Child Adolescent Psyc Mbchb4

CHILD AND ADOLESCENT - DEPRESSION AND ANXIETY

Questions

1. Prevalence pattern of depr in c/hood and adolescence
2. Who is most at risk from completed suicide
3. Impt things to assess when seeing someone who has attempted suicide
4. Depr tx in adolescence

Depressive Disorder

1. Major depressive d/o
a. >2 wks - Low mood or loss of interest (adolescents can be irritable) + 4 other sxs
b. L’SIG E CAPS
i. Low mood
ii. Sleep disturbance
iii. Interest loss (anhedonia)
iv. Guilt or worthlessness feelings
v. Energy loss
vi. Conc loss
vii. Appetite disturbance
viii. Psychomotor retardation/agitation
ix. Suicidal thoughts
2. Dysthymic d/o
a. Milder
b. Longer (>1 yr in child and adol)
3. Major Depressive Episode
a. With melancholia
b. With psychosis (differentiate from schizophrenia with depr)
4. *Epidemiology of depressive d/o
a. Children m=f
b. Low rates 1%
c. Rates rise throughout adol
d. Rates in girls rises to adult rates by age 15 – 2:1 F:M
e. 12 month prev 3.1% at age 15 to 16.7% at age 18
f. 20-24% have had depr d/o by age 18
g. Maori youth rate – x2 ↑
h. <20% receive optimal tx
i. Untx episode will last ~9 months
j. High rate of recurrence – 50% chance of depr as adult
5. Aetiology
a. Biopsychoscoial
b. Biological – genetics, illness, gender
c. Psychological – negative thinking (triad = self, world, future), sequelae of abuse
d. Social – low, stressful LE
6. Assessment issues
a. Under-recognized by parents and teachers
b. High co-morbidity
c. Stressful life events and evts
d. 20% have bipolar d/o
e. Risk 2-4x with a depr parent
f. Medial illness or meds can mimic depr sxs
7. Tx
a. Psychoeducation
b. CBT
c. Family/School
d. Anti-depressants
i. Fluoxetine is the only one recommended
ii. TCAs – no clear evidence
e. 2nd line – IPT, Exercise, Relaxation
8. Prevention
a. Psychosocial prevention generally – risk and reliance issues
b. School programmes
c. Programmes w identified at risk grps

Suicide and self-harm in childr/adol

a. Completed suicide
i. 15-24 yrs age
ii. Males w school failure, subst abuse, aggr, impulsivity
iii. Anxious, perfectionists
iv. Depr females
v. Psychotic adolescents
vi. Most have a psychiatric illness and often have made prev attempts
vii. 50% of those who attempt will attempt again, 10% will be successful
b. Post suicide attempt assessment
viii. Detail of attempt – how planned, likelihood of discovery, leave a note, want to die, believe attempt would be lethal
ix. Mental state – depr/anx, psychosis, current state
x. Supports – family, friends, school
c. Initiation of Management
xi. Psychoeducation + tx contract
xii. Identification and mitigation of hopelessness
xiii. Verbal no-suicide contract and coping plan
xiv. Remove means of suicide
xv. Then tx underlying problems
d. Non-suicidial self-harm
xvi. Usu cutting
xvii. Reasons?
xviii. F>M
xix. Depr, subst abuse, bulimia
xx. Tx approaches emphasise devt of better coping strategies

Anxiety Disorders in Children and Adolescents

Goals
1. Dx?
2. Presentation – physical sxs in a child w anxiety
3. Most common childhood anxiety disorders
4. Management

Anxiety
1. Anxiety vs Disorder – dx when anxiety causes distress and/or disability
2. 1/6 of young people complain of anxiety, 1/10 warrant intervention
3. Disorders
a. Phobias
b. GAD
c. Separation anxiety
d. Panic d/o
e. Social phobia
4. Issues in dx
a. Under-recognition in the community
b. Doctors don’t ask the right questions
i. Cognitions (worries)
ii. Beh (avoidance esp)
iii. Physiological sxs – CVS, Resp, Gastro, Neuro, Shakes, Sweats
iv. Panic attacks
5. OCD
a. Obessession – recurrent, intrusive unwanted thoughts, recognised as incorrect/silly by the persons
b. Compulsions – action upon obsessive thoughts, cause temporary reduction in anx if acted upon
c. Examples – checking stove repeatedly in response to obsessions about personal safety or handwashing due to fears of contamination

