Child & Adolescent Psychiatry 1.2 Flashcards
(244 cards)
1
Q
Impairments in children with anxiety
A
Behavioural avoidance
Extreme level of distress compared to peers
2
Q
Prevalence of anxiety disorders in children
A
5-15%
3
Q
M:F ratio of anxiety in childhood
A
Equal
4
Q
Prevalence of anxiety after adolescence in M:F
A
2:1
5
Q
Prevalence of separation anxiety
A
- 5% in children
0. 8% in adults
6
Q
Prevalence of GAD
A
4$ in adolescence
7
Q
Prevalence of simple phobia in children
A
10%
8
Q
Which gender is more likely to have simple phobia?
A
Twice as common in females
9
Q
Prevalence of social phobia
A
1% in children
5-15% in adolescence
10
Q
Prevalence of panic disorder in children
A
3-6%
11
Q
Peak age of onset of panic disorder
A
15-19%
12
Q
Sx of anxiety in preschool children
A
Tearfulness
Clinging
13
Q
Sx of anxiety in middle childhood
A
Somatic complaints
Hypochondriacal fretting
Irritability
Aggressive behaviour
14
Q
Which anxiety disorders occur later in childhood?
A
OCD
Social phobia
Panic disorder
15
Q
Which children are more likely to have comorbid specific phobia?
A
Children with SAD
16
Q
Which children are more likely to have comorbid mood disorders?
A
Children with GAD and social phobia
17
Q
How many young people with GAD have a comorbird diagnosis?
A
90%
18
Q
Definition of seperation anxiety disorder (SAD)
A
Developmentally inappropriate and excessive anxiety concerning separation from home or from those whom the individual is attached.
Interferes with age-appropriate functioning.
19
Q
Essential clinical feature of SAD
A
Excessive worry about losing or being permanently separated from major attachment figure
20
Q
Sx of SAD
A
Anxiety about separation or danger to attachment figure
Sleep disturbances, nightmares about separation
Refusal to go to sleep w/o being near attachment figure
Somatisation - especially on occasions of separation
Refusal to go to school
21
Q
Duration criteria for SAD
A
At least 4 weeks
Cause clinically significant impairment in social, academic and occupational domains
Age of onset <18 years
22
Q
What is SAD called if diagnosed in a child <6 years of age?
A
Early onset SAD
23
Q
Importance of attachment for the child
A
Allows the child to understand their inner world
Foundation for safe separation and development of autonomy
24
Q
How many children have secure attachment
A
60%
25
How many children have insecure ambivalent/resistant type attachment?
10%
26
How many children have disorganised/disorientated attachment?
15%
27
Describe secure attachment
Child uses carer as secure base to explore freely and go back for comfort if necessary
Carer sensitive to childs cues
28
Describe insecure, ambivalent/resistant attachment
Appears interested in caregiver
Minimal distress at separation
Sometimes ignores/avoids caregiver
29
Describe disorganised/disorientated attachment
Child displays contradictory behaviour patterns
| Thought to arise from either the child experiencing the carer as frighting or the carer being frightened themselves.
30
What was the Romanian Adoptees Study?
Data on severe attachment disorders was obtained from follow-up of children from severely deprived institutions in Romania and adopted by families in Canada and the UK.
31
What did the Romanian adoptees study show?
20% had severe disturbances at age of 6.
| Duration of exposure to deprivation was strong associated with severe disinhibited behaviour
32
Who does reactive attachment disorder occur in?
Infants
| Young children
33
What happens in reactive attachment disorder?
Persistent abnormalities in childs pattern of social relationships associated with emotional disturbance and reactive to changes in environmental circumstances
34
When is reactive attachment disorder diagnosed?
<5 years of age
35
How can reactive attachment disorder manifest?
Inhibited
| Disinhibited
36
Which children is reactive attachment disorder more common in?
