Psychiatry SC046: The Child Is Uncontrollable: Child And Adolescent Psychiatry Flashcards
Psychiatric disorders in Child and Adolescent
Common:
1. Anxiety disorder
2. Oppositional defiant disorder (ODD)
3. Conduct disorder (CD)
4. Attention-deficit/hyperactivity disorder (ADHD)
5. Depressive disorder
6. Tics disorder
Less prevalent:
7. Autistic disorder (ASD)
8. Eating disorder
9. Obsessive compulsive disorder (OCD)
10. Tourette’s syndrome
Classification of Child and Adolescent Psychiatric Disorder
- Externalising disorders
- ADHD
- ODD
- CD - Internalising disorders
- Anxiety disorders
- Depression and DSH (deliberate self-harm) - ASD
Overlapping diagnostic criteria of psychiatric disorder
- ADHD
- Restlessness
- Poor concentration
- Increased motor activity
- Distractibility - ODD, CD
- Irritability - GAD
- Restlessness
- Poor concentration
- Irritability - Depression
- Poor concentration
- Irritability - Mania
- Increased motor activity
- Distractibility
- Irritability
Attention-deficit/hyperactivity disorder (ADHD)
A neurodevelopmental disorder consisting of delays in 2 dimensions of neuropsychological functioning:
1. **Inattention (Executive / Meta-cognitive deficits)
- Poor **persistence toward goals, tasks, and the future (can’t sustain attention/action over time)
- **Distractible (impaired resistance to responding to goal-irrelevant external and internal events)
- Deficient task **re-engagement following disruptions (skips across uncompleted tasks)
- Impaired working **memory (forgetful in daily activities, cannot remember what is to be done)
- Diminished **self-monitoring
-
**Hyperactive-impulsive behavior (Executive Inhibition) (includes emotional impulsiveness)
- Deficient **motor inhibition (restless, hyperactive)
- Impaired **verbal inhibition (excessing talking, interrupting)
- Impulsive **cognition (difficulty suppressing task irrelevant thoughts, rapid decision making)
- Impulsive **motivation (aversive to delay, prefer immediate gratification even at cost, greater discounting of delayed consequences)
- **Emotion dysregulation (impulsive affect; poor “top down” emotional self-regulation)
Arises early in development:
- Often before school age
- 55-65% of cases by age 7
- 93% by age 12; 98% by age 16
Symptoms:
- **Developmentally inappropriate
- Across **several settings
- ***Impairment in major domains of life activities
- Not better accounted for by another disorder
- Must be corroborated by someone who knows the patient well
Executive function abnormalities:
**Problem solving + **Planning + **Maintenance + **Working memory
1. Activation
- Planning, organising, prioritising, activating to work
- Focus
- Sustaining focus + shifting focus to tasks - Effort
- Regulating alertness, sustaining effort + processing speed - Emotion
- Managing frustration + modulating emotion - Memory
- Utilising working memory + accessing recall
Working memory - Action
- Monitoring + self-regulating action
***DSM-5 criteria of ADHD
DSM-5:
1. Manifests **>=6 symptoms of either **inattention or **hyperactive-impulsive behavior (5 for adults)
2. Symptoms are **developmentally inappropriate
3. Have existed for **>=6 months
4. Occur across settings (2 or more)
5. Result in impairment in major life activities
6. Developed by age **12 years
7. Corroborate self-reports through someone else
8. Are not best explained by another disorder
9. 3 Presentations: Inattentive, Hyperactive, or Combined
- Hyperactivity / Impulsivity (6/9)
- Runs about, climbs excessively in situations in which it is inappropriate (restless)
- “On the go” / “driven by a motor”
- Fidgets with hands or feet or squirms in chair
- Leaves seat in classroom or other in which sitting is expected
- Difficulty playing in activities quietly
- Talks excessively
- Difficulty awaiting turn
- Blurts out answers
- Interrupts or intrudes on others - Inattention (6/9)
- Difficulty sustaining attention in tasks or play activities (attention span based on developmental age)
- Easily distracted by extraneous stimuli
- Fails to give close attention to details or makes careless errors in school work, or other activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish school work, chores or duties (not due to oppositional behaviour or failure to understand)
- Forgetful in daily activities (做漏功課)
- Loses things necessary for tasks
- Difficulty organising tasks / activities (時間管理+物件管理 (e.g. 執書包))
- Avoids, dislikes or reluctant to engage in tasks that require sustained mental effort
Different parts of brain in ADHD
- Frontal lobe
- **Executive function
- Interpreting, reasoning
- **Working memory - Reticular activating system
- **Alertness
- **Arousal - Mesolimbic system
- **Interest
- **Pleasure
- Fixing
- FIltering (signal: noise)
- Sustain attention - Anterior cingulate gyrus
- ***Short-term working memory
- Anticipation
- Shifting set - Temporal lobes
- **Long-term memory
- **Speech
- **Language
- **Auditory
- Visual - Parietal lobes
- ***Sensory input
- Orientation - Thalamus
- ***Arousal
- Relay between subcortical and cortical
- Mood - Basal ganglia
- **Motivation
- Affect intensity
- **Regulate movement
- Interpret perceptual experience (autonomic, pre-conscious) - Cerebellum
- ***Coordination of movement + timing (including cognition)
- Linking / integrating cortical function - Amygdala
- ***Fear response
Etiology of ADHD
- Runs in families and about ***1/4 of sibs have ADHD
