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Psychiatry > CAMHS > Flashcards

CAMHS Flashcards

1
Q

Proportion of children affected by psychiatric illness

A

Up to 15%

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2
Q

Risk factors for childhood mental health problems

A
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3
Q

Differences in presentation and management of depression in chidren/adolescence

A
  • Affects 1-2% of children and 8% of adolescents.
  • Sex ratio is equal before puberty, but more common in girls thereafter.
  • Children more commonly present with somatic symptoms.
  • Teachers may note irritability or poor school performance.
  • First-line treatment is CBT for mild depression, persisting for more than 4 weeks. First-line medication is Fluoxetine, prescribed by an MDT
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4
Q

Differences in presentation and management of anxiety disorders in children/ adolescence

A
  • 9-32% prevalence during childhood and adolescence.
  • Affects genders equally and may present with somatic symptoms.
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5
Q

Differences in management of self-harm presenting in children

A
  • All under 16-year-olds who self-harm must be reviewed by a CAMHS specialist before discharge (must admit to paediatric ward to facilitate if required.)
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6
Q

Differences in presentation of psychosis in children/ adolescents

A
  • Psychosis is very rare in children before puberty and so prognosis is poor, with disrupted social development.
  • Important to exclude ASD
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7
Q

What is separation anxiety disorder, how does it present and how can it be managed

A
  • Children present with excessive fear of separation from specific attachment figures.
  • This must be present for a period of months and cause significant stress or functional impairment.
  • May have thoughts of harm coming to parents, reluctance to attend school, marked distress and nightmares.
  • Need to manage with behavioural therapy gradually increasing separation.
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8
Q

What is school refusal and how does it differ from truancy. In whom does it usually present and how can it be managed

A
  • Unlike truancy this is unconcealed absence from school.
  • Common at times of transition and may occur in families with ‘precious’ children e.g. death of sibling, difficulty conceiving. Vulnerable parents are also implicated e.g. life-threatening illness.
  • Child typically gets tummy ache before school.
  • Management involves enlisting school support about anxiety about performance, bullying etc.
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9
Q

What is conduct disorder, how does it present and how can it be classified

A

A repetitive and persistent pattern (1 year or more) of behaviour violating either the basic rights of others, or major age-appropriate societal norms, rules, or laws. e.g. bullying, stealing, fighting, fire-setting, truancy and cruelty to animals/people.

  • ‘Socialised CD’: child has a peer group, ‘Unsocialised CD’: child rejected by other children
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10
Q

What are some risk factors for conduct disorder

A
  • CD affects 10% of 10-year-olds and is 4x more common in boys than girls
  • There is likely a genetic and environmental component. RFs include: urban upbringing, deprivation, parental criminal activity, harsh and inconsistent parenting, Fhx. of substance abuse
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11
Q

Diffentials for conduct disorder

A
  • Oppositional defiance disorder: A milder form of CD. A persistent pattern (6 months or more) of markedly defiant, provocative or spiteful behaviour towards an adult, more frequently than typical in children of comparable age. Occurs in children under 10. Is sufficiently severe to impair functioning.
  • ADHD (often comorbid)
  • Depression
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12
Q

Management of conduct disorder

A
  • Family education
  • Parental management training (must limit reinforcing patterns)
  • Family therapy
  • Educational support
  • Anger management
  • Treat comorbid problems
  • Up to 50% develop substance misuse problems or dissocial PD as an adult
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13
Q

Autism spectrum disorder characteristics, when can it be diagnosed

A

Autism spectrum disorder (ASD) represents a wide continuum of associated cognitive and neurobehavioral deficits, including deficits in socialization and communication, with restricted and repetitive patterns of behaviours. It exists across all intelligence levels.

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14
Q

What factors predispose development of autism

A

There is no single cause, however, it has a strong genetic basis (90% heritability) and some environmental input: risk of ASD may be increased by older parental age, maternal infections in pregnancy and obstetric complications leading to hypoxia.

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15
Q

What is the prevalence of ASD and why is it changing

A
  • The reported prevalence of autism has dramatically increased, and it is now recognized as one of the most common developmental disorders. This may be due to improved recognition and diagnosis
  • Median prevalence in UK ~ 1.1% (2020) vs 0.7% (2000), Median prevalence globally ~0.6%. Male: Female ratio is 4:1.
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16
Q

Genetic conditions associated with ASD

A
  • Fragile X (21-50% have ASD)
  • Tuberous sclerosis complex
  • Di George syndrome/ 22q11 deletion syndrome
  • Mitochondrial disorders
  • Down syndrome
17
Q

What conditions often co-exist with ASD

A

Epilepsy (~ 1/3rd), Specific learning difficulties, ADHD, Conduct Disorder, Schizophrenia & related disorders, Anxiety

18
Q

DSM-IV classification of Asperger’s disorder

A

According to DSM-IV it is a subset of autism which exists where there is no significant impairment in early communication in childhood and which instead has features of impairment in non-verbal communication. As of DSM-V this is now defined as part of ASD.

