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
Etiology of ODD, CD
Risk factors
1. Biological factors
2. Socio-cognitive styles in the child
3. Familial and environmental adversities
4. Multiple stressors
- Risk factors are inter-related and cumulative that undermine effective parenting
Treatment of ODD, CD
- Parent Management Training
- Teach specific techniques to alter parent-child interaction based on social learning theory + behavioural modification
- >50% normalized, wide impact
- Long term efficacy - Cognitive Problem - Solving Skills Training
- Using structural activities to teach children step-by-step approach to solve interpersonal problems
- Improve but not normalized
- Short term efficacy - Multi-systemic therapy
- Amalgamation of individual, family and extra-family techniques target on risk factors
- Promising in severely impaired youths
Prognosis of ODD, CD
- Conduct problem is a stable behavioural trait especially those with early onset problems
- Associating with substance use, poor academic performance, risk-taking, suicidal behaviours, and interpersonal problems in adolescents
Autistic disorder: Prevalence + Risk factors
Prevalence:
- 1 in 54 children
- Occur in all racial, ethnic, and socioeconomic groups
- ***M:F = 4:1
- Asia, Europe, North America: ~1%
- South Korea: 2.6%
Risk factors:
1. Identical twins (36-95%) / Non-identical twins (0-31%) / Siblings (2-18%)
2. Premature / Low BW
3. Older parents
4. Prenatal exposures (e.g. Valproic acid)
5. Associated disease
- 10% also have
—> **Down syndrome
—> **Fragile X syndrome
—> ***Tuberous sclerosis
—> Other genetic / chromosomal disorder
- Commonly co-occur with other developmental, psychiatric, neurologic, chromosomal, and genetic diagnoses
—> >=1 non-ASD developmental diagnoses: 83%
—> >=1 psychiatric diagnoses: 10%
Etiology of ASD
- Genetics
- ~3-4% of siblings has autistic disorder
- heritability of autistic disorder is over 0.9 - Cognitive
- Theory of mind
- Executive Function
- Central coherence
- “Extreme” male brain - Anatomical / Neurochemical
- Mesolimbic (Fronto-temporal)
- Cerebellar
- Generalised abnormality with macrocephaly
- Serotonergic system
- Mirror neurons: imitate observed behaviour
DSM-5 of ASD
DSM-5:
1. Currently, or by history, must meet criteria A + B + C + D
A. Persistent deficits in **social communication and social interaction across contexts, not accounted for by general **developmental delays, and manifest by **ALL 3 of the following:
1. Deficits in **social-emotional reciprocity
2. Deficits in **nonverbal communicative behaviors used for social interaction
3. Deficits in **developing and maintaining relationships
B. **Restricted, **repetitive patterns of behavior, interests, or activities as manifested by **>=2 of following:
1. **Stereotyped / Repetitive speech, motor movements, or use of objects
2. Excessive **adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change
3. Highly **restricted, fixated interests that are abnormal in intensity or focus
4. ***Hyper- / Hypo-reactivity to sensory input or unusual interest in sensory aspects of environment;
C. Symptoms must be present in ***early childhood (but may not become fully manifest until social demands exceed limited capacities)
D. Symptoms together limit and impair everyday functioning
DSM-IV of ASD
- Pervasive Developmental Disorders
- Autism
- Asperger disorder
- Rett syndrome
- Childhood disintegrative disorder (CDD)
- PDD-NOS (Pervasive Developmental Disorder – Not Otherwise Specified)
Clinical features of ASD
***Social:
1. Impair non-verbal social interaction
2. Poor peer relationship
3. Lack of spontaneous sharing
4. Lack of emotion reciprocity
***Communication:
1. Delayed language development
2. Impaired conversation (e.g. Syntax, Tone, Echolalia)
3. Odd language
4. No spontaneous imaginative play
***Behavioural:
1. Preoccupation with restricted interest
2. Rigid adherence to rituals
3. Preoccupation with parts of objects
4. Motor mannerism
Assessment of ASD
- Clinical interview / assessment (most important)
- Day Hospital Assessment (multi-disciplinary team)
- Standardised Assessment / Questionnaire / Rating Scale
- Childhood Autism Rating Scale (CARS)
- Autism Diagnostic Interview - Revised (ADI-R)
- Autism Diagnostic Observation Schedule (ADOS)
- Diagnostic Interview for Social and Communicative Disorders (DISCO)
- Aberrant Behaviour Checklist (ABC)
- Social Responsiveness Scale (SRS)
- Childhood Behaviour Checklist (CBCL)
- Teacher Report Form (TRF)
- Australian Scale for Asperger’s Syndrome (ASAS)
- Autism Spectrum Quotient (AQ)
- Social Stories Questionnaire
- Theory of Mind test
- Eyes test - Others: Educational Assessment, IQ Test, OT assessment, ST assessment
Theory of Mind (TOM) test
- First order (將自己代入別人想法)
- Sally Anne test
- The Smarties test - Second order
- Perner + Wimmer test - Others (e.g. Rate behaviours in social scenarios, Eyes test (guess people’s emotion))
Treatment of ASD
Aim:
Fostering acquisition of social, communicative, cognitive skills at developmentally appropriate level