Poverty-stricken
| Socially disrupted environments
37
Causes of reactive attachment disorder
Severe parental neglect, abuse and serious mishandling (direct cause)
Young, isolated, inexperienced and/or depressed carer
38
Features of reactive attachment disorder
```
Fearfulness
Hypervigilance - does not respond to comforting
Poor social interaction with peers
Aggression towards self or others
Growth failure
```
39
What is disinhibited attachment disorder?
Pattern of abnormal social functioning during first five years of life
40
How does disinhibited attachment disorder manifest in the early stages?
Clinging
| Diffuse non-selectively focused attachment behaviour
41
How does disinhibited attachment disorder manifest by the age of 4?
Diffuse attachment
Attention seeking
Indiscriminately friendly behaviour
42
Duration criteria for sibling rivalry disorder
Onset within 6 months of birth of immediately younger sibling
Duration at least 4 weeks
Emotional disturbance that is abnormal
43
Sx of sibling rivalry disorder
```
Anxiety, regression, tantrums, dysphoria
Attention seeking with one or both parents
Sleep difficulties
Oppositional behaviour
(2 of these must be present)
```
44
How do children with school refusal present?
Excessive fearfulness
Temper outbursts
Complaints of feeling ill when faced with school; usually physical
45
Incidence of school refusal in children
1-5%
46
Sex distribution of school refusal
Equal
47
Main incidence peaks of school refusal by age
5-7
11
14
48
Reason for school refusal at ages 5-7
Possible separation anxiety
49
Reasons for school refusal at age 11
Transition to secondary school
50
Reasons for school refusal at age 14 and older
First presentation of depression/anxiety
Bullying
Exam pressure
Specific stressors
51
Most common age of school refusal
11
52
How many children who refuse school successfully reintegrate?
70%
53
Signs in truants
```
Antisocial sx
FHx of antisocial behaviour
Inconsistent discipline
Poor academic achievement
Large family size
Male
Child is neither at home or school
```
54
Characteristics of children who refuse school
```
Emotional sx
FHx of neurosis
Over-protecting parenting
Satisfactory academic achievement
Small family or youngest member
Parents aware of childs absence
No gener difference
```
55
What is selective mutism?
Persistent failure to speak in specific settings
56
Onset of selective mutism
3-5 years
57
Which psychiatric disorder is seen in selective mutism commonly?
Social phobia
58
Rate of selective mutism in the UK
3-8/10,000
59
Gender differences in selective mutism
More common in girls
60
Helpful treatment for selective mutism
Behavioura approach with positive reinforcement techniques aimed at increasing frequency of talking and decreasing frequency of non-communication
Assert what communication is like at home
61
What is SAD a risk factor for?
Development of panic disorder or agoraphobia in adulthood
62
What is a temperamental predictor of social phobia?
Behavioural inhibition
63
What does GAD have a close genetic link with?
Depression
64
Which therapy has been found to be helpful for children with anxiety?
Individual CBT + family component
| Psychoeducation
65
CBT techniques for anxiety in children
Relaxation training
| Cognitive restructuring
66
Which groups of children can group CBT be helpful for?
Treatment of socially phobic children
67
First line medication treatment for anxiety in children
SSRI
68
What anxiety disorders in children are SSRIs efficacious for?
Social phobia
SAD
GAD
69
Changes in DSM V for PTSD in children
Diagnostic threshold lowered
Separate PTSD criterion added for children <6
70
When was PTSD formulated as a diagnosis?
1980
71
How many young people meet the criteria for PTSD?
6%
72
How many children aged 11-15 have PTSD?
11-15
73
M:F ratio of PTSD in children
1:2
74
Most common traumatic exposures in children
```
Physical and sexual abuse
Domestic, school or community violence
Kidnapped
Terrorist attacks
Motor vehicle/household accidents
Natural disasters
```
75
What must childs response to trauma require for PTSD diagnosis?
