Psychiatry - Child psychiatry Flashcards

1
Q

What is attachment theory?

A

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.

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2
Q

What are normal attachment behaviours?

A

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.

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3
Q

What are the categories of abnormal attachment?

A

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

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4
Q

What are Freud’s theories of child development?

A

Freud’s 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
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5
Q

What is attention deficit hyperactivity disorder?

A

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.

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6
Q

What is the aetiology of ADHD?

A

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.

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7
Q

What are the risk factors for developing ADHD?

A

Common co-morbidities include conduct disorder, learning difficulties, antisocial behaviour and depression.

Males are more affected than females.

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8
Q

What is the history of ADHD?

A

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.

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9
Q

How is ADHD diagnosed?

A

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.

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10
Q

How is ADHD managed?

A

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

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11
Q

What complications are associated with ADHD?

A

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.

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12
Q

What side effects are associated with ADHD medication?

A
Decreased appetite with resultant weight gain and possible growth retardation
Rebound hyperactivity 
Depression
Insomnia
Theoretically worsen epilepsy
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13
Q

What contraindications are there to ADHD medication?

A

Cardiovascular disease
Hyperthyroidism
Predisposition to tics or Tourette’s syndrome

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14
Q

How should ADHD medication be prescribed?

A

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.

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15
Q

What is the definition of child abuse? What are the associated risk factors?

A

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.

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16
Q

What signs should alert you to potential child abuse?

A

Physical abuse:

  • injuries without convincing explanation
  • bruises of varying ages
  • delayed presentation of injuries
  • recurrent injuries

Emotional abuse:

  • self harm
  • indiscriminate friendliness
  • immaturity

Neglect:

  • failure to thrive
  • inadequate hygiene
  • poor attachment to parent
  • speech and language delays

Sexual abuse:

  • genital trauma or infection
  • highly sexualised behaviour towards adults or children
  • pregnancy
  • unexplained decline in school work or change in behaviour
17
Q

What is the prognosis in child abuse?

A

Women who were sexually abused are at increased risk of psychiatric disorders in general, and in particular borderline personality disorder. Men who were sexually abused may become abusers and perpetuate the cycle.

18
Q

What is conduct disorder?

A

A disorder of childhood and adolescence (below age of 18) characterised by repetitive and persistent patterns of antisocial behaviours, which violate the basic rights of others and are out of keeping with age appropriate social norms.

19
Q

What is the aetiology of conduct disorder?

A

Exact unknown. Theories suggested include the following:
1) Parental - violence, failure to set rules, alcoholism, antisocial PD, divorce rejection

2) Child - difficult temperamant, low IQ, neurological impairment

20
Q

What are the risk factors for conduct disorder?

A

More common in those from deprived areas and children in the care system. ADHD and substance misuse are common co-morbidities. M>F

21
Q

What is the history of conduct disorder?

A

One episode is not significant enough to make a diagnosis; there must be a 6-12 month history. Problems reported by parents and teachers include:

  • frequent bad temper
  • disobedience
  • blaming others for their own mistakes
  • violence
  • bullying
  • inappropriate sexual behaviour
  • problems with the police
22
Q

How is conduct disorder managed?

A

1) Psychotherapies: family, problem solving skills, behavioural therapy and group therapies
2) Address educational needs with remedial teaching
3) Provision of alternative peer group activities
4) Parents skills training

23
Q

What is the prognosis in conduct disorder?

A

Half will develop antisocial personality disorder. Poor prognosis is predicted by early onset, low IQ co-morbidity, family criminality low SES and poor parenting.

24
Q

How common is bipolar effective disorder in children and adolesence?

A

Prevalence is 1%.
The presentation may be bizarre, mood incongruent and paranoid. Early onset bipolar affective disorder has a poor prognosis with half showing long term functional decline.

25
Q

How does depression present in children and adolescence?

A

Depression is common in young people (8% male adolescents and 14% in female adolescents) and the risk of suicide makes detection and treatment a priority. Family history is a significant risk factor. Young children present with apathy, failure to thrive, tantrums, separation anxiety and regressive behaviour. Older children present with somatisation, school refusal and sleep disturbance.

Adolescents present with low self esteem, suicidal acts, behavioural problems and biological symptoms of depression.

26
Q

How is depression in children and adolescents managed?

A

Psychotherapy should be used initially for mild to moderate depression. SSRIs are the first line medication but should be used at lower doses than in adults.

27
Q

How does OCD present in children?

A

Mild subclinical obsessions and compulsions are common and occur in up to a fifth of children. OCD is only usually recognised when severe, although 50% of cases have their onset by age 15. Presentation and management is the same as in adults.

28
Q

What are the risk factors for adolescent onset schizophrenia?

A

Schizophrenia can have an onset in adolescence. Earlier onset is associated with low IQ. The majority of cases have premorbid abnormalities including developmental delays, learning difficulties and speech and language problems. Thought disorder and hallucinations are common but delusions are rare. About 1/3 later receive a diagnosis of schizoaffective or bipolar affective disorder. When it occurs in this age group it is usually a chronic severe illness with a poor prognosis. The management principles are the same as in adults.

29
Q

What is school refusal?

A

The child refuses to go to school because of anxiety in spite of parental reassurance. It is common around the age of 5 years and 11 years when the change from junior to secondary school may precipitate it. If the problem is acute, the child should be returned to school as quickly as possible but if the problem is chronic then a graded return to school should be arranged. Truancy differs from school refusal in that it is intentional and likely to be associated with other antisocial behaviour.

30
Q

What sleep disorders are common in adolescence and childhood?

A

20% of children have night-time wakefulness, 3% sleepwalk. Night terrors – the child sits up terrified and screaming but cannot be woken enough to reassure. Associated with tachycardia and tachypnoea, may be associated with stress. Usually occur at age 4–7 years, especially in children with a positive family history.

31
Q

What is Tourette’s syndrome?

A

Characterised by multiple motor and one or more vocal tics. Mean age of onset is 7 years. Facial tics are often the initial symptom. Vocal tics range from sounds to coprolalia (expletives). It is three times more common in boys. It is commonly associated with OCD and ADHD. Management is with CBT and if tics are disabling, medication, such as haloperidol, can be used.