10 ChildPsychiatry PDF
10 ChildPsychiatry PDF
10 ChildPsychiatry PDF
Child Psychiatry
Paper B Syllabic content 10
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1. Adult mental illness and children
¬ The consequences on the child of parental mental illness affect their infancy, toddlerhood, preschool
age, school age and adolescence. The best-‐‑studied example of the influenced of parental illness on
child’s mental health is that of maternal depression.
¬ It is important to note that the effects of parental mental illness on children are mediated by complex
factors.
¬ Rutter has outlined a number of possible mediators of the effect of parental psychiatric disorder on a
child. First, the direct pernicious impact of exposure to the parental disorder. Second, an indirect
impact due to altered interpersonal behaviour and parenting capacity. Third, mediator variables, such
as the social adversity, genetic or constitutional factors could play a part (Murray & Cooper, 1997).
¬ Consequences of maternal depression on a growing child is summarised below:
Prenatal effects!
• Poor nutrition, higher preterm birth, low birth weight, pre-
eclampsia!
Effect on toddler!
• Passive noncompliance, reduced expression of autonomy,
internalizing and externalizing problems, and reduced social
interaction (e.g. no cooperative play)!
Adolescents!
• Affective disorders (depression), anxiety disorders, phobias,
panic disorders, conduct disorders, substance abuse and
alcohol dependence!
Adapted from Canadian Paediatric Society, Maternal depression and child development. (2004). Paediatrics & Child Health, 9(8),
575–583; Murray, L & Cooper, PJ.
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2. Negative life events during development
¬ Childhood adversities are significantly associated with adult mental disorders as shown in numerous
epidemiological studies.
¬ The association between retrospectively reported childhood adversities and the first onset of a wide
variety of mental disorders across the life course was studied in epidemiological surveys in 21
countries in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative
(Kessler et al., 2010). Some notable findings from this large study are as follows:
o Parental death is the most common childhood adversity (11.0–14.8%).
o Other adversities included physical abuse (5.3–10.8%), family violence (4.2–7.8%) and parental
mental illness (5.3–6.7%).
o Multiple childhood adversities (mean = 2 or more in nearly 2/3rd) were common among
respondents with any childhood adversities.
o Adversities associated with maladaptive family functioning elevate the risk of adult psychiatric
disorders (all major DSM-‐‑IV disorders) with an odds ratio of 1.3–2.4; the risk was lower and often
insignificant for other types of childhood adversities. These results were strikingly consistent
globally.
Child Abuse
¬ Physical abuse involves the intentional injury of a child by someone. Physical abuse can be defined as
any act that results in a nonaccidental physical injury, such as beating, punching, kicking, biting,
burning, and poisoning.
¬ Sexual abuse of children refers to sexual behaviour between a child and an adult or between two
children when one of them is significantly older or uses coercion. The perpetrator and the victim may
be of the same or opposite sex. The sexual abuse may be non contact or contact abuse and may include
exhibitionism; nongenital or genital fondling; fellatio; cunnilingus; or vaginal or anal penetration.
¬ Depression, PTSD, conduct disorders, somatisation and suicidal behaviour is seen in those with a h/o
sexual abuse. Girls are more often the victims [4:1], 90% abusers are male. Avg age 9-‐‑11 years
depending on the study.
¬ Psychological abuse or emotional abuse occurs when an adult repeatedly conveys to a child that he or
she is worthless, defective, flawed, unloved, or unwanted, flawed or endangered.
¬ Neglect, the most prevalent form of child maltreatment, is the failure to provide adequate care and
protection for children. Malicious or ignorant withholding of physical, emotional, and educational
necessities can harm children. Neglect includes failure to feed children adequately and to protect them
from danger.
¬ Of the cases reported, approximately 60% are for neglect, 20% for physical abuse, 10% for sexual
abuse, and 10% for other forms of maltreatment (e.g., psychological abuse, abandonment etc)
¬ Child maltreatment is a non-‐‑specific risk factor for multiple forms of psychopathology. They also have
increased rates of posttraumatic stress disorder, depression, self-‐‑destructive behaviour and borderline
traits, sexually inappropriate behaviours, drug and alcohol problems, eating disorders, oppositional
defiant disorder and conduct disorder.
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Signs of possible physical abuse
• Unexplained injuries,bruises or burns, especially if recurrent
• Improbable excuses given for injuries
• Refusal to discuss injuries
• Untreated injuries or delay in reporting them
• Excessive physical punishment
Signs of possible physical neglect
• Constant hunger
• Poor personal hygiene
• Constant tiredness
• Poor state of clothing
• Frequent lateness or non-‐‑attendance at school
• Untreated medical problems
Signs of possible non-‐‑organic failure to thrive
• Significant lack of growth
• Weight loss and hair loss
• Poor skin or muscle tone and circulatory disorders
Signs of possible emotional abuse
• Low self-‐‑esteem, continual self-‐‑deprecation
• Sudden speech disorder
• Rocking, head-‐‑banging, or other neurotic behaviour
• Self-‐‑mutilation
Signs of possible sexual abuse
Behavioural
• Lack of trust in adults or over-‐‑familiarity with adults
• Fear of a particular individual
• Social isolation, withdrawal, and introversion
• Sleep disturbances (nightmares, irrational fears, bed wetting, fear of sleeping alone, needing a nightlight)
• Running away from home
• Girls taking over the mothering role
• Unusual interest in genitals of adults, children, or animals
• Expressing affection in inappropriate ways
• Developmental regression
• Over-‐‑sexualised behaviour
Physical/medical
• Bruises, scratches, or other marks to the thighs or genital area
• Itch, soreness, discharge, unexplained bleeding from the rectum, vagina, or penis
• Pain on passing urine or recurrent urinary tract infection
• Recurrent vaginal infection
• Venereal disease
• Stained underwear
• Discomfort/difficulty walking or sitting
• Pregnancy, particularly when reluctance to name father
• Higher morning cortisol levels, than non abused children
Adapted from; Oxford Handbook of Psychiatry, 1st Edition
© SPMM Course 4
¬ Factitious disorder/Munchausen’s syndrome by proxy: when a person feigns or induces illness in a
child or others in order to obtain medical attention. A form of child abuse. Can be hard to detect as the
perpetrator may cover up or deny behaviour. Need to be aware when a young person repeatedly
presents for medical attention.
¬ Although child abuse occurs at all socio-‐‑economic levels, it is highly associated with poverty and
psychosocial stress, especially financial stress.
¬ Physical abuse most commonly begins around adolescence. Child maltreatment is strongly correlated
with less parental education, underemployment, poor housing, welfare reliance, and single parenting.
¬ Child abuse tends to occur in multiproblem families, that is, families characterized by domestic
violence, social isolation, parental mental illness, and parental substance abuse, especially alcoholism.
¬ Risk factors in the parent(s): young age, low IQ, criminal record, poor parenting skills, experience of
absue/neglect as a child and psychiatrc problems.
¬ Risk factors in the child include prematurity, congenital malformation, intellectual disability, chronic
illness, difficult temperament (eg. crying a lot).
¬ The risk of child abuse increases in families with many children.
Sexual Abuse
¬ Socioeconomic status is unrelated to the incidence of child sexual abuse, but lower socioeconomic
classes are more likely to come to attention.
¬ There is an inverse relationship between self blame and powerlessness in sexually abused children.
¬ Most common relationship is stepfather and stepdaughter
¬ Social, cultural, physiological, and psychological factors all contribute to the breakdown of the incest
taboo. Incestuous behaviour has been associated with alcohol abuse, overcrowding, increased physical
proximity, and rural isolation that prevent adequate extra familial contacts.
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3. Attention Deficit Hyperactivity Disorder
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Prevalence:
¬ Using DSM-‐‑IV criteria, proposed general prevalence in school age children is about 5%. Using ICD-‐‑10
criteria , prevalence is approximately 1-‐‑2%(Shorter Oxford Textbook of Psychiatry, 6th Edition).
¬ The prevalence in UK children, using DSM IV criteria is 3-‐‑4% (The British Child and Adolescent
Mental Health Survey 1999: the prevalence of DSM-‐‑IV disorders)
¬ ADHD is 3 times more prevalent in boys than in girls, and more common in areas of social deprivation
and amongst children living in institutions
Aetiology:
¬ Genetics: Siblings have 2-‐‑3 times increased risk; heritability of approximately 80%. Greater
concordance in monozygotic compared with dizygotic twins [concordance 79% in monozygotic and
32% in dizygotic twins]. Genes 5, 6, and 11 implicated. This condition is associated with dopamine
transporter gene [DAT1] and dopamine D4 receptor gene. SNAP-‐‑25 gene may also have a role.
¬ Neuroimaging: Areas of brain affected include:prefrontal cortex, striatum and cerebellum. Studies
using positron emission tomography (PET) have found lower cerebral blood flow and metabolic rates
in the frontal lobe areas of children with ADHD than in controls. PET scans have also shown that
adolescent females with the disorder have globally lower glucose metabolism than both normal
control females and males with the disorder.
¬ Neurotransmitters: DA and NA dysregulation in the prefrontal cortex is implicated. The most widely
studied drugs in the treatment of ADHD, the stimulants, affect both dopamine and norepinephrine,
leading to neurotransmitter hypotheses that include possible dysfunction in both the adrenergic and
the dopaminergic systems. Serotonin may have a role in modulating dopamine transmission and the
expression of ADHD.
¬ Potentially important environmental factors include a)prenatal and perinatal obstetric complications
b) low birth weight & prematurity c) prenatal exposure to alcohol, nictine and benzodiazepines d)
poor attachment and severe early deprivation e) institutional rearing
¬ Idiosyncratic reactions to food, Other food additives, lead exposure to toxic levels are not supported
by research evidence.
¬ Previous research shows that ADHD occurs in head injury in 25% cases. Retrospective cohort study
published in BMJ found that head injury before the age of 2 years does not seem to be causal in the
development of ADHD. Medically attended injury before 2 years of age may be a ‘marker’ for
¬ The quality of relationships within the family and at school can be considered as protective or
maintaining factors.
¬ Comorbidity: 50-‐‑80% of children with ADHD have a comorbid disorder. 50% children may meet
criteria of 2 comorbid conditions. Common comorbid problems in childhood include oppositional
defiant disorder (40%), anxiety disorder (34%); conduct disorder (14%), tics (11%) and mood disorder
(6%) (Young et al, 2011, BMC Psychiatry)
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Outcome:
¬ Approximately 15% of cases continue to meet diagnostic criteria for ADHD at the age of 25 years.
(Young et al, 2011, BMC Psychiatry). A further 50% of individuals will suffer some impairment from
residual symptoms.
¬ Children with hyperkinetic disorders are 5 times greater risk for antisocial behaviour, substance abuse
and other psychiatric disorders. 15-‐‑20% develop substance misuse problems
¬ Many children initially diagnosed with ADHD, combined type, exhibit fewer impulsive-‐‑hyperactive
symptoms as they get older and, by the time they are adults, will meet criteria for ADHD, inattentive
type.