Summary

1. Depr and anx are common
2. Clear dx criteria
3. Under-recognition is common
4. Suicide rates remain high in NZ
5. Most young people who suicide have depr or psychosis

CHILD AND ADOLESCENT – DISRUPTIVE BEHAVIOUR DISORDERS

Disruptive Beh D/os
1. ADHD
a. Limited attention span
b. Hyperactivity
c. Children are emotionally labile, impulsive and prone to accidents
d. N intelligence
e. Tx - methylphenidate (ritalin)
2. ODD (oppositional defiant d/o)
a. Child is non-compliant in the absence of criminality
3. Conduct d/o
a. Continued beh violating social norms
b. At >18 yrs age, dx antisocial personality d/o

Important → Assoc w violent crime, homicide, suicide, sexual assault, health risks and education failure

ADHD

1. Core Dx Features
a. Hyperactivity
b. Impulsivity
c. Distractability / Poor conc
2. Mnemonic – MOAT (around the classroom for the hyperactive child)
a. Movement excess – hyperactivity
b. Organisation problems – difficulty finishing tasks
c. Attention problems
d. Talking impulsivity
3. Diagnosis
a. Either 6 of inattention or 6 of hyperactivity-impulsivity (see below)
b. Impairment present <7 yrs age
c. Impairment present in 2 or more social settings
d. Clear evidence of clinically sig impairment of functioning
e. Not due to other conditions
f. Inattention – 6 or more of
i. Often fails to give close attn
ii. Often has difficulty sustaining attn
iii. Often doesn’t seem to listen
iv. Often doesn’t follow through/finish
v. Often forgetful
vi. Often has problems organising self
vii. Often avoids tasks needing sustained mental effort
viii. Often loses things
ix. Often easily distracted
x. Often forgetful
g. Hyperactivity – 6 or more of
i. Often fidgets
ii. Often leaves seat
iii. Often runs/climbs where inappropriate
iv. Often has problems playing quietly
v. Often on the go
vi. Often talks excessively
vii. Often blurts out anwers
viii. Often has problems waiting turn
ix. Often interrupts/intrudes
4. Background Info
a. Prev 3-5% school age children
b. Good assessment is the foundation of tx – differential dx, co-morbidity, devtal issues
5. Differential Dx and Co-morbidity
a. Normal Devt
b. Hearing and vision probs
c. Devt delay and learning d/os
d. Anx d/os
e. Tics, tourettes
f. Autistic spectrum d/o
g. BPAD
h. Conduct/Oppositional defiant d/o
6. Tx
a. Psycho-education
b. Developing therapeutic r/ship
c. Pharmacological
i. Stimulants – methylphenidate (short acting 3-4 hrs), dexamphetamine (common)
1. Improvements in core sxs – 60-70% to first, 80% to 2nd
a. Improved sustained atten
b. Reduced aggr beh
c. Improved performance on mem, vigilance, attn and conc tasks
d. Improved academic productivity
e. Improved soc interaction quality
f. Improved compliance
2. Stimulants most effective tx of ADHD – better than intensive behal mgt or community care
3. Methylphenidate 0.3-0.5 mg/kg/dose (reqs psychiatrist or pediatrition to approve initial prescription)
a. Morning after b/fast
b. Lunch
c. After school dose
4. Negative effects
a. Common (usu insig or ST)
i. Pulse, BP changes
ii. ↓ appetite, abdo pain, headache
iii. Irritability, crying, mood changes
b. Uncommon (uncommon but impt)
i. Tics, habits, stereotyped behs
ii. Behal or cogv toxicity at high doses
iii. Growth suppressions
iv. Drug dependence or abuse
c. Ø evidence of problems w LT administration
ii. Clonidine, imipramine, risperidone (uncommonly used, some evidence)
iii. SSRIs – Ø helpful
d. Psychological
i. Psychoeducation – for parents and teachers
ii. School based programs – behal mgt, learning support
iii. Psych interventions w children – social skills training, biofeedback/relaxn training
iv. Parents – behal mgt at home

