CAMHS Flashcards by Monty Teeder

A teacher would like help for a 7-yr old boy:

“He is disruptive in class, tends to talk and distract other children, to blurt out answers too quickly, doesn’t finish his school work, and to move around the class a lot. Such a difficult boy”

What is the most likely diagnosis?

ADHD

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A GP has referred a 12yr old girl:

•“This is the 18th time I’ve seen her in 3 months. There’s always something: abdominal pains, tiredness, headaches…but all the tests done by Paediatrics are negative. She does worry about schoolwork, and she is missing lots of school.”

What is the most likely diagnosis?

Anxiety of some sort
- Could be due to undiagnosed ASD leading to difficulties to adjust to a new school
  - This is a relatively common thing (think Issy)

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A Youth Offending worker is worried about a 16yr old boy:

“He’s always truanting and hanging out with gangs. Last week he was charged with arson, theft and assault. He can’t seem to control his actions, particularly when he’s drunk, and he’s angry all the time.”

What is the most likely diagnosis?

Conduct Disorder

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What are some important biological age-related factors to consider in children?

Brain still maturing
- Underpins developmental stage
- Underlies age-related differences in symptom pattern
- Increased sensitivity to
  - Cannabis-induced psychosis
  - Medication side effects (e.g. antipsychotics)
- Reduced efficacy of most anti-depressants
•Some physical disorders which present with similar symptoms commonly have onset in childhood:
- Epilepsy
- T1DM
- Asthma

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What are some important psychological age-related factors to consider in children?

Need to consider child’s developmental stage:
- Cognition, emotion, moral
Learning Difficulties can impact on:
- Development
- Likelihood & manifestation of psychiatric disorder.
Personality not yet set in stone
- Personality Disorder rarely diagnosed in children

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What are some important social age-related factors to consider in children?

Family
- Dependence on parents (parental responsibility)
  - Including who make decisions on treatment
- Exposure and sensitivity to family events & processes (eg. parenting skills, abuse)
Impact of environment in childhood
- Abuse
- School/Peers/Bullying
Alcohol/Substances
- Are less accessible to young children
  - But are particularly appealing to adolescents

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What is the management of psychiatric conditions in children?

Emphasis on Psychological Therapy and liaising with Social Institutions
- Therapy
  - Psycho-education
  - Parenting skills
  - Individual therapy
    - Cognitive / Behavioural therapy
    - Supportive / Counselling
    - Interpersonal psychotherapy
    - Dialectical Behavioural Therapy
    - Solution focussed therapy
    - Psychodynamic therapy
    - Creative therapy
    - EMDR
  - Family therapy
  - Group therapy
- Social Support
  - Family
  - School
  - Social Services
  - Wider Community

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Define ADHD.

A type of hyperkinetic disorder, with the triad of inattention, impulsivity and hyperactivity leading to persistent and severe impairment of psychological development.

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What are the signs and symptoms of ADHD?

Impaired attention – lack of persistent task involvement and quickly moving on from incomplete tasks
Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting
Impulsivity
Present prior to 12 years of age, and of long duration (at least 6 months)
Impairment present in two or more settings (e.g. home, classroom, clinic)

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What is the aetiology/risk factors for ADHD?

Boys > Girls (3: 1)
Prevalence of 2.5% (around double that of ASD)
Risk Factors:
- FHx
- Prematurity/LBW
- FAS
- ASD
- Learning Disability

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What are the appropriate investigations for suspected ADHD?

Assess social/educational impact in context of age (i.e. making friends if young, dangerous driving if older)
Rating scales – cannot provide a diagnosis
- Conner’s Comprehensive Behaviour Rating Scale; age 6-18
- Strengths and Difficulties questionnaire

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What is the management of ADHD?

1st line:
- Watchful waiting for up to 10 weeks
- Group-based ADHD-focused support for parents
Children <5 years:
- 2nd line:
  - ADHD-focused group parent-training programme to parents and carers
  - Education on ADHD, parenting strategies, environmental changes
- 3rd line:
  - Specialist service referral
Children >5 years:
- 2nd line:
  - ADHD-focused group parent-training programme to parents and carers
  - Education on ADHD, parenting strategies, environmental changes
- 3rd line:
  - Specialist service referral
  - Medications if ADHD persists:
    - 1st line (6 weeks) = methylphenidate trial for 6 weeks
    - 2nd line = lisdexamphetamine
    - 3rd line = dexamphetamine
    - 4th line = atomoxetine (NARI)or guanfacine
- 4th line:
  - CBT if problems in social skills, self-control, active listening, dealing with expressing feelings
Other medications:
- Clonidine - sleep disturbance, rages or tics
- Antipsychotics - aggression and irritability

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What is the prognosis of ADHD?

