Child and Adolescent Psychiatry

Mental health affects 10% of children with a primary emotional or behavioural presentation
but only 1 in 10 are in contact with specialist services.
These impact on development, education, relationships, parental mental illness can impact
child as carer, sibling mental illness, family difficulties, adversity/ poverty, domestic violence
NORMAL CHILD DEVELOPMENT:
- Newbornà preferential response to human face and voice, cries for comfort, food
- 6-weekà start smile socially
- 6-monthà plays peek a boo
- 9-monthà starts to indicate wants without crying
- 1 yearà first word
- 18 monthsà having tantrum, parallel play with peers
- 3-yearà associative play, turn-taking, start sharing, develop rivalries
- 5-yearà developing friendship

ATTACHMENT:
Mary Ainsworth - "strange situation" procedure to observe an infant to explore toys for
20 minutes while his mother and a stranger entering and leaving the room. Attachment is
important as it can lead to an internal model of the self as unlovable and inadequate, and
of others as unresponsive and punitive
- It may also predict a person's reaction to loss or adversity, and his pattern of relating
to peers, engaging in relationships and parenting children
Newborn Lack of selective attachments and stranger
anxiety Types:
9-month Stranger anxiety, selective attachments 1. Secure
begin
2. Insecure ambivalent –
18-month Peak of proximity seeking with
distressed/anxious behaviour clingy but not easily
3-4 years Separates more easily from parents soothed
5-year More stable “internal representations” of 3. Insecure Avoidant –
parents/relationships independent, caregiver is
Adolescent Culturally dependent; western culture- often insensitive to needs.
minimal dependency needs

Impacts of illness on development and family functioning:

• May halt development as young person preoccupied with illness
• Child may show delay/ regression in achieving normal social/ emotional
developmental milestones
• Separation out of ‘normal’ adolescent development from illness
• Makes it difficult for parents to let go

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AUTISTIC SPECTRUM DISORDER - BASICS
Prevalence – debate: most severe (Kanner autism) 10 in 10,000. Broad definition: 1 in 100.
Boys: girls 4:1. May present to services at any age. Persistent triad of deficits:
1. socialisation
2. communication
3. repetitive behaviour (restricted, stereotyped interests and behaviours, imagination)
Aetiology à genetic, biological, neurotransmitters,
brain injury, psychological/social factors affect how
problem presents and how patient copes with it
Management à Needs SALT, applied behavioural
analysis which helps to reduce the need for ritualization
and develop social skills. Usually needs 20-30 hours a
week. No medications
Comorbidities à learning disability, ADHD, epilepsy,
dyspraxia, Tourette’s, depression, OCD
Lack of theory of mind

ADHD - BASICS
Prevalence 1-5% (variable depending on the diagnostic criteria - much higher in US). Boys:
girls 3:1. Onset < 7 (12) years. Persistent: in more than 1 setting e.g. home & school and
must persist for more than 6 months. 85% settle through adolescence and adulthood
Core symptoms:
1. Inattention (≥6 symptoms)- highly distractible, not listening, ‘own world’, forgetful
2. Hyperactivity (≥6 of 2. Or 3.)- restless, fidgety, chatty, hard to engage in quiet things
3. Impulsivity - difficulty waiting turn, interrupt others, blurt out answers
Aetiologyà same as autism plus certain foods: may notice specific links with food and drink,
e.g. artificial colours but unclear
Maladaptive and inconsistent with child's developmental level and associated with: lower
academic performance, teenage pregnancy, criminality and interpersonal difficulties (often
seen as inattentive in relationships, forget things, feels impersonal)
Differentials: loads: anxiety, depression, ASD, personality disorder, conduct disorder,
specific learning disorder, substance use disorders, bipolar, auditory or visual impairment,
seizure disorder, fetal alcohol syndrome etc
INVESTIGATION AND MANAGEMENTà Conner’s Rating Scale is one of the observer-
rated questionnaires for ADHD.
1. Parenting group-based course for behaviour management: initially manage with
self-help& a 10 week watch and wait period (if not advised then refer to CAMHS).
2. Liaise with school for extra support

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 3. Medication: consider if still causing persistent significant impairment after
environmental modifications were made. Methylphenidate is 1st line (stimulating –
Ritalin, concerta etc) or atomoxetine (non-stimulating- if 1st line is contraindicated)
- Initiated by specialists and require close titration and monitoring: weight (3
monthly), height (6 monthly), BP and HR (before and after each dose change)
4. May offer CBT to young people still with significant impairment.