```
Intense fear
Terror
Helplessness
Horror
or Disorganized or agitated behaviour
```
76
Classification of childhood trauma
Type 1
| Type 2
77
What is type 1 trauma
Single, acute, traumatic event
78
Which type of trauma is more common in children?
Type 1
79
What is type 2 trauma?
Longstanding or repeated exposure to extreme external events
80
Sx of type 1 trauma
Full detailed memories
Omens or cognitive reappraisal
Misperceptions
81
Sx of type 2 trauma
```
Denial and psychic numbing
Self-hypnosis
Depersonalisation
Dissociation and rage
Extreme passivity
```
82
Treatment of PTSD in kids
Trauma-focused CBT
Crisis intervention
Medications
83
Should EMDR be used for PTSD in kids?
No evidence
84
Structure of trauma-focused CBT
8-12 sessions.
85
What is crisis intervention?
Structured sessions with group leaders discussing trauma to share feelings and knowledge and process it.
86
NICE guidelines for medication?
Should not be routinely prescribed for kids with PTSD
87
What medication has been reported to be helpful in kids with PTSD?
Citalopram 20-40mg OD - trial for 8 weeks
88
What is OCD?
Presence of recurrent intrusive thoughts (obsessions) associated with anxiety or repetitive purposeful mental or physical actions (compulsions) aimed at reducing fear caused by obsessions.
89
Difference in OCD between adults and children
Children do not always demonstrate awareness that their thoughts and behaviours are unreasonable.
Childhood OCD secrecy - they understand their behaviour is unusual so try to hide it.
90
How many children with OCD do not have obsessive thoughts?
40%
91
How many children with OCD have rituals/habits?
2/3
92
Prevalence of OCD in children
0.5%
93
Mean age of onset of OCD in children
10
94
M:F ratio of childhood OCD
2:1
95
M:F ratio of OCD post-pubertal
More common in girls
96
Heritability findings for OCD
Increased incidence in first degree relatives and MZ twins: 80% compared to 40%for DZ
97
Possible causes of OCD
```
Genetic
Autoimmune
Hyperactive orbitofrontal circuits
Serotonin receptor dysfunction
Dopaminergic dysfunction
```
98
What is the autoimmune hypothesis for OCD?
Reduced volume of caudate nucleus
99
What leads to the hypothesis of the dopaminergic dysfunction leading to OCD?
High dose stimulants increase OCD sx
100
Comorbidity of OCD
70% have one other disorder
101
How many patients with OCD have tic disorders
17-40%
102
How many children with OCD have depression
26%
103
How many children with OCD have specific developmental disabilities?
24%
104
Best treatment for OCD in kids
Combination of medication and therapy (CBT)
105
What drugs are licensed for OCD in children?
Fluoxetine
| Sertraline
106
Which children with OCD are recommended to be trialled fluoxetine?
Co-morbid depression
107
Structure of CBT for OCD in children
Developmentally appropriate exposure to feared stimulus coupled with response prevention
108
Treatment guidelines for children with mild OCD
Trial of CBT before medication
109
Treatment for severe OCD in children
CBT and SSRI
110
Which studies were conducted into treatment of OCD in children?
POTS - Paediatric OCD treatment study
111
What did POTS find?
Combination of therapy and medication is superior to either alone
112
What is PANDAS?
OCD sx associated with beta haemolytic strep infection
113
What does PANDAS stand for?
Paediatric autoimmune neuropsychiatric disorders associated with streptococcus
114
Onset of PANDAS
Pre-pubertal
115
How many children with Sydenhams chorea have OCD sx?
75%
116
Hypothesis behind PANDAS
Exposure to strep bacteria activates autoimmune system leading to inflammation of basal ganglia and disruption of cortico-striatal-thalamo-cortical function
117
Neuroimaging in PANDAS
Increased basal ganglia volume
| Proportional relationship between size of basal ganglia and severity of sx
118
Duration criteria for enuresis
Developmental or chronological age of at least 5 years
119
Duration of enerusis
3 months
120
When does voluntary control of micturition begin?
