Child and Adolescent Psychiatry

Question 1

what are genome wide association studies used for?

Answer 1

identifying genetic risk factors for psychiatric disorder

Question 2

how can GWAS help identify risk factors for psychiatric disorder?

Answer 2

They can indicate
that many genes are implicated, mostly of small effect. Many implicate micro-RNA and epigenetic
modulation. Genetic factors serving modulation of gene expression are likely to be important. They
control influence of environmental factors on genetic expression. Inflammatory and autoimmune
mechanisms are being implicated as well as genes controlling synapse formation, neurotransmission
and modification

Question 3

intrauterine and perinatal factors leading to development of psychiatric disorders

Answer 3

• Maternal health – Maternal antibodies, obesity, diabetes
• Substance misuse – alcohol, marijuana (no initial effects but tendency to depression later on)
• Toxins – lead, mercury and PCB’s
• Drugs – esp. psychotropics/antiepileptics (lipid soluble)
• Epigenetics – folate-controlled methylation
• Endocrine environment – esp. androgens
• Immune environment
• Premature birth/ Perinatal complications
• Twinning
• Impressive levels of resilience

Question 4

how does foetal alcohol syndrome affect growth?

Answer 4

body
head
brain (inc cerebellum)
eyes (small wideset eyes)
thin upper lip and absence of philtrum

Question 5

neurodevelopmental effects of alcohol during pregnancy

Answer 5

sensorimotor
cognitive development
executive function
language

Question 6

white matter connectivity and ADHD

Answer 6

White matter connections are important for functions that require interplay between brain areas e.g.
working memory between the hippocampus and anterior cingulate. Low connectivity is associated
with more neural “noise” in the system, intra-individual variability and “cognitive instability.” In
developing brains this is typically associated with ADHD – poor concentration and distractibility.
Poorer overall integration of function results in cognitive instability.

Question 7

common outcomes of foetal alcohol syndrome

Answer 7

variable
learning difficulties 
conduct disorders inc oppositional defiant disorder
combined ADHD or ADD or hyp-imp subtypes
anxiety disorders

Question 8

conduct disorders associated with foetal alcohol

Answer 8

frequent loss of temper, arguing, becoming easily angered or annoyed, showing vindictive or other negativistic behaviours

Question 9

what is ADD?

Answer 9

distractibility, sustaining attention to tasks that don’t provide high level of stimulation or frequent rewards, distractibility and problems with organization.

Question 10

what are hyp-imp subtypes?

Answer 10

difficulties with remaining still, most evident in situations that require behavioural self-control. Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.

Question 11

anxiety disorders associated with foetal alcohol

Answer 11

panic
phobic
separation
GAD

Question 12

environmental factors during childhood associated with psychiatric disorders

Answer 12

• Carer - child relationship (attachment)
• Parenting skill and parental mental disorder e.g. post-natal depression, substance misuse
• Marital harmony, family function
• Nutrition, poverty, deprivation
• Abuse, neglect
• Discipline
• Day-care and schooling
• Peer relationships
• Life events
• Physical disability

Question 13

describe the brains response to stress

Answer 13

The brain responds similarly to physical and mental stress. The response to stress involves interplay
of brain and body. Early life stress influences the function of the limbic circuit including the amygdala.
It determines subsequent patterns of stress response. Early life stress influences mood and patterns
of response to threat including withdrawal and/or aggressive response.
Experience of adversity trains the brain to adapt to a hostile environment:
1. Perceived behaviour and aggression
2. Limbic response and heightened amygdala activity
3. Cortical response and preparation of aggressive response
4. Behavioural response and aggression

Question 14

concepts in psychological development

Answer 14

reward based learning
executive function
delay-aversion
sharing emotion and empathy
expressed emotion

Question 15

describe executive and cortical control

Answer 15

• Taking control over ‘automatic’ and learned behaviours
• Applied in Cognitive Behavioural Therapy.
• Inhibit prepotent responses
• Intentional decision-making and forward planning.
• Requires self-awareness and capacity to self-monitor.

Question 16

temporal lobe epilepsy can present as what? why?

Answer 16

psychosis

auditory hallucinations

Question 17

what are conduct disorders?

Answer 17

Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive, or
defiant behaviours which violate age-appropriate societal norms. Course and outcome: persistent
disorder, associated with increased risk of early death, often by sudden or violent means. Also, at
increased risk of social exclusion, poor school achievement, long-term unemployment, criminal
activity, adult mental health problems, and poor interpersonal relationships including those with their
own children.

Question 18

core symptoms of ADHD

Answer 18

hyperactivity
impulsivity
inattention

Question 19

management of conduct disorders

Answer 19

based on biopsychosocial assessment
• Parent training programme (12 or younger) e.g. The Incredible Years
• Modification of school environment eg behavioural support
• Functional family therapy
• Multi-systemic therapy
• Child interventions: social skills, problem-solving, anger management, confidence building
• Treat comorbidity
• Address child protection concerns

Question 20

examples of hyperkinetic disorders

Answer 20

LD
ASD
CD
tics
motor coordination problems
substance misuse
anxiety 
depression

Question 21

what are hyperkinetic disorders associated with?

