Child and adolescent psychiatry – 4

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8 Child and adolescent psychiatry – 4

	T	F
1. ADHD is common in people with profound learning disability.
2. Atomoxetine is a noradrenaline uptake inhibitor.
3. Autistic disorders affect girls three times more often than boys.
4. When a child is diagnosed with autism, many parents look back and remember that something was wrong during infancy.
5. Autism has a 90% monozygotic twin concordance.
6. Difficulties with theory of mind are the same in patients with autistic spectrum disorders as in the general population.
7. Boys from large families are at higher risk of conduct disorder.
8. Unsocialized conduct disorder is associated with peer rejection.
9. Juvenile delinquency is more likely to be associated with future mental health problems in girls than in boys.
10. Truancy is often seen in children with somatization disorders.
11. Children rejected by peers tend to be aggressive.
12. The ratio of cortisol to DHEA is increased in adolescents with depression.
13. Tricyclic antidepressants are more effective than placebo in adolescent depression.
14. Encopresis is associated with a passive personality.
15. Primary enuresis in an 8-year-old boy with no urinary or psychiatric problems is an indication for IQ assessment.
16. Childhood complex partial seizures are commonly associated with emotional problems in childhood.
17. When a mother remarries, girls are more likely to be distressed than boys.
18. Adolescents have more symptoms related to body perception in psychosis.
19. Specific reading disorder is associated with spelling difficulties.
20. Specific reading disorder is associated with hard neurological signs.
21. School refusal may be secondary to a death in the family.
22. Child abuse is associated with an insecure attachment.
23. Children’s reporting of sexual abuse is consistently accurate.
24. There is increased cortical activity in children with tic disorders.
25. Central abdominal pain is a common presentation in children with emotional problems.

ANSWERS

1. ADHD is common in people with profound learning disability.

False: Learning disability increases the risk of ADHD. However, the majority of learning disabled children do not have ADHD. In addition, to diagnose ADHD, attentional abilities need to be impaired relative to the overall developmental stage of the child. People with profound learning disability (IQ<25) may never reach the developmental stage at which ADHD can be diagnosed (7 years). The statement is therefore false.

2. Atomoxetine is a noradrenaline uptake inhibitor.

True: Atomoxetine is a presynaptic noradrenaline reuptake inhibitor. This may be the basis of its therapeutic effect (Sadock & Sadock 2005, p. 2942).

3. Autistic disorders affect girls three times more often than boys.

False: Boys are 3.5–4 times more likely to have autism than girls. However, this varies with IQ levels. Among those within the normal IQ range the male:female ratio may be as high as 50:1 (Gelder et al 2000, p. 1726).

4. When a child is diagnosed with autism, many parents look back and remember that something was wrong during infancy.

True: Most parents would have been concerned by 12–24 months and all by 3 years about the child being slow to smile, being unresponsive and passive, disliking social contact or attention, poor language development and not responding to human voices.

However, ‘infancy’ is usually defined as the first year of life. Autism is rarely detected or suspected in the first year of life. Abnormalities must be evident by 36 months for the diagnosis to be made. When this happens, parents often retrospectively realize that development was never entirely normal (Goodman & Scott 1997, p. 43; Johnstone et al 2004, p. 589; Sadock & Sadock 2005, p. 3169).

5. Autism has a 90% monozygotic twin concordance.

False: Monozygotic twin concordance is in the range 36–91%, while dizygotic twin concordance is around 5%. Heritability is greater than 90% (Rutter & Taylor 2002, p. 643).

6. Difficulties with theory of mind are the same in patients with autistic spectrum disorders as in the general population.

False: Impairments in theory of mind tasks are more common in patients with autistic spectrum disorders than in the general population.

7. Boys from large families are at higher risk of conduct disorder.

True: Conduct disorder is associated with larger family size. This may be due to confounding variables associated with large family size rather than the direct effects of a large family (Gelder et al 2000, p. 1756).

8. Unsocialized conduct disorder is associated with peer rejection.

True: Poor integration with peers is the key differentiating factor for unsocialized conduct disorder.