¬ Poor prognosis depends on early stressful life experiences such as due poverty, overcrowding,
expressed emotions and parental psychopathology. Prognosis is worse when the symptoms are severe,
predominantly hyperactive-‐‑impulsive in nature, and associated with conduct, language or learning
disorder.
Management
¬ Treatment [long term, multimodal]: Before resorting to pharmacological treatments, efforts should be
made to provide psychological and social interventions. If medication is being considered, the young
person/family need to consent, and must be aware of the possible side effects of treatment.
¬ General management principles are:
o Educational/remedial interventions
o Parent training programme for child management skills– based on social learning theory and
behavioural interventions
o Individual/family/group therapies
o CBT methods, especially behavioural, are often effective
o Social skills training
¬ MTA Study: The Multimodal treatment study of children with ADHD was the largest, most rigorous
randomised controlled trail to date, involving 579 children. Despite methodological issues raised by
few authors, it is a trial that confirmed the effectiveness of medication management in children and
adolescents. The trial also found that intensive behavioural therapy involving the child; family and
teachers added little to well supervised medication management. However, psychological
interventions are important for families who do not wish to use medication. Also, there is lack of
evidence of efficacy over prolonged periods of treatment with medication.
¬ Stimulants – release noradrenaline, dopamine and also serotonin, increasing extracellular dopamine
and thus ‘inhibit’ impulses, helping persistence in motor and cognitive functions. They are rapidly
absorbed following oral administration.
¬ Methylphenidate has most rapid onset 1-‐‑3hr, and shortest half-‐‑life 2-‐‑3 hours so the effects wear off in
4-‐‑6 hours. Methylphenidate dose range – 5-‐‑60mg/day. Growth retardation may occur during acute
treatment, but no significant retardation seen in long term. Note: Prescription of stimulants does not
increase the rate of substance abuse by the patients.
¬ Pimoline is no longer licensed in UK as it causes abnormal liver function tests, and in some cases liver
failure following long term use.
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¬ Atomoxetine is a noradrenaline reuptake inhibitor – good evidence for use in hyperkinetic disorders.
It increases noradrenaline in the synaptic cleft. It doesn’t affect dopamine levels, and hence doesn’t
cause more tics. In December 2012, MHRA issued a note highlighting that Atomoxetine can cause
clinically relevant increases in blood pressure or heart rate, or both, in a small proportion of patients
and suggested monitoring heart rate and BP.
¬ Monitoring: Height, weight, blood pressure, heart rate monitoring is recommended for
methylphenidate (initially 3 monthly, then 6 monthly). Atomoxetine rarely causes liver damage; so
routine monitoring of LFT is not warranted. The MHRA also advises that patients on Atomoxetine
should be monitored for signs of depression, suicidal thoughts or suicidal behaviour. Monitoring of
height and weight is also recommended, initially three monthly and then six monthly.
Stimulants (methylphenidate)
1st Line Specifically treat ADHD core symptoms Adverse effects:
Medication [hyperactivity>inattention] Appetite, weight loss
Largest and most rapid effect on ADHD of any drug Sleep disturbance (if taken late in day)
class, indirect sympathomimetic by increasing DA and Cramps (first few weeks)
AND release. Headaches
Calms comorbid aggression and oppositional-‐‑defiant Mild BP and pulse increase
behaviour Evening crash
Except for pemoline, medically safer than most constricted affect and spontaneity, emotional
psychoactive drugs blunting, social withdrawal,
Results of given dose seen immediately; relatively easy Depression
titration Tics
Now available in XL preparation Hallucinations (skin crawling, visions)
Mild growth slowing first 2 years
Dose for behaviour may not be optimal for attention
(normal dose: Initially 5-‐‑10 mg daily titrated up to a
maximum of 60 mg/day in divided doses using
weekly increments of 5-‐‑10 mg.)
Atomoxetine
Noradrenaline reuptake inhibitor Adverse effects:
Specifically treats ADHD core symptoms Appetite, weight loss
Nearly as effective as stimulants; may help stimulant Gastrointestinal Sx (nausea, vomiting, diarrhea,
failures constipation)
Continuous duration of effect Fatigue, dizziness
Little or no insomniac side effect Probable, mild growth slowing
Can be given any time of day –once daily Allergic reactions
No tic side effect (good choice with comorbid tics ) Possibly longer time than stimulants to flush out if
May help comorbid depression adverse effect
Slower attainment of full effect than stimulants
Antidepressants
Tricyclics Treat both ADHD and comorbid depression and anxiety Adverse effects:
Helps some stimulant non-‐‑responders Sedation
Third most effective drug class for ADHD (except for BP changes (down or up)
SSRIs, which are not very effective) Dizziness (especially on standing)
Some patients/families who are prejudiced against Dry mouth
stimulants will accept antidepressants Cardiac conduction block: TCAs require ECG
May equal stimulant effectiveness for adults monitoring in children
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Alpha 2 agonists
Treat both hyperactivity-‐‑impulsiveness and comorbid tic Adverse effects:
disorder or comorbid aggression Response delayed
Helps some nonresponders to stimulants and Sedation
antidepressants Hypotensive dizziness (especially postural)
Good for those overaroused, possibly with comorbid Dry mouth
anxiety Rare hallucinations
Hypertensive rebound if dose missed
Not as helpful for attention as stimulants
Antipsychotics
May work when stimulant or atomoxetine does not, Adverse effects:
especially if stimulant makes worse Sedation
Good for comorbid anxiety, aggression, tic disorder, or Extrapyramidal side effects
bipolar disorder Endocrine effects
Tardive dyskinesia
Paradoxical agitation (akathisia)
Weight gain
Not specific. generally less effective than stimulants
or atomoxetine
Riskiest drug, last resort
Adapted from Lewis’s Child & Adolescent Psychiatry: A comprehensive textbook 4th edn
© SPMM Course 10
4. Disorders of childhood conduct
Disorders of childhood conduct comprise of (a) Conduct Disorder and (b) Oppositional Defiant Disorder.
Conduct disorder (CD) is characterized by a severe and persistent pattern of antisocial, aggressive or
defiant behaviours that defy age-‐‑appropriate societal norms. Oppositional Defiant Disorder (ODD) also
involves a persitent pattern of defiant behaviour. However, the behaviour in the latter does not defy age-‐‑
appropriate societal norms to the same extent as in CD. According to ICD10, oppositional defiant
disorder is a subtype of conduct disorder. DSM-‐‑5 excludes oppositional disorder if a conduct disorder is
present.
Conduct Disorder
Diagnostic criteria:
¬ Children with conduct disorder are likely to demonstrate behaviours in the following four categories
o Physical aggression or threats of harm to people, cruelty to people and animals
o Destruction of their own property or that of others
o Theft or acts of deceit
o Frequent and serious violation of age-‐‑appropraite rules (Like truating or running away)
¬ ICD-‐‑10 requires at least one behaviour to be present for at least six months. According to DSM-‐‑5
criteria, atleast 3 out of a list of 15 behaviours should begin before the age of 13, for a period of 12
months. DSM-‐‑5 has added a limited prosocial emotions specifier to the diagnosis of conduct disorder
for children who do not meet the full criteria but present with limited prosocial emotions, such as
limited empathy and guilt. Other specifiers retained from DSM-‐‑IV a childhood onset type – symptoms
present before age 10 and an adolescent onset type – symptoms develop after age 10.
¬ CD is the cause of great suffering in both the individual and in society; it is one of the major risk
factors for adult antisocial behaviour, posing a major burden on public resources. Conduct disorder
occurs with greater frequency in the children of parents with antisocial personality disorder and
alcohol dependence than in the general population. In the Isle of White study, CD was found to be the
most common psychiatric disorder amongst 10-‐‑11 year olds.
¬ A prevalence of 5-‐‑7% is noted in the UK (Oxford Handbook of Psychiatry, 3rd Edn.). The disorder is
more common among boys than girls, and the male: female ratio is 4:1.
Aetiology:
¬ Ontario Child Health Survey[1987] : Three most significant risk factors:
o Family dysfunction
o Parental mental illness
o Low income
¬ Rutter [1978] :
o Low socioeconomic status, [Low family income]
o Criminality of father,
o Overcrowding,
o Maternal neurosis,
o Institutional care
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o Chronic marital discord
¬ Biological risk factors:
o Genetic: CD clusters in families. Heritable trait of being more susceptible to externalizing disorders
in general (CD, ODD and and ADHD) (Shorter Oxford Textbook of Psychiatry, 6th Edition).
o Temperament: ‘callous-‐‑unemotional’
o Brain injury
o Neurochemical: Low CSF serotonin, deficient serotonergic activity is seen in those with early onset
and more aggressive behaviour. Autonomic under-‐‑arousal e.g., consistent lower mean resting
heart rates, lower electro dermal activity etc. HR indices can predict later onset of aggression.
Low salivary cortisol levels are also reported.
o Low IQ. Performance IQ may be higher than Verbal IQ
o Neuroimaging: Prefrontal brain regions may have reduced volumes in affected children.
¬ Psychosocial risk factors:
o Maternal smoking during pregnancy
o Parental criminality and substance abuse
o Harsh and inconsistent parenting
o Lack of a warm parental relationship and cold/rejecting family relationships
o Domestic violence in the family and child abuse
o Large family size
o Low socio-‐‑economic status / Low family income and social disadvantage
o Early loss and deprivation
o School failure and poor school achievement
o Social isolation;
o Exposure to urban life does not increase the rate of conduct disorders, though some studies have
found higher prevalence rates in urban locations
Outcome
¬ Childhood conduct disorders further predict risk for numerous problems in adulthood that includes
(Moffitt et al-‐‑2002)
o Criminality and antisocial personality disorder. Less than 50% of conduct disorder children have
persistent and severe antisocial problems as adults (Zoccolillo et al 1992).
o Serious difficulties in education, work and finances
o Homelessness and abuse
o Drug and alcohol dependence
o Poor physical health including injuries, sexually transmitted infections, compromised immune
function
o Variety of mental disorders and suicidal behaviour
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Protective factors
• Female gender
• High IQ
• Resilient temperament
• Good parenting
• Warm relationship with a key adult
• Commitment to social values
• Increased economic equality.
Treatment:
¬ As the causes and risk factors are multifactorial, treatment is multimodal. Explore specific support for
academic and social skills. Psychological therapies form the mainstay of treatment for conduct
problems. Parent Management Training based on the principles of social learning theory has been very
successful in altering the course of conduct disorders. NICE recommends that group based parent
training/education programmes should be the mainstay of treatment for children of 12 years and
under with oppositional defiant disorder and conduct disorder.
¬ Cognitive behavioural therapy: CBT for conduct problems in children and adolescents typically includes
social skills training and anger management. The most common targets are aggressive behaviour,
social interactions, self-‐‑evaluation and emotional dysregulation.
