Child Psychiatry Flashcards
(25 cards)
General considerations in assessment of children
Internalising (psychological state) vs Externalising (to outwards env)
- need various collateral info to get full picture – parents, teachers, child
- interviewing parents also allows indirect evaluation of their personalities, parenting etc.
Multi-dimensional assessment
- psychiatric diagnosis – COMORBIDITIES ARE COMMON
- developmental delays
- intellectual level
- medical conditions
- psychosocial situation
Risk factors and protective factors for child psychiatric problems
Interaction of genes and environment
Risks: Predisposing - genetic - perinatal e.g. substance/alcohol in pregnancy, extreme low weight/prematurity (ADHD, ASD risk), birth complications, physical disabilities - insecure attachment - temperament - chronic illness, CNS trauma
Precipitating/Perpetuating
- parental mental illness
- family: parenting problem, conflicts, violence, abuse
- school: academic failure, bullying, rejection
- society: poverty, discrimination, isolation
Protective factors:
- good self esteem, happy temperament
- good problem solving and social skills
- appropriately involved and consistent parenting
- harmonious family, able to resolve conflicts
- sense of achievement and belonging
General mx in child psychiatry
Multidisciplinary Physical, psychological, social Collaboration and liaison with community partners - family, school - share understanding and difficulties - skills in handling child
Specific developmental disorders - definition, intelligence
Disturbed acquisition of specific cognitive or motor function during child’s development e.g. language, reading, spelling, calculation, motor skills
Other areas of cognition are normal
NORMAL INTELLIGENCE
Pervasive developmental disorders - features, disorders included
Severe impairments in SOCIAL INTERACTION AND COMMUNICATION SKILLS
RESTRICTED, STEREOTYPED INTERESTS and BEHAVIOUR
Pervades all areas of functioning and usually evident in first few years of life
Diagnosis NOT BASED ON INTELLECTUAL FUNCTIONING
Autism Spectrum Disorder
- includes: autism, Asperger’s, Rett’s, Childhood disintegrative disorder
Autism Spectrum Disorder - epidemiology, M:F, aetiology, syndromal vs non-syndromal, similarities with schiz
1-2% of children
M>F 3:1
Aetiology: exact cause not identified - genetic (56-95% heritability), prenatal, peri-natal, immunological factors implicated
Can be non-syndromal or syndromal e.g. tuberous sclerosis, Rett’s, Di George, fragile X
Social withdrawal, communication impairment and poor eye contact similar to negative symptoms of schizophrenia
ASD - main symptoms
IMPAIRMENT IN SOCIAL INTERACTION and COMMUNICATION SKILLS
- verbal: speech delay, difficulty in initiating or sustaining convo
- non-verbal: poor eye contact, restricted facial expressions, poor use of gestures
- weak social awareness, reciprocity (e.g. less response to name calling), empathy, emotional recognition (can’t adjust well)
- failure to develop and share enjoyment of peer relationships (always alone)
RESTRICTED, STEREOTYPED INTERESTS and BEHAVIOURS
- insistent on sameness, inflexible adherence to routines and rituals
- unusual intense preoccupations with interests such as dates, numbers, timetables; hard/moving objects e.g. bus, spinning wheels (selective attention)
- repetitive stereotyped (no function) movements e.g. clapping, rocking, flicking
- sensory problems – hyper or hypo: may be sensory seeking e.g. massage, rubbing, hitting themselves
- lack of imaginative play
ASD - onset, intelligence, comorbidities, other behavioural problems
Early onset but usually present later
Intelligence: most have normal IQ
High rates of psychiatric comorbidity - MUST SCREEN!
- ADHD (30-40%), anxiety, depression (esp when older), ODD, conduct problems
May exhibit behavioural problems e.g. aggression, impulsivitym, self-harm – RISK
Physical comorbidities
- GI, immunity, 25-30% develop epilepsy
ASD management - initial assessment, main form of treatment, indications for medication
Usually child assessment service paediatrician screens development and physical syndromes if parents suspect problem –> then refer to PSY
Psychoeducation
ONGOING SUPPORT
ONGOING TRAINING (OT and CP)
- parents involved (parenting skills, stress)
- social skills (how to handle certain situations)
- rigid behaviour modification
Emotional regulatory skills
Refer Ed Psy for Educational needs and support
Refer PT for gross motor development
Refer ST for speech therapy
Pharmacological treatment only if:
- comorbid MDD, GAD, ADHD etc
- high self harm risk – may need SGA to decrease irritability or aggression
- SSRI may have repetitive behaviours
ASD prognosis, good prognostic factors
Generally poor – only 1-2% achieve full independence but 50% have sufficient social skills
Good prognostic factor
- IQ>70, good language development, home environment supportive
Asperger’s syndrome - M:F, main features, IQ, onset age, comparison with autism
Outdated, now part of ASD
M>F
Same core features of ASD but NO IMPAIRMENT in LANGUAGE ACQUISITION AND ABILITY (still have impairment in reciprocal social interaction) or in cognitive development and intelligence
IQ and language may be superior in some cases (high functioning)
Onset usually >5 (may be later in teenage yrs when more complex interactions develop - due to emotional problem, temper outburst, self harm)
Mild social deficits, active but odd interactions (whereas autism is passive), pedantic speech, more sophisticated interests, high verbal IQ
Rett’s syndrome - cause, onset, features
Mutation in gene MECP2 on X chromosome
Apparently normal development in first 5 months after birth
6 months -2 yrs –> PROGRESSIVE AND DESTRUCTIVE ENCEPHALOPATHY
- deceleration of head growth