9. Juvenile delinquency is more likely to be associated with future mental health problems in girls than in boys.

True: Juvenile delinquency is more common in boys than girls. Juvenile delinquency is more likely to be part of a group activity, without underlying mental illness, in boys. In girls, a higher proportion of delinquency is associated with mental health problems, especially substance misuse and personality disorders.

10. Truancy is often seen in children with somatization disorders.

False: However, children with somatization disorder are at increased risk of school refusal, i.e. not wanting to go to school due to anxiety around being at school.

11. Children rejected by peers tend to be aggressive.

False: Peer rejection may lead to aggression, but only in a minority.

12. The ratio of cortisol to DHEA is increased in adolescents with depression.

False: Some, but not all, studies have shown increased cortisol in adolescent depression. Raised cortisol:DHEA (dehydroepiandrosterone) ratio in depressed adolescents vs. controls has not been found. However, raised cortisol:DHEA ratio has been shown to predict persistent as opposed to remitting depression in currently depressed adolescents and adolescents at risk for future depressive episodes.

It has been postulated that DHEA levels vary at different stages of depression – in the early stages, there is an increase, to counteract the harmful effects of the cortisol; the body is eventually exhausted in persistent depression and so DHEA levels fall to below those of controls. Therefore an undifferentiated depressed sample will contain a mixture of raised, normal and lowered cortisol:DHEA ratios (Goodyer et al 1998, p. 2003; Kaufman et al 2001).

13. Tricyclic antidepressants (TCAs) are more effective than placebo in adolescent depression.

True: This is a difficult question to answer. The Cochrane meta-analysis of TCAs in adolescents showed that there is no statistically significant increase in numbers of participants meeting improvement criteria in the adolescent TCA group than control group. However, using differences in continuous rating scales, TCAs cause slightly more reduction in symptoms than placebo in adolescents (effect size = −0.47, 95% confidence interval −0.92 to −0.02) but not in children. There were significant side-effects in the TCA group. In view of the little efficacy and significant side-effects, NICE has recommended that TCAs should not be used in adolescents (Hazell et al 2002).

14. Encopresis is associated with a passive personality.

False: There is no evidence for this.

15. Primary enuresis in an 8-year-old boy with no urinary or psychiatric problems is an indication for IQ assessment.

False: Around 5% of 8-year-old boys will have primary enuresis. It is usually a specific, rather than global, developmental disorder. It is often hereditary, with 70% having an affected first-degree relative. 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.

16. Childhood complex partial seizures are commonly associated with emotional problems in childhood.

True: 29% of a sample of epileptic children showed some psychiatric disorder compared to only 6.8% of controls. Complex partial seizures are associated with higher rates of psychiatric disorder than other types of epilepsy (Gelder et al 2000, p. 1155; Lishman 1997, p. 260).

17. When a mother remarries, girls are more likely to be distressed than boys.

False: Boys are more likely to have problems than girls (Black & Cottrell 1993, p. 46).

18. Adolescents have more symptoms related to body perception in psychosis.

False: There is no evidence for this. Adolescents with psychosis have lower rates of formal thought disorder than adults.

19. Specific reading disorder is associated with spelling difficulties.

True. Specific reading disorder is associated with spelling difficulties. In fact, spelling difficulties may persist after reading has improved significantly (Goodman & Scott 1997, p. 189).

20. Specific reading disorder is associated with hard neurological signs.

False: Normally there are no focal neurological deficits.

21. School refusal may be secondary to a death in the family.

True: School refusal may be precipitated by problems in the family, such as illness, bereavement, or moving house (Gelder et al 2006, p. 689).

22. Child abuse is associated with an insecure attachment.

True: Child abuse is associated with inconsistent responses to the infant. This is a major risk factor for insecure attachment.

23. Children’s reporting of sexual abuse is consistently accurate.

True: Children’s reporting of childhood sexual abuse is usually accurate. The main reducer of accuracy is suggestion by poor interviewing, such as the use of closed questions. Deliberately false allegations are rare (1.5% in one study).

24. There is increased cortical activity in children with tic disorders.

True: PET and fMRI studies have shown decreased metabolism in frontal, cingulate and insular cortices (Gelder et al 2000, p. 1776).

25. Central abdominal pain is a common presentation in children with emotional problems.

True: Younger children may show their distress through abdominal pain, rather than by cognitive symptoms.

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