Psychiatry - Child psychiatry Flashcards
What is attachment theory?
Attachment theory was developed by John Bowlby and relates to a child’s social development.
Small babies accept separation from their parents without distress. At about 6-7 months of age they start to become attached to a particular individual known as the attachment figure.
Attachment refers to the tendency of infants to remain close to certain people (attachment figures) with whom they share strong emotional ties. Children may not form adequate attachments due to reasons such as prolonged maternal separation or rejecting parents.
What are normal attachment behaviours?
When attachment figures leave the room, the child will cry, call for them and crawl or toddle after them.
The child may cling hard when anxious/fearful, tired or in pain.
Hugging, climbing onto their lap.
Talking and playing more in their company.
Uses the attachment figure as a secure base from which to explore.
They will immediately seek contact with the attachment figure after separation.
What are the categories of abnormal attachment?
These categories are derived from Aisnworth’s strange situation test which considers the child’s behaviour following a period of separation from the attachment figure. Children with abnormal attachment are predisposed to later neurotic disorders and other mental health problems.
1) Anxious avoidant
- child ignores the mother
- few signs of distress when mother leaves
- can be easily comforted by strangers
2) Ambivalent
- extreme distress on parental departure
- seeks contact on parents return but is angry
- resist contact with strangers
3) Disorganised
- chaotic behaviour
- child displays unusual behaviour on reunion and may even adopt strange postures for long periods
What are Freud’s theories of child development?
Freuds theories of child development and identity are very much concerned with the body and with family relations. In early childhood, the identity develops progressively through the phases – oral, anal and phallic.
- Oral – mouth is the focus of stimulation and interaction during feeding
- Anal – anus is the focus of stimulation during toilet training
- Phallic – awareness of self (genitals) and gender role
What is attention deficit hyperactivity disorder?
ADHD is also known as hyperkinetic syndrome. It is a severe form of long term overactivity associated with inattention and impulsivity arising before the age of 6 years.
What is the aetiology of ADHD?
50% risk in MZ twins.
There is increased conduct disorder and substance misuse amongst parents.
Functional imaging shows frontal metabolism.
There is dopamine and noradrenaline dysregulation in the prefrontal cortex.
What are the risk factors for developing ADHD?
Common co-morbidities include conduct disorder, learning difficulties, antisocial behaviour and depression.
Males are more affected than females.
What is the history of ADHD?
Hyperactivity-impulsivity symptoms:
- fidgeting
- interrupting others
- jumping the queue
- talking excessively
Inattention symptoms:
- easily distracted
- does not listen
- forgetful
Examination should be developmental assessment and full neurological screen.
How is ADHD diagnosed?
Diagnosis is by specialist assessment, including psychometric testing. Collect information from parents and teachers to ensure symptoms are present in more than one environment. Connor’s assessment scale may be useful.
How is ADHD managed?
1) Information and support for parents and teachers
2) Attend to educational deficits and environmental factors.
3) Behavioural modification - educate parents and teachers about appropriate methods (e.g. reward good behaviour and discourage reinforcement of problem behaviour)
4) Medication (methylphenidate or atomoxetine) under specialist supervision
What complications are associated with ADHD?
Difficulties learning (child does not sit still and learn)
Risk of accidents (due to impulsivity)
Low self esteem and peer rejection (behaviours upset other children)
Symptoms usually reduce by puberty. Severe cases may persist into adulthood. Conduct disorder and other co-morbidities give a poorer prognosis and may persist.
What side effects are associated with ADHD medication?
Decreased appetite with resultant weight gain and possible growth retardation Rebound hyperactivity Depression Insomnia Theoretically worsen epilepsy
What contraindications are there to ADHD medication?
Cardiovascular disease
Hyperthyroidism
Predisposition to tics or Tourette’s syndrome
How should ADHD medication be prescribed?
These drugs are very rarely prescribed for children under 6.
Drug treatment should be reserved for severe cases that have not responded to other interventions.
High doses may cause slowing of growth in children.
Drugs may be needed for months to years and careful monitoring of height and weight is essential.
Need to give 4 hourly doses (morning, lunchtime and possibly evening) as methylphenidate has a short half life.
What is the definition of child abuse? What are the associated risk factors?
Child abuse includes neglect, emotional, physical and sexual abuse.
Associations/ risk factors: unwanted child, mental/physical handicap, young/single parent with their own history of abuse, adverse socio-economic situation.