- loss of language development
- loss of purposeful hand movements and fine motor skills with subsequent development of stereotyped hand movements
Prognosis: wheelchair bound, incontinence, muscle wasting, rigidity, no language (after 10 yrs)
Childhood disintegrative disorder - main feature
2 years of normal development followed by LOSS OF PREVIOUSLY ACQUIRED SKILLS
- language, social, adaptive, play, bowel/bladder control, motor skills before age 10
A/w autism like impairment of social interaction, repetitive behaviour
Acquired disorders with onset usually in childhood or adolescence
ADHD Conduct disorder, ODD Separation Anxiety Phobic Anxiety Social Anxiety
Attention Deficit Hyperactivity Disorder - M:F, prevalence, risk factors, age of onset
5-8% school-aged children
M>F 3:1
Aetiology/ Risk factors:
- highly heritable (80%; underdevelopment of frontal lobe with NE/DA dysfunction)
- environment: fetal alcohol syndrome, maternal smoking, lead poisoning, birth complications, hypoxia, brain injury
Onset: toddler years but presentation at school age
- hx of kindergarten complaints
Things to ask in Hx include daily routine, behaviours in different settings etc
ADHD main features
IMPAIRED ATTENTION
- difficulty sustaining attention in tasks
- not listening when being spoken to, highly distractible
- reluctance to engage in activities that require sustained mental effort
- forgetful, lose things regularly
HYPERACTIVITY
- restlessness, running around and jumping in inappropriate situations
- incessant fidgeting
- excessive talkativeness or noisiness
- difficulty engaging in quiet activities
IMPULSIVITY
- difficult awaiting turn, interrupting others’ conversations or games
- prematurely blurting out answers to questions
- short tempered
All symptoms are DISPROPORTIONATE TO AGE (clinical diagnosis)
Can be combined type, IA type or HI type
ADHD comorbidities
Dysfunction to family, education, social, self-esteem hence HIGHLY COMORBID!!
Dyslexia, motor clumsiness, sleep problem, behaviour problem (school refusal, drop out, change jobs frequently), relationship problems
ODD (30-40%), anxiety, mood disorder, conduct disorder, substance abuse, teenage pregnancy
ASD, tics
ADHD management - initial assessment, mild-moderate tx, severe tx
Thorough assessment of
- comorbidities (and treat)
- family relationship and parenting
- psychosocial stresses
- functional impairment
For mild to moderate cases: 1st line is PSYCHOSOCIAL
- parental education or training
- CBT
- CP for social skills training, behavioural strategies for impulsivity and functional impairments e.g. organisation
- educational needs and support (EP)
- self-esteem building
For severe cases: pharmacological (should be >5 yrs old)
- Methylphenidate (stimulant) –> S/E: CVS problems (monitor bp, HR, ECG), suppress appetite and growth, insomnia, epilepsy (but no sig long term effects); avoid during asthmatic attack
- Atomoxetine (non-stimulant)
- Other options if ineffective: bupropion, clonidine, modafinil, amphetamine based, imipramine
ADHD prognosis - response to treatment, future problems, poor prognostic factors
60-70% response to decrease symptoms and adverse comorbidities
- hyperactivity improves
- inattention and impulsivity may continue
- doesn’t change trajectory of illness
1/3 outgrow it, 2/3 need lifelong meds
Risk of developing conduct problem, antisocial PD, interpersonal/occupational/forsenic problems
Poor prognostic factors: unstable family dynamics, coexisting conduct disorder
Conduct disorder and ODD – prevalence, age of onset, aetiology, features, management
1-10%
M>F 4:1
Onset before 18
Aetiology: genetic, parental problems, child abuse/neglect, educational impairment, poor SE status
Repetitive persistent pattern of:
- aggression to people and animals
- destruction of property
- deceitfulness or theft
- major violations of societal expectations or rules
Oppositional defiant disorder = persistent negativistic defiant and hostile behaviour in the ABSENCE OF BEHAVIOUR THAT VIOLATES THE LAW
e.g. angry, resentful, deliberately defy rules or requests, annoy others
Management: CBT, family therapy
Anxiety disorders in childhood/pre-adolescents
Separation anxiety
- normal is 6 months-2/4 years
- developmentally inappropriate and excessive anxiety when separation from home – life threatening feeling that harm will befall on attachment figure (repeated phoning, can’t sleep, refuse school)
Phobic anxiety
- minor phobic symptoms common in childhood and varies through development
- Dx when AGE INAPPROPRIATE or clinically abnormal levels
Social anxiety
- normal stranger anxiety is 8 months-1 year
- persistent or recurrent fear/avoidance of strangers with abnormal anxiety
Management of depression in adolescence
Symptoms may be misinterpreted
Mx:
- SSRI (fluoxetine, sertraline, citalopram) ONLY WHEN CLEARLY INDICATED – AVOID IF <12 yrs old
- -> monitor S/E, dosage, suicidal risk when start med
- PSYCHOLOGICAL THERAPY
- mild: 2 wks FU, self-help + short CBT
- mod-severe: CBT, IPT, family therapy for 12 wks
Social: counselling, play therapy (for younger kids)
Selective mutism - must r/o, features, onset, may develop ? later
MUST R/O AUTISM
Child is mute in many social situations but can speak freely to familiar people (need evidence)
- adequately developed language skills
Onset <5, F>M
Often a/w anxiety symptoms, may develop social phobia later
Tic disorders - characteristics, types of tics
Sudden repetitive non-rhythmic motor movements or vocalisations
INVOLUNTARY
Often prominent during stress
Simple motor tics: eye blinking, neck jerking, facial grimacing
Simple vocal tics: grunting, coughing, barking
Complex motor tics: jumping, touching self, copropraxia
Complex vocal tics: repeating words, coprolalia
