

		• Impairment of social relationships:
						◦ Poor social skills
						◦ Socially withdrawn
						◦ No eye to eye gaze or intense eye contact 
						◦ Doesn’t seek to share enjoyment/interests with other people

		• Ritualistic/repetitive behaviours or interests:
						◦ Preoccupied with restricted patterns of interest 
						◦ Compulsive adherence to specific routines or rituals
						◦ Repetitive motor mannerisms (stimming) involving hand, finger-flapping and whole-body movements (usually done when feeling stimulated)
						◦ Asking the same question repeatedly

Question 19

Investigations for ASD

Answer 19

• Autism Diagnosis and Assessment (Gold-Standard)

• Developmental exam: focus on hearing, speech, language and social behaviour + play

• Cognitive assessment

Question 20

Management of ASD

Answer 20

• MDT + Patient-centred care
• Paediatrician, GP, psychiatrist, SALT, OT, educational and social services

• Psychosocial play-based intervention:
◦ Play specialists and SALT team can increase attention, engagement and communication
◦ Earlybird can increase parents’ understanding of communication

• Applied Behavioural Analysis:
• Improves social skills, communication and helps in learning skills (e.g. hygiene, grooming)

• Adjust social and physical environment for child
• Check if there are any co-existing physical or mental problems impacting child (e.g. otitis media, ADHD, vision issues)

Question 21

Transition to adult services (>16yo) in ASD

Answer 21

• Care Plan Approach (CPA) system
• Offer social care assessment at 18yo

Question 22

What is conduct disorder

Answer 22

Repetitive and persistent pattern of disruptive/antisocial behaviour affecting <18yo

Question 23

Risk factors for conduct disorder

Answer 23

RISK FACTORS:
• Child factors:
• ADHD, low IQ, chronic illness, in care, male
• Family factors:
• Poor parenting
• Abuse
• Family history
• Environmental factors:
◦ Low socioeconomic background
◦ Deprivation

Question 24

Duration of conduct disorder

Answer 24

• Must occur for >6 months

Question 25

Time of presentation of conduct disorder

Answer 25

• Usually presents in early adolescence (11yo)

Question 26

Presentation of conduct disorder

Answer 26

• Repetitive and persistent patterns of antisocial, aggressive and defiant conduct ◦ >6 months E.g.: ◦ Excessive levels of fighting or bullying ◦ Cruelty to people or animals ◦ Destruction of property ◦ Deceitfulness ◦ Theft ◦ Fire-setting ◦ Vandalism ◦ Running away from home ◦ Poor academic performance ◦ Truancy

Question 27

Conduct disorders investigations

Answer 27

• Reports from parents + teachers • Developmental assessment • CAMHS assessment

Question 28

Management of conduct disorder

Answer 28

1) Parent Training Programmes: 2) Child individual or group programmes: ◦ Focuses on problem-solving, anger management, social skills

Question 29

Complication of conduct disorder

Answer 29

• 50% will develop antisocial personality disorder

Question 30

What is learning disability

Answer 30

Defined as: • IQ <70 (normal=100) • Impaired social/adaptive functioning (impact on daily living) • Onset in childhood (<18yo)

Question 31

Risk factors for learning disability

Answer 31

RISK FACTORS: • Genetic: ‣ Down’s Syndrome (most common cause) ‣ Fragile X syndrome • Perinatal: ‣ Hypoxia ‣ Intracranial haemorrhage ‣ Infection • Postnatal: ‣ Hypoxia ‣ Hypothyroidism ‣ Psychosocial deprivation

Question 32

Mild learning disability:

Answer 32

IQ- 50-69 (some learning difficulties in school, but most can manage in society)

Question 33

Moderate learning disability

Answer 33

IQ 35-49 (marked developmental delay in childhood, but most can learn some degree of independence)

Question 34

Severe learning disability:

Answer 34

IQ 20-34 (need continuous support)

Question 35

Profound learning disability

Answer 35

IQ <20 (severe limitations in all aspects)

Question 36

Presentation of learning disability

Answer 36

• Milestone delay: • Language delay + Global developmental delay • Immature behaviour, play or self-help skills • Learning difficulties: ◦ Difficulty managing school work • Younger sibling ‘overtaking’ child • Poor sleep-wake cycle • Difficulty with peers • ASD co-occurs: ◦ Language + Social + Cognitive skills issues ◦ Repetitive stereotyped behaviour

Question 37

Investigations for learning disability

Answer 37

• Intellectual Impairment: ‣ Wechler Adult Intelligence Scale (WAIS III) • Impaired Adaptive and Social Functioning: ◦ Adaptive Behaviours Assessment System (ABAS II) • MAKATON language + use pictures • Check for other conditions, especially ASD

Question 38

Management of learning disability

Answer 38

• Biopsychosocial MDT ‣ Psychiatrist, OT, SALT, educational support • Choice boards, scheduling boards, self-help boards, communication aids