Conduct Disorder

1. Core features
a. Repetitive and persistent pattern of beh where the basic rights of others or major societal norms are violated
b. Manifested by at least 3 of 15 criteria from 4 possible grps over the last 12 months
2. Diagnostic criteria
a. Aggr to people/animals – eg bullying, fights, use of weapons, cruelty, stealing while confronting a victim forced sexual activity
b. Destr of property
c. Deceitfullness or theft
d. Serious violation of rules – eg running away, truancy
3. Co-morbidity
a. ADHD – 10x
b. MDD (major depressive disorder) – 7x
c. Subs abuse – 4x in adolescents
d. Anx, PTSD, somatoform d/os
e. Boys w ADHD + CD → earlier onset, worse outcome
f. Axis 11 – MR, BPD, APD
g. Axis 111 – head trauma, epilepsy
4. Parents of children with disruptive beh
a. Parents respond early in child’s life with higher levels of negative parent beh
b. ST – pos impact, stops negative child beh (parent is stronger, bigger)
c. LT – neg impact, child learns to use neg beh to get their own way
5. Families in which there is high rate of coercive beh have –
a. Inconsistent overly harsh and/or unsuccessful discipline
b. Low levels of pos beh towards child
c. Low parental monitoring of children’s whereabouts
6. Children in such families show → antisocial triad of behs
a. Non-compliance with adult requests
b. Temper tantrums
c. Avoidance of responsibility
7. Stages
a. Stage 1 – preschool non-compliance
b. Stage 2 – school age, habitual defiance – behaviours generalise, peer rejection, academic failure, parental rejection, depr mood, low self-esteem
c. Stage 3 – teen years, aggression – assoc w deviant peer grp, subst abuse, delinquency
d. Stage 4 – adult offending, poor employment hx, disrupted adult r/ships, institutionalisation

Oppositional defiant disorder (ODD)

1. Definition
a. Pattern of negativistic, hostile and defiant beh lasting >6 months with at least 4 of –
i. Often loses temper
ii. Often argues w adults
iii. Often actively defies or refuses to comply w rules/requests
iv. Often deliberately annoys people
v. Often blames others for their misbehav
vi. Often touchy, easily annoyed
vii. Often angry/resentful
viii. Often spiteful/vindictive
2. Prevalence
a. 3-5% of children and adolescents - ↑
b. ↑ prev after 12 yrs age
c. Boys:Girls 2:1
d. Point prev of ODD and CD = 5%
3. Etiology
a. Multiple risk factors and vulnerabilities rather than single causal agent
b. Heritability of antisocial beh estim ~50%
c. Risk factors
i. Biological-individual
1. Genetic
2. LBW
3. Prenatal/antenatal complications
4. brain injury/dis
5. Male gender
6. Below ave IQ
7. difficult temperament
8. impulsivity, hyperactivity, inattn
9. Lang/reading probs
ii. Family
1. prenatal antisocial beh/subst abuse
2. single parent, divorce
3. harsh discipline, maltx, neglect
4. maternal depr/anx
5. early motherhood
iii. Social-school
1. poverty, disorganised, disadvantaged, high crime neighbourhood
2. Deviant peers/siblings
3. hx of victimisation, being bullied, rejection by peers
4. Dysfunctional or disorganised schools
5. media violence
4. Course
a. Improves at young adulthood
b. 30-50% → ASPD
c. High suicide risk
d. Poorer outcomes if early onset, poor soc skills
5. Tx
a. Education – for parents and kids re beh probs
i. Importance of compliance
ii. Supervision and monitoring
iii. Practical supports
iv. Addressing family factors
v. Persistent early intervention
vi. Routines and structures
b. Problem solving skills training
c. Parent mgt training
d. Multi-systemic therapy (MST)
e. Meds
i. Stimulants
ii. Lithium
iii. Other mood stabilsers
iv. Neuroleptics
v. Clondidine
vi. Risperdone
1. Some pos effects potentially
2. Low dose 0.25-2 mg
3. Negative effects – weight gain, fatigue, nasal congestion etc
f. Tx co-morbidities

Tourette’s

1. Features
a. Tics – vocal, motor
2. Impact of disorder
a. Depr
b. Anx
c. Social withdrawal
d. Suicidal ideation
e. School refusal
3. Tx
a. Support and education
b. Behal
c. Meds – clonidine, low dose respiridone

