Child Psychiatry - Ryst Flashcards
What are some characteristics of a child assessment?
- usually occurs within a family context
- ideally interview the child together and separately from the family
- requires detective work and integration of data from separate sources
Things to ask about in a child assessment.
- behavioral difficulties
- functional impairments
- subjective distress
- stressors and environmental factors
- adverse impact on development
- want to know how they are functioning at home with the family, with peers, at school and in their extracurricular activities
What sorts of things would you want to ask about for the physical development and medical history in a child assessment?
- height, weight and vitals - especially important for prescribing medications and assessing development
- gross motor development
- coordination, activity status
- eating, sleeping and toileting status
- chronic and acute illnesses
- seizures , head injuries
- allergies, vision/hearing impairment
- exposure to lead or toxins
- current and past medications
- sexual developments
What are some other domains that are important to ask about in a child assessment?
- School - want to know their progress, how often are they absent, are they in special education classes etc.
- emotional development and temperament
- substance use
- peer relations
- family relations
- trauma
What sorts of things are you looking for with the family interview portion of the child assessment?
- How does the parent talk about and describe the child?
- discipline practices
- parental attachment
- parental attitude towards child
- goodness of fit between parental personality type and child personality type
- socio-cultural factors
- communication styles
Describe some characteristics of the child interview portion of the child assessment.
- Requires flexibility and creativity—must use techniques appropriate to child’s developmental level (not the same as an adult interview).
- Can use interactive play, projective techniques or direct discussion.
- Perform developmental mental status.
- Ask about child abuse.
- Establish alliance with the child.
What are some things you should consider during the child assessment?
- does the child need psychological testing
- does the child need medical evaluation
- does the child need educational assessment
- does the child need speech and language evaluation
- is there a need for social service referral or evaluation of the home environment
After the interviews are done in the child assessment, what are the next steps?
- Come up with a diagnostic formulation. This is an evaluation of how the child developed, what are the main issues and what are the child’s strengths that may be used to help in treatment of the issues. Should include all the pertinent findings that lead to a diagnosis.
- communicate the findings and recommendations to the family
Describe some principles of child treatment.
- Everything happens within a developmental context.
- Goal is to promote continued, healthy, optimum development
- Maximize the child’s adjustment in these domains: home, friends, school, play.
- Multi-modal treatment usually the best. Medication alone is usually not appropriate treatment.
- Must weigh the risks and benefits of treatment (or no treatment.) Sometimes no treatment is more hurtful and risky than the effects of medications.
What are some of the tools that psychiatrists can use in treatment of children?
- pscyhotherapy
- medications
- advocacy - can advocate for kids with school, help them get social resources and advocate with family members who may not understand
What are some components of psychotherapy?
- play therapy
- interpersonal psychotherapy
- cognitive-behavioral therapy - not really appropriate for those under age 7 or so
- parent guidance therapy
- family therapy
What are some considerations for using medications in treating psychiatric disorders in children?
- medication use is ‘off label’ - there are no meds indicated for use in children
- kids are not little adults - therapeutic and adverse effects vary by developmental stage and by developmental disorder
- kids metabolize drugs more quickly than adults - more mg/kg are prescribed for kids than adults
- Tricyclics are not effective in children due to differences in their NE transmission system
- meds are appropriate for kids - but should be used with caution. Not using meds could lead to progression of disease and disrupted development
What is oppositional defiant disorder?
- A recurrent pattern of negativistic, hostile and defiant behavior
- Must have at least four of the following for at least six months:
Often loses temper
Often argues with adults.
Often actively defies or refuses to comply with adults’ requests or rules.
Often deliberately annoys people.
Often blames others for mistakes or misbehavior.
Often touch and easily annoyed.
Often angry and resentful
Often spiteful and vindictive
What is conduct disorder?
- Violation of the rights of others and age-appropriate social norms.
- Must have at least three symptoms in the last 12 months, with at least one symptom in the last 6 months.
- symptoms include the following:
Bullying or threatening others.
Fighting
Using a weapon that can cause serious physical harm.
Physically cruel to animals.
Physically cruel to people.
Stealing while confronting a victim.
Forcing someone into sexual activity.
Fire setting.
Destroying property.
Breaking into a house, building or car.
Frequent lying or “conning.”
