Child and adolescent psychiatry |

Question 1

What is the prevalence of mental health difficulties in children?

Answer 1

10%

Question 2

What % of primary emotional or behavioural presentations go to GPs or paediatricians?

Answer 2

GP - 50%

Paeds - 30%

Question 3

What are some causes of mental health difficulties in children?

Answer 3

1. Mental health impact on development, education, relationships
2. Parental mental illness, child as carer
3. Sibling mental illness
4. Family difficulties
5. Adversity/poverty
6. Domestic violence/abuse

Question 4

What is the attachment theory?

What are the 3 categories?

Answer 4

Psychological model that attempts to describe the dynamics of long-term and short-term interpersonal relationships between humans.

3 categories:

• Secure attachment
• Anxious-ambivalent insecure attachment
• Anxious-avoidant insecure attachment

Question 5

Why is attachment in infants important?

Answer 5

1. It can lead to an internal model of the self as unlovable and inadequate, and of others as unresponsive and punitive
2. It may also predict a person’s reaction to loss or adversity, and his pattern of relating to peers, engaging in relationships and parenting children

Question 6

What are the normal stages of attachment in the following age groups:

1. Newborn
2. 9 month
3. 18 month
4. 3-4 years
5. 5 year
6. Adolescent

Answer 6

Newborn: Lack of selective attachments and stranger anxiety

9-month: Stranger anxiety, selective attachments begin

18-month Peak of proximity seeking with distressed/anxious behavior

3-4 years Separates more easily from parents

5-year More stable “internal representations” of parents/relationships

Adolescent Culturally dependent; western culture-minimal dependency needs

Question 7

How does mental health impact their development and family functioning?

Answer 7

1. May halt development as young person preoccupied with illness rather than growing up
2. Child may show delay/regression in achieving normal social/emotional developmental milestones
3. Separation out of “normal” adolescent development from illness
4. Makes it difficult for parents to let go

Question 8

What is the prevalence of autism?

Answer 8

Widest possible definition (complete spectrum) 1 in 100

Question 9

What is the prevalence of ASD in boys vs girls?

Answer 9

4:1

Question 10

What is the triad of difficulties in ASD?

Answer 10

1. Socialisation
2. Communication
3. Repetitive behaviour

Question 11

What are the 3 main causes of ASD?

Answer 11

1. Genetics
2. Biological: neurotransmitters, brain injury
3. Psychological/social factors affect how problem presents and how patient copes with it

Question 12

What is the prevalence of ADHD?

Answer 12

1-5%

Question 13

What is the prevalence of ADHD in boys vs girls?

Answer 13

3:1

Question 14

Before what age does ADHD start?

Answer 14

<7 years

Question 15

To be diagnosed as ADHD, symptoms have to be persistent, what does this mean?

Answer 15

Symptoms occur in more than 1 setting e.g. home and school

Question 16

What are the 3 core symptoms of ADHD?

Answer 16

1. inattention
2. hyperactivity
3. impulsivity

Question 17

What are the aetiology of ADHD (3)?

Answer 17

1. Genetic
2. Biological, neurotransmitters, brain injury, ? certain foods
3. Psychological/social

Question 18

What is the prevalence of dyslexia:

1. most severe type
2. widest possible definition

Answer 18

1. 4%

2. 10%

Question 19

What is the prevalence of dyslexia among boys vs girls?

Answer 19

4:1

Question 20

How do children with dyslexia often first present to services?

Answer 20

often presents to CAMHS with secondary behaviour problems at any age

Question 21

What are symptoms of dyslexia?

Answer 21

Persistent difficulties in processing and producing written material out of keeping with the persons other abilities

Question 22

What is the aetiology of dyslexia (3)?

Answer 22

1. genetic
2. biological, neurotransmitters, brain injury,
3. psychological/ social factors affect how problem presents and how patient copes with it.

Question 23

What are important principles in the assessment of child and adolescent mental health?

Answer 23

1. Always include family (unless young person refuses) - especially for older children, you may want to speak to the child before their parents
2. Remember to consider risk and any underlying mental illness
3. Social context is even more vital than it is in adults, children can’t choose where they live or go to school, they get what the adults around them supply
4. Always seek help and advice if you are not sure!