15-18 months
121
By what age re children dry by day
18 months
122
By age 5 how many children have daytime wetting
1%
123
By 2 years how many children are dry at night
50%
124
By 3 years how many children are dry at night
75%
125
How many boys have nocturnal enerusis at age of 7?
22%
126
By age of 7 how many girls have nocturnal enerusis?
7-15%
127
M:F ratio of nocturnal enerusis
2:1
128
Types of enuresis
```
Primary
Secondary
Nocturnal
Diurnal
Mixed
```
129
Prevalence of enuresis in school-aged children
2-5%
130
Most important predictor of primary nocturnl enuresis
FHx of enuresis
131
What predicts secondary enuresis?
Delay in control over bedwetting
High rate of adverse life events
Reduced sensitivity to vasopressin in kidneys
Sexual abuse
132
What is daytime enuresis likely to be due to?
Structural abnormalities
133
Medical causes of enuresis
```
UTI
Obstruction
Genitourinary pathology
Neurological conditions e.g. spina bifida occulta
Diabetes
```
134
What factors is enuresis associated with?
```
Stressful life events
UTI
Constipation
Low socioeconomic background
Large families
Overcrowded conditions
```
135
Psychiatric sx of children with enuresis
Poor self-image
Low self-esteem
Social embarrassment and restriction
Intrafamilial conflict
136
What psychiatric disorder do children with enuresis have higher risk of?
ADHD
137
Treatment of enuresis
```
R/o medical cause
Psychoeducation - avoid punishment
Record keeping - can be a reinforcer
Behavioural interventions
Medications
```
138
First line treatment of enuresis
Behavioural interventions
139
Name some behavioural interventions for enuresis
Bell and Pad (most effective)
Enuresis Alarm
Star chart
140
Effectiveness of Bell and Pad?
60%
141
Medications for childhood enuresis?
Imipramine
Desmopressin
Rebocetine
Oxybutynin
142
What age must a child be for a diagnosis of encopresis?
4 years or older (mental age)
143
M:F ratio of encopresis?
6:1
144
How many children over 4 will have encopresis?
5%
145
How many children with encopresis show evidence of chronic constipation?
75%
146
What organic causes can cause encopresis?
```
Hirschprungs
Anorectal pathology
Neurological problems
Nutritional disorders
Medication SEs
```
147
What is encopresis associated with?
Sexual abuse
Psychiatric disturbances
Maternal hostility
Harsh/punitive parenting
148
What is secondary encopresis?
Emerging after a period of normal bowel habits
149
Factors associated with secondary encopresis?
Unhappy child in family with ongoing difficulties
Recent acute stress in family
Over-tolerant parents
150
Treatment of encopresis
Paediatric assessment
Psychoeducatino
Behavioural approach
Family support
151
How is family support used for encopresis?
Reduce family tensions about the sx and establish a non-punitive atmosphere.
152
When does most encopresis stop by?
Age of 16
153
What is pica?
>1 month of eating of non-nutritive substances at a developmentally inappropriate age (>1 year) at least twice a week
154
When does pica typically occur?
2-3 years of age
155
What psychiatric disorder is pica common in?
Developmental disability
156
Consequenecs of pica
Toxicity
Infection
GIT ulceration/obstruction
157
Hypothesised causes of pica
```
Hunger
Malnutrition
Nutritional deficiencies
Psychosocial stressors
Brain disorders e.g. lesion in hypothalamus
```
158
What are pervasive developmental disorders (PDD)?
Several disorders characterised by impaired reciprocal social interactions, communication difficulties, aberrant language development and restricted behavioural repertoire.
159
Onset of PDD
<3 years of age
160
What does PDD include?
