Psychiatry- Child Psychiatric Disorders Flashcards
Diagnostic criteria of ADHD
• 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
Risk factors for ADHD
RISK FACTORS:
• Boys
• Family history
• Obstetric (prematurity, low birth weight)
• Conduct disorder
• Autism
• Learning disability
Inattention symptoms in ADHD
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
Hyperactivity/impulsivity symptoms in ADHD
Hyperactivity/Impulsivity:
‣ Unable to play quietly
‣ Talks excessively
‣ Does not wait their turn
‣ Interruptive or intrusive
‣ Spontaneously leaves their seat
‣ Fidgeting
Investigations for ADHD
• Collateral history (parents, teachers)
General management of ADHD
• 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
If parent training programme fails, what to do for children <5yo with ADHD
Children <5 years old:
3) Refer to specialist ADHD Service:
• If parent training programme fails, refer here for advice
If parent training programme fails, what to do for children >5yo
3) Refer to specialist ADHD service + offer Medication:
• Pharmacotherapy ONLY for those >5 years old
• 1) Methylphenidate (Ritalin) 6 week trial
• 2) Lisdexamphetamine
Mechanism of action of methylphenidate
◦ Inhibits dopamine + noradrenaline reuptake
Side effects of methylphenidate
abdo pain, nausea, dyspepsia, STUNTED growth
Monitoring for methylphenidate
◦ 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
Prognosis of ADHD
• As child gets older, hyperactivity reduces and inattention becomes more pronounced
• 90% get conduct disorder if untreated
What is ASD
Neurodevelopmental condition characterised by qualitative impairment in social interaction + communication and repetitive stereotyped behaviour, interests and activities
Risk factors for ASD
• RISK FACTORS:
• Male
• Family history
• Chromosomal abnormalities (Fragile X syndrome, Down’s syndrome)
• Prematurity or Low birth weight
Typical associations with ASD
• Most have decreased IQ
• ASD children likely have ADHD and epilepsy
When does ASD present
• Typically present at 2-4 years old: when language and social skills normally rapidly develop
What is Asperger’s syndrome
Type of ASD where there is NO delay in communication/language or cognitive abilities
(Still have repetitive behaviours and issues with social interaction)
Diagnostic triad of ASD
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
Investigations for ASD
• Autism Diagnosis and Assessment (Gold-Standard)
• Developmental exam: focus on hearing, speech, language and social behaviour + play
• Cognitive assessment
Management of ASD
• 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)
Transition to adult services (>16yo) in ASD
• Care Plan Approach (CPA) system
• Offer social care assessment at 18yo
What is conduct disorder
Repetitive and persistent pattern of disruptive/antisocial behaviour affecting <18yo
Risk factors for conduct disorder
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
Duration of conduct disorder
• Must occur for >6 months
Time of presentation of conduct disorder
• Usually presents in early adolescence (11yo)
Presentation of conduct disorder
• 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
Conduct disorders investigations
• Reports from parents + teachers
• Developmental assessment
• CAMHS assessment
Management of conduct disorder
1) Parent Training Programmes:
2) Child individual or group programmes:
◦ Focuses on problem-solving, anger management, social skills
Complication of conduct disorder
• 50% will develop antisocial personality disorder
What is learning disability
Defined as:
• IQ <70 (normal=100)
• Impaired social/adaptive functioning (impact on daily living)
• Onset in childhood (<18yo)
Risk factors for learning disability
RISK FACTORS:
• Genetic:
‣ Down’s Syndrome (most common cause)
‣ Fragile X syndrome
• Perinatal:
‣ Hypoxia
‣ Intracranial haemorrhage
‣ Infection
• Postnatal:
‣ Hypoxia
‣ Hypothyroidism
‣ Psychosocial deprivation
Mild learning disability:
IQ- 50-69 (some learning difficulties in school, but most can manage in society)
Moderate learning disability
IQ 35-49 (marked developmental delay in childhood, but most can learn some degree of independence)
Severe learning disability:
IQ 20-34 (need continuous support)
Profound learning disability
IQ <20 (severe limitations in all aspects)
Presentation of learning disability
• 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
Investigations for learning disability
• 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
Management of learning disability
• Biopsychosocial MDT
‣ Psychiatrist, OT, SALT, educational support
• Choice boards, scheduling boards, self-help boards, communication aids
