Child and adolescent psychiatry – 3

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7 Child and adolescent psychiatry – 3

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1. Perinatal insult increases the risk of ADHD.
2. Atomoxetine has a half-life of 24 hours.
3. In children who are adopted, genetic factors explain emotional problems more than environmental factors.
4. Most children with autism have a learning disability.
5. Autism is associated with an increased risk of schizophrenia.
6. Autistic children become less isolated as they grow older.
7. Temperament in the first 6 months of life can accurately predict conduct disorder in adolescence.
8. Children with unsocialized conduct disorder have low self-esteem.
9. About 10% of British urban teenagers are delinquent.
10. Truancy is often a group activity.
11. Children who are rejected by peers are likely to have a mother who is unsociable.
12. 80% of depressed children have a positive dexamethasone suppression test.
13. Tricyclic antidepressants (TCAs) have been clearly shown to have better efficacy than placebo in children with depression.
14. Encopresis is associated with primary enuresis.
15. Encopretic children are more difficult to treat if there is associated nocturnal enuresis.
16. Fluid restriction is indicated in 7-year-olds with primary enuresis.
17. Children of parents with personality disorder are more likely to have mental disorder than children of parents with schizophrenia.
18. The management of pica is mainly pharmacological.
19. The prevalence of specific reading disorder in Japanese school children is 1%.
20. Specific reading disorder is associated with other psychiatric problems.
21. In large families, the oldest child is most likely to show school refusal.
22. School refusal is usually treated with gradual reintegration and support.
23.Memories of childhood sexual abuse are relived through flashbacks.
24. Coprophagia is a feature of Gilles de la Tourette’s syndrome.
25. Children with chronic fatigue syndrome have more emotional problems than those with chronic juvenile arthritis.

ANSWERS

1. Perinatal insult increases the risk of ADHD.

True: Aetiological factors in ADHD include fetal exposure to the mother’s use of alcohol, drugs, or cigarettes; perinatal obstetrical complications and prematurity (Gelder et al 2000, p. 1739).

2. Atomoxetine has a half-life of 24 hours.

False: Atomoxetine is a noradrenaline reuptake inhibitor used in the treatment of ADHD. It has a half-life of approximately 5 hours. It is extensively metabolized principally by CYP 2D6. In poor metabolizers, i.e. 7% of whites and 2% of blacks, the half-life is 21 hours. It is administered once daily (King 2004, p. 427; Sadock & Sadock 2005, p. 2942).

3. In children who are adopted, genetic factors explain emotional problems more than environmental factors.

False: Adoption studies have not been able to tease out whether environmental factors within the adoptive family or genetic factors are more important contributors to emotional problems. There are also likely to be interactions between genetic and environmental factors (for example, in girls, genetic family history of alcohol dependence interacts with adoptive parental psychiatric illness to increase risk of mood disorder). Early environmental adversities are more common in children who are later adopted, increasing their risk of later emotional problems. Adopted children are likely to have better outcomes than their non-adopted peers who are not removed from adverse environments (Gelder et al 2000, pp. 697, 1843).

4. Most children with autism have a learning disability.

True: 70% of autistic children have learning disabilities. Only 5% have an IQ above 100. On the Wechsler scales, they perform poorly on Similarities and Comprehension, but do relatively well on Block design and Digit recall subtests. Up to 10% may have islets of special abilities called splinter skills or savant skills, i.e. high or prodigious performance on a specific skill in presence of learning disability (Johnstone et al 2004, p. 590; Sadock & Sadock 2005, p. 3170).

5. Autism is associated with an increased risk of schizophrenia.

False: There is no evidence of increased risk for schizophrenia. Depressive and anxiety symptoms may occur in high-functioning adolescents who become painfully aware of their inability to form friendships (Johnstone et al 2004, p. 590).

6. Autistic children become less isolated as they grow older.

True: ‘Autistic aloofness’ tends to improve in over half of cases. This is often replaced by being interested in social interactions, but behaving abnormally in social situations – ‘active but odd’ (Goodman & Scott 1997, p. 48).

7. Temperament in the first 6 months of life can accurately predict conduct disorder in adolescence.

False: The New York Longitudinal Study showed that children with certain temperamental characteristics were more likely to develop problems. However, correlations are low and the prediction is not ‘accurate’.

8. Children with unsocialized conduct disorder have low self-esteem.

True: Unsocialized conduct disorder is conduct disorder with pervasively abnormal peer relationships. There is isolation, unpopularity and peer rejection. Relationships with adults are often marked by discord and hostility. All these increase the risk for low self-esteem.

9. About 10% of British urban teenagers are delinquent.

False: Juvenile delinquency is a legal term. It refers to an act committed by a young person, for which they are convicted, and which would have been regarded as criminal if they were adults. 3–6% of males are ‘persistent’ young offenders, while 20% of boys are convicted at some point in adolescence. _10% is therefore likely to be wrong (Gelder et al 2006, p. 680).

