CAMHs

Question 1

ADHD - History Background

Answer 1

• Age?
• Current education?
• Onset of problems? How long for? (ADHD >6 months and onset before age of 7)
• Birth/developmental issues?

Question 2

Tics - Assessment

Answer 2

• Age?
• Known to CAMHs?

For both motor and vocal

• Description
  
  • Motor where? simple or complex?
  • Vocal what? simple (sounds) or complex (words/phrases)
• Onset? Any indentifiable event linked?
• Frequency and severity
• Duration? Periods free and for how long for?
• Triggers/exacerbators?
• Obscene gestures of words (copropraxia/lalia)
• Any funny feelings before tics?
• Able to consciously suppress?

Question 3

ADHD - Explanation

Answer 3

• Children diagnosed with ADHD tend to have symptoms in three domains:
  
  • Hyperactivity
  • Inattention
  • Impulsivity
• Affects up to 1.7% of school-aged children in the UK, more common in males
• Causes:
  
  • There is often a genetic component:
    
    • If a sibling has it then 2x risk in the next child
  • Other causes may include infections or other problems during pregnancy
• We still don’t know a lot about what the underlying process is in the brain but we have reason to suspect that there is some kind of deficient action of the stimulating brain chemicals dopamine/noradrenaline, particularly in the front of the brain which regulates activity in the rest.

Question 4

ADHD - Assessment Process

Answer 4

• No specific test or scan
• Assessment in person with child, see and observe them
• Take a history of development from family
• With permission speak with school
• Perform Connor’s rating scale, gold standard
• Consider IQ/academic assessment to rule out LD

Question 5

ADHD - Psychosocial Management

Answer 5

• Parent skill course if behavioural issues
• Parent education course around ADHD including management and coping strategies
• School adaptations such as extra time, 1:1 learning, movement breaks, prompts, sitting at the front
• Behavioural treatment - positive reinforcement of good behaviours (and vice versa)

Question 6

ADHD Management - Pharmacological (Stimulants)

Answer 6

• 1st line is stimulant treatment - in children Methylphenidate first choice (90% show some response)
  
  • Works best for attention and hyperactivity
  • Start at low dose IR Ritalin 5mg up to three times a day
  • Titrate up and switch to modified release when dose stable
• Common side effects: decreased appetite, abdominal pain, insomnia, headache, dry mouth, irritability, insomnia
• Risk of hypertension - therefore BP/HR ehecked beforehand, after dose changes and therafter at least 3 monthly.
• Risk of triggering cardiac problems therefore do an ECG beforehand.
• Risk of growth suppression - therefore height and weight checked before starting and every 6 months
  
  • Consider taking drug holidays at weekends and school holidays
  • Take with food if it affects appetite
• Caution in: thyroid problems, glaucoma, epilepsy, cardiac problems, tics

Question 7

ADHD - Pharmacological (Non-Stimulants)

Answer 7

• Atomoxetine - second line if unable to tolerate or unresponsive to stimlants (both types), stimulants contraindicated.
  
  • Side effects - nausea, abdominal pain, dry mouth, difficulty passing urine.
  • Rare risk of liver damage (1:50,000) therefore need to monitor LFTs
• Consider Melatonin for persistent sleep problems unresponsive to sleep hygeine
• Clonidine also second line option - sedating.

Question 8

ADHD - Prognosis

Answer 8

• 25% of chilren with ADHD will have symptoms age 30
  
  • Usually hyperactivity improves with age but other symptoms may persist and be an issue
  • Whilst most children with ADHD do not need medication as adults some do and this is appropriate.

Question 9

Conduct Disorder - Assessment Backgroun

Answer 9

• Age? (onset before 10 = early)
• Concerns? Onset?
  
  • If <1 month after major stressor and <6 months duration may be adjustement)
• Known to services?

Question 10

Autism Assessment - Background

Answer 10

• Background:
  
  • Age?
  • Concerns? What makes them think Autism?
  • Age of onset of these symptoms? (<3 to be childhood autism)
  • Progression?
  • Current schooling situation? Mainstream?