Question 24

What are the 3 aspects of the assessment of mental health in a child/adolescent?

Answer 24

1. History
2. Mental state exam
3. Risk assessment

Question 25

What are important things to consider in the risk assessment of a child/adolescent?

Answer 25

1. Remember risk to self and others 2. One particular concern is child protection/safeguarding children - Physical - Sexual - Emotional - Neglect 3. You need to be aware that abuse may underlie presenting symptoms 4. There is a duty of all professionals to protect children and the role of social/children services in safeguarding

Question 26

What are the biological management options of mental health disorders in children and adolescents?

Answer 26

Generally less common as 1st line But: 1. Antidepressants for depression in adolescents 2. Medication for hyperactivity (ADHD)

Question 27

What are the psychological management options of mental health disorders in children and adolescents?

Answer 27

Usually 1. CBT 2. Family therapy (depending on disorder)

Question 28

What are the social management options of mental health disorders in children and adolescents?

Answer 28

Social very important - Links to wider network especially education, social services

Question 29

What are the concerns with use of antidepressants in adolescents?

Answer 29

1. Concerns over suicidal behaviour in teens taking SSRI - should be prescribed by child psychiatrist only - Only fluoxetine should be used 2. Less evidence that antidepressants are effective compared to adults

Question 30

What is the NICE stepped-care model of treating adolescents with depression and where are they managed?

Answer 30

1. Detection - Risk profiling 2. Recognition - Identification in presenting children or young people - Refer to CAMHS 3. Mild depression (including dysthymia) - Watchful waiting - Non‑directive supportive therapy/group cognitive behavioural therapy/guided self‑help - Manage in 1o care and community 4. Moderate to severe depression - Brief psychological therapy +/– fluoxetine - Tier 2/3 CAMHS 5. Depression unresponsive to treatment/recurrent depression/psychotic depression - Intensive psychological therapy +/– fluoxetine, sertraline, citalopram, augmentation with an antipsychotic - Consider inpatient care

Question 31

What is the biological treatment of ADHD?

Answer 31

Medication: 1. Stimulants - methylphenidate - Ritalin, Concerta 2. Non-stimulants - Atomoxetine

Question 32

What is the psychological treatment of ADHD?

Answer 32

Parenting course

Question 33

What is the social treatment of ADHD?

Answer 33

Liason with education e.g. special needs

Question 34

According to GMC, what are the definitions of: 1. Children 2. Young person/people 3. Adults

Answer 34

1. Those younger children who lack the maturity and understanding to make important decisions for themselves 2. Older or more experienced children who can make important decisions themselves 3. Aged above 18

Question 35

At what age is it legally presumed that children have the ability to make decisions about their own care?

Answer 35

over 16 years old

Question 36

What are the principles of using the Mental Health Act/Mental capacity on children and adolescents?

Answer 36

1. No age restriction for Mental Health act, but can only be used in treatment of mental disorder, (not physical unless it manifests with mental health symptoms) 2. Mental Capacity Act generally only applies to individuals above 16. However, the principle of assessing capacity as in the Mental Capacity Act can be used at any age. If consent is needed below aged 16, consider parental consent. 3. If you are not sure, seek professional and legal advice!

Question 37

What is Gillick competence/Fraser guidelines?

Answer 37

Widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions.

Question 38

What are the principles of confidentiality and disclosure around mental health in children/adolescents?

Answer 38

1. The same duties of confidentiality apply when using, sharing or disclosing information about children and young people as about adults. 2. Largely dependent on whether the child or young person has capacity in consenting for disclosure/confidentiality 3. If a child or young person does not agree to disclosure there are still circumstances in which you should disclose information: - When there is an overriding public interest in the disclosure - When you judge that the disclosure is in the best interests of a child or young person who does not have the maturity or understanding to make a decision about disclosure - When disclosure is required by law

Question 39

According to GMC, if a child who lacks capacity to consent shares information with you on the understanding that their parents are not informed, what should you do?

Answer 39

1. Try to persuade the child to involve a parent in such circumstances. 2. If they refuse and you consider it is necessary in the child’s best interests for the information to be shared (for example, to enable a parent to make an important decision, or to provide proper care for the child), you can disclose information to parents or appropriate authorities. 3. You should record your discussions and reasons for sharing the information.