Psychiatry Seminar: Assessment for Child & Adolescent Psychiatry

Question 1

History taking

Answer 1

Background
1. Age of child
- Stage: Preschool, School, Adolescent

2. Birth + Developmental history
   - Nutrition
   - Disorder of motor + speech: speech, gross + fine motor, social emotional, sphincters
   - Medical history
   - School history: result, conduct, relation, ECA, comment from teacher
   - Social history: drug, alcohol
   - Courtship
   - Daily routines
3. Parents
   - Demographic
   - Physical / Mental history
   - Personality: temper, coping style, hobbies, ASD / ADHD traits
   - Discipline + Parenting: reasoning, lecturing and scolding, rewards and punishment, corporal punishment, risk of abuse, inconsistency between parents
   - Relation with patient
   - Marital relation
4. Family history
   - Siblings
   - Mental illness

Question 2

Mental state examination

Answer 2

1. Appearance / Behaviour / Attitude
2. Speech
   - Volume
   - Flow
   - Tone
   - Articulation
   - Spontaneity
   (e.g. poverty of speech / pressure of speech
   e.g. formal thought disorder (FTD) / flight of ideas
   e.g. circumstantiality / loosening of association)
3. Mood
   - Nature of mood (elated / depressed / anxious / irritable)
   - Range / Fluctuation of mood (labile vs flat affect)
   - Congruity of affect (incongruous affect)
4. Perception
   - Hallucinations (Visual / Auditory / Tactile or Somatic / Olfactory / Gustatory)
   - Other perceptual abnormalities e.g. illusions
5. Thoughts
   - Delusions
   - Obsessions
   - Over-valued ideas
6. Risk assessment
   - Self-harm / Suicide intent
   - Violence risk
7. Insight
   - Awareness to symptom
   - Awareness to illness
   - Awareness to consequence of illness
   - Awareness to need for treatment
8. Brief cognitive assessment
   - Orientation to time, place, person
   - Memory (immediate registration + recall)
   - Attention + Concentration (serial 7 test)

Question 3

MSE for Child

Answer 3

1. Observation
2. Brief introduction
3. Play by himself
   - Warm up
   - How he plays and interacts with parents and CMO (computer game not allowed)
4. Symptoms manifestation
5. 3 Step task
   - Chinese, English writing
   - Drawing about his family or school
   - Short-term memory (STM)
6. Copying task: any dyslexia
7. Interview the child alone
   - Any separation anxiety
   - Talk with him on family and then school, peer and classroom behaviour and studies, why he comes this time
   - Aspiration
   - Projective questioning on 3 wishes
8. Theory of mind (TOM) tests
   - 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))

Question 4

Attention Deficit Hyperactivity Disorder (ADHD)

Answer 4

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

1. 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
2. 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

Question 5

Management of ADHD

Answer 5

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 muiltimodal treatment programs
- Comorbid disturbances often require separate treatment

Medications:
1. Methylphenidate (Ritalin / Concerta)
- CNS stimulant
- 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, **Weight loss, **Insomnia, Headache, Abdominal pain, Irritability, Mood swing, **Motor tics, **Tachycardia
- Effect size: 1.0

2. Lisdexamfetamine (Vyvanse)
   - CNS stimulant
   - onset 90 mins, duration ***13 hours, OD dose
   - SE ~Methylphenidate
   - Effect size: 1.0
3. 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

Question 6

Behavioural treatment

Answer 6

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

Question 7

Autism Spectrum Disorder (ASD)

Answer 7

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

Clinical features:
***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

Question 8

Management of ASD

Answer 8

1. Advice + Support parents
   - Good liaison among parties
   - Family-focused
2. Appropriate education: School based
   - Training based on behavioural modification
   - Focus on improving communication: social skill training
3. Appropriate structured and predictable environment: Graded change approach
4. Drug treatment for target behaviours

Question 9

Oppositional Defiant Disorder (ODD)

Answer 9

• 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)

History taking:
1. Overall compliant to parents commands (%)
2. Noncompliant: on what aspect and how the parent handles
3. Worst temper/outburst: how severe and how frequent, how parent cope and latest situation
4. Screen ODD S/S
5. Screen CD (Conduct disorder) S/S if presence of ODD S/S
6. Give you an impression how difficult is the child and how good is the parenting