DYSLEXIA - BASICS
Prevalence – debate: most severe 4%, widest possible definition 10%. Boys: girls 4:1.
May present at any age but often presents to CAMHS with secondary behaviour problems
and persistent difficulties in processing and producing written material out of keeping with
the person’s other abilities. Aetiology is the same as for autism
Managementà early intervention is beneficial. Specialist teaching (multi-sensory,
computer based, phonics), supportive home and school environment (praise), regular eye
checks and consider colour overlays (Irlen coloured overlay lenses)

ADOLESCENCE: modern concept, challenging part of development. Indices for full maturity:
• Identity formation
• High priority for human relationships
• Comfortable alone or with others
• Empathy and appreciation for needs of others
• Formation of reciprocal, meaningful and mutually dependent relationships
Adolescents can develop mental illnesses such as mood disorder, anxiety disorder (10%),
substance misuse, eating disorder and psychosis. Self-harm is common. Stigma

ASSESSMENT IN CHILD AND ADOLESCENT PSYCHIATRY

Same as adults - history, MSE and risk assessment but remember the following:
• Always include family (unless young person refuses) - especially for older children,
you may want to speak to the child before their parents
• Remember to consider risk and any underlying mental illness
• Social context is even more vital than it is in adults, children can't choose where
they live or go to school, they get what the adults around them supply
RISK ASSESSMENT
Remember risk to self and risk to others. Important concern is child protection/safeguarding:
• Physical
Remember abuse may underlie presenting symptoms. There is
• Sexual a duty of all professionals to protect children and the role of
• Emotional social/children services in safeguarding
• Neglect

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MANAGEMENT OF MHD IN CHILDREN AND ADOLESCENTS:
Biologicalà limited evidence for their success. NICE indicates biologics in hyperactivity
(ADHD) in children and depression in adolescents (concerns regarding suicidal behaviour
so only use fluoxetine and by specialist prescribers (child psychiatrist))
Psychologicalà depends but often includes: CBT, family therapy, interventional behaviour
therapy (finding positive and negative behaviours and reinforcing)
Socialà very important, links to wider network (education, social services)

CONSENT ‘PSYCH ONLINE’ NOTES HAVE LOTS OF EXAMPLES

It is legally presumed that over 16 years old have the ability to make decisions about their own care.
General rules and tips:
- There is no age restriction for the MHA but this can only be used for the treatment
of mental disorder (i.e. not physical illness unless it manifests with MH symptoms)
- MCA generally only applies to individuals above 16 (there are a few exceptions but
more related to social care) but the principle of assessing capacity as in the MCA can
be used at any age. If consent is needed below aged 16, consider parental consent
- If you are not sure, seek professional and legal advice
Gillick competency and Fraser guidelines whether doctors should be able to give
contraceptive advice or treatment to under 16-year-olds without parental consent.
Now more widely used to help assess whether a child has the maturity to make their own
decisions and to understand the implications of those decisions.

CONFIDENTIALITY AND DISCLOSURE

The same duties of confidentiality apply when using, sharing or disclosing information about
children and young people as about adults and it is largely dependent on whether the child
or young person has capacity in consenting for disclosure/confidentiality.
If a young person does not agree to disclose there are circumstances in which you should:
1. When there is an overriding public interest in the disclosure
2. When you judge that the disclosure is in the best interests of a young person who
does not have the maturity or understanding to make a decision about disclosure
3. When disclosure is required by law
Children will usually be accompanied by parents or other adults involved in their care, and
you can usually tell if a child agrees to information being shared by their behaviour.
Occasionally, children who lack the capacity to consent will share information with you on
the understanding that their parents are not informed. Here you should try to persuade
the child to involve the parent, if they refuse but you think it is in their best interest (e.g.
to provide proper care), you can disclose info to parents or authorities.
- Record your discussions and reasons for sharing the information
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 Intellectual Disability
Intellectual disability (term used by DSM-V, ICD-10 calls it mental retardation):
1. Significantly sub-average intellectual functioning: An IQ below 70 on an individually
administered IQ test
2. Deficits or impairments in adaptive behaviour, taking into account the person’s age.
3. Onset of intellectual impairment before the age of 18 years
Epidemiology: males > females, higher in lower social classes (and overcrowding, poverty,
irregular unskilled employment)
Aetiology: 30% no identifiable cause, polygenic inheritance of low intelligence, social and
educational deprivation (environment). Other: genetic, pre-natal, perinatal, post-natal

