CAMHS

Question 1

Familial risk factors for behavioural disorders

Answer 1

Angry discord between family members
Parental mental illness, especially maternal depression
Bereavement
Divorce and subsequent loss of parent figure
Intrusive overprotection
Lack of parental authority
Physical/sexual abuse
Emotional rejection
Excessive criticism
Inconsistent, unpredictable discipline
Using child to fill parental emotional needs
Inappropriate responsibility or expectation of the child

Question 2

Features meal refusal

Answer 2

Child refusing to eat any/much of prepared meals
“mealtimes are a battle”
Child healthy and well-nourished with normal growth

Question 3

Factors contributing to meal refusal

Answer 3

Past history of force feeding
Irregular meals: child is not predictably hungry
Unsuitable meals
Unreasonably large portions
Multiple opportunity for distraction

Question 4

Mx meal refusal

Answer 4

Offer adequate range of wholesome food
Avoid confrontation at mealtimes
delevop a relaxed atmosphere
Use favourite foods as rewards: use other rewards for compliance at mealtime .e.g. TV
Reduce eating between meals

Question 5

Difficulty settling at night causes

Answer 5

Too much late afternoon sleep
Displaced sleep/wake cycle
Separation anxiety
Overstimulated/overworked in evenings
Kept awake by environmental factors
Erratic parenting
Use of bedroom as punishment
Dislike of darkness and silence
Chronic physical conditions .e.g. sickle cell crisis

Question 6

Mx sleeping difficulty

Answer 6

Creating bedtime routine which cues child
Telling child to lie quietly until they sleep
No screen time 1h before sleep
Graded pattern of leaving child

Question 7

Features night terrors

Answer 7

Occur 1.5hrs after settles
Child sitting up in bed, eyes open, seemingly awake
Disorientated, confused, distressed
Unresponsive to questions or reassurance
Child settles within minutes
No recollection of episode

Question 8

Mx toddler disobedience

Answer 8

Ensure demand is reasonable for development of child
Positive instructions not negative instructions
Praise for compliance even when spontaneous
“if you do… we can do…”
Avoid empty threats
Follow through with consequences
Ignore non-significant episodes

Question 9

Medical factors of poor behaviour

Answer 9

Global or language delay
Hearing impairment
Medication with bronchodilators and anticonvulsants

Question 10

Mx tantrums

Answer 10

Affect and attention before the tantrum
Distraction
Avoiding antecedents
Ignoring: effective, no surrender
Time out from positive reinforcement: walk away, separate from other children
Hold firming if risk of danger
Star chart
1-2-3 principles: stop-if-consequence

Question 11

Causes nocturnal enuresis

Answer 11

UTI
Faecal retention reducing bladder volume and causing bladder neck dysfunction
Polyuria from osmotic diuresis/ concentrating disorders
Developmental, attentional and learning difficulty

Question 12

Ix nightime enuresis

Answer 12

Indicated with recent onset bed wetting, daytime enuresis, UTI, diabetes, ill health
Urinalysis

Question 13

Normal development nocturnal enuresis

Answer 13

Infrequent bed wetting is common in children
>2 nghts/week present in 6% of 5y and 1.5% 10y
More common in boys
Usually genetically determined delay in sphincter competence
Typically resolves spontaneously

Question 14

Mx Nocturnal Enuresis

Answer 14

Reassurance and explanation
Ceasing punishment
Excessive fluid intake/ abnormal toileting addressed
Waking and lifting does not promote long term dryness
Star chart for sheet change NOT dry nights
No child blame for wet nights
Enuresis alarm
-1/3 relapse but succeed with second trial of alarm
Desmopressin (ADH synthetic analogue): children >7y
-short term use .e.g. sleepovers and holidays
-sublingual tablet and fluid restriction
-continued for 3-6m

Question 15

Factors contributing to faecal soiling

Answer 15

Faecal retention and constipation:
-pain from fissure
-fear of punishment for incontinence
-toileting anxiety
Urgency of defecation
Neuropathic bowel
Diarrhoea overwhelming bowel control
Mental age below 4y
Intentionally as a hostile act

Question 16

Mx Constipation

Answer 16

Treatment of fissures
Emptying rectum: stool softener .e.g. macrogol 2w +/- stimulant laxative
Maintenance laxative therapy
Regular toileting
star charts

Question 17

Features somatic symptoms

Answer 17

Recurrent medically unexplained symptoms
Aggrevated by dtress
Usually recurrent abdo pain (9y) and headache (12y)
Limb pain, aching muscles, fatigue, neurological signs with increasing age
Pain further away from umbilicus more likely to be organic (Apley’s rule)
Pain may be limited to school days or specific events

Question 18

Features Tics

Answer 18

Quick, sudden, co-ordinated movement
Apparently purposeful
Recurrs in the same part of the body
Can be suppressed to some extent
Typically around face and head: blinking, frowning, head fliching, sniffing, throat clearning, grunting
Boys more commonly affeced
Average onset 8y, peak at 11y
Occur when child is inactive
Disappears when concentrating

Question 19

Gilles de Tourette syndrome features

Answer 19

Multiple motor and vocal tics
Typically persistent
Swearing (coprolalia) is uncommon