Childhood autism
Aspergers
Retts
161
Triad of PDD
Deficits in social skills, communication/language and behaviour
162
what does DSM IV categorise PDD as?
```
Autism
Aspergers
Retts
Childhood disintegrative disorder
PDD-NOS
```
163
What is different in DSM V re PDD?
Autism Spectrum disorder is a new description that includes autism, aspergers, childhood disintegrative disorder and PDD-NOS as a single category
164
What characterises ASD?
Deficits in social communication and interaction
| Restricted repetitive behaviours, interests and activities
165
If there is a deficit in social communication but no repetitive behaviour, what diagnosis is given?
Social communication disorder
166
What characterises childhood autism?
Qualitative impairment in social interaction
Impairment in communication
restricted repetitive and stereotyped patterns of behaviour or interests
167
Onset of childhood autism by definition?
<3 years of age
168
M:F ratio of autism
4:1
169
Recurrence rate of ASD in siblings
2-8%
170
Risk of ASD in sibling of 2 autistic children
25-30%
171
Heritability of ASD
90%
172
MZ vs DZ rates of ASD
36% vs 0%
173
Genes involved in ASD
```
2
4
7
13
15
16
17
19
NRXN1
NLGN3
```
174
Which genetic disorder is associated with ASD?
Fragile X
| Tuberous sclerosis
175
How many children with ASD have Fragile X?
1-4%
176
How many children with ASD have Tuberous Sclerosis?
2%
177
Which neurological conditions is associated with ASD?
Congenital Rubella and Phenylketonuria
178
How many children with ASD have a medical conditino?
10%
179
How many children with ASD have a LD?
80%
180
How many children with ASD have mild to moderate intellectual disability?
33%
181
MRI findings in ASD
Larger brain volumes
Early acceleration in brain growth
Increase in size of lateral and 4th ventricles, frontal lobe and cerebellar abnormalities:
hypoplasia of cerebellar vermal lobules VI and VII
182
Where is the greatest increase in brain size in ASD?
Occipital, parietal and temporal lobes
183
Hypotheses around increased brain sizes in ASD
Increased neurogenesis
Decreased neuronal death
Increased production of non-neuronal brain tissue such as glial cells and blood vessels
184
Cerebellar pathology in ASD
Abnormal purkinje cells in cerebellar vermis
| Abnormal limbic architecture
185
Neurotransmitter findings in ASD
33% have high plasma serotonin concentrations
| Some have high concentration of homovanillic acid in CSD
186
Prenatal associative factors with ASD
Congenital rubella infection during pregnancy - mainly first trimester exposure
187
Predictors of good prognosis of ASD
Communicative speech by age of 6
IQ >50
Skill consistent with secure employment
188
How many people with ASD will be unable to lead an independent life?
60%
189
How many people with ASD have a very good outcome?
12%
190
How many people with ASD have a good outcome?
10%
191
How many people with ASD have a fair outcome?
19%
192
How many people with ASD have a poor outcome?
46%
193
How many people with ASD have a very poor outcome?
12%
194
Which skills are impaired most in ASD in adulthood?
Communication
Reading
Spelling
195
Intervention programmes for ASD
Applied behavioural analysis
| TEACCH
196
Describe aplpied behavioural analysis for ASD
Intense program - 40 hours a week for 3 years
| Based on operant conditioning, imitation and reinforcement
197
What does TEACCH stand for?
Treatment and Education for Autistic and related Communication Handicapped Children
198
What is TEACCH?
Based on belief that children are motivated to learn language.
199
What is TEACCH good at?
Reducing self-injurious behaviour
| Enhancing llife skills
200
What are SSRIs used to treat in ASD?
Repetitive behaviour
201
Dose of SSRIs for repetitive behaviour in ASD?
Lower than antidepressant dose
202
First line pharmacological treatment for children with ASD and associated irritability?
Atypical antipsychotics
203
Licensed antipsychotic for ASD in children?