Children:
1. **Intensive structured training
2. **Behavioural modification techniques
3. ***Education
Parent / Family:
1. ***Psychoeducation, counseling and training of parent as co-therapist
2. Practical help for families
Medication:
- NO medication that can cure / treat main symptoms
Treat symptoms:
1. **Antipsychotic (Risperidone, Aripiprazole)
- Control of aggression, irritability
2. **SSRI
- Control of obsession
Prognosis of ASD
- Continuous course
- 1/3 achieves some level of independence, but only ***a few manage to live fully independently
- **IQ score and **language development at age of 5 are important prognostic markers
- 1/5 develops seizure at adolescence
ASD Service in HK
GP / MCHC / School / NGO
—> Child Assessment Centre (CAC)
—> Paediatrician / Child and Adolescent Psychiatric Centre (C+APC) (Psychiatrist)
—> Psychiatrist
—> Asessement + Training (MD team): Drug treatment, Behavioural therapy, Training classes, Treatment of comorbidities
—> Child Assessment Centre (CAC)
—> OPRS (On-site Pre-school Rehabilitation Services) / EETC (Early education and training centre) / ICCC (Integrated programme in KG cum child care centre) / SCCC (Special child care centre) / Special school (+ NGO + Private + Community services)
Anxiety disorders in Children / Adolescents
***Commonest psychiatric disorder in youth population
Classification:
Early childhood:
1. Separation anxiety
2. Specific phobias
3. Selective mutism
Late childhood / Early adolescence:
1. OCD
2. Social phobia
3. Panic disorder
All ages:
1. GAD
2. PTSD
Types:
1. Generalized Anxiety Disorder
2. Phobic disorders (Agoraphobia, Social phobia, Specific phobia)
3. Panic disorders
4. Post-traumatic stress disorders
5. Adjustment disorders / acute stress reaction
6. Anxiety disorder due to a general medical condition
7. Substance induced anxiety disorder
8. Emotional disorders with onset specific to childhood
- **Separation anxiety disorder
- **Phobic anxiety disorder
- **Social anxiety disorder
- **Sibling rivalry disorder
Rule out organic causes:
- Hyperthyroidism, Arrhythmias, Neurological disease, Substance induced anxiety (alcohol, illicit drugs, caffeine)
Clinical features of Anxiety disorder in Children / Adolescents
3 components:
1. Behavioural
- School refusal
- Cognitive
- Difficulties with peer relationships
- Low self-esteem - Physiological
- Frequent somatic complaints
- Developmental influence on the nature of anxiety —> Anxiety and Fears can be developmentally appropriate
- Anxiety disorder = Irrational worry / fear causing significant distress + functional impairment
- Similar categories of anxiety disorders in adults could be found in children
Separation anxiety disorder
- Onset specific to childhood
Clinical features:
- Recurrent excessive distress on separation from home / major attachment figures
- Worry about losing or harms befalling loved ones
- Anticipatory distress on separation
- Great difficulties at bedtime, going to school and being alone
- Repeated nightmares about separation
- May present with psychosomatic complaints
Etiology of Anxiety disorder in Children / Adolescents
- Weak to moderate genetic contribution
- Anxious attachment: bidirectional effect of escalating anxiety in the mother-child dyad
- Dysregulation **5HT and **NA systems: overactive behavioural inhibition system
- Inhibit temperament commonly reported
Treatment of Anxiety disorder in Children / Adolescents
- ***Psychological treatment (1st line)
- CBT, Relaxation training, Psychoeducation
- Educational support to children
- Behavioural treatment
- Parenting support - Medication:
- Few data to support anxiolytic use
- Severe cases may require SSRI / Imipramine / Anxiolytics
Prognosis of Anxiety disorder in Children / Adolescents
- Nearly 2/3 of expected to disappear in 3 to 5 years’ time
- 1/3 of them will have other categories of anxiety disorders
Adolescent depression
- Only 2-3% have MDD
- Prevalence ↑ after puberty
- ~70% of depressed youths had anxiety disorders, conduct disorder, substance misuse, and/or dysthymia
Clinical features:
- Most features of adult depression
- Tend to have more:
—> **Somatic complaints
—> **Irritable mood
—> **Behavioural problems
—> **Anxiety features
Etiology:
1. Stress induced atrophic changes in hippocampus
—> interrupt serotonin neuro-transmission
2. Genes (like serotonin receptor or promoter)
—> may interact with adverse environments leading to depression
3. Negative cognitive style + Lack of social confidence,
perfectionistic traits
- often associated with depression
4. Personally salient adverse life event
—> precipitate the onset of juvenile depression
Treatment:
1. ***SSRI (1st line)
- 2% taking SSRIs may become suicidal
- CBT
- effective for mild-moderate cases
- less effective than SSRI in severe depression
Prognosis:
- Episodic relapsing course
- Majority of cases recovered within the first 3 months, but 15% last longer than 18 months
- ~25% of Bipolar affective disorder first presented as a juvenile depression in their first episode