Stealing without confronting a victim.
Staying out late despite parental prohibitions.
Running away from home.
Being truant from school.
The majority of kids with oppositional disorders do not go on to adult criminal behavior but some can move from ODD to CD to adult criminal behavior. How are the subset of these kids identified for early intervention?
- CD kids can be diagnosed with a specifier called - ‘with limited prosocial emotions’
- Data have identified a subgroup of children with CD that display a lack of guilt and empathy, lack of concern over performance in important activities, and shallow affect. Compared to other children with CD, this subgroup appears to have more severe symptoms, a more stable course, and greater levels of aggression. Addition of this specifier will inform the development of specialized treatments separate from those used with other CD populations
What is the prevalence of ODD?
- 2-16%
2. twice as common in males
What is the prevalence of CD?
- 9% of males less than 18
- 2% of females less than 18
- males with early onset CD are much more likely to show aggressive symptoms
What is the association between CD and ODD and ADHD?
- onset of CD is particularly early in ADHD boys (these are often comorbid)
- CD boys with ADHD have a worse outcome than those without ADHD - important because ADHD can be treated
- early onset of CD is often preceded and predicted by persistent ODD symptoms
What are some symptoms associated with ODD that are predictive of future CD diagnosis?
- Single syx of cruelty to people and weapon use were best predictive of subsequent diagnosis of CD in one study.
- In another study, physical fighting + ODD were best predictors of the onset of CD.
- Proactive aggression seems to be worse than reactive aggression. Overt disruptive behavior may be worse than covert disruptive behavior.
- severity of symptoms are highly predictive
- Age- and gender-atypicality are prognostic of later outcome:
In younger kids, syx of cruelty, running away and breaking into a building most predictive of CD.
For girls, fighting and cruel behavior are atypical symptoms and most predictive of CD.
The presence of early Anti-Social Personality or psychopathy-related symptoms (egocentricity, callousness, manipulativeness) may predict what?
The eventual development of Anti-Social Personality Disorder.
Describe some frequent comorbidities among psychiatric disorders in children.
- ADHD: earlier age of onset of CD, more physical aggression, more persistent CD.
- Anxiety: Youths with CD are increased risk for anxiety disorders.
- Mood Disorders: Joint presence of these two increases risk of substance abuse and suicide.
- Substance Abuse: Reciprocal relationship: each exacerbates the other.
- Learning Disabilities: (Language problems, memory, sensory integration, executive function deficits, academic deficiencies, low intellectual functioning.)
Conduct disordered youth are more likely in adulthood to what?
- Have greater psychiatric impairment: Anti-social Personality Disorder, alcohol and drug abuse, anxiety, somatic complaints, psych hospitalization.
- Have higher rates of driving while intoxicated, criminal behavior, arrest records, convictions and period of time spent in jail.
- Be less likely to be employed, shorter employment history, lower status jobs, frequent job changes, lower wages, more dependence on welfare, serve less frequently and perform less well in the armed services.
- Have higher rates of school drop-out, lower academic achievement.
- Have higher rates of divorce, remarriage and separation.
- Less contact with relatives, friends and neighbors, less church involvement.
- Higher mortality rate, higher rate of hospitalization for physical problems.
Treatment of disruptive behavior disorders is successful when?
Interventions address multiple needs from multiple domains and involve the parents.
What components are part of successful treatment of disruptive behavior disorders?
- parent-directed component
- social-cognitive skills training 3. academic skills training
- proactive classroom management and teacher training.
Isolated, individual treatments don’t work!
Are there FDA approved medications for treatment of disruptive behavior disorders?
No.
What are some meds that are used clinically to treat disruptive behavior disorders?
- mood stabilizers
- typical and atypical antipsychotics
- Clonidine and the stimulants may help to decrease aggression, reduce emotional reactivity and moderate levels of emotional arousal.
- treatments are not great at this time but if there is a treatable comorbidity such as ADHD then this can help
What are some well-established psychosocial treatments of disruptive behavior disorders?
- For younger children (ODD):
Parent Management Training: Trains parents to interact with child in a way that promotes pro-social behavior. Focuses on antecedents and reinforcement. Combination of parent and child training is superior to working with parent alone.
PCIT (Parent-child Interaction Training): Studied in RAPC trials.