Manifestation of ADHD will change as the child gets older
- Hyperactivity tends to become less of a problem
- Inattention becomes more pronounced as the tasks they face become more complex
Outcome:
- Some may grow out of it
- 90% get conduct disorder if untreated
- 15% have ADHD as an adult

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What are the risk factors for ASD?

FHx of ASD
Parental psychotic/affective disorder
Birth CNS defect
Prematurity (<35w GA)
Sodium valproate
Learning disability
Chromosomal disorders/Genetic disorders
ADHD
Hypoxic-ischemic encephalopathy (HIE)

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What conditions are associated with ASD?

Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George
Rett’s syndrome
Mitochondrial disorders
Down’s syndrome
Prader-Willi/Angelman’s syndrome
Epilepsy

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What is Rett syndrome?

X-linked; MECP2 gene
Affects girls > boys
Develop normally until to 2 before sudden deterioration
- Less social interaction
- Struggle to feed

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What are the diagnostic criteria for ASD?

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Abnormal or impaired development evident ≤ 3 years-old
- Receptive or expressive language
- Development of selective social attachments or of reciprocal social interaction
- Functional or symbolic play
Total of ≥6 symptoms
- (1) Qualitative impairment in social interaction (≥2):
  - Failure of adequate eye-to-eye gaze
  - Failure to develop peer relationships
  - Lack of socio-emotional reciprocity
  - Lack of spontaneous seeking to share enjoyment/interests with other people
- (2) Qualitative abnormalities in communication (≥1):
  - Delay in or total lack of, development of spoken language
  - Relative failure to initiate or sustain conversation
  - Stereotyped and repetitive use of language or idiosyncratic use of words/phrases
  - Lack of varied spontaneous make-believe play
- (3) Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities (≥1):
  - Preoccupation with stereotyped and restricted patterns of interest
  - Apparently compulsive adherence to specific routines or rituals
  - Repetitive motor mannerisms involving hand, finger flapping and whole-body movements
  - Preoccupations with non-functional elements of play materials (such as their odour)
Clinical picture is not better described by another medical disorder
Other - Sensory sensitivity, Impaired motor skills

What is the short diagnostic trio for ASD?

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Verbal and non-verbal communication
- Hallmark = immediate/delayed (>2yo) echolalia
Reciprocal social interaction
Restrictive or repetitive behaviours/interests

What are the appropriate investigations for suspected ASD?

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Hearing, speech and language assessment
Cognitive assessment (e.g. WISC, WPPSI)
Autism diagnosis and assessment – GOLD STANDARD
- ADI-R / Autism Diagnostic Inventory – Revised
- ADOS / Autism Diagnostic Observatory Schedule
Childhood Autism Rating Scale (CARS)

What is the management of ASD, in terms of the person with ASD?

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1st line = Psychosocial play-based intervention
- Include techniques to expand the child’s communication, interactive play and social routines
Applied Behaviour Analysis
- Focuses on improving specific behaviours as well as adaptive learning skills
Challenging behaviour
- 1st line: psychosocial assessment
  - Reduce impairment in communication
  - Address co-existing physical and/or mental disorders (i.e. otitis media)
  - Physical environment
  - Reduce unintentional reinforcement of behaviour that reinforces
- 2nd line: pharmacological
  - Antipsychotic medication
  - Melatonin - sleep difficulties
  - Methylphenidate - attention difficulties
  - SSRIs - obsessional behaviours or depression / anxiety

What is the management of ASD, for people in the support group of an ASD sufferer?

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Increase understanding of patient’s communication/interaction pattern
Adjust the social and physical environment (i.e. lighting, noise levels, visual support)
Families and Carers support
- Plan for the future including health transition for the child

Define Conduct Disorder.

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Repetitive and persistent pattern of antisocial behaviour which violates basic rights of others that are not in line with age-appropriate social norms

The patient must be <18

What are the risk factors for Conduct Disorder?

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Low socioeconomic status
Deprived living
Children in the care system
ADHD
Substance misuse
Male

What are the types of Conduct Disorder?