Summary

• Disruptive beh d/os are common
• CD is often costly and difficult to tx
• Etiology is complex
• Co-morbidity is the rule rather than the exception
• Assessment needs to be multi-dimensional and involves multiple informants and diff settings
• Thorough assessment should identify the primary/principal dx and co-morbid d/os and lead to formulation and devising of an individualised mgt plan

CHILD AND ADOLESCENT PSCHIATRY - INTRODUCTION

60 minute lecture blocks
1. Intro
2. Infant mental health and somatic presentations
3. Anxiety, depression and suicidal behaviour in children and adolescents
4. ADHD, ODD, Conduct Disorder
5. Behavioural management of common problems
6. Autistic spectrum – autism and aspergers

Cases
1. Aspergers/Autism Case – see lecture
2. Family issues - ?dx
a. 10 Boy
b. PC – f-up asthma clinic, poorly controlled asthma last 2/12, 5x ED visits
c. O/E – seems angry and withdrawn, mother looks stressed, both insist he is taking his meds
d. Hx – father left to live w new girlfriend, mother distraught and cries a lot, father not so interested anymore, he blames himself for the breakup bec they used to argue about him a lot, mother doesn’t want to talk about it
3. ADHD
a. Boy
b. PC – catch-up meningococcal b injection bec was away from school
c. Hx – was off school bec he hates school and loves staying home, he says his teacher hates him and is mean, making progress at school, in class he calls out to the teacher, irritates other children, never completes work, frequently loses workbook and shoes, other children don’t include him in games bec he wont wait his turn, at home he fights with his brother and tantrums
4. PTSD
a. 9 Girl
b. Car accident 2/12 ago, saw mother cut from wreckage w serious injuries, she received a tibia #
c. She now has poor sleep, nightmares of car crashes and people dying, started wetting bed, refuses to travel in car, says she cant remember the accident, wont play with friends
5. Risk assessment
a. Girl
b. Pres to ED following O/D of anti-inflammatory meds, 6/12 hx of incr irritability and arguments w parents and brother, school grades declining, feels depressed, not sleeping well, feels life is too hard, parents expect too much
c. Parents do not want you to contact school and reluctant for her to see a psychiatrist, shes says shell be find, registrar cant get there for 4 hours, could you do a risk assessment
6.
a. 16 Boy
b. Binge drinking in weekends with matees, broke arm falling off deck at party, gets into fights after drinking, started smoking at age 12 and experimenting w TCH, now smokes THC 3-4x daily as it calms him, mother upset at his school truancy, father had drinking problem, left 10 yrs ago

Mental Illness
1. Longitudinal tractories (mental illness starts in c/hood)
a. Anx d/os
b. Depr d/os
c. Conduct/anti-social d/os
d. Somatisation
e. Psychotic illness
f. Personality d/o
2. Outcome of severe adult mental illness largely determined by –
a. Quality of r/ships w people around them
b. Level of fam support
c. Family expressed emotion
d. Attahcment hx
3. Outcome of child and adult physical illness also strongly influenced by –
a. 4 factors above and emotional well being and coping style
4. Physical health is associated with psch and emotional issues
5. Epidemiology
a. 11 years age – 17%
b. 15 years age – 22%
c. 18 hears age – 36%
d. 5% of childr and adolescents have severe psych d/o requiring specialist mental health service input
e. At age 15
i. Anxiety 10%
ii. Mood d/os 7%
iii. Conduct/oppositional 9%
iv. ADHD 4%
v. Substance abuse 6%
6. chr dis and physical disability – 3x risk of psych d/o and considerable risk of social maladjustment, less risk w chr dis alone

