MRCPsych CASC: Assessment of School Refusal

This MRCPsych CASC Sample Case assesses a child's refusal to attend school. It is important to consider several key factors when evaluating the situation.

First, it is crucial to determine the age of the child and whether they desired to attend the scheduled appointment. It is also important to determine who is currently responsible for their care and if they have any connections to CAMHS (Child and Adolescent Mental Health Services) or social services.

The duration of the child's refusal to attend school should also be considered, as well as the different perspectives on the cause of the refusal from the child, their parents, and the school. It is important to determine if the child is refusing other situations.

If the child is exhibiting signs of separation anxiety, it is important to note that they may have worries about the safety of their caregiver and follow them closely in all situations. It is also important to assess the potential risks to the child, to others, from others, and for neglect.

It is important to consider any history of drug and alcohol use and the impact of the school refusal on the child's life at home, at school (academically), and with their friends. A mental state examination should be performed, evaluating the child's mood (such as low mood) and any potential symptoms of psychosis. The child's level of anxiety should also be assessed, including any possible experiences of bullying, checking and washing behaviours, and any specific concerns they may have about the school or a teacher.

A comprehensive developmental and psychiatric history should be obtained, as well as any history of medication use. The child's past medical history and family history should also be considered.

The management of the child's refusal to attend school may involve a gradual return to school, liaison with the school to address any potential bullying, and involving an educational social worker and psychologist as necessary. Incentives for attending school may also be implemented, and group tutorials should be considered if the child falls academically behind.

Virtual Scenario

Psychiatrist: Good afternoon, thank you for coming in today. Can you tell me a little bit about your child and their recent refusal to attend school?

Parent: Yes, my son has been refusing to go to school for the past few weeks. He used to love going to school, but now he just refuses to leave the house in the morning.

Psychiatrist: I see. How old is your son?

Parent: He is 11 years old.

Psychiatrist: Is he refusing to attend any other activities or events besides school?

Parent: No, just school. He seems to have a lot of anxiety about it.

Psychiatrist: I understand. Have you or the school noticed any changes in his behavior, mood, or overall functioning?

Parent: He has become increasingly withdrawn and has been complaining of low mood. He used to have a lot of friends, but now he just wants to be alone all the time.

Psychiatrist: That's concerning. Has there been any history of bullying or other adverse events at school?

Parent: Not that we're aware of. The school hasn't mentioned anything, and my son hasn't talked about it.

Psychiatrist: I see. Can you tell me about his developmental and psychiatric history?

Parent: He has never had any major developmental or psychiatric issues. He's always been a happy and healthy child.

Psychiatrist: Okay, thank you. Can you tell me about any medications he is currently taking and his past medical history?

Parent: He is not currently taking any medications, and he has no significant past medical history.

Psychiatrist: Alright. And what about his family history, is there any history of mental illness or substance abuse in the family?

Parent: No, there is no history of mental illness or substance abuse in our family.

Psychiatrist: Okay, thank you. Based on what you've told me, it seems like there may be some anxiety or mood-related issues contributing to his school refusal. I would like to perform a mental state examination to get a better understanding of his current state.

Parent: Yes, of course.

Psychiatrist: After the examination, we can discuss potential management options, such as graded exposure to school, liaising with the school to address any potential bullying, and involving an educational social worker and psychologist as necessary. We may also consider using incentives for attending school and providing group tutorials if necessary.

Parent: That sounds like a good plan. Thank you for your help.

Psychiatrist: You're welcome. We'll work together to help your son get back to school and feel more comfortable.

Preferred Choices for the Treatment of Bipolar Depression in Children: Mnemonic

Preferred Choices for the Treatment of Bipolar Depression in Children

The Maudsley Prescribing Guidelines in Psychiatry, 14th Edition, enlists lurasidone, olanzapine and quetiapine as the preferred choices of treatment for bipolar depression in Children.

Mnemonic: LOQ

• Lurasidone 
• Olanzapine
• Quetiapine 

See the Maudsley Prescribing Guidelines in Psychiatry for further details. 

Fragile X Syndrome

Fragile X Syndrome

Fragile x syndrome is characterised by large ears, velvety skin, flat feet, testicular enlargement after puberty, speech “cluttered” attentional deficit, hand flapping.

Autistic traits. CGG repeats over two hundred.

Support –MDT. Speech and language, physio, psychological techniques for teachers/parents, look at educational needs. family support –carers' assessment.

Genetic Aberration

A mutation on the X chromosome at the Xq27.3 site. 

Fragile-X mental retardation -1 Gene

FMR1 is a human gene that codes for a protein called Fragile-X mental retardation protein (FMRP) that may help regulate synaptic plasticity, important for learning and memory. 


Prevalence

1 of every 1,000 males

1 of every 2,000 females

Intellectual disability

Mild to severe. Eighty per cent of boys with fragile X syndrome have an intelligence quotient lower than 80.

Co-morbidities

Attention deficit hyperactivity, learning disorders, autism spectrum disorders

Physical Features

long face, long ears, high, arched palate, macroorchidism, hyperextensible finger joints, flat feet.