¬ Functional family therapy: One of the best-‐‑known interventions for serious antisocial behaviour is
functional family therapy. It is designed to be practicable and relatively inexpensive. The target age
range is 11-‐‑18 years. Between eight and twelve 1-‐‑hour sessions are given in the family home to
overcome attendance problems. For more intractable cases, 12-‐‑16 sessions are offered and it usually
lasts for three months. There are four phases of treatment which includes Engagement, Motivation,
Behavioural Change and Generalisation. The aim is first to keep the family in treatment and only then
to move on to finding what precisely they want. The therapist must understand the parents’ goals
before specific techniques are taught. Functional family therapy addresses family processes, which
need to be present, such as improving communication between parent and young person, reducing
interparental inconsistency, tightening up on supervision and monitoring, and negotiating rules and
the sanctions to be applied for breaking them. Functional family therapy has been shown to reduce
reoffending rates by around 50 per cent.
¬ Multisystemic therapy: It is one of the best-‐‑developed treatments of conduct disorder, which rests on
nine treatment principles. The clinicians take on only four to six cases at a time and the team is
available 24 hours a day. Treatment is usually given for three months and then stopped. In
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Multisystemic therapy the young person'ʹs and family'ʹs needs are assessed in their own context at
,
home and in their relationships with other systems such as school and peers. Following the
assessment, proven methods of intervention is used to address difficulties and promote strengths. In
this therapy, assessing and promoting the strengths in the young person and the system is very
important. The therapist is responsible for ensuring appointments are kept and for making change
happen—families cannot be blamed for failing to attend or ‘not being ready'ʹ to change. Regular
written feedback on progress towards goals from multiple sources is gathered by the therapist and
acted upon and the parents and teenagers fill in weekly questionnaires on whether they have been
receiving therapy as planned. There is close attention to ‘quality control’ by offering weekly
supervisions and the supervisor checks adherence weekly. Several randomised controlled trial attest to
effectiveness, with reoffending rates typically cut by half and time spent in psychiatric inpatient care
further reduced.
¬ Other treatment options:
o Treat any comorbidity
o Address any child protection concerns
o Anger Management Programmes
Depressive disorder
¬ The same diagnostic criteria for a major depressive episode apply in both adult and youth
populations, but the way that young people can present can vary (see ‘clinical features’ section below).
Core symptoms of low or irritable mood, fatigue or anhedonia, along with at least five other
symptoms, such as social withdrawal, worthlessness, guilt, suicidal thoughts or behaviour, sleep
increase or decrease, decreased motivation and/or concentration, and increased or decreased appetite.
¬ The prevalence of depression amongst young people is increasing. Pre-‐‑puberty: about 1%, no sex
difference; Post-‐‑puberty: about 3%, commoner in females.
¬ 50% of young people with depression remain clinically depressed after 12 months. Most young people
with major depression will recover from the episode within 2 years. Adolescent depression however
shows significant continuity [eg 30% will have a recurrence within 5 years] into adulthood.
¬ The single most important distinction between depression as an illness and the normal ups and downs
of childhood and adolescence is that depression is associated with functional impairment, mediated
through the intensity, duration, and lack of responsiveness of depressed mood and associated
symptoms.
¬ The full, pure clinical syndrome of depression is very uncommon before puberty. In early adolescence,
cognitive changes such as formal operational thought allow hopelessness to be experienced and a
clinical picture akin to adult depression can be seen. Depression should only be diagnosed when there
is impairment of social role functioning, or with symptoms leading to significant suffering, or
psychopathy eg suicidality.
¬ It is important to rule out organic pathology and ask about possible substance misuse/abuse .
Clinical features:
¬ Young children: Poor feeding, failure to thrive, tantrums, irritability, separation anxiety, hyperactivity,
regressed behaviour such as enuresis, soiling etc.
¬ Older children: Somatisation like pain in head, abdomen, chest and/or Hypochondriacal ideas, school
refusal, Poor academic achievement at school, decline in school work, sleep disturbance, antisocial
behaviour
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¬ Adolescents: Low mood may not be fixed and is more influenced by environment. Anhedonia and
social withdrawal are powerful indicators of the presence of depression. Other features may include
Low self-‐‑esteem, biological symptoms, suicidal acts, behavioural problems, and substance abuse.
¬ Serious depressive episodes are rare before puberty, increasing in mid and late adolescence to adult
levels. Clinical features are essentially the same as in adulthood but impairment may not be as salient,
as in adults.
¬ Dysthymic disorder is a chronic condition with fewer symptoms than major depression, but lasts a
minimum of one year.
¬ Risk factors: 95% of major depression in young people is seen in children with longstanding
psychosocial dificulties. Other risk factors include
o Family history of depression
o Early loss of a parent
o Parental separation, divorce and marital conflict
o Stressful life events
o History of abuse (physical, emotional and sexual)
¬ Maintaining factors
o Persistence of subthreshold symptoms
o Scarring: First episode of depression sensitizes people to further episodes
o Personality, temperament, cognitive abiities
o Persisting adversity
o Comorbidity
¬ Comorbidity: Comorbidity is the rule (50-‐‑80%) rather than the exception in depressed children and
adolescents. Anxiety [50 – 80%] is frequently a precursor of mood disorder and may also occur
simultaneously with depression. Conduct disorder – 25% , OCD – 15%, eating disorder – 5%
¬ ADHD and depression are also often co morbid and the two disorders may be co transmitted in
families. Alcohol, drug, and tobacco abuse and conduct disorder are associated with depression
Treatment
¬ Establish therapeutic alliance and provide education to the child and family. A multidisciplinary
approach should be adopted.
¬ Mild depression: 2 weeks of watchful waiting. After 4 weeks – supportive therapy, self help or group
CBT. With self help consider, advice on exercise, sleep hygiene and anxiety management to the young
person. Moderate to severe depression – CAMHS review, +/-‐‑ 3 months of individual CBT, IPT, or
shorter term family therapy. Consider an alternate psychotherapy if first mode doesn’t help. CBT can
reduce the duration of illness as compared to the other psychological treatments. NICE guidance for
moderate to severe depression recommends psychotherapy before considering pharmacotherapy.
¬ Combination treatment should be considered in all cases (i.e. psychotherapy + medication).
¬ Several studies have demonstrated efficacy with selective serotonin reuptake inhibitors (SSRI)
antidepressants, especially using fluoxetine. NICE guideline recommends fluoxetine as first line and
sertraline or citalopram as second line. Fluoxetine is the best-‐‑studied antidepressant with the strongest
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efficacy data, and consequently is the only antidepressant to receive FDA and MHRA approval and
has been allowed by CSM for use for the treatment of depression in children and adolescents. Monitor
for emergence of agitation, irritability, unusual changes in behaviour and emergence of suicidality at
initiation and when dosages are changed. Paroxetine – evidence shows that Paroxetine has little
impact to treatment, symptom levels, functional status or clinical improvement. Paroxetive is also
more likely to bring serious adverse effects [and discontinuation] and increased suicidal behaviour.
¬ TCAs are not supported by trials and have been associated with cardiac toxicity.
¬ Psychotherapy is considered as a reasonable initial treatment in mild to moderate depression and this
may be individual, group, or family therapy. CBT is one of the most researched techniques, but IPT,
behaviour therapy, psychodynamic therapy, and supportive therapy are used.
¬ Treatment of Adolescents with Depression Study (TADS) : TADS is the only published study to compare
CBT, fluoxetine, their combination, and placebo. In this large [n=439], well-‐‑powered investigation, CBT
(43% significantly improved) was not superior to placebo (35%), whereas both combination (71%)
including fluoxetine, and fluoxetine alone (61%), were markedly superior to both CBT and to placebo.
The combination treatment (CBT + fluoxetine) showed a faster recovery than any of the other
treatments, although fluoxetine alone had a favourable outcomes with respect to the Clinical Global
Impression Improvement (CGI-‐‑I) and baseline-‐‑adjusted endpoints and in more severely depressed
patients. Combined treatment was superior to fluoxetine alone with regard to remission (37 vs. 20%).
¬ A possible explanation for the relatively weak performance of CBT in this study could be the nature of
TADS treatment package, which attempted to deliver a large number of approaches such as problem
solving, behaviour activation, cognitive restructuring, emotion regulation, relaxation training etc in a
brief period.
¬ ECT not recommended for 5-‐‑11 year olds. In older persons, only in severe depression, life threatening
symptoms, or severe intractable symptoms not responding to other treatment.
¬ Suicide is the third leading cause of death for adolescents, following accidents and homicides (Hawton
1986). 12% of adolescent deaths are due to suicide. Male suicides outnumber females at all ages and in
all cultures.
¬ Suicidal ideation is very common in adolescents – 14% boys, 25% girls. Suicide attempts and
deliberate self harm (DSH) are more common in females, completed suicides are more common in
males.
¬ Few adolescents who make suicide attempts actually have psychiatric disorder and serious suicidal
intent is low. In contrast, almost all children and teenagers who commit suicide suffer from a
psychiatric disorder at the time of death – mood disorder, alcohol/substance abuse, anxiety disorders,
or conduct disorders.
¬ Self-‐‑poisoning is the commonest form of parasuicide-‐‑the usual agents, being analgesics and
psychotropic agents. Others include attempted hanging, jumping from heights, car exhaust fumes and
shooting being most frequent. Hanging is the most common method used by boys who completed
© SPMM Course 17
suicide. Overdose or jumping from heights is the most common method used by girls who completed
suicide.
¬ 10% of adolescents who attempt suicide repeat within a year. 40% suicides will have made a previous
suicide attempt.
Bipolar disorder
¬ The symptoms of mania commonly reported in children include: increased energy,distractibility,
pressured speech, irritability, grandiosity, racing thoughts, decreased need for sleep, euphoria/elation,
flight of ideas and poor judgement.
¬ Children experiencing a manic episode typically present with atypical or mixed features characterized
by irritability, labile mood and behavioural problems. Mood lability is a common and impairing
presentation in youth, which may not always be a sign of mood disorder.
¬ Elated/euphoric mood and irritability are the two symptoms with the most variability in rates across
studies. However, though there was also significant heterogeneity in the rates of decreased need for
sleep, racing thoughts, poor judgment, pressured speech, and distractibility.
¬ Epidemiology: Prevalence in adolescents is approximately 1% and as high as 6% when including soft
subsyndromal symptoms. M>F in childhood cases; M=F in adolescents. Retrospective studies in adults
with Bipolar Affective Disorder have consistently reported that up to 60% had the onset of their mood
symptoms before the age of 20 years.
¬ Co-‐‑morbidity: Approximately 70% have ADHD, 40% ODD, 30% anxiety disorder, 40% have substance
misuse problems, 8% Tourette’s syndrome and 3% bulimia nervosa.