When do conditions present
1. Infancy and Pre-school
a. PDD
b. Reactive attachment d/os
c. Feeding d/os
2. Primary school aged children
a. Disruptive beh d/os – attention deficity, hyperactive d/o, ADHD, oppositional defiant, conduct
b. Anxiety – separation anx, phobias, OCD, PTSD
c. Tic d/os – tourettes
d. Elimination d/os – encoresis, eneuresis
e. Somatoform d/os – conversion, pain
3. Adolescent
a. Mood d/os – major depr d/o, BPAD
b. Schizophrenia
c. Anx d/o – generalised anx, panic d/o, separation anx, obsessive compulsive
d. Eating d/os
e. Subst abuse
f. Personality d/o
4. Psychological Interventions
a. Supportive therapy – education, advice, interest and empathy, ongoing contact
b. Behal therapy
c. CBT – esp useful anx, depr, pain, individual or grp, incr use of computer programs an d self help manuals
i. Cogv restructuring – recog habital neg interpretations and replacing w positive
ii. Activity scheduling – doing enjoyable things to improve mood
iii. Problem solving
iv. Relaxation training
v. Conflict resolution
d. Play therapy or child psychotherapy
i. Play, art or child appropr activities
ii. Pre-adolescents and younger pre-verbal children
e. Focused strategies – (technique according to need)
i. stress mgt (relaxation tape, recog stress, distraction techniques)
ii. anger mgt (triggers, adaptive strategies for dealing with anger)
iii. social skills (greating people, what to talk about, taking turns, dealing with teasing) – useful in aspergers, ADHD, oppositional children, social phobia
5. Medications
a. Psychotropic medication – question to ask before Rx
i. Correct dx
ii. Appropr non-pharm methods employed – education, support, behal and cogv therapies, family and school interventions
iii. Good evidence to support use – eg TCAs for depr ineffective in childr/adolscents, best evidence for stimulant use in ADHD
iv. Risk-benefit – LT side effects, impact on developing brain of NT alteration, risk of not treating (eg disruption of education, soc devt, suicide etc)
v. Dosage appropr
vi. Informed consent
b. Learn –
i. Stimulants for ADHD
ii. SSRIs for depr and OCD
iii. Neuroleptics for psychosis
iv. Mood stabilisers for BPAD

CHILD AND ADOLESCENT – MANAGEMENT OF SIMPLE BEHAVIOURAL PROBLEMS

1. Assessment
a. Problem identification
b. Maintaining factors
c. Select target beh – objective, observable, measurable
d. Evaluate resources
2. Observation
a. Consider r/ships
b. Consider the behs
c. Think about child’s strengths/interests
d. Can child actually do what’s being asked of them?
3. Parents
a. Engagement – takes time and energy
b. Collaboration
c. Money in the bank – positive sentiment
4. Intervention
a. Plan tx program
b. Work ot practicalities – eg specific instructions for a babysitter etc
c. Evaluate
d. Initiate and monitor
e. Phase out
5. Techniques
a. Positive reinforcement
i. Reward follows desired beh
ii. Does the young person u/stand?
iii. Do the parents interpret – clearly, fairly, consistently?
b. Differential reinforcement
i. incompatible or alternative beh – ie reward good beh when you see it eg when playing nicely
ii. shaping – reinforcement almost good beh etc
iii. keystoning – what are the most impt things for this family (eg compliance)
c. Changing the context
i. Enrichment – eg box of toys in drs office
ii. Rescheduling – Ø active play around bedtime
iii. Preceding with another request – get them to do something they like/want to do then follow with request for something you want them to do
iv. Exercise - ↓ aggr + self harm (esp autism and aspergers)
d. Modelling
i. Give child chance to observe new beh – eg as an adult, emotional control is internalised, ensure you vocalise it so the child can hear
ii. Changing learned fears
iii. Learning complex behs
e. Punishment
i. Withdrawal of positive re-inforcement
ii. Response cost – eg child breaks window, has to pay for window and a bit more!
iii. Overcorrection – make someone do s/thing over and over
iv. Aversive stimuli – only use when child has PDD and self harming (eg chilli on tongue, icey mist) – be cautious!
v. Avoid physical punishment – aggressive model leads to escalation
6. Practical Strategies
a. Star charts
i. Useful in pre-school and school aged children
ii. Short burst – to help form new habits
iii. Must be developmentally appropr
b. Planned ignoring
i. Good for pre-school childr
ii. Very difficult for parents to implement – reqs some acting!
iii. Useful for whinging, swearing (esp)
c. Looking for good beh
i. Useful for all ages
ii. Parents often have a negative mindset
iii. Reinforce behs that are already in place
d. Time out / Quiet time
i. Quiet, boring safe place
ii. 1 min for each yr of age
iii. Practice first
iv. One warning
v. Eye contact, down on their level, explain why they are going there
vi. Calmly and firmly place child in time-out
vii. Pretend to ignore
viii. When time is over, talk to them again, ?get them to apologise or ?fresh start
e. Ground Rules / Contracts
i. Rules – consistency, collaborative effort, clearly written and agreed on, time to review/revise set in place
ii. Contracts – useful for older children/teenagers, business-like, can be a longer term arrangement, useful on wards