- Heritability is 0.7-0.8 (equivalent to schizophrenia / BPA)
- Candidate genes focused on dopamine and serotonin system
- Neuroimaging studies suggested Frontal-striatal circuit mediated by dopamine + NE transmission
Common associated comorbidities:
1. ***ODD
2. AD (Adjustment disorder)
3. LD (Learning disability)
4. MD
5. CD
6. SA (Substances abuse)
7. Tics
Developmental impact of ADHD
Pre-school
1. Behavioural problems
School-age:
1. Behavioural problems
2. Academic problems
3. Difficulty with social interactions
4. Self-esteem issues
Adolescence:
1. Behavioural problems
2. Academic problems
3. Difficulty with social interactions
4. Self-esteem issues
5. Legal issues, smoking, injury
College-age:
1. Academic problems
2. Self-esteem issues
3. Substance abuse
4. Occupational difficulties
5. Injury / accidents
Adult:
1. Occupational difficulties
2. Self-esteem issues
3. Relationship problems
4. Substance abuse
5. Injury / accidents
Common adult manifestations
Hyperactivity often changes to ***Restlessness in adult:
1. Workaholic
2. Overscheduled/overwhelmed
3. Self-select very active job
4. Constant activity leading to family tension
5. Talks excessively
Impulsivity (carry more serious consequences):
Low frustration tolerance
1. Losing temper
2. Quitting jobs
3. Ending relationships
4. Driving too fast
5. Addictive personality
Inattention:
1. Difficulty sustaining attention
- Meetings, reading, paperwork
2. Paralysing procrastination
3. Slow, inefficient
4. Poor time management
5. Disorganised
Management of ADHD
Mild cases:
- Advice, support, watch
- Group “parent training”
Moderate cases (school age):
- Refer to specialist
- Behavioural therapy
- Medication
Severe cases:
- Refer to specialist
- Medication (***1st choice)
Drugs:
1. **Psychostimulant
2. **Specific NE reuptake inhibitor
3. Imipramine
4. Clonidine
- ***More effective than psycho-social treatment
- Part of an individualised comprehensive multimodal treatment programs
- Comorbid disturbances often require separate treatment
Medications:
1. Methylphenidate (Ritalin / Concerta)
- CNS stimulant (Block reuptake of **Dopamine + **NE)
- Ritalin: onset 20-60 mins, duration **1-4 hours, >OD dose
- Ritalin LA: onset 20-60 mins, duration **8 hours, OD dose
- Concerta (Extended release Ritalin): onset 30-120 mins, duration **12 hours, OD dose
- SE: **↓ Appetite (Dose-dependent (SpC Psychi PP)), **Weight loss, **Insomnia, Headache, Abdominal pain, Irritability, Mood swing, **Motor tics, **Tachycardia
- Effect size: 1.0
- Lisdexamfetamine (Vyvanse)
- CNS stimulant
- onset 90 mins, duration ***13 hours, OD dose
- SE ~Methylphenidate
- Effect size: 1.0 - Atomoxetine (Strattera) (**SNRI)
- Non-stimulant
- onset 4-6 weeks, duration **24 hours, OD dose
- SE: Epigastric discomfort, N+V, Sedation, ↓ Appetite, Dizziness, Mood swing, Deranged LFT
- Effect size: 0.7
Behavioural treatment
PMT (Parent management training):
- Most effective behavioural therapy
- Specific strategies
1. Reward system
2. Time out
3. Cost system
4. Social reinforcement
5. Behaviour modelling
- Identify problem situations + precipitating factors
- Parent–child interactions —> enhance positive and limit negative interactions
Classroom:
- Similar to the approach used in home with parents
- Goal: Reduce inattention + disruptive behaviour
- Specific school accommodations:
1. Ensure structure + predictable routines
2. Employ cost-response token economy systems
3. Use daily report cards
4. Teach organisational + work/study skills
5. Attention to place in class
Prognosis of ADHD
- Age-dependent decline in severity: ***Hyperactivity (disappear first in adolescence (SpC Psychi PP))»_space; Impulsivity»_space; Inattention
- But many continue to have impairment extending to late adolescence and early adulthood
- Early school dropouts + under achievers in work
- ADHD comorbid with ***CD are particularly at risk of antisocial, criminal behaviors, substance abuse
Oppositional defiant disorder (ODD) and Conduct disorder (CD)
- ODD: 5% of school age children
- CD: 3-4%
- M:F=3:1
ODD:
Persistent + Recurrent pattern of negativistic, disobedient, and hostile behaviour towards authority figures
Clinical features:
1. Temper tantrums
2. Non-compliance
3. Argumentative
4. Deliberate provocation
5. Blames others for his mistakes
6. Easily annoyed, resentful
7. Vindictive behaviours
DSM-5:
>=4 for 6 months:
Angry / Irritable mood:
1. Often loses temper
2. Often touchy or easily annoyed
3. Often angry and resentful
Argumentative / Defiant behaviour:
4. Often argues with adults
5. Often actively defies or refuses to comply
6. Often deliberately annoys people
7. Often blames others for his/her mistakes or misbehaviours
Vindictiveness (報復心):
8. Often spiteful or vindictive (>= twice within past 6 months)
Conduct disorder (CD)
Repetitive + persistent pattern of norm violating behaviours
1. Various forms of aggression
2. Destructive behaviours
3. Theft or Deceitful behaviours
4. Serious violations of rules: stay out, run away, truant
ODD is a developmental ***precursor of CD
History taking in ODD, CD
- Overall compliant to parents commands (%)
- Noncompliant: on what aspect and how the parent handles
- Worst temper/outburst: how severe and how frequent, how parent cope and latest situation
- Screen ODD S/S
- Screen CD (Conduct disorder) S/S if presence of ODD S/S
- Give you an impression how difficult is the child and how good is the parenting