¬ Outcome: Early onset BPD has a poor outcome with 50% showing long-‐‑term decline in function. The
course is often chronic and less responsive to treatment, with atypical and rapid-‐‑cycling features
especially difficult to treat.
¬ Some studies suggest that approximately 20% of adolescents who have an episode of major depression
experience a subsequent manic episode by adulthood. In depressed children and adolescents, the
following features predict subsequent development of mania
o Rapid onset depressive episode with psychomotor features
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o Depressive episode with psychotic features
o Family history of mood disorder, especially mania
o History of hypomania or mania following treatment with antidepressant medications
¬ Suicide risk is high with rates of completed suicide approximately 10%.
¬ Treatment: NICE guidelines on bipolar disorder in children & adolescents recommend using adult
medication guidelines but in lower doses. Atypical antipsychotics (Olanzapine, Risperidone) are
preferred first line for acute mania followed by valproate/lithium.For maintenance the same choice of
medication that controlled manic symptoms is preferred.
¬ Polycystic ovaries and associated infertility are particular concerns when valproate is used for
adolescent girls and NICE recommends avoiding its use in girls and young women.
¬ As children have a higher renal filtration rate, and higher proportion of body water, higher doses of
lithium (mg/kg of body weight) may be needed [to achieve a level of 0.4-‐‑1.0 mEq/L]. In younger
children, neurological side effects such as tremors , drowsiness, ataxia and confusion may be seen moe
often than in adults.
Epidemiology:
¬ Schizophrenia in prepubertal children is exceedingly rare; In adolescents, the prevalence of
schizophrenia is estimated to be 50 times that in younger children, with probable rates of 1 to 2 per
1,000. Boys seem to have a slight preponderance among children diagnosed with schizophrenia and
are often identified at a younger age than girls.
¬ In very early onset schizophrenia, onset before age 13, the sex ratio is approximately 2:1 with males
predominating.
¬ All of the symptoms included in adult-‐‑onset schizophrenia may be manifest in children with the
disorder. Childhood onset schizophrenia is characterised by more negative symptoms, disorganised
behaviour, greater disorganisation both of thought and sense of self and fewer systematized or
persecutory delusions. It also runs a more chronic course with less chance of a full recovery. The onset
is frequently insidious; after first exhibiting inappropriate affects of unusual behaviour, a child may
take months or years to meet all of the diagnostic criteria for schizophrenia.
¬ Premorbid course: EOS cases have increased delays in language, reading, bladder control, and social
functioning than adult-‐‑onset cases. Reports have documented marked neuropsychological deficits in
attention, working memory, and premorbid IQ among children who develop schizophrenia and its
spectrum disorders. These premorbid manifestations also indicate a genetic/developmental
component to schizophrenia
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Clinical features
¬ Children who eventually meet the criteria often are socially rejected and clingy and have limited social
skills. They may have histories of delayed motor and verbal milestones and do poorly in school,
despite normal intelligence. They often have an insidious onset. Desuions and hallucinations are
prominent especially in those whopresent to services. Visual hallucinations are experienced by a
significant number of children with schizophrenia and are often frightening. Delusions are present in
more than one half of children with schizophrenia; the delusions take various forms, including
persecutory, grandiose, and religious. Delusions increase in frequency with increased age Blunted or
inappropriate affects appear almost universally in children with schizophrenia. Children with
schizophrenia may giggle inappropriately or cry without being able to explain why.
Formal thought disorders, including loosening of associations and thought blocking, are common
features among children with schizophrenia. Illogical thinking and poverty of thought are also often
present. These clincal symptoms are associated with poor premorbid function with developmental
delays.
¬ It is important to rule out organic conditions (such as TLE, Thyroid disease, brain tumour, Wilson’s
disease).
Aetiology:
¬ Genetic factors: Schizophrenia is known to be up to eight times more prevalent among first-‐‑degree
relatives of those with schizophrenia than in the general population. Heritability estimates are as high
as 82%. 5-‐‑10% risk amongst first degree relatives of people with schizophrenia compared with 0.2-‐‑0.6%
amongst first degree reltives of controls. Adoption studies of patients with adult-‐‑onset schizophrenia
have shown that schizophrenia occurs in the biological relatives, not the adoptive relatives. Genetic
evidence is supported by higher concordance rates for schizophrenia in monozygotic twins than in
dizygotic twins; cytogenetic abnormalities are more common in early onset cases than in Adult onset
cases.
¬ Brain imaging: enlarged lateral ventricles compared with AOS; Recent studies have documented grey
matter loss in the brains of children with COS that started in the parietal region and proceeded
frontally to dorsolateral prefrontal and temporal cortices, including superior temporal gyri.
¬ Obstetric complications similarly implicated as in AOS. (maternal infections like rubella, obstertric
complications eg hypoxia)
¬ High expressed emotion, characterized by overly critical responses in families, has been shown to be
correlated with increased relapse rates among patients with schizophrenia
¬ Early attentional deficits, deficits in social functioning, deficits in organisiational ability and a lower
intellectual ability at age 16 and 17 predict later development of schizophrenia in at-‐‑risk individuals.
(The Oxford Handbook of Child and Adolescent Psychiatry-‐‑219)
¬ Course and outcome: Childhood-‐‑onset schizophrenia appears to be a more malignant type of
schizophrenia, which presents a greater challenge to treat with pharmacology and psychosocial
interventions. It seems to respond less to medication than schizophrenia with adult onset or adolescent
onset, and the prognosis may be poorer.
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¬ Important predictors of the course and outcome of early-‐‑onset schizophrenia include the child'ʹs level
of functioning before the onset of schizophrenia, the age of onset, IQ, duration of first episode,
duration of untreated psychsis, presence of negative symptoms, response to pharmacological
interventions, how much functioning the child regained after the first episode, and the amount of
support available from the family.
¬ Risk of premature death is higher than in adult form of the disorder. 8.5% in a study of 106 cases. The
risk of suicide or accidental death as a result of psychotic symptoms appears to be about 5%. (Adult
suicide rate for schizophrenia is 10%)
Treatment:
¬ Algorithms for treating psychosis in young people are the same as those for adult patients. Metabolic
side effects are more common in this age group and more intensive monitoring is required.
¬ Atypical antipsychotics favoured over typical ones. Although first generation drugs such as
haloperidol are effective, young people are more prone to EPSEs than adults. Drug induced akathasia
is less common in children, but acute dystonia is more common.
¬ Randomised controlled trails of antipsychotics in early onset psychosis suggest that olanzapine and
risperidone are effective, with advantages over Haloperidol. Atypicals are commonly used as first-‐‑line
agents in EOS.
¬ Clozapine seems to be effective in treatment resistant psychosis in adolescents although this
population may be more prone to neutropenia and seizures than adults.
¬ Avoid depot and sedating antipsychotics
¬ Psychosocial treatments should include family work and focus on psychoeducation, social skills, and
problem-‐‑solving strategies and CBT methods.
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6. Anxiety Disorders
¬ Fear and anxiety represent normal reactions to danger. One critical differentiation between normal
fears or anxiety and an anxiety disorder derives from the so-‐‑called impairment criterion: to receive an
anxiety disorder diagnosis, there must be evidence of significant impairment or interference in the
child'ʹs everyday functioning. Anxiety disorders adversely impact self-‐‑esteem, social relationships, and
academic performance.
¬ Behavioural avoidance is a primary area of impairment that might lead children to avoid many typical
experiences enjoyed by peers. Anxiety or fear is also considered abnormal when the level of distress
evoked by danger is considered extreme, relative to a child'ʹs peers
Prevalence
¬ Prevalence rates seem to vary. Overall rates range from 5-‐‑15%, with 8% requiring clinical treatment
(Oxford Textbook of Psychiatry 3rd edn.) Male: female ratio is equal in childhood; Prevalence increase
in girls after adolescence when the female: male ratio is around 2:1. Prevalence rates (Oxford
Handbook of Psychiatry, 3rd edn):
o Separation anxiety disorder-‐‑3.5% in children and 0.8% in adolescents
o Generalized anxiety disorder-‐‑ approximately 4% of adolescents.
o Simple Phobia-‐‑ 10% in some studies; twice as common in females.
o Social phobia-‐‑1% in children and between 5-‐‑15% in adolescents
o Panic disorder-‐‑3-‐‑6%, peak onset 15-‐‑19 years.
¬ Age of onset and presentation of symptoms vary for each disorder. Anxiety symptoms vary with age.
Tearfulness and clinging in preschool children. Somatic complaints and hypochondriacal fretting are
common in middle childhood (5-‐‑12 years) as are irritability and aggressive behaviour. Separation
anxiety disorder and specific phobia usually have onset in early childhood. Generalized anxiety
disorder occurs across all age groups, while obsessive-‐‑compulsive disorder, social phobia, and panic
disorder tend to occur in later childhood and adolescence.
¬ Co-‐‑morbidity: Children with SAD are more likely to have co morbid specific phobia than children
with GAD or social phobia. In contrast, children with GAD and social phobia are more likely to have
comorbid mood disorders as compared to children with SAD. Up to 90% of young people with GAD
have a comorbid diagnosis-‐‑ anxiety disorders, CD and substance abuse are most common. Depression
is 8.2 times as likely in children with anxiety disorders than in children without anxiety disorders.
Specifically, there is a significant link between GAD and depression that persists into adulthood.
Clinical presentations
Separation anxiety disorder
¬ Separation anxiety disorder (SAD) is defined as developmentally inappropriate and excessive anxiety
concerning separation from home or from those to whom the individual is attached. This anxiety will
interfere with normal age-‐‑appropriate functioning. The essential clinical feature of separation anxiety
is excessive worry about losing or being permanently separated from a major attachment figure.
¬ Symptoms: anxiety about actual or anticipated separation from or danger to attachment figure; sleep
disturbances and nightmares -‐‑ Persistent reluctance or refusal to go to sleep without being near or next
© SPMM Course 22
to a major attachment figure, repeated nightmares about separation; Somatisation -‐‑ Repeated
occurrence of physical symptoms that includes nausea, vomiting, headache, stomach aches etc.
especially on occasions that involves separation from a major attachment figure; School refusal
(especially in adolescents) -‐‑ Persistent reluctance or refusal to go to school because of fear of
separation. School refusal and excessive somatic complaints in the context of actual or anticipated
separations are the most common reasons for parents and children to seek treatment for SAD
¬ The disturbance must last at least 4 weeks and cause clinically significant impairment in social,
academic, and occupational domains. The onset must occur before 18 years of age, and it is generally
not expected to occur below 6 years of age. If the onset occurs before the child is 6 years old, it is
labeled as early onset separation anxiety disorder.
Attachment disorders:
¬ Attachment: the emotional bond between child and caregiver. Develops though appropriate parental
responses to child’s behaviour. It allows the child to understand their ‘inner world’ and it is the
foundation for safe separation and development of autonomy (Oxford Handbook of Psychiatry, 3rd
edn).