Question 20

Mx severe tics and Tourettes

Answer 20

CBT with habit reversal techniques

Medication .e.g. clonidine or rispiradone

Question 21

Features chronic tics

Answer 21

Persist more than 12m
Multiple, child is rarely free
Most resolve by adulthood

Question 22

Reasons for antisocial behaviour

Answer 22

Failure to learn when to exercise social restraint
Lacking social skills.e.g. negotiation
Responding to peer challenge
Chronically angry or resentful
Overwhelmed by sadness or temptation

Question 23

Features of conduct disorder

Answer 23

Serious antisocial behaviour infringing on rights of others

Handicap to general functioning

Question 24

Features oppositional-defiant disorder

Answer 24

Milder form of conduct disorder

Angry defiant behaviour to authority figures

Question 25

Mx conduct disorder

Answer 25

Parental management training programmes .e.g. Webster Stratton, Triple P Child individual or group therapy -problem solving skills and anger management

Question 26

Mx School Refusal

Answer 26

Advise and support parents and school Treat underlying emotional disorders Plan and facilitate early graded return at a pace tolerable to child Make school more rewarding than home Address bullying and educational difficulty

Question 27

Quality of preschool thought

Answer 27

Child is centre of world Everything has purpose Inanimate objects are alive Poor categorisation Use of magical thinking Use of sequences or routine rather than time Use of toys and imaginative play to make sense of world

Question 28

Adolescent formal operational thought

Answer 28

``` Ability to form abstract thoughts Comparing implications of hypotheses Thinking about one's own thinking Testing logic that links propositions Manipulating interactive abstract concepts ```

Question 29

Features of school refusal

Answer 29

Inability to attend school on account of overwhelming anxiety Nausea, headache, illness, hyperventilation effects Disproportional to stress at school .e.g. bullying, attainment Typical in children until age 11y May be provoked by adverse life event

Question 30

Causes of underachievement at school- chronic

Answer 30

``` Visual problems Hearing problems Dyslexia Generalise learning problems Hyperactivity Anti-education family background Chaotic family background ```

Question 31

Causes of underachievement at school- acute

Answer 31

``` Preoccupations Fatigue Depression Rebellion Unsuspected poor attendance Sexual abuse Drug abuse Prodromal period of psychotic illness Degenerative brain condition ```

Question 32

Features Anorexia Nervosa

Answer 32

Self induced weight loss BMI <17.5/ plotted on centile chart Distorted perception of body increasing with weight loss Determined attempt to lose weight by restricting intake or purging behaviour Halted pubertal development Need for control Parental attention may promote features Denies hunger/problem/hide behaviours May cook for others and show interest Character traits: perfectionist, obsessional

Question 33

Physiological effects of starvation in AN

Answer 33

``` Low metabolic rate Slow to relax reflexes Reduced peripheral circulation Bradycardia Amenorrhea Fine lanugo hair over trunk and limbs Puberty delayed Low T3 low plasma proteins (ankle oedema) Low non-cyclical LH and FSH ```

Question 34

Feature Bulimia

Answer 34

Weight loss attempt by use of purging following binging episodes Wide fluctuations in weight Metabolic abnormalities: hypokalaemia, alkalosis Typically affects older teens

Question 35

Mx AN

Answer 35

``` Refeeding to restore body weight -hospital admission and NG if needed Cx: refeeding syndrome Family therapy Individual psychological therapy -challenge cognition ```

Question 36

Prognosis Anorexia

Answer 36

50% fail to make full recovery Poor outcome: low BMI, physical complications, bulimic symptoms, family disturbance, interpersonal difficulty High mortality Death by medical complications and suicide

Question 37

Features Chronic Fatigue Syndrome

Answer 37

Persisting high levels of subjective fatigue Rapid exhaustion Commonly depressive symptoms Myalgia, migratory arthralygia, headache, difficulty sleeping, poor concentration, irritability

Question 38

Mx Chronic fatigue syndrome

Answer 38

Remits spontaneously, can take years Continuous rest is unhelpful Graded exercise therapy and CBT

Question 39

Features of depression in adolescents

Answer 39

``` Apathy, boredom, inability to enjoy oneself Separation anxiety reappears Decline in school performace Social withdrawal Hypochondriacal ideas Complaints of chest, abdo, head pain Irritable mood Antisocial behaviour Less commonly: loss of appetite/sleep/libido, slowing thought and movement, delusional ideas ```

Question 40

Mx depression in children

Answer 40

``` Mild depression: primary care -may recover spontaneously (wait 4w) -supportive therapy or guided self help Referral to specialist if symptoms >2-3m CBT, interpersonal and family therapy >6w therapy: consider SSRI .e.g. fluoxetine ```

Question 41

Features psychosis

Answer 41

Breakdown of the perception and understanding of reality and lack of awareness they are unwell Delusional thinking Odd behaviour Speech difficult to follow- thought disorder Hallucinations

Question 42

Psychotic disorders in adolescents

Answer 42

Schizophrenia Bipolar effective disorder Organic psychosis .e.g. delirium, substance induced

Question 43

Ix Psychosis

Answer 43

Urine drug screen | Exclusion of infection, seizures, thyroid abnormality, sleep disorders, dementia

Question 44

Behaviours suggestive of heavy drug misuse

Answer 44

``` intoxication unexplained absence from home or school mixing with known users high rates of spending or stealing money possession of equipment medical complications ```

Question 45

Psychological treatment

Answer 45

``` Explanation and formulation Counselling of child or parents Parenting groups Behavioural therapy Family therapy Cognitive therapy Individual or group dynamic psychotherapy ```