First phase: Parents trained in nondirective play skills to alter quality of parent-child interactions.
Second phase: Parents taught to give clear instructions, praise for compliance, time-out for noncompliance. - MST (Multisystemic therapy): Addresses risks at the individual, family, peer, school and neighborhood level. Treatment is intensive and addresses therapeutic barriers such as parental substance abuse, parental psychopathology, marital conflict, associations with delinquent peers, poor school performance and deficient problem-solving or perspective-taking skills. Very expensive and hard to do.
Why have mood disorders been historically misunderstood and misdiagnosed?
- Children’s inability to express emotions verbally,and tendency to present with somatic syx and complaints.
- Tendency of parents and teachers only to notice obvious, external symptoms (disruptive behaviors.)
- Bipolar Disorder difficult to diagnose in children due to developmentally different presentation in children as well as significant symptoms overlap with ADHD.
What is the diagnostic criteria for childhood depression?
Same DSM5 diagnostic criteria as for adults, except:
- For children and adolescents, can have irritable mood instead of depressed mood.
- Failure to make expected weight gains is equivalent to weight loss.
- For Dysthymic Disorder (new name = Persistent Depressive Disorder) : mood can be irritable rather than depressed, and duration must be at least one year (not two).
What is the difference between irritable mood vs depressed mood?
Depressed mood is more about internal feeling and is described by the patient (hard for children) whereas irritable mood is something that can be observed.
What are some differences in symptoms between adults and children/adolescents in depression?
Phenomenological differences in children:
- Somatic complaints, psychomotor agitation, mood-congruent hallucinations more prevalent.
- Can also manifest as separation anxiety, phobias, and behavioral problems.
- Look for deviations from developmental trajectory: school failure, withdrawal from peers, lack of interest in prior activities.
Phenomenological differences in adolescents:
1. Can present as antisocial behavior, substance use, restlessness, grouchiness, aggression, withdrawal, school or family problems, feelings of wanting to leave home, feelings of not being understood, loved or approved.
Describe the criteria for juvenile bipolar disorder.
- Same DSM criteria as for adults.
- Now generally accepted that clinical presentation of mania in children is atypical by adult standards:
- More frequently “mixed” states (mania + depression)
- “Rapid cycling”
- Chronic and continuous rather than acute and episodic
- Seldom associated with euphoria, usually prominent irritability with affective storms, prolonged aggressive temper outbursts, emotional lability
- In older children (> age 9), euphoria, elation and grandiosity more common
What is an affective storm?
Extreme emotional outburst out of proportion to the situation or triggering event.
What are some associated symptoms that occur with juvenile bipolar disorder?
- Decreased need for sleep
- Rapid speech, talkativeness
- Distractibility, racing thoughts, tangentiality
- Hypersexuality - (not really sex but other behaviors like masturbation or removing clothes in public etc.) Not really seen in other disorders, need to make sure not a result of abuse
- Increased goal-directed activity
- Impulsivity
- Abnormal thought content, paranoia
What is a new diagnosis added to DSMV that is meant to capture those who have some symptoms of bipolar but don’t meet criteria?
Disruptive mood dysregulation disorder or DMDD.
Rationale: This addresses the disturbing increase in pediatric bipolar diagnoses over the past two decades, which is due in large part to the incorrect characterization of non-episodic irritability as a hallmark symptom of mania. DMDD provides a diagnosis for children with extreme behavioral dyscontrol but persistent, rather than episodic, irritability and reduces the likelihood of such children being inappropriately prescribed antipsychotic medication. These criteria do not allow a dual diagnosis with oppositional-defiant disorder (ODD) or intermittent explosive disorder (IED), but it can be diagnosed with conduct disorder (CD). Children who meet criteria for DMDD and ODD would be diagnosed with DMDD only.
Describe the epidemiology of mood disorders in children.
Based on small studies: 1. Depression: Preschoolers: 0.3% Elementary: 1-2% Adolescents: 5% Adults: 5-9% women, 2-3% men
2. Juvenile Bipolar Disorder: Prepubertal: ? About 0.5%; males possibly more Adolescent: Lifetime prevalence 1% Core syx but subsyndromal 5.7% No gender differences Adults: 0.4-1.6% (Bipolar I)
