Encopresis
Ensure neurological conditions, Hirschsprung’s disease, overflow incontinence ruled out
Onset, duration and progress
Aggravating/relieving factors
Child is usually continent by 4 years
ABC analysis
Associated behaviours - aggression, agitation, anxiety
Consequences - mother/school reaction, punishment, positive or negative reinforcement
Comorbidities ax
-pervasive developmental delay, social interactional deficits, ritualistic behaviour
-learning difficulties: IQ testing
-anxiety - school refusal, separation anxiety, teariness, crying, sleep disorders, nightmares
Developmental history - maternal first
-attachment difficulties
-for anxiety: separation anxiety as a child/anxious temperament or anxious/avoidant traits
-high EE, overinvolvement, parent criticality or hostility and dependency
-pregnancy complications or during delivery e.g. hypoxia
-substances or smoking exposure
-early childhood illnesses or infections
-neuro conditions
-delay in achieving milestones (motor, speech, emotional, social) indicative of PDD
-school: peer relationships, academic
Psychosocial
-relationship with mother and father
-DV, exposure to violence
-risk of harm to child involvement of DCJ
-mother’s maternal health
-financial relationship vocational and accommodation instability contributing to stressors
Reasons why star chart has not worked
Maternal
-lack of belief in star chart
-difficulty in implementing star chat consistently
-inadequate training regarding use of star chart
-administration of laxatives too frequently
-non compliance with use of laxatives or star chart
-maternal stressors: mother having not enough time or support
Child factors
-ODD or aggression
You see harm to the child
- Rule out severe injuries by involving ED or paed for full PE
- Evaluation for suspicion of abuse
- Communication with child
-stay calm
-communicate in age and developmentally appropriate way
-private and child friendly environment
-sensitive and caring manner
-not being judgemental
-listen to what they have to say first
-use open ended qs
-avoid leading qs
-involve health professional with expertise in ax of child abuse, SW, MH, C&A psych - Communication with parent
-non judgemental
-no leading qs
-empathise but do not condone abuse
-clear advice of what constitutes abusive behaviour
-consider mandatory reporting if risk of harm identified, involve other legal guardians and SWs
-if no risk of harm, child can be dced w mother with f/u with CAMHS
-involve health professional as above
Ethical issues of parent refusing tx
- Autonomy and capacity
-child is unable to make a decision for self, requiring proxy guardian
-if parent is legal guardian and not acting in best interest, consider consent from other guardians
-if both guardians not acting in best interest, emergency guardianship
-medicolegal/hospital legal/clinical director advice - Benefience
-reasons for treatment, is it in the best interest - Non malefience
-delaying lead to harm? - Duty of care to child
-mandatory reporting obligations if risk of harm has been identified - Duty of care to parent
-involvement of MH team to ax
Parent stops work to care for her
Enmeshment
Secondary gain
Interdependent relationship
Developmental:
-abnormal illness behaviour in parents
-conditioning phenomenon resulting in nurture or care through illness as a learned behaviour
-history of parental physical illness
Organic causes of fatigue and ix
Anaemia
B12/folate deficiency
vit D def
thyroid dysfunction especially hypothyroid
dietary intake
EBV infection/glandular fever
Evaluation of fatigue
Worse on exertion - chronic fatigue syndrome e.g. subsequent to viral infection
Onset, duration, progress
All day or end of day
Allodynia (unexpected pain to stimulus) , body aches - fibromyalgia
Aggravating, relieving factors
Evaluation of anxiety
Generalised anxiety symptoms related to school or other stressors e.g. bullying
Presence of specific phobias
Presence of panic attacks
School anxiety disorders
Presence of school refusal
Poor sleep - mx
- General advice about sleep hygiene, sleep hygiene recommendations, sleep diary, stimulus control and sleep restriction
- Psychoeducation about circadian rhythm disturbances and importance of sleep routine
- Psychoeducation about meds - short term or last resort. BZD can lead to dependence
- Sleep study, if sleep hygiene does not help
- Melatonin on a short term basis 1-3 months
- CBTI with referral to psychologist
- Sleep specialist input, diet and lifestyle changes
Explain behaviour - Aboriginal group home damaging property
- Trauma related
-heightened emotional sensitivity, dysregulation which could be exacerbated by traumatic reminders - Acute stress reaction exacerbated by cultural dislocation
- Aggression as a coping mechanism with exposure to early life violence. Identification with aggressor (psychodynamic coping mechanism)
- Impulse dysregulation as part of DMDD or neurodevelopmental disorder
- Repeated attachment disruptions impacting on emotional dysregulation
- ID with impulse dysregulation (causes - neurodevelopmental, FAS, head injuries from DV)
- Prodromal MI - psychosis or mood disorder
- Exposure to trauma in group home
- Significant changes in GH - residents, staff
- Externalising coping mechanisms - anger expression
- Undiagnosed conduct disorder, ADHD
- Complex PTSD/complex trauma disorder
Differentials in pt with childhood bipolar
- Untreated DMDD - usually between 6 and 10.