Question 11

Childhood Sexual Abuse - Immediate Management (A+E)

Answer 11

• Establish need with child to break confidentiality and share information
• Clarify need for admission to either a paediatric medical ward or CAMHs bed
• Clarify ongoing risk to self from suicide/self-harm
• Inform:
  
  • Speak to nurse in charge
  • Social worker - safeguarding referral
  • Local child protection officer
  • On call consultant
  • Social worker and CP officer will liase with Police
  • Consider informing mother or other NOK with parental responsibility if appropriate and explain the immediate plan, need to restrict access to offender, find out if any others at risk at home
• Special child protection interview will take place
  
  • If intercourse suspected then paediatric examination may take place after
• Short term Social Worker or Police can offer emergency protection order or police protection order to ensure child is kept in a place of safety.

Question 12

Childhood Abuse - Further Management

Answer 12

• If allegations are proved true Social Services/Police can help finding alternative accomodation, via child care order if parents do not agree
• Needs full psychiatric assessment:
  
  • Context and consistency of account
  • Impact on childs physical and emotional condition
  • Evidence of emotional and behavioural disturbances
  • Recognising child’s therapeutic needs
  • Childs view on safe and protective environment
  • Family dynamics, family members and parental psychopathology
• Individual psychotherapy may help the child overcome emotional issues arising from abuse:
  
  • Short term – Social isolation, depression, anxiety, sexualised behaviour
    Long term – Low self-esteem, self-harm, impact on relationships, link with eating disorders and PD.
• Family therapy may be indicated to restore roles and boundaries within the family

Question 13

ADHD History - Attention With Examples

Answer 13

Attention

• Able to pay attention? Conversation/tasks/classes
• Do they make careless mistakes?
• Are they very forgetful?
• Do they abandon tasks easily?
• Do they struggle to follow instructions?
• Are they very disorganised?

Question 14

ADHD History - Hyperactivity/Impulsivity with Examples

Answer 14

Hyperactivity/impulsivity

• Do they struggle to sit still?
• Are they very fidgety?
• Are they visibly restless?
• Do they struggle to wait for their turn?
• Are they prone to interrupting?
• Do they engage in dangerous/risky behaviours?

Question 15

ADHD History - Impact

Answer 15

• Drugs and alcohol
• Risk to self/others - agression, risky behaviours, inattention
• Bullying

Question 16

Tics Assessment - Follow-Up Qs

Answer 16

• Do tics wax and wane
• Do they cause child/family distress
• Impact on family/school/social - any bullying?

Question 17

Autism Assessment - Core Symptoms - Abnormal Reciprocal Social Interactions

Answer 17

• Do they make eye contact when being spoken to?
• Reciprocates when hugged?
• Does he come to you when hurt?
• Able to make friends with other children?
• Can he play games and share toys with other children?

Question 18

Autism Assessment - Core Symptoms - Communication Problems

Answer 18

• Any difficulties using language?
• Able to sustain a conversation?
• Delay in speech/first words?
• Tends to repeat things?

Question 19

Autism Assessment - Core Symptoms - Restricted, stereotyped or repetitive behaviour

Answer 19

• Any unusual interests?
• Any unusual interactions with toys?
• Able to have imaginative play?
• Does he do anything repeatedly?
• Any rituals?
  
  • Repetitive movements? e.g. hand flapping
  • How does he react to changes in his environment/routine?
• Sensitivity to certain stimuli?

Question 20

Autism Assessment - Developmental History

Answer 20

• How was the pregnancy? Any complications before/during/after?
• Did he meet developmental milestones?
  
  • When did he first smile, turn over, crawl, sit and walk?
• Any skills he used to have he has now lost?
• Any unusual physical characteristics?
• Past medical history? Any history of seizures or head injury?
• Has he had his hearing and vision checked?

Question 21

Autism Assessment - Comorbidities

Answer 21

• How has mood been recently? Any loss of interest in things he used to enjoy?
• Any things he is specifically afraid of?
• How has sleep and appetite been?
• Any agressive behaviour to others? Any self-harming behaviour?