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<10 years old
- Oppositional-Defiant Disorder (mild CD; characterised by angry, defiant behaviour to authority)
>10 years old
- Unsocialised CD (significant abnormality with relationships with other children)
- Socialised CD (generally well-integrated into a peer group)
- CD confined to family context

What are the signs and symptoms of Conduct Disorder?

* Repetitive and persistent (\>6 months) pattern of dissocial, aggressive, or defiant conduct, e.g. * Excessive levels of fighting or bullying * Cruelty to other people or animals * Severe destructiveness of property * Fire-setting * In the absence of features suggestive of another medical diagnosis (i.e. ADHD)

What is the management of Conduct Disorder?

* 1st line = Parent management training programmes * 2nd line = Child individual or group interventions focussed on problem-solving and anger management * Often, affected children do not have the motivation to engage with these well * Remedial educational teaching (for missed school) * Alternative peer activities

What is the prognosis of Conduct Disorder?

* 50% develop **Antisocial personality disorder** * Poorer prognosis: * Early onset * Low IQ * Co-morbidities * Family criminal record * Low socio-economic status * Poor parenting

Define Learning Disability.

Any restriction or lack of ability (from impairment) to perform an activity independently, which started before adulthood and had a lasting affect. * Triad of: * IQ \<70 * Impaired social/adaptive functioning * Onset in childhood

What are the levels of intellectual disability?

* Must be taken into context of LD * Mild = IQ 50-70 - *often no specific cause; 2-3 per 100* * Moderate = IQ 35-50 - *specific cause; 3 per 1,000* * Severe = IQ 20-35 - *specific cause; 3 per 1,000* * Profound = IQ \<20 - *specific cause; 3 per 1,000*

What are the signs of Learning Disability in childhood?

* Milestone delay * Difficulty managing schoolwork * Poor sleep-wake cycle

What are the signs of Learning Disability in adolescents?

* Difficulty with peers * Inappropriate sexual behaviour * Difficulty transitioning

What are the signs of Learning Disability in adulthood?

* Difficult day-to-day functioning * Needing extra support

What investigations should be done for suspected Learning Disabilities?

* Intellectual impairment: * **WAIS III** – Verbal IQ + Performance IQ = Full Scale IQ * Adaptive and social functioning: * **ABAS II** * Clinical interview * Physical examination (sight and hearing) * School reports * Check for other conditions and disorders: * Poor diet and obesity, epilepsy, sensory impairment * Schizophrenia - *3% prevalence* * Mood disorders - *4x more likely to have depression* * Autism - *75% of ASD have a learning disability*

What is the management of Learning Disabilities?

* **Biopsychosocial MDT** - *psychiatrist, OT, SALT, specialist nurse, educational support, social support* * General help: * Choice board (coffee or tea?) * Scheduling board (wake up, clean teeth, etc.) * Self-help board * Communication aids * Medications – *treat co-morbid medical and psychiatric problems* * Melatonin – *helps with poor sleep-wake cycles* * Psychosocial interventions – CBT, family therapy, psychodynamic therapy, art therapy * Challenging behaviours * Risperidone – *short-term use, last line if no cause of challenging behaviour can be found* * Information to family and carers about support groups * Community inclusion / Skills training

What are the complications of Learning Disabilities?

* Higher prevalence of psychological symptoms * Can be difficulty diagnosing other psychological conditions due to language difficulties and atypical presentations (i.e. schizophrenia may present with simple repetitive hallucinations and persecutory delusions) * Prognosis – *chronic problems but handicap can be modified by social support*

What influence do factors outside of a person family have on someone's mental health in the moment and future?

* The child’s family is the most potent influence on a child’s mental health * Adversities outside of the family (i.e. bullying) can aggravate any situation

Define Bullying.

* Unwanted, aggressive behaviour, involving real/perceived social power imbalance * Repeated behaviour, purposeful actions intended to hurt or make the victim feel uncomfortable

What are the signs and symptoms of Bullying?

* Injuries or illness without plausible explanation * Lost or damaged belongings * Somatic symptoms – *changes in habit, nightmares* * Avoidance of school or social situations * Feeling of helplessness or decreased self-esteem * Self-harm or suicide intent

What are the complications of childhood Bulling?

* Perpetual isolation, general mistrust of people, self-harm * Can have long-term psychological impact

What are the physical features of Fragile X Syndrome?

* Prominent Ears * Long Face * Smaller mouth

CAMHS Flashcards

(40 cards)