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Flashcards in Community paediatrics and psychiatry ||| Deck (68):
1

What are the 4 fields of developmental skills?

1. Gross motor
2. Vision and fine motor
3. Hearing, speech and language
4. Social, emotional and behavioural

2

When considering developmental milestones, what is the definition of median age?

The age when half of a standard population of children achieve that level

3

When considering developmental milestones, what is the definition of limit ages?

The age by which the developmental milestones should have been achieved

4

How do you assess developmental age of a preterm baby?

When do you stop correcting for age?

Calculate it from the expected date of delivery

At 2 years of age

5

Define normal development

Steady progress in all 4 developmental fields with acquisition of skills occurring before limit ages are reached

6

What should be considered when evaluating a child's development (5)?

1. Each skill field separately
2. The sequence of developmental progress
3. The stage the child has reached for each skill field
4. If progress is similar in each skill field
5. Only at the end, the child's overall developmental profile and how that relates to the child's age

7

At what age does each developmental progress accelerate the fastest (4)?

1. Motor: 1st year of life
2. Vision and fine motor development: from 1 year onwards
3. Hearing, speech and language: from 18 months
4. Social, emotional and behavioural: from 2.5 years of age

8

What are the milestones of gross motor function (5)?

Newborn - Flexed posture
7 months - sits without support
1 year - Stands independently
15-18 months - walks independently and steadily
2.5 years - runs and jumps

9

What are the milestones of vision and fine motor (5)?

newborn - Follows face or light by 2 weeks
7 months - transfers objects from hand to hand
1 year - pincer grip (10 months), points
15-18 months - immature grip of pencil, random scribble
2.5 years - draws

10

Define global developmental delay, what age does it become apparent at?

Delay in acquisition of all skill fields, apparent around first 2 years of life.

11

What investigations would you do for someone with possible global developmental delay (7)?

Do investigations for possible cause
1. Cytogenic testing
2. Metabolic e.g. thyroid tests, LFTs, bone chemistry, U+Es, etc
3. Infection e.g. congenital infection screen for cytomegalovirus
4. Imaging e.g. CT/MRI brain scans, skeletal survey
5. Neurophysiology e.g. EEG for seizures
6. Histopathology i..e. nerve, skin and muscle biopsy
7. Other e.g. hearing, vision, psychiatry etc

12

What are the possible causes of abnormal development and learning difficulty?
1. Prenatal (5)
2. Perinatal (3)
3. Postnatal (6)
4. Other (3)

Prenatal
1. Genetic i.e. Down syndrome
2. Cerebrovascular i.e. stroke
3. Metabolic i.e. hypothyroidism, phenylketonuria
4. Teratogenic i.e. alcohol/drug abuse
5. Congenital infection i.e. rubella, cytomegalovirus, toxoplasmosis, HIV

Perinatal
1. extreme prematurity i.e. intraventricular haemorrhage/periventricular leucomalacia
2. birth asphyxia i.e. hypoxic-ischaemia encephalopathy
3. metabolic i.e. symptomtaic hypoglycaemia, hyperbilirubinemia

Postnatal
1. infection i.e. meningitis/encehalitis
2. anoxia i.e. suffocation, near drowning seizures
3. trauma i.e. head injury
4. metabolic i.e. hypoglycaemia, inborn errors of metabolism
5. cerebrovascular i.e. stroke
6. nutritional deficiency i.e. food intolerance, maternal deficiency (breast fed)

Other
1. chronic illness
2. physical abuse
3. emotional neglect

13

Define cerebral palsy

An umbrella term for a permanent disorder of movement and/or posture and of motor function due to a non-progressive abnormality in the developing brain

14

What are the 3 types of cerebral palsy?

1. Spastic cerebral palsy
2. Dyskinetic cerebral palsy
3. Ataxic (hypotonic) cerebral palsy

15

What is the pathophysiology of spastic cerebral palsy and the key signs on a neurological examination (3)?