Fragile-X Syndrome is the best answer. An elongated face is the most common physical feature. Prominent ears are also common. Macroorchidism, which refers to an increase in the size of testicles, becomes apparent at age 8 to 10 years and 80% of post-pubertal boys exhibit the feature). These hallmark features are subtle during early childhood and normally only become prominent in early adolescence.

Mitral-valve-prolapse is the most common cardiac abnormality in these patients. Seizures are also common. Septal defects occur in those with down’s syndrome. See List ‎01‑3 Manifestations of Fragile-X Syndrome for details.

An elongated face is the most common physical feature. Prominent ears are also common. Macroorchidism, which refers to an increase in the size of testicles, becomes apparent at age 8 to 10 year and 80% of post-pubertal boys exhibit the feature). These hallmark features are subtle during early childhood and normally only become prominent in early adolescence.

-       List ‎01‑3 Manifestations of Fragile-X Syndrome

Hallmark features

Elongated face

Prominent ears

Macroorchidism^[1]        

Other manifestations

High-arched palate

Flat feet

Hyperextensible joints

Behavioural Characteristics

Attention-deficit

Hyperactivity [2]

Autistic symptoms [3]

Aggressiveness

Intellectual disability [4]

Medical

Seizures [5]

Mitral prolapse

What are the physical features seen in patients with Fragile X syndrome?

Patients with Fragile X syndrome have a high rate of what co-morbidities?

Patients with Fragile X Syndrome have what severity of intellectual disability?

What is the prevalence of Fragile X Syndrome?

Describe the chromosomal aberration in Fragile X syndrome.

---

[1] an increase in the size of testicles become apparent at age 8 to 10 year and 80% of post-pubertal boys exhibit the feature

[2] Most common behavioural manifestation

[3] Such as hand flapping, hand biting, perseverative speech, shyness, poor eye contact

^[4] Intellectual functioning differs in individuals with fragile-X, ranging from average intelligence to severe intellectual disability. Verbal IQ is more likely to be impaired.

^[5] Most common neurological condition

Staccato Speech

Staccato speech is because of incoordination of larynx muscle of articulation. In this, each the patient utters each syllable separately, thus speaking in fragments of sentences. Pauses punctuate these sentences, which interrupt and destroying the flow of speech. Such speech is abrupt, broken, and usually quite hard to follow for extended periods, and may make the speaker look confused or focused on something else. 

Scanning Speech Versus Staccato Speech

In cerebellar dysarthria, the patient speaks slowly and deliberately, syllable by syllable, as if scanning a line of poetry, and it loses the normal prosodic rhythm, and we call it a scanning speech. Staccato speech is similar and has an explosive character & slurring of consonants.  

Cause of Staccato speech

Cerebellar lesions in multiple sclerosis produce staccato speech.

Child Psychiatry MCQ for MRCPsych Paper B

A 7-year-old child came with his mother to your Outpatient clinic for assessment because of ongoing difficulties for the past 1 year. The mother shared that the child is always on the go and cannot sit still. Recently, he nearly had an accident when he dashed across the traffic junction. The school report card mentions he is inattentive most of the time.

What psychometric tool will you apply in this case?

CY-BOCS

CONNORS

ADOS

DISCO

CDI

Non-evidence-based Treatments for Autism Spectrum Disorders

The non-evidence-based treatments for Autism Spectrum disorders

What are some non-evidence-based treatments for children with autism spectrum disorders?

The following is a list of non-evidence-based treatments for autism spectrum disorders that are in common use.  

• Facilitated communication (not recommended)
• Holding therapy (not recommended)
• Sensory integration therapy, 
• Gluten-free/ casein-free diet, 
• Auditory integration training, 
• Chelation treatment, 
• Hyperbaric oxygen therapy, 
• Alternative biomedical treatments

What is the discrete trial format?

The discrete trial format:

It is one to one, Short and clear instructions, Planned, uses prompting and prompt fading, reinforcement.

What was the 1970s psychoanalytic approach to children with autism?

The 1970s psychoanalytic approach:

Applied Behavior Analysis (ABA), based on operant-conditioning, target behaviors (excess of unwanted and or deficits of wanted) are modified with reinforcement approximations (shaping).

Applied behavior analysis, also called behavioral engineering,
applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. It is the applied form of behavior analysis; the other two forms are radical behaviorism and the experimental analysis of behavior. (Wikipedia)

What are the psychoanalytic approaches to the treatment of patients with autism?

Holding therapy (Tinbergen 1983):
A failure to bond Parent holds child to cause the autistic defense to crumble.

Humanistic play therapy (Axline 1965): Encouraged the expression of feelings through play and unconditional positive regard.

OPTIONS (Kaufman 1976) Parents spent every waking hour with child follow child lead

Causes of school refusal in children

• Physical illness (most common) 


• Anxiety and depression 


• Deliberately kept home by parents 


• Truancy


• Miserable conditions at school e.g. Bullying