¬ Children exhibit considerable variation in their attachment relationships to their mothers. Different
patterns of attachment have been described:
o Secure (about 60%) – child uses carer as secure base but able to explore freely and go back to
caregiver for comfort if necessary, carer sensitive to child’s cues)
o Insecure, avoidant/anxious type (about 15%) – appears interested in caregiver, minimal distress at
separation, sometimes ignores/avoids caregiver
o Insecure, ambivalent/resistant type (about 10%) – high levels of distress upon separation, resist
comforting and can take a while to settle. Thought to be due to inconsistent care giving.
o Disorganized/disorientated (about 15%) – child displays contradictory behaviour patterns.
Thought to arise from either the child experiencing the caregiver as frightening or the caregiver
being frightened themselves.
¬ Mary Ainsworth created a way of studying the quality of the attachment of a child to their
mother/caregiver-‐‑ she developed the Strange Situation procedure (1978).
¬ Romanian Adoptees Study – Data on severe attachment disorders have been obtained from follow up of
children taken from severely deprived institutions in Romania and adopted by families in Canada or
UK. 20% had severe disturbances at the age of 6. Duration of exposure to deprivation was strongly
associated with severe disinhibited behaviour.
¬ This disorder, occurring in infants and young children is characterized by persistent abnormalities in
the child’s pattern of social relationships, which are associated with emotional disturbance and
reactive to changes in environmental circumstances.
¬ It is diagnosed before the age of 5 years, and may manifest as either inhibited or disinhibited subtypes.
¬ It is more common in poverty-‐‑stricken and socially disrupted environments.
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¬ Causes: It occurs as a direct result of severe parental neglect, abuse and serious mishandling. Other
contributory factors include young, isolated, inexperienced, and/or depressed caretaker.
¬ Features: Fearfulness and hypervigilance that do not respond to comforting are characteristic. Poor
social interaction with peers is typical; aggression towards self & others is also common; growth
failure occurs in some cases.
¬ Disinhibited attachment disorder of childhood is characterised by a particular pattern of abnormal
social functioning that arises during the first 5 years of life.
¬ In the early stages, it is usually manifest by clinging and diffuse non-‐‑selectively focused attachment
behaviour.
¬ By the age of 4 years, diffuse attachment remains but clinging tends to be replaced by attention
seeking and indiscriminately friendly behaviour.
¬ During middle and later childhood this behaviour often persists and depending on circumstances,
there may also be associated emotional or behavioural disturbance.
School refusal
¬ Refusal to go to school or stay in school, even when under pressure from parents and school
authorities. This is not a psychiatric disorder per se -‐‑ it can have many causes.
¬ School refusal is considered as a problem rather than a diagnosis. It is a condition that can co-‐‑occur
with anxiety and depressive disorders. Significant difficulty attending school, resulting in prolonged
absence and/or severe emotional upset in children, characterizes school refusal.
¬ These children often display excessive fearfulness, temper outbursts, or complaints of feeling ill when
faced with the prospect of going to school. The complaint is more of physical symptoms such as
headaches, abdominal pain, nausea, palpitations etc.
¬ The nature of the anxiety associated with school refusal behaviour is likely to change with age, as is
the nature of the precipitating events. For example, fear of separation is more common in younger
school refusers, while in older children social-‐‑evaluative fears, such as fears of teachers or peers, are
more commonly reported.
¬ Incidence in children and adolescents reported as 1-‐‑5%. Prevalence uncertain. Sex distribution-‐‑equal
¬ Three main incidence peaks by age:
o 5-‐‑7 years: School entry. Possible separation anxiety
o Age 11: Commonest age of presentation. May be triggered by transition to secondary school.
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o Age 14 years and older: Possibly partly due to first presentations of depressive or anxiety
features/disorders. Also need to consider bullying, pressure of exams or any specific stressors in
individual cases.
Selective mutism
¬ Characterized by a persistent failure to speak in specific settings, such as school (where there is an
expectation to speak), despite full use of language at home or with family. Normally begins between
ages of 3-‐‑5 years, after normal speech has been acquired.
¬ Rates of associated psychiatric disorder, especially social phobia, high. A child with selective mutism
may remain completely silent or near silent, in some cases whispering instead of speaking out loud.
¬ Rare-‐‑ affecting about 3-‐‑8/10,000 in the UK. Prevalence varies with age, with younger children at
increased risk for the disorder. Persistent mutism affects less than 1 per 1000 children.
¬ Slightly more common in girls.
¬ Some cases will last for months to years. No evidence that any particular treatment is generally
effective. A behavioural approach with positive reinforcement techniques aimed at increasing the
frequency of talking and decreasing the frequency of non-‐‑communication will be helpful. It is
important to ascertain what communication is like at home.
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Treatment
¬ Cognitive Behavioural Therapy (CBT) has proven to be effective at treating anxiety disorders in children
and adolescents. Most CBT interventions were initially developed for adult anxiety and phobic
disorders. The techniques for child and adolescent populations are conceptually and structurally
similar but modified according to the developmental level.
¬ CBT technique focuses on relaxation training and cognitive restructuring. Individual CBT plus the
family component was shown to effectively reduce anxiety symptoms and may have some added
benefits, particularly for female children. Group CBT interventions have been shown to be effective for
the treatment of socially phobic children and adolescents.
¬ Psychoeducation and parent training are also useful.
¬ Psychodynamic therapies include group, family, and individual/play techniques
¬ Pharmacological interventions: SSRIs are first-‐‑line agents. Overall, efficacy and safety data support the
use of selective serotonin reuptake inhibitors (SSRIs) to treat childhood social phobia, separation
anxiety disorder and generalised anxiety disorder. Recent studies have demonstrated the efficacy of
SSRIs for specific anxiety disorders. Benzodiazepines are not indicated as a routine treatment in
children due to their potential adverse effects. There is also little or no evidence for the efficacy of
other anxiolytics, such as buspirone or beta-‐‑blockers.
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7. Other anxiety-related disorders
Post traumatic stress disorder:
¬ When PTSD as a diagnosis was first formulated in 1980, it was initially believed that this would not be
relevant to children! But it is now known that PTSD occurs frequently in children and adolescents with
up to 6 percent of young people meeting criteria for this diagnosis at some point. The British National
Survey of Mental Health reported that 0.4% of children aged 11-‐‑15 was diagnosed with PTSD, girls
showing twice the rate for boys [Nice Guidelines].
¬ Most common traumatic exposures for children and DSM-‐‑5 AND PTSD IN CHILDREN
adolescents include physical or sexual abuse [can be chronic
Diagnostic threshold is lowered for
stress]; domestic, school or community violence; being
children. In addition, a separate PTSD
kidnapped; terrorist attacks; motor vehicle or household
criterion has been added for children less
accidents; or disasters, such as floods, hurricanes, tornadoes, than age 6.
fires, explosions etc. The child'ʹs response must involve
intense fear, terror, helplessness, horror, or disorganized or agitated behaviour
¬ Classification of childhood trauma
o Type 1: Classic single, acute, traumatic event; the most common form in children. Symptoms: Full,
detailed memories, ‘omens’ or ‘cognitive reappraisal’, misperceptions.
o Type 2: Follows longstanding or repeated exposure to extreme external events, (e.g. chronic
abuse). Symptoms: Denial and psychic numbing, self-‐‑hypnosis, depersonalisation, and
dissociation and rage, self-‐‑harm, and/or extreme passivity
Treatment
¬ Trauma-‐‑Focused Cognitive-‐‑Behaviour Therapy: Several randomized clinical trials have provided evidence
for the efficacy of trauma-‐‑focused cognitive-‐‑behaviour therapy (CBT) in the treatment of PTSD in
children and adolescents. This treatment is generally administered over 8 to 12 treatment sessions,
including a number of components. Group treatments are preferred for large number of people, with
separate groups for girls and boys.
¬ Crisis intervention/psychological debriefing has been adapted for groups of children following trauma.
Role of crisis intervention with adults is being called into question. This involves structured sessions
with group leaders discussing the trauma with a group of children to share feelings and knowledge
and process it. Single session debriefing for children is not supported by evidence.
¬ NICE guidelines advise that medications should not be routinely prescribed for children and young
people with PTSD. Serotonin reuptake inhibitors (SSRIs) are frequently used in children with PTSD in
the absence of evidence demonstrating efficacy. Citalopram from 20 mg to 40 mg has been reported to
be helpful in the management of PTSD in children and adolescents according to results of an open trial
over an 8-‐‑week period.
¬ EMDR – no controlled trials – one unpublished trial with inconclusive results.
¬ Families should be involved, where appropriate.
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¬ No good evidence for efficacy of other treatments, including play therapy, art therapy, or family
therapy.
¬ Obsessive-‐‑compulsive disorder (OCD) is characterized by the presence of recurrent intrusive thoughts
(obsessions) associated with anxiety or tension and/or repetitive purposeful mental or physical actions
(compulsions) aimed at reducing fears and tensions caused by obsessions. It has become increasingly
evident that the majority of cases of OCD begin in childhood or adolescence.
¬ The clinical presentation of OCD in childhood and adolescence is similar to that in adults and the only
alteration for children is that they do not necessarily demonstrate awareness that their thoughts or
behaviours are unreasonable. Childhood OCD is characterised by secrecy i.e. – they understand that
their OCD behaviour is unusual, and so try to hide it. 40% children with OCD do not have obsessive
thoughts.
¬ Rituals and habits are seen in 2/3rd of children but they are less frequent, less intense and do not cause
distress.
¬ Epidemiology: Prevalence of OCD in children and adolescents is estimated as 0.5%. OCD may occur as
early as 5 years of age, thought the mean age of onset is 10 years. Childhood onset OCD has a ratio of
2 boys to every girl. The onset of OCD post-‐‑pubertal is more common in girls.
¬ Aetiology: Increased incidence in 1st degree relatives and in monozygotic twins (80% compared to 40%
in monozygotic twins); possible autoimmune process; reduced volume of caudate nucleus;
hyperactive orbitofrontal circuits (SPET); 5HT/serotonin receptor dysfunction (clinical response to
SSRI’s in both children and adults), and dopaminergic dysfunction [high dose stimulants may increase
OCD symptoms]
¬ Symptoms: Contamination fears with ritualized washing and avoidance; repetitive doubting and
checking (e.g. locks); repetitive counting, arranging, hoarding or touching.
¬ Comorbidity: 70% have at least one co morbid disorder. OCD is commonly found to be comorbid with
other psychiatric disorders, such as Tic disorders (17-‐‑40%), major depression (26%) specific
developmental disabilities (24%), phobias and other anxiety disorders. There are also higher than
expected rates of attention-‐‑deficit/hyperactivity disorder (ADHD), autism spectrum disorders, and tic
disorders, including Tourette'ʹs syndrome, among children and adolescents with OCD. DSM IV allows
a diagnosis of OCD in the presence of schizophrenia.