1. Damage to the upper motor neurone pathway
2. Limb tone is persistently increased (spasticity) with associated brisk deep tendon reflexes and extensor plantor responses
3. Sometimes there is initial hypotonia particularly of the head and trunk

16

What are the 3 types of spastic CP and how do they often present?

1. Unilateral (hemiplegia)
-unilateral involvement of the arm and leg.
-At 4-12 months, they present with fisting of affected hand, a flexed arm, a pronated forearm, asymmetric reaching, hand function or toe pointing when lifting the child.

2. Bilateral (quadriplegia)
-all 4 limbs affected often severely.
-The trunk is involved with a tendency to opisthotonus, poor head control and low central tone

3. Bilateral (diplegia)
-all 4 limbs but the legs are affected to a much greater degree than the arms.
-Motor difficulties are apparent with functional use of the hands, walking is abnormal.

17

What is the pathophysiology of dyskinetic cerebral palsy and the key signs on a neurological examination (6)?

Damage to basal ganglia and extra-pyramidal pathways.

Presents with:
1. Floppiness
2. Poor trunk control
3. Delayed motor development in infancy.
4. Abnormal movements towards the end of the first year of life.
5. Muscle tone is variable
6. Primitive reflex patterns predominate

18

What is the pathophysiology of ataxic (hypotonic) cerebral palsy and the key signs on a neurological examination (6)?

Usually genetically determined

1. Early trunk and limb hypotonia
2. poor balance
3. delayed motor development.
4. incoordinate movements
5. intention tremor
6. Ataxic gait may be evident later

19

What are the early features of CP (4)?

1. Abnormal limb and/or trunk posture and tone in infancy with delayed motor milestones
2. Feeding difficulties, with oromotor incoordination, slow feeding, gagging and vomiting
3. Abnormal gait once walking is achieved
4. Asymmetric hand function before 12 months of age

20

What are the ddx of abnormal motor development (4)?

1. Central motor deficit e.g. CP
2. Congenital myopathy/primary muscle disease
3. Spinal cord lesions e.g. spina bifida
4. Global developmental delay as in many syndromes or of unidentified cause

21

What can you look for in a neurological exam in the developmental screening (7)?

1. Abnormal posture/symmetry
2. wasting
3. tone and power
4. deep tendon reflexes
5. clonus
6. plantar responses
7. cranial nerves

22

Key delays when performing a developmental assessment according to age:
1. Prenatal (2)
2. Infancy (3)
3. Preschool (5)
4. school age (6)
5 any age (1)

Prenatal
1. Dysmorphic features
2. Abnormal neurological behaviour i.e. tone, feeding, movement, seizures, visual inattention

Infancy
1. Global developmental delay
2. delayed or asymmetric motor development
3. vision or hearing concerns

Preschool
1. speech and language delay
2. abnormal gait
3. Clumsy motor skills
4. poor social communication skills
5. behaviour - stereotypical, overactivity, inattention

School age
1. problems with balance and coordination
2. learning difficulties
3. attention control
4. hyperactivity
5. specific learning difficulties
6. social communication difficulties

Any age
1. loss of skills

23

What are possible reasons for speech and language delay (5)?

1. Hearing loss
2. Global developmental delay
3. Difficulty in speech production from an anatomical deficit e.g. cleft palate
4. Environmental deprivation/lack of opportunity for social interaction
5. Normal variant/familial pattern

24

What are the different types of speech and language disorders (5)?

1. Language comprehension
2. language expression - inability or difficulty in producing speech whilst knowing what is needing to be said
3. intelligibility and speech production such as stammering (dysfluency), dysarthria or verbal dyspraxia
4. Pragmatics (difference between sentence meaning and speakers meaning), construction of sentences, semantics and grammar
5. social/communication skills (ASD)

25

How do you define Asperger syndrome?

Asperger syndrome refers to a child with the social impairments of an ASD but at the milder end, and near-normal speech development

26

How is ASD diagnosed?

Observation of behaviour and use of formal standardized tests (Autism diagnostic interview, Autism Diagnostic observation schedule and diagnostic interview for social and communication disorders)

27

How is ASD managed (2)?