Question 22

ADHD management

Answer 22

Explanation of ADHD

• Developmental disorder characterised by difficulties in three domains: maintatining attention, hyperactivity and impulsivity.
• Features arise in early childhood and persist over time and across different situations.
• Affects about 1.7% of school age children - boys more affected than girls.
• No specific test for the condition - diagnosis is based on clincial assessment including self, parent and school reports plus standarised assessment scale’s such as the Connor’s.
• In terms of causation there is a strong genetic component (heritability 70-80%), if one sibling has it risk in others in 2-3x normal.
  
  • Also environmental factors such as low birth weight, drug/alcohol/smoking in pregnancy, perinatal infections.
• Main theory is that symptoms are due to insufficient activation of frontal lobe with stimulating brain chemicals: dopamine and noradrenaline.

Management

Pharmacological

• 1st line treatment is stimulant medication - work by normalising activity in the front of the brain responsible for regulating the activity of the rest.
• First stimulant choice is methylpheniate in children.
• 90% respond - especially for hyperactivity and inattention
• Side effects: decreased appetite, abdominal pain, headache, dry mouth, irritability, difficulty sleeping.
• Growth suppression is noted sometimes with long term treatment, as a result we will monitor his height and weight at clinic appointmentments. Can be managed sometimes with drug holidays/only using during schoolweek.
• Check no history of thyroid problems, heart conditions, glaucoma or epilepsy. Also exclude tics.
• Prior to initiating we will do blood tests and an ECG. We start at the lowest dose and titrate up until adequate response met.
• At clinical reviews at least 3 monthly we will monitor height, weight, BP and pulse - plot on centiles chart. Will also monitor effectiveness with Connor’s scale.
• 2nd line Atomoxetine - SEs: nausea and abdominal pain, dry mouth, difficulty PU and sexual dysfunction. Rarely liver problems (1/50,000)

Non-Pharmacological

• If is important that you are referred to a course that can help parents learn about ADHD, its management and coping strategies
• Child can be referred to a psychologist for group CBT or individual if older.
• Regular exercise, healthy balanced diet and good sleep important.
• Environmental changes at school and home e.g. putting child in the front of the class, reminders, extra time,reducing distractions.

Prognosis

• About 1/4 of children with ADHD will go on to have it as adults, usually hyperactivity becomes less noticable.

Question 23

Conduct Disorder - Assessment D

Answer 23

Defiance

• Frequently argumentative?
• Violated set rules by adults?
• Staying out after dark? Running away? Truanting?
• Evidence of stealing?
• Involvement in any crimes?
• Relationship with peers?

Question 24

Conduct Disorder - Assessment Core AVD

Answer 24

Aggression/violence

• Getting into fights?
• Physically agressive to others?
• Sexually coercive?
• Cruel to others/animals?

Destruction of property

• Any incidents of deliberately destroying things?

Question 25

Conduct Disorder - Assessment Risk Factors

Answer 25

* Family history of mental health problems? * Crimes/substance use in family? * Financial situation at home? * Severe physical/verbal punishments when growing up?

Question 26

Conduct Disorder - Differentials/Comorbidities

Answer 26

* How has mood been recently? Any loss of interest in normal things they used to enjoy? * Any evidence of increased anxiety? * Can they focus on things? Are they always on the go? Do they interrupt a lot? * Problems during infancy/growing up? * What was previous academic perfomance like? Always struggling? Paricular areas? * Any possibility using alcohol or drugs at the moment?

Question 27

Conduct Disorder - Follow-Up Qs

Answer 27

* Impact - at home, at school, socially, bullying? * Past psych history * Past medical history * Medication

Question 28

Anorexia Nervosa - Management - Criterion for Admission

Answer 28

Admission only usually if condition a risk to life * BMI \<13.5 * Severe depression or suicidal risk * Rapid wieght loss in patients who are already low in weight (80-85% of healthy weight) * Severe electrolyte imbalance - hypokalaemia or hyponatraemia * Failure of outpatient treatment * Dehydration * Bradycardia \<40 or orthostatic hypotension \>200mmHg drop * Organ failure