CHILD AND ADOLESCENT MENTAL HEALTH – PERVASIVE DEVELOPMENTAL DISORDERS

Case
3 boy
PC – concern over hearing, he doesn’t say much, not interested in other children at kindy, started talking at 18 months age and seemed to be understanding what they said
O/E – poor eye contact, hyperactive and poor attn span, little communicative lang but repeats advertising jingle frequently, plays w wheels of toy but little else in the room, flicks his fingers repeatedly while sitting in mothers lap
Hearing assessment – normal ears, uncooperative during assessment, hearing probably normal

Pervasive Developmental Disorders – Autism and Asperger’s
1. Core Features
a. Impaired communication – 3rd person pronouns, repetitive speech, lang not considered a reciprocal process
b. Impaired social interaction – no eye contact,
c. Stereotyped beh and interests – repeatitive beh, likes the same thing over and over, consistency
2. Differential Dx
a. Severe depriviation/neglect
b. Snesory deprivation through sensory abnormalities eg hearing/visual impairments
3. Management of Autism or Aspergers
a. No curative tx
b. Best evidence for –
i. Educational interventions to foster acquisition of basic social, lang and cogv skills (IEP = Individual Education Plan)
ii. Behal mgt
iii. Early intensive and continuous tx
c. Family support, community agency support
d. Respite care, supported accom in a/hood
e. Medications
i. May be helpful for specific sxs if these are not responding to etal or careful behalinterventions
ii. Low dose antipsychotics – to settle aggressive or self-injurious beh / stereotypes (risperidone and haloperidol)
iii. Stimulants for severe hyperactivity – less effective than in ADHD
iv. SSRI – for anx and depr
4. Issues for parents and families of children w these disorders

CHILD AND ADOLESCENT PSYCHIATRY

Overview

1. Determinants of outcome in severe mental illness
a. Quality of r/ships around them
b. Level of family support
c. Family expressed emotion
d. Attachment hx
e. Individual’s emotional well being and coping style
2. When conditions present
a. Infancy and pre-school – PDD
b. Primary school age – disruptive disorders (ADHD, ODD, conduct d/o), anx d/os (separation, phobias, OCD, PTSD)
c. Adolescent – mood d/os (MDD, BPAD), schizophrenia, anx d/os (gad, panic, ocd), eating d/os, subst abuse
3. Interventions
a. Psychological
i. Supportive – education, advice, interest and empathy, ongoing contact
ii. BT
iii. CBT
1. Cogv restructuring
2. Activity scheduling
3. Problem solving
4. Relaxation training
5. Conflict resolution
iv. Play therapy
v. Focused strategies (according to need)
1. stress mgt
2. anger mgt
3. social skills – aspergers, ADHD, ODD, social phobia
b. Medications – stimulants for ADHD, Prozac for depr and OCD

Risk and Resilience

1. High risk factors for mental health outcomes in a child
a. SES
b. Impaired parenting
c. Neglect or abusive home evts
d. Marital conflict
e. Family violence
f. Adverse life events
2. Early risk factors
a. Poor attachments
b. Ineffective parenting
c. Chaotic home evt
d. Exposure to parental subst abuse, mental illness or criminal beh
3. Later risk factors
a. Inappropr classroom beh
b. Academic failure
c. Poor social coping skills
d. Assoc w peers w problem behs