1. Applied behaviour analysis - behaviour modification approach that helps to reduce ritualistic behaviour, develop language, social skills and play, and to generalize use of all these skills.

2. Being in an appropropriate educational placement

28

How do you define ADHD?

The child is undoubtedly overactive in most situations and has impaired concentration with a short attention span or distractibility

29

How is ADHD managed (2)?

1. Promotion of behavioural and educational progress - specific advice to parents and teachers to build concentration skills, increase self-esteem
2. Medication - stimulants e.g. methylphenidate or dexamphetamine, or non-stimulants such as atomoxetine

30

What are the diagnostic criteria of ADHD (5)?

1. been displaying symptoms continuously for at least six months
2. started to show symptoms before the age of 12
3.been showing symptoms in at least two different settings – for example, at home and at school, to rule out the possibility that the behaviour is just a reaction to certain teachers or parental control
4.. symptoms that make their lives considerably more difficult on a social, academic or occupational level
5. symptoms that aren't just part of a developmental disorder or difficult phase, and aren't better accounted for by another condition

31

What are the key professionals involved in the management of ADHD (4)?

1. Educational psychologist
2. behavioural programmes at school
3. psychiatrist
4. paediatrician

32

What is dyspraxia?

Developmental coordination disorder, a disorder of motor planning and/or execution with no significant findings on standard neurological examinations. It can lead to problems with handwriting, dressing, cutting up food etc

33

What are the health professionals involved in the diagnosis of dyspraxia (5)?




What are the diagnostic criteria for dyspraxia?

1. Occupational therapist
2. Speech and language therapist
3. Vision assessment
4. paediatrician
5. physiotherapist

Motor ABC test = Assessment of childs gross (ability to do significant body movements such as jumping and fine motor skills for coordinated movements. The scores are added and compared to normal scores within their age range. There also needs to be evidence of normal mental ability in their age range

34

What is dyslexia?

A disorder of reading skills disproportionate to the child's IQ

35

What are the health professionals involved in the assessment of dyslexia (2)?

1. Assessment of vision and hearing
2. Educational psychologist

36

What is nocturnal enuresis?

Bed wetting

37

What are the causes of enuresis (5)?

1. UTI
2. Faecal retention
3. Polyuria from osmotic diuresis
4. Associated with developmental, attention or learning difficulties
5. Can be interfered with my emotional stress

38

What investigation should be done for enuresis?

urinalysis if bed wetting is of recent onset, occurs during the day or if there are features of DM, or ill health

39

What is the management of enuresis (5)?

1. Explanation to parents and child that the problem is common and beyond conscious control
2. star chart can be done where child earns praise and a star given for agreed behaviour like helping to change the sheets rather than dry nights
3. enuresis alarm
4. desmopressin = synthetic analogue of antidiuretic hormone
5. self-help groups

40

What are the diagnostic criteria for anorexia and eating disorders (3)?

1. Self-induced weight loss resulting in a low BMI
2. a distorted perception of her body which increases with weight loss
3. a determined attempt to lose weight or avoid weight gain by either restricting food intake, self-induced vomiting, laxative abuse, excessive exercise or a combination

41

What is the management of anorexia and eating disorders?
Medical (1)
Psychological (2)

Medical:
1. restore near-normal body weight by refeeding

Psychological:
1. family therapy
2. individual psychological treatment to improve self-esteem, handling conflict, personal autonomy and relationships etc

42

What is school refusal?

An inability to attend school on account of overwhelming anxiety. It is disproportionate to stresses at school

43

How can school refusal present (4)?

1. Hyperventilation
2. Nausea
3. Headache
4. Otherwise not being well

=all confined to weekday, term-time mornings, clearing up by midday

44

What are the 2 most common causes of school refusal and at what age do they normally present at?

1. separation anxiety persisting beyond the toddler years, usually under the age of 11. It can be provoked by an adverse life event such as an illness etc
2. true school phobia - anxiety provoked by some aspect of school. This is seen in slightly older anxious children who are frequently uncommunicative and stubborn.