Answer 21

reduced academic and employment success
increased criminal activity
increased adult mental health problems

Question 22

ADHD management (non pharmacological)

Answer 22

• Psychoeducation
• Medication – stimulants, atomoxetine, guanfacine
• Behavioural interventions e.g. realistic expectations, contingency management
• Parent training - PinC
• School interventions
• Treat comorbidity
• Voluntary organisations
• Benefits

Question 23

medication for ADHD

Answer 23

methylphenidate

2nd line - atomoxetine nonstimulant

Question 24

discuss self harm

Answer 24

Self-injury is a coping mechanism. An individual harms their physical self to deal with emotional pain,
or to break feelings of numbness by arousing sensation. Self-poisoning, cutting, burning etc. Can
indicate psychiatric disorder, or significant psychosocial problems. Many risk factors for self-harm are
shared with those for suicide. Self-harm is not an act of suicide it is a form of release that soothes the
person. Can be a form of self-punishment. It is not a diagnosis.

Question 25

factors increasing risk of suicide

Answer 25

* Persistent suicidal ideas * Previous suicidal behaviour * High lethality of method used * High suicidal intent and motivation * Ongoing precipitating stresses * Mental disorder * Poor physical health * Impulsivity, neuroticism, low self-esteem, hopelessness * Parental psychopathology and suicidal behaviour * Physical and sexual abuse * Disconnection from support systems

Question 26

management of a suicidal person

Answer 26

• The safety of the young person is the first priority • Take it seriously • Usually admit to age appropriate medical ward after serious attempt for medical treatment and psychosocial assessment. • Mental health and risk assessment by specially trained staff member with ready access to psychiatric opinion. • Confidentiality (with exceptions). • Further referral to agencies as appropriate e.g. CAMHS, child protection

Question 27

mental health problems associated with being out of school

Answer 27

``` anxiety conduct disorder autism depression OCD ```

Question 28

effects of mental health problems on school attendance and learning

Answer 28

* Learning difficulties due to poor attention * Co-morbid specific (or general) learning problems * Difficulty controlling emotion e.g. frustration, escalation of anger, frequent conflict. * Anxiety * Lack of energy, motivation * Difficulties joining in – wanting to be alone or unable to make friends (feeling different). * Sensory problems – too noisy * Preoccupation e.g. fear of germs and contamination * Associations between mental health and learning difficulties e.g. dyslexia

Question 29

2 common anxiety disorders in children

Answer 29

separation anxiety | social phobia

Question 30

3As of anxiety disorders

Answer 30

o Anxious thoughts and feelings (e.g. impending doom) o Autonomic symptoms o Avoidant behaviour

Question 31

motivational factors affecting school attendence

Answer 31

affecting willingness to go to school | encouraging one to stay at home

Question 32

what factors affect willingness to go to school?

Answer 32

learning difficulties lack of friends bullying lack of parental attention or concern

Question 33

what may encourage a child to stay ay home?

Answer 33

maternal depression of psychiatric disorder inc separation

Question 34

treatment of anxiety in children

Answer 34

• Behavioural o Learning alternative patterns of behaviour o Desensitisation o Overcoming fear o Managing feelings • Medication o Serotonin reuptake inhibitors e.g. fluoxetine

Question 35

discuss ASD

Answer 35

• Defined as a syndrome of distinctive behavioural abnormalities. • Often associated with Low IQ but not defined by low IQ. • Pervasive: present across the life span (onset <3yrs) and across settings (a feature of brain development and function) • Highly heritable. • Now thought to affect 1% • Male: female ratio 3:1 • Girls less likely to present: likely to superficially feign emotion

Question 36

social reciprocity and communication in ASD

Answer 36

reciprocal conversation expressing emotional concern non-verbal communication (declaritive pointing, modulated eye-contact, facial expression, others)

Question 37

repetitive behaviour in ASD

Answer 37

mannerisms and stereotypes • Obsessions, preoccupations and interests • Rigid and inflexible patterns of behaviour o Routines o Rituals o Play

Question 38

what is decreased in ASD?

Answer 38

self-other perspective taking sharing/divided attention flexible learning social understanding

Question 39

what is increased in ASD?

Answer 39

rigidity sameness fixed learning patterns technical understanding

Question 40

lower IQ in ASD is associated with?

Answer 40

joint attention/attention to others emotional responses movements/actions

Question 41

higher IQ in ASD is associated with?

Answer 41

conversation empathy interests

Question 42

what clinical problems are associated with ASD?

Answer 42

* Learning disability – mild to severe * Disturbed sleep and eating habits * Hyperactivity * High levels of anxiety and depression * Obsessional compulsive disorder * School avoidance * Aggression * Temper tantrums * Self-injury, self-harm * Suicidal behaviour (6 x)

Question 43

causes of ASD?

Answer 43

``` congenital/genetic co-morbid disorders: rubella Callosal agenesis Down's syndrome Fragile X Tuberous sclerosis ```

Question 44

broader phenotype in siblings and parents of ASD people is associated with?

Answer 44

increased rates of depression, OCD, anxiety disorders, language impairment poor set-shifting ability, increased visuospatial ability, careers in engineering, computing or mathmatics

Question 45

management of ASD

Answer 45

* Recognition, description and acknowledgement of disability * Establishing needs * Appreciating the can’t and the won’t. * The broken leg metaphor * Decrease the demands à reduce stress à improve coping * Psychopharmacology

Question 46

key features of ODD

Answer 46

* Refusal to obey adults request * Often argues with adults * Often loses temper * Deliberately annoys people * Touchy or easily annoyed by others * Spiteful or vindictive

Question 47

ODD vs ADHD

Answer 47

• ODD: o Relates to temperament – irritable and ‘headstrong’ o Behaviour is learned o Enacted to obtain a desired result § More likely to result from impaired parenting o Associated with adversity • ADHD: o Aggression is impulsive, (and aggression may not be a feature). o Poor cognitive control and ability to sustain a goal o Often remorseful o Resistant to pure behavioural management o Stronger genetic component.