10. Truancy is often a group activity.

True: Truancy is staying away from school to engage in more appealing activities. It is often carried out with peers, and there is an association with other aspects of conduct disorder.

11. Children who are rejected by peers are likely to have a mother who is unsociable.

False: There are many possible reasons for peer rejection of children. Having an unsociable mother increases the risk. However, the majority of children who are rejected by peers do not have a mother who is unsociable.

12. 80% of depressed children have a positive dexamethasone suppression test (DST).

False: 50–70% of depressed children and 40–60% of depressed adolescents are DST non-suppressors (Kaufman et al 2001).

13. Tricyclic antidepressants (TCAs) have been clearly shown to have better efficacy than placebo in children with depression.

False: The Cochrane review of TCAs in young people has shown no difference in remission rates between TCAs and placebo in children and adolescents, and a small benefit of TCAs in reducing depressive symptoms in adolescents but not children (Hazell et al 2002).

14. Encopresis is associated with primary enuresis.

True: Specific developmental delays in bladder and bowel control are due to delays in maturation of similar mechanisms and so are associated. In addition, constipation can cause overflow encopresis and also makes bladder control harder, due to pressure from the overloaded bowel.

15. Encopretic children are more difficult to treat if there is associated nocturnal enuresis.

False: The opposite, however, is true. Encopresis may be due to constipation, and constipation makes nocturnal enuresis harder to treat, due to pressure effects from the overloaded bowel on the bladder.

16. Fluid restriction is indicated in 7-year-olds with primary enuresis.

False: Fluid restriction may reduce the number of episodes of wetting and is often used by parents of younger children in the early stages of nighttime toilet training to make the process easier. However, it does not actually cure the enuresis in 7-year-olds. The aim of treatment is for the child to associate a full bladder with the need to wake up and go to the toilet. Behavioural treatment (initially with ‘star charts and rewards’ and later with ‘pad and bell’ if necessary) is the best treatment approach and has high success rates. Overlearning, giving the child larger quantities of bedtime fluids, is sometimes used, and this reduces relapse rates (Gelder et al 2000, p. 1793).

17. Children of parents with personality disorder are more likely to have mental disorder than children of parents with schizophrenia.

False: No studies have directly compared these. There is more research for schizophrenia. Parental schizophrenia leads to increased risk of schizophrenia and also sub-syndromal schizophrenic symptoms. It also increases the risk of suboptimal parenting and family disruption. There is also evidence for increased risk of problems in children of parents with personality disorders, e.g. conduct disorders in children of those with antisocial personality disorders.

18. The management of pica is mainly pharmacological.

False: Pica, the eating of items normally regarded as inedible, is often associated with other behaviour problems and is more likely in children with learning disabilities. It is sometimes associated with emotional distress. Management is the identification and treatment of the underlying factors, which almost never involves medication.

19. The prevalence of specific reading disorder in Japanese school children is 1%.

False: Despite an earlier report that reading disorder was rare in Japan, more recent studies found that among Japanese children aged 8 to 13 years, 16% had a 1-year delay and 15% had a 2-year delay in reading. The definition of specific reading disorder is reading ability more than two standard deviations below that predicted by age and overall IQ, which corresponds to a 21/2-year delay in a 10-year-old. Hence, the prevalence is the same as in the West.

20. Specific reading disorder is associated with other psychiatric problems.

True: Particularly hyperactivity. There is also a link between specific reading disorder and conduct disorder, but this may mainly be mediated by ADHD (Goodman & Scott 1997, p. 197).

21. In large families, the oldest child is most likely to show school refusal.

False: The youngest child may be at the greatest risk.

22. School refusal is usually treated with gradual reintegration and support.

False: A behavioural ‘back to school’ approach is particularly likely to be successful when refusal to attend school began recently and relatively suddenly. A rapid return to full-time school is often possible once the parents are persuaded that consistent firmness is in the child’s best interests. In the majority of cases, the child goes straight back to school and mental health services are not involved. In cases with severe anxiety, gradual reintegration may be needed (Goodman & Scott 1997, p. 77).

23. Memories of childhood sexual abuse are relived through flashbacks.

True: Post-traumatic stress disorder with associated flashbacks occurs in victims of childhood sexual abuse (44% in one study).

24. Coprophagia is a feature of Gilles de la Tourette’s syndrome.

False: Coprophagia is the eating of faeces. Coprolalia is uttering swear words, which can be a vocal tic in Tourette’s syndrome.

25. Children with chronic fatigue syndrome have more emotional problems than those with chronic juvenile arthritis.

True: Both increase the risk for emotional problems, but a direct comparative study showed this to be greater for chronic fatigue syndrome (Rutter & Taylor 2002, p. 815).

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