Child Psychiatry

MUMPS Revision Day

Tips

Be aware of time restraints

Ask to speak to the child if not present

May be a history or explanation station

Leave time to summarise appropriately and

explain what you would do if you ran short of
time

Dont forget appropriate medical history (birth

hx, family hx etc)

Tips

Try and understand the daily routine of the

child (most of the functional impact will then
be covered)

Children tend to be less forthcoming with their

answers

ALWAYS risk assess the situation any threat to

the child?

Clues usually always hidden in school hx.

Past stations

Behaviour

Self harm

Conduct disorder

Weight disorder

Examiner looking at:

History: appropriate questions and assessing risk

Differential and further management

Child Psychiatry History

Presenting Complaint
Description of recent events (open questions)

1. When did it start?

2. Timeline of events
3. Who has it affected?
4. Help sought?
Behaviour Recent behaviour at home and at school
.

Disobedience/anger/lack communication

Drugs/alcohol/smoking

Suicidal ideation/self harm/rituals and obsessions

Food obsessions/refusal

Child Psychiatry History

Social

Home - who do they live with/ pressures at home/ abuse

School- Bullying/ academia/ friends/ boyfriends.

Development

Milestones/communication/behaviour as a child

PMH

Illness/operations

Chronic problems/co-morbidities

Previous involvement with CAMHS

FH

Significant mental illness

Alcohol/drugs

DH

You are based at a general practice.

The GP has asked you to take a history from Jane, a
14 year old girl that has attended with her mother
due to feeling tired. Please take a history from
Jane.
Depression??

Depression
Symptoms

Low mood

Sleep disturbance

Irritability

Reduced concentration

Reduced self esteem/confidence

Pessimistic view of the future

Boredom

Weight changes

Suicidal ideation

Depression
Prepubertal children

Somatic complaints (stomach ache/headache)

School refusal

Attachment and separation anxiety

Depression
Adolescents

Hopelessness

Anhedonia

Hypersomnia

Alcohol and drugs

Reduced academic achievement

Antisocial behaviour

Anxiety

Depression History

Depression symptoms

Home

Relationships: boyfriend/girlfriend/parents/siblings/friends

Recent loss

Home environment

School

Attendance

Friends

Bullying

Family life and support network

Thoughts of self harm

Past psychiatric history

Previous involvement with CAMS

Management
NICE recommendations: stepped-care model of depression

Detection and recognition

Psychological therapies and watchful waiting

CBT

Family therapies

CAMHS

SSRIs

Fluoxetine = 1st line (only recommended antidepressant)

Sertraline and citalopram = 2nd line

Increased risk of suicide with antidepressants, prescribe with caution

You are based on a medical ward.

Your consultant has asked you take history from
James, a 14 year old boy. He has been admitted
recently but you have not been given any further
information.
Please take a history from James to find out why he
was admitted and the events leading to this.
Self harm??

Self harm history

Before

What happened prior to the event?

Was it planned?

What did they use - tablets, knife etc

Did they think it was sufficient to end their life?

Did they leave a note/will?

During

Who found them and how?

After

How do they feel now they're in hospital?

Has this happened before?

Do you think you would do it again?

Overdose/suicide
Risk factors

Female

Disrupted family background

Suicidal ideation

Psychiatric disorder
1. Depression
2. Substance Abuse
3. Conduct disorder

Precipitating factors

Last straw event - argument with boyfriend/parents

Response to stress/distress

Feelings of loneliness/anger prior to self harm

Management
Refer to CAMHS

Advise carers to remove medications or other

means of self harm immediately

Treat any underlying psychiatric disorder and

ensure underlying social problems are
addressed

Family interventions/psychological
therapies/CBT

Weight History
You are based in a general practice.
The GP has asked you to take a history from 16
year old Amanda who has come in with her mother
as she has lost some weight recently.
Anorexia Nervosa
Bulimia Nervosa

Eating Disorders
Anorexia Nervosa

5% below expected weight and height, for the age and height of the child

Deliberate dietary restiction+/- excessive exercise/ appetite suppressants and purging,

laxatives, insulin abuse

Obsession with weight/ fear of obesity

Amenorrhea/ delayed onset of puberty

Bulimia Nervosa

Episodes of overeating and feeling out of control

Compensatory behaviours to avoid weight gain

Body weight may be normal, low or overweight

Often episodic with relapsing remitting course

Eating Disorder Quick Screen (SCOFF)

Do you make yourself SICK

Do you worry you have lost CONTROL over what

you eat?