Somatoform Disorders – Ex. Pain disorder

1. Pain disorder
a. Definition
i. Sufficient severity of pain to warrant clinical attn
ii. Pain causes clinically sig distress or impaired functioning
iii. Psych factors judged to have role in onset, severity, exacerbation or maintenance of the pain
iv. Sxs not intentionally produced or feigned
b. Evidence for psych factors
i. Onset after specific trauma or stress
ii. Disability out of proportion to reported pain
iii. Clear 2ndry gain
iv. Exacerbations linked predictably to stressful events
2. Case – Pain disorder
a. PC – sudden onset pain after minor surgery, all ixs N, pain preventing school attendance, extreme distress on rehab
b. S.hx – high achiever, champion gymnast, punitive and rigid coach, in accelerate class, afraid of falling behind, anx and temperamentally difficult when younger
c. Mgt
i. Engage parents – education
ii. Develop pain mgt and rehab program – realistic goals, physiotherapy, graded exercise, CBT (eg distraction), encourage child to take responsibility
iii. Anx mgt strategies – CBT, controlled breathing, ?SSRI
iv. Return to school – immed reduce academic pressures (normalisation of child’s routine, limit setting to ↓ 2ndry gain)
v. Family work – achievement pressure re gymnastics, positive family activities
vi. Regular r/v

Depression in children/adolescents

1. Epidemiology
a. Low rates in children, 1%, M=F
b. Age 15, F:B 2:1, 3.1% prev
c. Age 18 – 16 %
d. Untx episode lasts ~9 months, <20% receive optimal tx
2. Etiology → biopsychosoical
a. Biological – genes, illness, gender
b. Psychological – negative thinking (triad = self, world, future), sequelae of abuse
c. Social – low SES, stressful LE
3. Tx
a. Psychoeducation
b. CBT
c. Family/School
d. Anti-depressants – fluoxetine, Ø TCAs
e. Other – IPT, Exercise, relaxation

Suicide and self harm in children/adolescents

1. Completed suicide risk factors
a. 15-24
b. Males – school failure, subst abuse, aggr, impulsivity
c. Females – depr
d. Most have a psychiatric illness (depr or schizophrenia)
2. Assessment after suicide attempt
a. Details of attempt – how planned, likelihood of discovery, wanted to die, believed method would be lethal
b. Mental state – depr, anxiety, psychosis, current state
c. Supports – family, friends, school
3. Initial Management
a. Psychoeducation
b. Identification and mitigation of hopelessness
c. Verbal no suicide contract and coping plan
d. Remove means of suicide
e. Close observations
f. Then tx of underlying problems

Pervasive Developmental Disorders – Autism and Aspergers

ASD = Autism spectrum disorders
1. Autism - brain development d/o characterised by impairments in social interaction and communication and restriced and repetitive beh exhibited before a child is 3
2. Aspergers – one of the ASDs, characterised by difficulties in social interaction and by restricted and stereotyped interests and activities
a. Distinguished from other ASDs → Ø general delay in language or cogv devt
3. Epidemiology
a. 1/1000 autism
b. 6/1000 ASD
c. 4:1 M:F
4. Etiology - Genetics (complex)
a.
5. Core features
a. Impaired language/communication – reverse pronouns (refer to onself as he, she, you or their name), repetitive speech (echolalia), lang not considered a reciprocal process
b. Social impairment – unable to understand social communication, no eye contact
c. Stereotyped behaviours and interests
i. Sterotypy – apparently purposeless mvment eg hand flapping, body rocking
ii. Compulsive behaviours – eg arranging objects in a certain why
iii. Sameness – resistance to change
iv. Restricted behaviour – limited in focus eg preoccupation with one certain tv show
6. Differential Dx
a. Severe deprivation / neglect
b. Sensory deprivation – eg hearing or visual impairments
7. Management
a. Early and continuous educational and behavioural interventions
i. Educational interventions – foster basic social, language and cogv skills (IEP = individual educ plan)
ii. Behaviour mgt
b. Family support
c. Medications
i. Low dose antipsychotics (respiridone, haloperidol) – may help settle aggressive or self-injurious beh and stereotypes
ii. Stimulants for severe hyperactivity (less effective than for ADHD)
iii. SSRI – for anx and depr
8. Case example
a. 3 year boy
b. PC - Concern over hearing, doesn’t say much, not interested in other children, started talking 18 months of age and seem to be understanding what was said
c. O/E – poor eye contact, hyperactive, poor attn span, little communicative lang but repeats advertising jingle frequently, plays w wheels of toy but little else in room, flicks fingers repeatedly