Ongoing irritability, anger and frequent intense temper outbursts
Bipolar disorder rare in 12 years old - Impulse dysregulation and anger dyscontrol as a presentation of ADHD
- Stimulation - activation effects of stimulant. Can cause hypomania and mania in context of bipolar disorder
- Organic - epilepsy/seizure disorder - can also be worsened by stimulants
- Complex PTSD with emotional dysregulation, aggression
- ID comorbid with BPAD/ADHD - pts can be resistant to change and can present w aggression
- PDD - resistant to change and routine and can present with behavioural disturbance
- Antidepressant may exacerbate irritability, aggression and self harm in BPAD. Can also lead to SI
- Non adherence
- Valproate and olanzapine for BPAD. valproate for impulse dysregulation
Behaviour mx plan is not working
Patient factors
-ODD or conduct disorder
-ID and may not understand instructions or language (use AV aids, speak slowly)
-untreated impulse control may make it difficult for patient to control aggression to unpleasant stimuli (psychological: timeout, mindfulness, debriefing)
Carer factors
-poor therapeutic alliance
-lack of trust
-lack of time for carer to implement plan
-punishment may maintain the behaviour, impact on therapeutic alliance, lead to acting out (usually only temporary change)
System factors
-lack of consistency in treatment
-lack of consistency in treatment provider
-other strategies may be needed - ABC chart, reward chart, planned ignoring, time ins and outs, goal setting/target behaviours
Conduct Disorder/difficult behaviour mx
- Engage the family
- Select which treatment to use and who should deliver it
-parent training program for home
-advice to teacher and school staff for staff
-individual work on anger mx and social skills for pervasive problems - Developing strengths
-encouraging their abilities and prosocial activities - Treat comorbid conditions
- Promote social and scholastic learning
- Treat their child in their natural environment
Parent management training
Key targets of parenting skills include:
* promoting play
* developing a positive parent–child relationship
* using praise and rewards to increase desirable social behaviour
* giving clear directions and rules
* using consistent and calmly executed consequences for unwanted behavior
* reorganising the child’s day to prevent problems
e.g. parent child interaction therapy
Targets of CBT and social skills therapy
- To reduce children’s aggressive behaviour such as shouting, pushing,
and arguing - To increase prosocial interactions such as entering a group, starting a
conversation, participating in group activities, sharing - To correct the cognitive deficiencies, distortions and inaccurate self-evaluation exhibited by many of these children
- To ameliorate emotional dysregulation and self-control problems so
as to reduce emotional lability, impulsivity and explosiveness, enabling the child to be more reflective and able to consider how best to respond in provoking situations
Targets of classroom techniques
- Promoting positive behaviours such as compliance and following
established classroom rules and procedures - Preventing problem behaviours such as talking at inappropriate times and fighting
- Teaching social and emotional skills such as conflict resolution and
problem-solving - Preventing the escalation of angry behaviour and acting out
Functional family therapy for antisocial behaviour
4 phases:
-engagement
-motivation
-behavioural change
-generalisation
- determine the fit between the young person’s problems and the wider environment, identifying strengths and difficulties
- emphasises the positive and uses systemic strengths as levers for change
- promote responsible behaviour and reduce irresponsible behaviour
- target behaviour with specific well defined goals
- implementation by family members with daily or weekly effort
- interventions to promote generalisation by child’s needs being addressed over multiple contexts
Causes of self harm
-Mental illness
-Release from predicament or current/past trauma
-Emotion regulation/coping: anger, guilt, inadequate coping strategies, feelings of loss of control, alcohol and drug use, personality disorder
-Unhealthy care seeking
-Cultural identification
ASD DSM
- Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by
a) Deficits in social-emotional reciprocity
b) Deficits in nonverbal communicative behaviours used for social interaction
c) Deficits in developing, maintaining, and understanding relationships - Restricted, repetitive patterns of behaviour, interests, or activities manifested by
a. Stereotyped or repetitive motor movements, use of objects or speech
b. Insistence on sameness, inflexible adherence to routines
c. Highly restricted, fixated interests that are abnormal in intensity or focus
d. Hyper-or hypo reactivity to sensory input or unusual interest in sensory aspects of
the environment
Aspergers has features of autism without the language abnormalities
Separation Anxiety - presentation & tx
Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached
- Return to school is priority to avoid disruption to education
- This is done in liaison with parents and school psychologists
- Specific behavioural programme based on graded desensitisation
- Treat the psychiatric condition
- Use specific techniques from cognitive behavioural therapy for anxiety and phobias
- Chronic problem may require assessment in a psychiatric unit
- Home education may be required
- Family therapy to address any family issues
Tourettes - presentation & tx
- Both multiple motor tics and one or more vocal tics must be present at the same
time, although not necessarily concurrently - The tics may wax and wane in frequency but have persisted for more than 1 year
since first tic onset - The age at onset must be less than 18 years;
- The disturbance must not be due to the direct physiological effects of a substance
(e.g. stimulants) or a general medical condition (e.g. Huntington’s disease or
postviral encephalitis). - Haloperidol
- Pimozide (not available due to prolonged QT interval)
- Clonidine
- SSRIs for comorbid OCD
- Atomoxetine for ADHD as does not worsen tics
Foetal alcohol syndrome features – behavioural and psychiatric
o Social processing difficulties
o Executive functioning difficulties
o Emotional volatility
o Deficits in adaptive behaviour and daily functioning skills
o Low IQ
o Features of ADHD
Dyspraxia
Developmental coordination disorder
Verbal oral and motor
Reactive attachment disorder
Unable to form normal attachments
E. G. From severe trauma, neglect, frequent change of caregivers, lack of caregiver responsiveness to child