Have you lost more than ONE stone recently?

Do you believe yourself to be FAT when others say

you are thin?

Does FOOD dominate your life?

One point for every YES. (more than or equal to

two likely)

Eating Disorder
HPC

Intended to lose weight?

Insight how do you feel about your weight? How would they react if they put on weight?

Do they exercise or use medications to control weight - how often?

Binging

Physical symptoms - ask about periods

Mood

Risk

Social

School/social pressures

Family life/boyfriends/girlfriends

Drugs/alcohol

Management

Ideally take a full psychiatric history

Blood tests (FBC, TFTs) to rule out organic cause

Engage with family to make aware (If >16

confidentiality implications)

Aim for weight gain in anorexia using structured

plan with small meals

Therapy - individual and family

Hospital admission only in severe cases

Behaviour History
You are an FY1 at a general practice.
Mrs Smith has attended with her 9 year old son
who was recently suspended from school. Please
take a history from Mrs Smith.
Oppositional defiant disorder
Conduct disorder
Attention deficit hyperactivity disorder (ADHD)

Conduct disorder

Repetitive and and persistent dissocial,

aggressive or defiant behaviour

More common in boys

Defiance of the will of an authority figure

Aggressiveness

Antisocial behaviour violates others rights,

property or person.

DSM IV & ICD 10 has to impair every day

functioning

Oppositional defiant disorder

Must have a 6 month hx of at least 4 of:

Losing temper

Arguing with adults

Disobeying rules

Deliberately annoying others

Shifting blame

Angry and resentful

Often spiteful and vindictive

Touch and easily annoyed

Conduct disorder

Must have a 12 month history of:

Bullying or intimidating others

Fights

Using weapons in fights

Physically cruel to people

Physically cruel to animals

Stealing with force

Fire setting

Destruction of property

Running away from home

Truanting

Antisocial behaviour may be with others or lack of close friends.

Conduct Disorder History

Behaviour

Home

School

With friends

Any trouble with the police?

Family

Recent upset/living/loss

Siblings

Development

Normal or delayed - milestones met?

OSCE CUES WILL BE OBVIOUS (not expected to make advanced psychiatric diagnoses in a
short station

Management
Child focussed

Behaviour Modification

Social skills training

Individual psychotherapy

Medication and diet

Family focussed

Family counselling

Family therapy

Parent management training (best established approach)

Attention deficit hyperactivity disorder

(ADHD)

Inattention

Hyperactivity

Impulsivity

ADHD History
Marked Restlessness

Squirming, wriggling, fiddling with clothing, wandering about all the time

Changing task frequently

Easily distracted

INABILITY TO SUPPRESS ACTIVITY WHEN STILLNESS REQUIRED

ACTING IMPULSIVELY (INTERRUPTING) DDx behaviour disorder

Pervasiveness

Has to be present at home and at school

Chronicity

AT LEAST 6 MONTHS

Management

CAMHS

Strategies for home and school

School involvement

Parenting classes

Stimulants

Methylphenidate

Dexamphetamine

Hyperactivity should decrease with age

Autistic Spectrum Disorders

ASD History

Most likely to come from the parent

What was the child like as a baby- social smile/ emotional

facial expressions?

What were they like as a toddler- communication/

preference of being alone?

Ask about birth- were there any complications during

pregnancy/ delivery?

Does anyone else in the family suffer with ASD?

ICE- explore the parents ideas, concerns and expectations.

Management

Behavioural intervention to help with

challenging behaviours.

Communication sessions.

TEACCH education programme that incorporates

these factors into a programme for parents and
children.

Children benefit more from therapy focused

around improving communication/ language skills.

Adolescents treatment should focus more on

social skills.

Summary

Take a good history. Start open and then ask

focussed questions to show you are thinking
about differentials

Always ask about behaviour, school and

development

Don't forget ICE