They can coexist

45

How is school refusal managed (5)?

1. Advise and support parents and school about condition
2. Treat any underlying emotional disorder
3. Plan and facilitate an early and graded return to school at a pace tolerable for the child
4. Help the parents make it more rewarding for the child to return to school than stay at home
5. Address bullying or educational difficulties if present

46

What professionals are involved in the management of school refusal (4)?

1. Family
2. Teachers
3. Educational psychologist
4. Educational welfare officers

47

What questions should be asked regarding a temper tantrum (3)?

ABC

Antecedents - what happened in the minutes before the episode

Behaviour - exactly what did the episode consist of

Consequences - what happened as a result, including what you did and the outcome

48

What should you investigate for in a child with temper tantrums (3)?

Identify any potential medical or psychological factors

Medical:
1. global or language delay
2. hearing impairment e.g. glue ear
3. medications e.g. bronchodilators or anticonvulsants

49

What are the management strategies that can be adopted for a tantrum (5)?

1. Distract child
2. let the tantrum burn itself out while the parent leaves the room, returning a few minutes later when things quieten down OR time out
3. When tantrums are coercive, the parent should refuse to give in
4. Star chart to reward child for complying with parental requests
5. Make rules clear

50

What are the possible reasons that children can be aggressive (3)?

1. Learnt:
-being rewarded inadvertently
-by copying parents
2. Tired or stressed child
3. Children whose communication skills are compromised by deafness or a developmental language disorder so are frustrated

51

How is aggressive behaviour in small children managed (6)?

1. Make rules clear
2. Stick to rules
3. keep cool
4. do not give in
5. time out
6. 1-2-3 principle

52

What is conduct disorder?

When serious antisocial behaviour which infringes the rights of others is the dominant feature of the clinical picture and is so severe as to represent a handicap to general functioning

53

What are the risk factors for conduct disorder (3)?

1. Coming from homes where there is discord
2. Homes where there are coercive relationships
3. Homes where there are limited boundaries that are inconsistently enforced and poor supervision by adults

54

How is conduct disorder treated (2)?

1. Parent management training programmes
OR
2. Individual or group based interventions focusing on problem-solving skills and anger management where parents are unwilling or unable to cooperate

55

What are the key professionals in the management of conduct disorder and behavioural difficulties (4)?

1. paediatrician
2. GP
3. School
4. Social care

56

What are the features of depression (7), and the at risk groups in children (3)?

1. Low mood that affects motivation, judgement, the ability to experience pleasure and proves emotions of guilt and despair.
2. Can present as apathy, boredom and an inability to enjoy oneself
3. Can present as separation anxiety which reappears having resolved in earlier life
4. Decline in school performance
5. Social withdrawl
6. Hypochondriacal ideas and complaints of pain in chest, abdomen and head
7. Irritable mood or antisocial behaviour

At risk groups:
1. Girls
2. Adolescents
3. Low self-esteem

57

Define psychosis






What are the key questions you could ask to discriminate it when obtaining a history (£)?

Psychosis is a breakdown in the perception and understanding of reality and a lack of awareness that the person is unwell. This can affect ideas and beliefs, resulting in delusional thinking where abnormal beliefs are held with an unshakable quality and lead to odd behaviour

1. Have you taken any drugs?
2. Do you have any disturbance of mood?
3. Does your mood alternate from lowered or elevated mood?

58

Describe the methods of self harm


What are the strategies for eliciting an accurate history which incorporates their emotional health (8)?

cutting, burning, biting, bruising, scratching skin, or tying ligatures around the neck

1. Hx taken alone
2. Create safe environment
3. Allow sufficient time for history
4. Validate young person's distress
5. set rules about confidentiality clearly
6. Give assurance that they will be supported
7. Normalize the problem of self-harm
8. Use screening tools such as PATHOS

59

What is CFS/ME and what are its features (6)?


How is it managed (2)?

