Child Psychiatry, and learning disabilities Flashcards
defining charactersitics of ADHD?
hyperactivity and restlessness
impulsivity
inattention-don’t pay attention, distracted
poor concentration
factors promoting resilience (protective factors) in the development of psychiatric illnesses in children?
temperament coping strategies problem solving self-esteem stability secure relationships friendships achievement
all of these can be strengthened by psychosocial interventions.
how can problems at birth affect neurodevelopment of a child?
fetal hypoxia- reduced function of the frontal lobe
born prematurely- frontal lobe not fully developed.
importance of considering ongoing development in the presentation of psychiatric conditions in children?
presentation following childhood abuse may be significantly delayed due to ability to recognise this as abuse only occurring once cognitive development adequate.
how can parental mental health disorders affect the mental health of a child?
attachment issues
poor emotional response
reduced ability to parent the child-becomes insecure attachment
how can poverty have an effect on the development of mental illness?
constant stress
physical health deterioration e.g. inadequate nutrition, poor management of physical illnesses, chronic pain
lack of opportunities e.g. education, employment, social activities or sports that allow a sense of achievement and self-esteem to develop.
5 axes of classification in child psychiatry?
psychiatric disorder specific developmental delay global developmental delay physical disorders social factors
ADHD prevalence?
more common in boys than girls (3:1)
aprrox. 0.5% in all school-age children
onset in pre-school yrs
Methylphenidate (a stimulant) may be used in ADHD treament, what are some side-effects?
common or very common: dyspepsia, diarrhoea, nausea reduced weight gain, growth restriction movement disorders, irritability, aggression, tics alopecia cough tachycardia, arrhythmias depression
monitoring required with methylphenidate treatment?
monitor for psychiatric disorders
pulse, BP, psychiatric symptoms, appetite, weight and height should be measured at start of therapy, after each dose adjustment and at least every 6mnths thereafter.
key points of ICD-10 criteria for ADHD (hyperkinetic disorder) diagnosis?
ADHD classified under ICD-10 as a Behavioural and emotional disorder with onset usually occurring in childhood and adolescence
core symptoms of hyperactivity, inattention and impulsivity
symptoms must have started before age of 7
symptoms present in at least 2 settings e.g. home and school
must be definite evidence of impaired function
symptoms not caused or related to another mental health disorder
common co-morbidities in children with ADHD?
depression tic disorders anixety oppositional defiance disorder substance abuse pervasive developmental disorders e.g. autistic disorder and asperger's syndrome
aetiology of ADHD?
genetics: risk of ADHD in 1st degree relative of sufferer 5 times the risk of the general pop. condition linked to various genes mainly related to dopamine action e.g. receptors, transporters and the monoamine system.
brain structure and function abnormalities: smaller frontal lobe, cerebellum and striatum. abnormality in prefrontal cortex suggested by restlessness and difficult concentrating, and these areas rich in catecholamines.
psychological factors-early deprivation-emotional, nutritional, stimulatory
environmental-prenatal-maternal stress, substance abuse
postnatal-head injuries, another brain disease
prognosis in ADHD?
overactivity in adolescence tends to improve greatly, but in those where it doesn’t, there is high risk of conduct disorder, antisocial behaviour, juvenile delinquency.
continuation into adulthood more likely if initial symptoms more severe, FH, or co-morbid psychiatric disease.
patients more likely to attain poor qualifications, become unemployed, be involved in multiple RTAs and serve a prison sentence.
also future problems with intimate relationships, childcare and organising household tasks. and problems with substance misuse and emergence of personality disorders.
how is methylphenidate thought to work in the tment of ADHD?
centrally acting sympathomimetic, mild CNS stimulant
blocks reuptake of NA and dopamine into presynaptic neurone, increasing their release into the extraneuronal space.
stimulates the underactive frontal lobe inhibitory system in pts with ADHD.
what interventions can be put in place before a formal ADHD diagnosis is made but condition is suspected?
offer parents or carers a referral to a parent training/education programme
initial diagnosis and starting of drug treatment should be made in secondary care
tment of ADHD in pre-school children?
parents or carers should be referred to a parent training/education programmes, these can be group programmes, or offer individual programmes if difficulty attending group e.g. transport difficulties or language barriers
if ineffective, consider referral to tertiary services
tment of ADHD in school age children and young people and moderate impairment?
group-based parent training/education programmes
group psychological tment (CBT and/or social skills training) for the younger child, and consider individual psychological tment for older child
drug tment can be tried next if therapies fail or severe symptoms or impairment. drug tment=1st line if severe ADHD, but parents should also be offered training/education programme.
drugs considered for ADHD tment?
methylphenidate for ADHD without significant comorbidity
methylphenidate for ADHD with comorbid conduct disorder
methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.
consider dexamfetamine if ADHD unresponsive to max tolerated dose of methylphenidate or atomoxetine.
side effects to be particularly cautious of in pts treated with atomoxetine (NA reuptake inhibitor) for ADHD?
suicidal thinking and self-harming behaviour
agitation
irritability
abdo pain, nausea, malaise, jaundice or darkening or urine suggesting liver damage.
1st line tment for adults with ADHD?
drug treatment, unless person would prefer a psychological approach
methylphenidate usually considered 1st, atomoxetine or dexamfetamine considered if unsuccessful tment with methylphenidate trialled for at least 6 wks, special caution with dexamfetamine prescribing to those likely to engage in substance misuse or diversion. atomoxetine may be considered 1st line in adults where risk of diversion.
if stable on tment but remains functional impairment, or unresponsive to tment, consider group CBT.
triad of symptoms in autism spectrum disorder?
impaired social interaction
delayed and abnormal language development
rigidity of mind-may be manifest as ritualistic behaviour and difficulties in coping with change in routine.
ICD-10 classification of childhood autism?
classified under pervasive developmental disorders: characterised by qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities. These are a pervasive feature of their functioning in all situations.
childhood autism: a type of pervasive developmental disorder that is defined by:
(a) the presence of abnormal or impaired development that is manifest before the age of 3, and
(b) the characteristic type of abnormal functioning in all the three areas of psychopathology: reciprocal social interaction, communication, and restricted, stereotyped, repetitive behaviour.
In addition to these specific diagnostic features, a range of other nonspecific problems are common, such as phobias, sleeping and eating disturbances, temper tantrums, and (self-directed) aggression.
what is ASD and what does it describe?
autism spectrum disorder
this is widely used to describe a group of pervasive developmental disorders: childhood autism, asperger’s syndrome, rett’s disorder, other childhood disintegrative disorder and atypical autism, recognising that the disorders may overlap to some extent and that within any category there is a wide variation in symptom severity.
what is atypical autism?
a type of pervasive developmental disorder.this subcategory should be used when there is abnormal and impaired development that is present only after age three years, and a lack of sufficient demonstrable abnormalities in one or two of the three areas of psychopathology required for the diagnosis of autism (namely, reciprocal social interactions, communication, and restricted, stereotyped, repetitive behaviour) in spite of characteristic abnormalities in the other area(s). Atypical autism arises most often in profoundly retarded individuals and in individuals with a severe specific developmental disorder of receptive language.