¬ Treatment: Results from multiple randomised placebo-‐‑controlled trials of both medication and CBT
interventions in children and adolescents with OCD have confirmed the most evidence for successful
treatment of this disorder compared to any of the other anxiety disorders of childhood. A multi-‐‑site
National Institute of Health funded investigation of Sertraline and CBT each alone, and then in
combination for the treatment of childhood onset OCD-‐‑the Paediatric OCD Treatment Study (POTS)-‐‑
revealed that the combination was superior to either treatment alone
¬ Fluoxetine and Sertraline are licensed for the treatment of OCD in children and adolescents, and
should be prescribed as per BNF guidelines. (NICE guidelines)
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¬ Fluoxetine is recommended for OCD in young people with significant co-‐‑morbid depression.
¬ Clomipramine is not recommended as a first line treatment due to its greater potential risks compared
to other SSRI agents, including cardiovascular risk of hypotension and arrhythmia, and seizure risk
¬ CBT geared toward children of varying ages is based on the principle of developmentally appropriate
exposure to the feared stimulus coupled with response prevention, leading to diminishing anxiety
over time experienced upon exposure to feared situations
¬ Most treatment guidelines for children and adolescents with mild to moderate OCD recommend a trial
of CBT prior to initiating medication. However, there is evidence from POTS that optimal treatment
includes the combination of both SSRI medication and CBT
¬ Young people with mild functional impairment are initially offered self help guides. If self help hasn’t
worked, or for those with mild and moderate impairment, CBT [including exposure response
prevention] should be offered. In the event of an inadequate response, or for those with severe
impairment, supplement psychotherapy with SSRI should be considered.
PANDAS syndrome
¬ Some children appear to develop obsessive-‐‑compulsive symptoms associated with beta haemolytic streptococcal
infection and this presentation represents a minority of OCD cases in this population. This association has led to
the studies of immune responses in OCD. Cases of infection triggered OCD have been termed paediatric
autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) and believed to signify an
autoimmune process such as that of Sydenham'ʹs chorea during rheumatic fever. It is associated with OCD
and/or Tic Disorder.
¬ Pre-‐‑pubertal onset is common.
¬ 75% of children and young people with Sydenham’s chorea also have OCD symptoms. Specific characteristics
include episodic or ‘sawtooth’ course, choreiform movements. Typically, symptoms arise along with tics and this
phenomenon may be related to obsessive-‐‑compulsive symptoms seen in Sydenham'ʹs chorea. It is very common
for children with tic disorders and perhaps OCD to report an abrupt onset and experience exacerbation of
symptoms with infection. Singer and co-‐‑workers reported that over 50% of clinic patients with tic disorders
reported this finding and that 11% reported exacerbation of illness within 6 months of streptococcal infection
¬ It is hypothesized that exposure to streptococcal bacteria activates the immune system leading to inflammation
of the basal ganglia and resulting disruption of the cortical-‐‑striatal-‐‑thalamo-‐‑cortical function.
¬ Scanning data suggest that increased basal ganglia volumes are associated with PANDAS; just as they are in
OCD, tic disorders and Sydenham'ʹs chorea. MRI has documented a proportional relationship between the size of
the basal ganglia and the severity of OCD symptoms.
Elimination Disorders
Enuresis
¬ Enuresis is the repeated voiding of urine into a child'ʹs clothes or bed; the voiding may be involuntary
or intentional. For the diagnosis to be made, a child must exhibit a developmental or chronological age
of at least 5 years. Duration of disorder is at least 3 months.
¬ Voluntary control of micturition does not begin until 15-‐‑18 months. Most children are reasonably dry
by day at 18 months. By 2 years 50% are dry at night, by 3 years 75% are dry at night. By 5 years, only
1% of children have problems with daytime wetting. However, nocturnal enuresis can still affect 15-‐‑
© SPMM Course 29
22% boys and 7-‐‑15% girls at the age of 7 years. A small minority continues to have problems into
adulthood.
¬ Enuresis can occur as a psychiatric complication of stressful life events or emotional disturbance; it is
not always accompanied by encopresis. It is twice as common in boys than girls. Types: Primary or
secondary, nocturnal or diurnal or mixed.
¬ Reported prevalence: 2-‐‑5% among school-‐‑aged children.
¬ Nocturnal enuresis: Most important predictor of primary nocturnal enuresis is a family history of
enuresis. 70% of children with nocturnal enuresis have a parent or sibling who was late in becoming
dry. Secondary enuresis is predicted by delay in control over bedwetting, and experiencing a high rate
of adverse life events. There is also a reduced sensitivity to vasopressin [antidiuretic effect] in the
kidneys.
¬ Daytime enuresis is likely to be related to structural abnormalities. Sexual abuse is associated with
secondary wetting. Enuresis is diagnosed only if the behaviour is not caused by a medical condition. It
is important to rule out organic factors, such as the presence of urinary tract infections, obstructions,
genitourinary pathology, neurological conditions like spina bifida occulta; other organic disorders that
can cause polyuria and enuresis, such as diabetes mellitus and diabetes insipidus.
¬ Association of enuresis has been made with a high rate of stressful life events, UTI, constipation, and
with children from low socioeconomic backgrounds, living in large families or overcrowded
conditions.
¬ Enuresis is often self-‐‑limited, and a child with enuresis may have a spontaneous remission without
psychological sequelae. The significant emotional and social difficulties of these children usually
include poor self-‐‑image, decreased self-‐‑esteem, social embarrassment and restriction, and intrafamilial
conflict. Children with enuresis are at higher risk for ADHD compared with the general population.
They are also more likely to have comorbid encopresis
Treatment
¬ Rule out organic causes of urinary dysfunction –e.g.: UTI may lead to obstruction. The first step in any
treatment plan is to review appropriate toilet training.
¬ Psychoeducation: Child with nocturnal enuresis is not being lazy. Avoid punishments.
¬ Record keeping is helpful in determining a baseline and following the child'ʹs progress and may itself
be a reinforcer.
¬ Behavioural interventions are the first line of treatment for bed-‐‑wetting. Ball and pad, or enuresis alarm.
Classic conditioning with the bell and pad apparatus is generally the most effective treatment for
nocturnal enuresis, with dryness resulting in more than 60 percent of cases. A star chart may be
particularly helpful.
¬ Medications: Imipramine is efficacious and has been approved for use in treating childhood enuresis,
primarily on a short-‐‑term basis. Desmopressin, an antidiuretic compound that is available as an
intranasal spray, has shown some initial success in reducing enuresis. Adverse effects that can occur
with Desmopressin include headache, nasal congestion, epistaxis, and stomachache. One case of
hyponatraemic convulsion. Reboxetine a norepinephrine reuptake inhibitor with a non cardiotoxic
© SPMM Course 30
side effect profile has recently been investigated as a safer alternative to Imipramine in the treatment
of childhood enuresis. Oxybutynin is an anticholinergic, which increases bladder capacity though
rarely employed in clinical practice.
Encopresis
¬ Voluntary or involuntary soiling of normally formed stools in inappropriate places in a child of 4 years
(mental age) or older, in the absence of a sufficient organic cause. Soiling occurs at least once a month
for 6 months.
¬ Males are found to be about six times more likely to have encopresis than females. Approximately 5%
children will be soiling over 4 years of age.
¬ Parents present more often to paediatrics than child psychiatric services. Although encopresis is
considered a nonorganic disorder, more than three quarters of children with encopresis may show
evidence of chronic constipation, leading to infrequent defecation, withholding of bowel movements,
which then leads to impaction and eventual overflow soiling. However, it is important to exclude
organic cause such as Hirschprung'ʹs disease, anorectal pathology, neurological problems; nutritional
disorders and medication side effects.
¬ Encopresis has been demonstrated to occur with significantly greater frequency among children with
known sexual abuse compared with a normal sample of children. This can be seen as possible defense
against further abuse, or retention due to pain.
¬ It occurs with greater frequency among children with a variety of psychiatric disturbances compared
with controls and some evidence indicates that encopresis in children is associated with measures of
maternal hostility, and harsh and punitive parenting.
¬ Encopresis, in some children, can be considered secondary, that is, emerging after a period of normal
bowel habits. Family patterns such as an unhappy child in a family with clear ongoing difficulties
[abuse, domestic violence], recent acute stress in the family [death, birth of sibling etc.], and over
tolerant parents have been found in half the families studied in an audit [Silver,1996].
Treatment
¬ Initial paediatric assessment, including imaging of the gut if indicated. First line of treatment is to
evacuate any stool. Laxatives may be used to prevent further retention.
¬ Education of the family and correction of misperceptions that a family may have about soiling must
occur before treatment
¬ Psychological treatment: Behavioural approach – operant training with rewards and positive
reinforcement.
¬ Family support/therapy. It is important to reduce the family tensions about the symptom and a
nonpunitive atmosphere is established. Randomised control trials show that biofeedback adds nothing
to laxative treatment.
¬ In many cases, encopresis is self-‐‑limiting, and it rarely continues beyond middle adolescence. Most
soiling stops by the age of 16 years.
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Pica
¬ This condition is characterised by persistent (>1month) eating of non-‐‑nutritive substances at a
developmentally inappropriate age (>1 year) and it occurs at least twice a week.
¬ It typically occurs during the 2nd and 3rd years of life and common substances are: dirt, stones, plastic,
paper, hair, faeces, wood etc. It is common in people with developmental disability.
¬ Consequences may include toxicity, infection, or GIT ulceration/obstruction.
¬ Hypothesized causes include: hunger, malnutrition, nutritional deficiencies, psychosocial stressors
and brain disorders such as lesions in the hypothalamus
8. Developmental disorders
Pervasive developmental disorders (PDD)
¬ Pervasive developmental disorders include several that are characterized by impaired reciprocal social
interactions, communication difficulties, aberrant language development, and restricted behavioural
repertoire. They typically emerge in young children before the age of 3 years. Parents often become
concerned about a child by 18 months if language development does not occur as expected.PDD is an
umbrella term, which includes disorders such as childhood autism, Asperger’s syndrome and Rett’s
syndrome.
¬ PDD’s frequently involve a triad of deficits in social skills, communication/language, and behaviour.
The feature that all have in common is a difficulty with social behaviour.
¬ DSM-‐‑IV categorised PDDs as follows: Autism, Asperger'ʹs syndrome, Rett'ʹs syndrome, Childhood
disintegrative disorder and PDD-‐‑NOS. In DSM-‐‑5, Autism Spectrum Disorder is a new description that
will now include autism, Asperger’s, Childhood Disintegrative Disorder, and Pervasive
Developmental Disorder (not otherwise specified) in a single category. ASD is characterized by 1)
deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests,
and activities (RRBs). If no RRBs are seen, then a diagnosis of social communication disorder can be
applied.