Risperidone
204
What is Risperidone indicated for in children with ASD?
Autism with aggressive behaviour
205
What must be monitored in children on Risperidone?
Weight gain
Somnolence
Hyperglycaemia
206
Difference between Aspergers and ASD
Aspergers shows no significant delays in relation to language development, cognitive development or age-appropriate self-help skills
207
Prevalence of Aspergers?
6 in 10,000
208
Factors associated with good prognosis of Aspergers?
Normal IQ
| High level social skills
209
Which psychiatric disorders are common with Aspergers?
Depression
Bipolar
Schizophrenia
210
What is Retts?
X linked dominant disorder of arrested neurodevelopment
211
What mutation is Retts associated with?
MeCP2 gene
212
Gender impact of Retts?
Almost exclusively in females
213
Sx of Retts
Deceleration of head growth between 6-18 months
Loss of purposeful hand movements, replaced by stereotypic motions
Loss of previously acquired speech
Psychomotor retardatino
Ataxia
214
What skills plateau in Retts by 1 year?
REceptive and expressive communication
| Social skills
215
How many children with Retts develop seizures?
75%
216
EEG in Retts in young children
Epileptiform discharges
217
Breathing sx of Retts
Irregular respiration - episodes of hyperventilation and apnoea
Particularly when awake
218
What is another name for Childhood disintegrative disorder (CDD)?
Hellers disease
| Disintegrative psychosis
219
What happens in CDD?
Marked regression in several areas of functioning after at least 2 years of normal development
220
What sills are lost in CDD and by what age?
Loss of acquired motor, language and social skills between ages 3-4
221
What is required for diagnosis of CDD?
Loss of skills in 2 of: language, social or adaptive behaviour; bowel or bladder control; play; or motor skills.
Abnormalities must be present in at least 2 of: reciprocal social interaction, communication skills, and stereotyped or restricted behaviour.
222
Main neurological feature of CDD
Seizures
223
Gender ratio of CDD
Male predominance
224
What diagnostic categories of learning disorders are there in DSM IV
Reading disorder
Mathematics disorder
Disorder of written expression
Learning disorder not specified
225
What can contribute to learning disorders?
Genetic predisposition
Perinatal injury
Neurological conditions
Other medical conditions
226
How many school-aged children have a learning disorder?
5%
227
What psychiatric disorders are associated with learning disorders?
ADHD
Communication disorders
Conduct disorders
Depression
228
DSM IV groups together learning disorders based on sharing which features?
Performance significantly below expected for IQ or age
Discrete developmental disability in absence of learning disability
Commonly present as emotional or behavioural problems
50% have comorbid psychiatric disorder
Most show strong evidence of heritability
229
Most common disorders in childhood?
Communication
230
What do communication disorders include?
Expressive and mixed receptive-expressive language disorders
Phonological disorder
Stuttering
231
How many children have reading disorder/dyslexia?
75%
232
What characterises dyslexia?
Impaired ability to recognise words
Slow and inaccurate reading
Poor comprehension
233
When can dyslexia be identified?
By age of 7
234
What are reading errors in dyslexia characterised by?
Omissions
Additions
Distortions of words
235
What do children with dyslexia have difficult with?
Distinguishing between printed letter characters and sizes, especially those that differ only in spatial orientation and length of line
236
How many school-aged children have dyslexia?
4%
237
M:F ratio of dyslexia
4:1
238
How many children with dyslexia have CD or ADHD
20%
239
How many children with ADHD have a learning disorder?
15-30%
240
What can be used to measure reading ability?
WORD
TOWRE
WISC
241
What is WORD?
Weschler Objective Reading Dimension
| Single word reading test
242
What is TOWRE?
Test of word reading efficiency
| Measures word reading rate and accuracy
243
What is WISC
Wescler intelligence scale for children
Measures overal cognitive ability
244
Management of dyslexia
1: remedial teaching
| Parental involvement