Disruptive Behaviour Disorders

1. ADHD
a. Definitions
i. ADD – a disorder of attention, organisation and impulse control appearing in childhood and sometimes persisting into adulthood (hyperactivity may be a feature, but not necessary for the dx)
ii. ADHD – a d/o of childhood and adolescence manifested at home, school and in social situations by developmentally inappropriate degrees of inattention, impulsiveness and hyperactivity
b. Core Dx features
i. Limited attention span, poor concentration
ii. Hyperactivity
iii. Impulsivity
c. Diagnosis
i. Either 6 of inattention or 6 of hyperactivity
ii. >6 months
iii. Impairment <7 yrs age
iv. Impairment in 2+ social settings
v. Clear evidence of clinically sig impairment of functioning
vi. Not due to other conditions
d. Epidemiology – 3-5% of school age children
e. Tx
i. Stimulants
1. Methylphenidate (ritalin) – short acting 3-4 hrs, tds dosing reqd
a. Improvement in core sxs - ↑ sustained attn etc
b. More effective than intensive behal mgt
c. Common adv effects – pulse/BP ∆s, ↓ appetite, abod pain, headache, irritability
d. Uncommon but impt adv effects – tics, stereotyped behs, cogv tox, growth suppression, drug dep
ii. Psychological
1. Psycho-education and behal mgt – parents, teachers
2. School based programs – behal mgt, learning support
3. Pschological interventions with children – social skills training, relaxation training
f. Case
i. Boy with hx of being off school, hates school, loves staying home, teacher hates him and is mean, class out in class, irritates other children, never completes work, frequently loses workbook and shoes, other children don’t include him bec he wont wait his turn, tantrums and fights at home
2. ODD (oppositional defiant disorder)
a. Definition
i. A childhood or adolescent d/o characterised by a recurrent pattern of negativistic, hostile and defiant beh toward authority figures, absence of criminality
b. Diagnosis
i. At least 4 of –
1. loses temper
2. argues with adults
3. Actively defies or refuses to comply with requests
4. deliberately annoys people
5. touchy, easily annoyed
6. angry/spiteful
7. etc
ii. >6 months
c. Epidemiology – 3-5% prev in children and adolescents, ↑ prev after 12 yrs age, B:G 2:1
d. Etiology
i. Biological – genetic (~50%), LBW, prenatal/antenatal complications, brain injury…
ii. Family – prenatal antisocial beh/subst abuse, single divorced parent, harsh discipline
iii. Social – poverty, disorganised, high crime neighbourhood, deviant peers
e. Course
i. Improves at young adulthood
ii. 30-50% → ASPD
iii. High suicide risk
f. Tx
i. Education (parents and children)
ii. Problem solving skills
iii. Parent mgt training
iv. Meds – low dose respiridone may be beneficial
v. Tx of comorbidities
3. Conduct disorder
a. Definition - A mental d/o of childhood or adolescence characterised by a persistent pattern of violating societal norms and the rights of others
b. Diagnosis - 3/15 from 4 possible groups over last 12 months
1. Aggression to people or cruelty to animals
2. Destruction of property – eg vandalism
3. Deceitfulness or theft – eg cheating, lying, robbery
4. Serious violation of rules – eg truancy, running away
c. Co-morbidities
i. ADHD – 10x
ii. MDD (major depr d/o) – 4x
iii. Subst abuse – 4x
d. Natural course – at 18 yrs age, dx becomes ASPD

Management of Simple Behavioural Problems

1. Techniques
a. Positive reinforcement – reward follows desired beh
b. Changing the context – enriching the evt, rescheduling active play around bedtime, preceding with another request, exercise
c. Modelling – parents models and vocalises desired beh
d. Punishment – withdrawal of pos re-inforcement, response cost, overcorrection; caution w aversive stimuli; Ø physical punishmt
2. Practical strategies
a. Star charts – pre-school and school aged, short bursts to form new habits
b. Planned ignoring – pre-school children, useful for whining/swearing
c. Looking for good beh – all ages
d. Time out – quiet boring safe place, 1 min for each yr of age, one warning, pretend to ignore
e. Rules and Contracts – older children and teenagers, collaborative, written, business-like

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