Autism
¬ Childhood autism (previously called early infantile autism, Kanner'ʹs autism) is characterized by
features from the following three symptom domains:
o Qualitative impairment in social interaction
o Impairment in communication [language delay is most common cause for initial referral]
o Restricted repetitive and stereotyped patterns of behaviour or interests.
¬ The failure of those with autism to understand others’ situations or feelings if often refererred to as a
lack of theory of mind.
¬ By definition, the onset of childhood autism is before the age of 3 years. In some cases, a diagnosis is
not made until a child is much older (sometimes in adulthood).
¬ Autism is four times more frequent in boys than in girls. There has been an apparent increase in
prevalence rates over the years.
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Aetiology and Pathogenesis
Genetic Factors
¬ Family studies: Increased risk of austistic spectrum disorder in siblings of those with ASD, compared
to general population. The recurrence rate in siblings of affected children is 2-‐‑8%. The risk of atusitic
disorder in a sibling of 2 autistic children is 25-‐‑30%.
¬ Autistic spectrum disorders are subject to a significant degree of heritability (overall 90% heritability).
The concordance rate of autistic disorder in the two largest twin studies was 36% vs. 0% in
monozygotes vs. dizygotes in one study and about 96% vs. 27% in another.
¬ It now appears that multiple genes are involved in the development of autism and linkage analyses
have demonstrated that regions of chromosomes 2, 4,7, 13,15,and 19 are likely to contribute to the
genetic basis of autism. Likely locations for autism-‐‑related genes were also found on chromosomes 16
and 17, although the strength of the correlation was somewhat weaker. Some analyses have implicated
genes such as NRXN1 and NLGN3 (Short Oxford Textbook of psyhiatry, 3rd Edn).
¬ Fragile X syndrome, a genetic disorder in which a portion of the X chromosome fractures, appears to
be associated with autistic disorder. Approximately 1-‐‑4 percent of children with autistic disorder also
have fragile X syndrome. Tuberous sclerosis, a genetic disorder characterized by multiple benign
tumours, with Autosomal dominant transmission is found with greater frequency among children
with autistic disorder. Up to 2 percent of children with autistic disorder may also have tuberous
sclerosis.
¬ Autistic disorder is also associated with neurological conditions, notably congenital Rubella and
phenylketonuria
Biological Factors
¬ About 10% of children with autism (1 in 10 cases) have a medical condition of some type (Shorter
Oxford Textbook of Psychiatry, 6th edn). The high rate of intellectual disability among children with
autistic disorder and the higher-‐‑than-‐‑expected rates of seizure disorders further support the biological
basis for autistic disorder.
¬ Approximately 80% of people with childhood autism have learning disability. About one third of
these children have mild to moderate intellectual disability. In contrast, about 80% of people with
Autism Spectrum Disorders more generally have intellectual abilities within the normal range.
¬ MRI findings include larger brain volumes and early acceleration in brain growth; increase in the size
of the lateral and 4 ventricles; frontal lobe and cerebellar abnormalities (hypoplasia of cerebellar
th
vermal lobules VI and VII). The greatest average percentage increase in brain size occurred in the
occipital lobe, parietal lobe, and temporal lobe. No differences were found in the frontal lobes. The
increased volume can arise from three different possible mechanisms: increased neurogenesis,
decreased neuronal death, and increased production of nonneuronal brain tissue, such as glial cells or
blood vessels. Brain enlargement has been suggested as a possible biological marker for autistic
disorder.
¬ Cerbellar pathology: abnormal purkinje cells in cerebellar vermis; abnormal limbic architecture. An
autopsy study revealed fewer Purkinje'ʹs cells.
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¬ A number of studies have demonstrated that about one third of patients with autistic disorder have
high plasma serotonin concentrations. In some autistic children, a high concentration of homovanillic
acid in cerebrospinal fluid (CSF) is associated with increased withdrawal and stereotypes.
¬ There are various associations between autistic spectrum disorder and congenital rubella infection
during pregnancy. Most associations are with first trimester exposure, suggesting that an impact on
early brain development is of particular significance. Obstetric complications are currently not thought
to represent a causative factor
¬ Child rearing practices do not account for autism.
¬ MMR vaccination was hypothesised to be related to a regressive form of autism. These links arose due
to the findings of a single methodologically flawed study. Other studies that aimed to replicate these
findings were unable to do so. (Ref: The Handbook of Child and adolescent Psychiatry-‐‑pg 132)
¬ Autism is a neurodevelopmental disorder that persists lifelong. Predictors of good prognosis include
communicative speech by the age of 6 years and higher IQ (>50) and having a skill that is consistent
with a secure employment. A significant proportion of people with autism (at least 60%) will be
unable to lead an independent life, and some will require long term residential care (Shorter Oxford
Textbook of Psychiatry, 6th edn).
¬ Findings of long term follow up studies into adult life-‐‑ 12% very good outcome, 10% as good, 19% as
fair, 46% as poor, 12% as very poor. Communication, reading and spelling were impaired in most.
Steretypies and restricted interests remained for most. (Ref: The Handbook of Child and adolescent
Psychiatry-‐‑pg 140)
Treatment
¬ There is no cure or treatment for autism. Early and effective management is desirable for a better
outcome, and involves a comprehensive assessment of the child and family’s needs. There are many
management models, aimed at helping the family, providing vocational training and support to the
person, addressing health requirements etc. Psychotherapy with the individual may be in the form of
specific CBT techniques for those with verbal skills, and behaviour management programmes.
However, young people with autism can find CBT dfficult due to their tendency to sometimes have
literal understanding and rigid thinking.
¬ Two specific intervention programmes are
o Applied Behavioural Analysis program: an intense program [40 hours a week for 3 years] based
on operant conditioning, imitation and reinforcement.
o TEACCH – Treatment and Education for Autistic and related Communication Handicapped
Children program is based on the belief that children are motivated to learn language. Successful
in reducing self injurious behaviour, and enhancing life skills.
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¬ Pharmacotherapies are commonly used in individuals with autistic spectrum disorder (ASD) as
adjuncts to psychological interventions. SSRIs have become the most widely prescribed medications to
treat restricted repetitive behaviours in paediatric ASD populations. However the evidence supporting
the effectiveness of SSRIs in ameliorating these symptoms remains limited. When using SSRIs to treat
repetitive behaviour in ASD patients, it has been found that lower doses are required than the
therapeutic antidepressant dose. Second generation antipsychotics are the first line pharmacological
treatment for children and adolescents with ASD and associated irritability. The only licensed
medication in UK is risperidone. It is indicated for the treatment of autism with aggressive behaviour
in children and adolescents. Weight gain, somnolence and hyperglycemia require monitoring.
Melatonin has been shown in several small studies to be beneficial in children with ASD with
reductions in sleep latency as well as efficiency.
Asperger’s syndrome
¬ Individuals with Asperger’s syndrome have same type of qualitative abnormalities in reciprocal social
interaction that typify autism with a restricted, stereotyped and repetitive, repertoire of
behaviour/interests. IQ and language are ususally within normal limits.
¬ Unlike in childhood autism/autistic disorder, there were in Asperger'ʹs disorder no significant delays
occur in relation to language development., cognitive development, and/or age-‐‑appropriate self-‐‑help
skills.
¬ Mild motor clumsiness and a family history of autism may be present, as is the case for other autism
spectrum disorders.
¬ Epidemiology: Global prevalence rate is uncertain. Estimated to be about a third as common as autism
with a prevalence of about 6 in 10,000 (Shorter Oxford Textbook of Psychiatry, 6thedn).
¬ The factors associated with a good prognosis are a normal IQ and high-‐‑level social skills. Psychiatric
comorbidity is high with depression most common. BPAD and schizophrenia are more common than
in the general population.
Rett's syndrome
¬ Rett'ʹs syndrome is a rare X linked dominant disorder of arrested neurodevelopment associated with
mutations in the MeCP2 gene. It almost exclusively affects females.
¬ Head circumference normal at birth and developmenatal milestones are unremarkable in early life.
Between 6 and 18 months, head growth begins to decelerate and produces microcephaly. Other signs
often include the loss of purposeful hand movements, which are replaced by stereotypic motions, such
as hand wringing; the loss of previously acquired speech; psychomotor retardation; and ataxia.
¬ Other stereotypical hand movements may occur, such as licking or biting the fingers and tapping or
slapping. Language skills are lost, and both receptive and expressive communicative and social skills
seem to plateau at developmental levels between 6 months and 1 year. Poor muscle coordination and
an apraxia gait with an unsteady and stiff quality develop.
¬ Associated features include seizures in up to 75 percent of affected children and disorganized EEGs
with some epileptiform discharges in almost all young children with Rett'ʹs disorder, even in the
absence of clinical seizures.
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¬ An additional associated feature is irregular respiration, with episodes of hyperventilation, apnoea,
and breath holding. The disorganized breathing occurs in most patients while they are awake; during
sleep, the breathing usually normalizes. Many patients with Rett'ʹs disorder also have scoliosis and
spasticity.
¬ Developmental arrest plateaus and many may reach adulthood, although disability is great and
prognosis poor.
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9. Learning and communication disorders
¬ Learning disorders are problems that make educational achievement difficult. Specific learning
difficulties can be underachievement in reading, written expression, or mathematics in comparison
with the overall intellectual ability of the child.
¬ The most recent revised version of the DSM-‐‑IV (DSM-‐‑IV-‐‑TR) includes four diagnostic categories of
learning disorders: reading disorder, mathematics disorder, disorder of written expression, and
learning disorder not otherwise specified
¬ Genetic predisposition, perinatal injury, and neurological and other medical conditions can contribute
to the development of learning disorders, but many children and adolescents with learning disorders
have no specific risk factors
¬ Learning disorders affect at least 5% of school-‐‑age children. They are associated with higher than
average risk of a variety of co morbid disorders, including attention-‐‑deficit/hyperactivity disorder
(ADHD), communication disorders, conduct disorders, and depressive disorders.
¬ DSM-‐‑IV groups together a number of learning disorders that share the following:
o Performance significantly below that expected for IQ or age
o A discrete developmental disability in the absence of learning disability
o Commonly present as emotional or behavioural problems
o 50% have a comorbid psychiatric disorder and many have other LLDs
o Most show strong evidence of heritability
¬ Communication disorders are among the most common disorders in childhood. They include
language disorders such as expressive and mixed receptive-‐‑expressive language disorder, and speech
disorders such as phonological disorder and stuttering.
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¬ Tools used to measure reading ability are WORD (Weschler objective reading dimension)-‐‑ a single
word rreading test commonly used in Bristish schools, TOWRE (Test of word reading efficiency)-‐‑
measures word reading rate & accuracy, WISC (Wescler intelligence sacle for children)-‐‑ measures
overall cognitive ability of the child
¬ Management includes 1:1 remedial teaching and parent involvement improves long-‐‑term outcome.