19
Q

Common pathology in ASD

A
  • Abnormalities in major cortical and subcortical brain structures have been observed on MRI and in post-mortem studies
  • Some studies have found significantly increased cerebellar volume and increased synaptic connections
  • Elevated blood 5HT levels have been reported
20
Q

Clinical presentation of ASD, when does it usually present

A

Symptoms of ASD are often identified within the first 3 years of life and are sufficienctly severe to impair educational, occupational and other functioning.

All individuals on the autistic spectrum demonstrate deficits in THREE core domains:

  1. Reciprocal social interactions
  2. Verbal and nonverbal communication
  3. Restricted and repetitive behaviours or interests

There is marked variability in the severity of symptoms and marked variation in cognitive functioning in the LD population (mild-profound)

21
Q

How does impairment of social interactions present in ASD

A
  • ‘Impairment’ in either quality or quantity (& not total lack of it)
  • Behaviours range from total lack of awareness of another person to simple things like difficulty making eye contact.
  • Children often do not lift their arms in anticipation of being held, avoid eye contact or make contact but only as brief glance and not to get someone’s attention.
  • Lack of curiosity in their surrounding / lack of interest in other children.
  • Lack of empathy • Socially isolated, one-sided social interaction
  • Find it hard to form friendships and maintain them
22
Q

How is verbal and non-verbal communication affected in ASD

A
  • Often have ‘concrete thinking’- interpreting language literally.
  • Speech onset is often delayed. When present it can be monotonous.
  • A hallmark of autistic speech is immediate or delayed echolalia > ‘Immediate echolalia’ refers to immediate non-communicative repetition of words or phrases – the child is simply repeating exactly what was heard without synthesizing the intrinsic language. This ability is a crucial aspect of normal language development in infants under the age of 2 years, but it becomes pathologic when still present as the sole and predominant expressive language after the age of about 18– 24 months.
  • Delayed echolalia or scripts refers to the use of highly ritualized phrases that have been memorized, such as from videos, television, commercials, or overheard conversations.
  • May also use literal idiosyncratic phrases or neologisms.
  • Verbal autistic children may speak in detailed and grammatically correct phrases, which are none the less repetitive, concrete, and pedantic.
  • Impairment in pretend play. Some cannot grasp the concept of pretend play while others use restricted objects in a repetitive / mechanical fashion
23
Q

Give some examples of repetitive and restricted behaviours in ASD

A
24
Q

Differentials for ASD

A
  • Untreated deafness impairing language acquisition
  • Developmental language disorder or disorder of intellectual intelligence
  • Neglect
25
Q

What investigations are required for ASD

A

ASD can be reliably diagnosed in children as young as 2 years and outcomes are significantly improved with early detection & intervention. It is a clinical diagnosis which must be given by a specialist paediatrician or psychiatrist.

Must rule out differentials by doing a hearing test for deafness, speech and language assessment, cognitive assessment, EEG is epilepsy is suspected, genetic testing.

Diagnostic tools include:

  • Autism Diagnostic Inventory – Revised (ADI-R)
  • Autism Diagnostic Observatory Schedule (ADOS)
  • Diagnostic Interview for Social and Communication Disorders (DISCO)
26
Q

Management of ASD

A
27
Q

Examples of early education and behavioral interventions for ASD

A
  • Applied behavioural analysis (ABA): A behavioural programme for treating young children (age 2 to 3 years at the start of intervention) with ASD. ABA may be used if it is considered that the child would benefit from a heavily structured environment with the use of a reward system to lessen the impact of either repetitive behaviours or overactivity.
  • Early Start Denver Model (ESDM): ESDM intervention is based on developmental and applied behavioural analytical principles and delivered by trained therapists and parents.
  • More Than Words (Hanen programme): Designed to help parents of all children <6 years of age who are experiencing difficulties in social interaction and communication. Parents learn a number of strategies that help to improve their child’s communication and interaction.
28
Q

What biological therapies exist for ASD

A
  • Psychopharmacology should only be used where there are comorbid conditions such as anxiety
  • Dopamine blockers often help stereotypical behaviour (motor)
  • Irritability often treated with Aripirazole & Risperidone (low dose / short duration)
  • SSRIs effective in treating obsessional behaviours (> serotonergic response needed)
29
Q

What advice can be given to parents of children with ASD

A
  • ASD is a spectrum: Every person with Autism is different with significant variability with symptoms
  • Sensory sensitivity with bright lights, noises etc
  • Use loved ones and carers to assist communication and the interaction
  • Ask about the best communication strategy- verbal? Sign? Visual aids?
  • Remember the importance of routines for patients- Show patience and empathy
  • Refer to National Autistic Society

Psychiatry (15 decks)

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