CFS - persisting high levels of subjective fatigue leading to rapid exhaustion on minimal physical or mental exertion. The term is broader than myalgic encephalomyelitis whcih follows an apparently viral febrile illness.

Features are:
1. myalgia
2. migratory arthralgia
3. headache
4. difficulty getting off to sleep
5. poor concentration
6. irritability

Management:
1. Graded exercise therapy
AND/OR
2. CBT

60

What are the various sleep disorders in children and how are they managed (4)?

1. Difficulty getting to sleep at bedtime - child will not go to sleep unless parent is present.
- Create a bedtime routine, have a period of an hour before sleep when there are no screens, graded pattern of lengthening periods between tucking child in bed and coming back after a few mins to visit

2. Waking at night - associated with difficulty settling in the evenings which should be treated first
- graded approach as above.

3. Nightmares - bad dreams which can be recalled by child
-reassurance to child and family

4. Night terrors - Child sits up in bed, eyes open, seemingly awake but obviously disorientated, confused and distressed, but unresponsive to questions and reassurances.
- child settles back to sleep in a few minutes so reassurance can be given to parents

61

Who are the key professionals involved in the management of child abuse (7)?

1. Doctors and other health professionals
2. Social workers
3. Health visitors
4. Police
5. GP
6. Teachers
7. Lawyers

62

What is fabricated or induced illness in a child (2)?

Group of behaviours where carers cause harm to child. It can be:

1. Verbal fabrication - parents fabricate symptoms and signs leading healthcare professionals to believe they are ill and require treatment or investigation

or

2. Induction of illness - which can involve suffocation, administration of noxious substances, excessive or unnecessary administration of ordinary substances, excess or unnecessary use of medication

63

What are the presenting features of sexual abuse in a child?
Recognition (4)
Physical (2)
Behavioural (3)

Recognition
1. child may tell someone
2. they may be identified in pornographic material
3. be pregnant
4. have an unexplained STI

Physical symptoms
1. Vaginal bleeding, itching, discharge
2. Rectal bleeding

Behavioural symptoms
1. Unexpected awareness or acting out of sexualised behaviour beyond what is expected for age
2. soiling, secondary enuresis
3. self-harm, aggressive or sexualised behaviours

64

What are the forms of neglect and psychological deprivation (6)?

How does it affect the child?

Neglect is the persistent failure to meet a child's basic physical and/or psychological needs. It can include the failure to provide:
1. adequate food and clothing
2. shelter including abandonment
3. protection from physical and emotional harm or danger
4. adequate supervision, including the use of inadequate caregivers
5. access to appropriate medical care or treatment
6. neglect or unresponsiveness to child's basic emotional needs

It can lead to serious impairment of the child's health or development

65

List the types of child abuse (5)

1. physical
2. sexual
3. emotional
4. neglect
5. fabricated illness

66

Questions to ask/consider in a history when concerned about child abuse and neglect (7)?

1. Child's age and stage of development
2. Hx given by child
3. Plausibility of explanation for injury
4. Any background e.g. previous child protection concerns
5. Delay in reporting injury
6. Inconsistent histories from caregivers
7. Inappropriate reaction of caregivers e.g. vague or aggressive

67

What would you look for in an examination when concerned about child abuse and neglect (6)?

1. Physical symptoms and signs
2. Psychological symptoms and signs
3. A concerning interaction observed between the child and parent
4. Child may tell someone about abuse
5. Abuse may be observed
6. Seek advice from colleagues i.e. paediatric radiologists/orthopaedic surgeons.

68

What indications can point to the possibility of neglect in child and parents?
Child (7)
Parent (4)

Child:
1. constantly misses appointments
2. is ravenously hungry
3. Lacks needed medical/dental care
4. wearing indequate clothing in cold weather
5. is abusing alcohol or other drugs
6. says no one is at home to provide care
7. is dirty

Parent:
1. indifferent to child
2. seems apathetic or depressed
3. behaves irrationally or in a bizarre manner
4. is abusing alcohol/drugs