Mathematics disorder
¬ Epidemiological studies have indicated that up to 6 percent of school age children have some difficulty
with mathematics. It is reported more commonly in females.
¬ Often associated with visuo-‐‑spatial deficits and attributed to right parietal dysfunction.
¬ Common features of mathematics disorder include difficulty with various components of
mathematics, such as learning number names, remembering the signs for addition and subtraction,
learning multiplication tables, translating word problems into computations, and doing calculations at
the expected pace. A Child with mathematics disorder generally has significant problems with
concepts, such as counting and adding even one-‐‑digit numbers, compared with classmates of the same
age
¬ Currently, the most effective treatments for mathematics disorder combine teaching mathematics
concepts with continuous practice in solving math problems. Flash cards, workbooks, and computer
games can be a viable part of this treatment
Phonoogical disorder
¬ Children with phonological disorder are delayed in, or incapable of, producing speech sounds that are
expected for their age, intelligence. Their inability to produce clear speech is not due to physical
problems as may be seen in dysarthria.
¬ Phonological disorder can be recognized in early childhood. In severe cases, the disorder is first
recognized at about 3 years of age.
¬ Omissions, distortions, and substitutions also occur normally in the speech of young children learning
to talk. But, whereas young, normally speaking children soon replace these misarticulations, children
with phonological disorder do not.
¬ Children with phonological disorder cannot articulate certain phonemes correctly and may distort,
substitute, or even omit the affected phonemes. With omissions, the phonemes are absent entirely for
example ca for car, or whaa? for what'ʹs that? With substitutions, difficult phonemes are replaced with
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incorrect ones for example, wabbit for rabbit. With distortions, the correct phoneme is approximated
but is articulated incorrectly.
Stuttering
¬ Stuttering is a condition in which the normal flow of speech is disrupted by involuntary speech motor
events. Stuttering can include a variety of specific disruptions of fluency, including sound or syllable
repetitions, sound prolongations, dysrhythmic phonation, and complete blocking or unusual pauses
between sounds and syllables of words. Usually struggle with initial syllables.
¬ Male predominance of 3:1 is noted. The prevalence of stuttering is about 1% in the general population.
Stuttering tends to be most common in young children and has often resolved spontaneously by the
time the child is older. The typical age of onset is 2 to 7 years of age with a peak at age 5 years. Of all
children who stutter, mostly those with mild cases, 50 to 80 percent recover spontaneously. Most
children grow out of it but stuttering affects 1-‐‑2% of adults.
¬ Preschoolers and school-‐‑age children who stutter exhibit an increased incidence of social anxiety,
school refusal, and other anxiety symptoms. When stuttering persists into adolescence, social isolation
occurs at higher rates than in the general adolescent population.
¬ Stuttering is also associated with a variety of abnormal motor movements, upper body tics, and facial
grimaces. Other disorders that coexist with stuttering include phonological disorder, expressive
language disorder, mixed receptive-‐‑expressive language disorder, and ADHD.
¬ However, stuttering is not normally associated with a psychiatric disorder (Shorter Oxford textbook of
Psychiatry, 6th edn.). Majority of cases are developmental but occasionally there are acquired cases (e.g.
head injury). Aetiology: genetic; incomplete cerebral dominance; hyperdopaminergic state.
¬ Management: speech therapy.
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¬ Wax and wane in frequency with periods of remission. The periods of exacerbations are often related
to physical and emotional stress. These are known to be exacerbated by external factors such as stress,
anxiety and fatigue
¬ The onset is before age 18 years. Suggested prevalence in children of 1%. Monozygotic twin
concordance 50%, dizygotic 10%. Mean age of onset is 7 years. It is 3-‐‑4 times more likely in males than
females (Shorter Oxford Textbook of Psychiatry, 6th edn).
Aetiology
¬ Genetic factors: Autosomal dominant and polygenic common (with increase in Monozygotic twins and
first degree relatives). Family history very common. Overlap with genetic liability for OCD.
¬ Neurotransmitter abnormalities thought to underlie tic disorders. Functional excess of dopamine system
is a popular speculation as antipsychotics reduce symptoms. The effectiveness of Clonidine suggests
the role of Noradrenaline
¬ Neuroimaging studies implicate circuits involving the basal ganglia, premotor and motor cortex.
¬ Post-‐‑infectious autoimmune mechanisms: It is well established that group A beta haemolytic streptococci
(GABHS) can trigger immune-‐‑mediated disease in genetically predisposed individuals. Speculation
concerning a post-‐‑infectious (or at least a post-‐‑rheumatic fever) etiology for tic disorder symptoms
dates from the late 1800s. An increased proportion of GABHS infections (odds ratio = 3.1) is found in
the preceding 3 months in children with newly diagnosed TS compared to well matched controls.
Larger odds ratio (OR = 12.1 for TS) is demonstrated when subjects were required to have multiple
GABHS infections in the previous year, suggesting a dose-‐‑dependent effect of exposure. There was
also a statistically significant positive association between preceding streptococcal infection and a new
diagnosis of OCD and tic disorders.
¬ Comorbidity: OCD [1/3rd to 2/3rd of children and adolescents exhibit OCD symptoms) and ADHD
[upto 50%] common; depression, anxiety, impulse and conduct disorders and other behavioural
problems. These are more prevalent than would be expected by chance association alone. 1/3rd of
adults with Tourettes have persistent OCD into adulthood.
Management:
¬ Psychoeducation for the individual, family and the people they interact with, especially schools is
crucial. Both tics and OCD symptoms may improve with CBT, if succesful exposure-‐‑response
prevention can be acheived. Techniques include a) Relaxation b) Exposure-‐‑response prevention c)
massed practice (forced reptition of the tic) d) Habit reversal (movements incompatible with the tic)
(Ref: The Oxhord handbook of child and adolescent psychiatry; pg 198)
¬ Medications can be used if tics are disabling and non-‐‑responsive to other therapies.Medications used
to treat Tourette’s disorder include Haloperidol, Pimozide, Sulpiride, Risperidone and Clonidine at
low doses. All these drugs have been shown to be more effective than placebo in a number of small-‐‑
randomised studies.
¬ Clonidine (adrenergic alpha 2 agonists) should be tried first.It helps to reduce the severity and
frequency of tics. Main side effects are sedation and postural hypotension. Guanfacine also an
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adrenergic alpha 2 agonists has been shown to lead to a 30% reduction in tic rating scales. These drugs
are more acceptable in terms of adverse effects.
¬ Antipsychotics like Risperidone, Haloperidol and sulpiride are effective in alleviating tics but their
side effects may outweigh benefits and should not be tried as first line drugs.
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¬ In terms of steroid use, in the US, 4 and 12% of male adolescents have used anabolic steroids to
improve performance at sport or alter body size. No UK data is available, but the rates are often
reported to be less than the US.
¬ Use of LSD/hallucinogens is down since a peak in the 1990s and now used only by a small minority.
(Ref: The Oxford handbook of Child and Adolescent Psychiatry: 382-‐‑383)
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Beck Depression Inventory It could be used for screening of children with depression only after the age of
14.
CY-‐‑BOCS It is the paediatric version of Y-‐‑BOCS (Yale Brown Obsessive-‐‑Compulsive Scale)
useful to measure symptoms of childhood OCD
¬ In general, psychiatric hospitalization is not a preferred option for the assessment and treatment of
most childhood-‐‑onset and adolescent psychiatric disorders, as this is seen as disruptive to the normal
developmental context provided by a child’s home and school environments.
¬ Dalton et al. (1989) cited the following factors to argue against hospitalisation:
o Disruption of the child’s family and community relationships
o Expense s incurred by the family and health services
o Reinforcement of parental denial or guilt
o Sibling’s confused and distorted perception of the issues treated
o Removal of the child from the continuum of education
o Predictable noxious stigmata and labeling
o potential for unresolved transference and institutionalisation
¬ Hersov (1994) proposed a set of admission criteria that specify the need for hospitalisation (numbers
1–3) and the need to remove a child from its home (numbers 4 and 5):
1. For diagnostic work that cannot be obtained on an outpatient basis
2. A severe psychiatric disorder with need for treatment by a multiprofessional team in a safe setting
3. Impaired physical status of the child that requires skilled medical and nursing care
4. Adverse environmental circumstances that preclude the child’s improvement within the home or
severely distorted family interaction that leads to progressive interference with the child’s progress
5. Gross overprotection by parents after a trauma/injury that precludes recovery.
DISCLAIMER: This material is developed from various revision notes assembled while preparing for
MRCPsych exams. The content is periodically updated with excerpts from various published
sources including peer-reviewed journals, websites, patient information leaflets and books. These
sources are cited and acknowledged wherever possible; due to the structure of this material,
acknowledgements have not been possible for every passage/fact that is common knowledge
in psychiatry. We do not check the accuracy of drug-related information using external sources;
no part of these notes should be used as prescribing information
© SPMM Course 44
Notes prepared using excerpts from:
! Blanz B and Schmidt, MH. (2000). Practitioner Review: Preconditions and Outcome of Inpatient Treatment
in Child and Adolescent Psychiatry. Journal of Child Psychology and Psychiatry, 41, pp 703-‐‑712
! Canadian Paediatric Society, Maternal depression and child development. (2004). Paediatrics & Child Health,
9(8), 575–583;
! Coghill, D., et al (2009). Child and Adolescent Psychiatry (Oxford Specialist Handbooks in Psychiatry series).
! Geddes et al., Shorter Oxford Textbook of Psychiatry, 6th Edition
! Johnstone, E. C., Owens, D. C., & Lawrie, S. M. (2010). Companion to psychiatric studies. Elsevier Health
Sciences.
! Kessler RC, McLaughlin KA, Green JG, et al. Childhood adversities and adult psychopathology in the WHO
World Mental Health Surveys. The British Journal of Psychiatry. 2010;197(5):378-‐‑385. doi:10.1192/bjp.bp.110.080499.
! Lewis, M. (Ed.). (2002). Child and adolescent psychiatry: A comprehensive textbook. Philadelphia: Lippincott
Williams & Wilkins.
! Murray, L & Cooper, PJ. Effects of postnatal depression on infant development. Arch Dis Child 1997;77:99-‐‑101;
http://adc.bmj.com/content/77/2/99.full
! Rutter, M., Bishop, D., Pine, D., Scott, S., Stevenson, J. S., Taylor, E. A., & Thapar, A. (2011). Rutter'ʹs child and
adolescent psychiatry. John Wiley & Sons.
! Sadock, B. J., & Sadock, V. A. (2011). Kaplan and Sadock'ʹs synopsis of psychiatry: Behavioral sciences/clinical
psychiatry. Lippincott Williams & Wilkins.
! Semple, D., & Smyth, R. (2013). Oxford handbook of psychiatry. Oxford University Press.
! Taylor, D., Paton, C., & Kapur, S. (2015). The Maudsley prescribing guidelines in psychiatry. John Wiley & Sons.
© SPMM Course 45