SEVERITY OF ID
Is classified as mild, moderate, severe or profound (by both DSM-V and ICD-10). Used to
be based on IQ but DSM now grades according to adaptive functioning too:
Mild ID Moderate ID
• IQ score 50-69 • IQ score 35-49
• Prev: 1.5-3% (85% of all IDs) • Prev: 0.5% (w/ severe LD)
Often not recognised& only need help if Often capable of substantial autonomy in daily
problems. Can sustain relationships and living with some supervision and able to
hold a routine job communicate and do simple household jobs
Needs limited assistance and support finding May need a supervised environment and work
accommodation and sorting bills in a sheltered workshop
Severe ID Profound ID
• IQ score 20-34 • IQ score <20
• Prev: 0.5% (w/ moderate LD) • Prev: 0.05%
Need help with daily living, though can be able Usually need extensive or total help with daily
to wash and usually continent; often physically living
disabled Usually need continuous care Minimal communication
Limited communication (often not speech) Needs continuous care

GENETIC CAUSES:
Down's syndrome - Trisomy 21
- Most common cause of ID.
- Associated with characteristic physical abnormalities.
- Increased risk of deafness, cataracts,
hypothyroidism& early onset Alzheimer's
Fragile X syndrome
- 2nd most common cause of ID (M>F)
- Abnormality on long arm of chromosome X.
- More common in males.

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 Cri du chat syndrome
- Deletion of short arm of
chromosome 5

Tuberous sclerosis
- Mutation in the tumour suppressor gene on chromosome 9 or 16.
- Can result in autism and epilepsy with ID.
- Characteristic skin changes and tumours of brain and other organs
Neurofibromatosis
- Mutation of gene on chromosome 17.
- Usually with mild ID.
- Cafe au lait spots and abnormalities of skin, soft tissues, nervous system and bone

Phenylketonuria
- 1 in 10,000 births, autosomal recessive.
- High serum phenylalanine.
- ID with short stature, hyperactivity, irritability, epilepsy, lack of pigment and eczema.

OTHER AETIOLOGY:
Perinatal: period of time when you become pregnant and up to a year after birth. Pre-natal
(antenatal): before birth, Postnatal (postpartum): after birth
Pre-natal: Peri-natal: Post-natal:
- Foetal alcohol syndrome - Intraventricular - Brain infection
- Congenital hypothyroidism haemorrhage - Chronic lead poisoning
- Placental insufficiency - Birth trauma and hypoxia - Childhood brain tumour
- Infection: rubella, CMV, - Hyperbilirubinemia - Malnutrition
toxoplasmosis, syphilis NB: is no link with mother - Head injury
- Pre-eclampsia depression and ID - Neglect and abuse
- TORCH

Management of moderate to severe ID usually involves the ID team in the community

(massive MDT) and sometimes in the inpatient or residential setting
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RISK IN INTELLECTUAL DISABILITY:
Possible risks (depending on level of ID): Concept of Risk Assessment and
- Suicide Management Plan (RAAMP)
- Self-harm - Collecting evidence
- Damage to property - Identifying triggers and context
- Harm towards others - Plan the consequences
- Unsupervised exit, harm from - Develop strategies to minimise risky
others behaviour

Family Response to ID:

AUTISM AND ID:

Over 66% individuals with autism have intellectual disabilities
Possible presenting features:
• Aloof • Speech:
• Repetitive movements - 49% no speech
• Little /no interaction with mother - Exact repetition
• Do not bring toys to show to - Pronoun reversal
mother - Difficulty with abstraction
• Do not run to greet parents - Poor non-verbal communication
• Do not follow mother around • Can be agile, but clumsy at copying
• Little eye contact movements
• No imaginative play • Cannot understand the world:
• Carry same object around temper tantrums

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Asperger’s Syndrome/ Autism Spectrum Disorder:

• Good speech, but long winded and literal

• Long monologues, regardless of response
• Monotonous
• Good memories, but not interested in wider applications
• Lack of common sense in social interactions
• Physically clumsy
• Intelligence - variable but usually at least average, but sometimes highly intelligent

MANAGEMENT OF ASD:
BASIC PRINCIPLES:

• Sufficient personal space and a quiet location with planned space for their rituals
• Each day to be organised and explained and activities within their capabilities
• Organised physical activities can reduce challenging behaviour
• Treatment of epilepsy and other physical problems

Behavioural Approach: used for obsessions

Graded changes: Setting limits:
• Aim to reduce frequency gradually - • Mainly for challenging behaviours -
e.g. remove an item at a time in the some might need to be interrupted
case of obsessive collection of items • First to gain attention of individual
• Positive Reinforcers (e.g. reward) • Warn before interruption
- Immediate • Any destructive behaviour should be
- Appropriate interrupted quickly
- Consistent • Avoid ‘No’: use positive direction
- Paired with attention& praise • Use short and concrete explanation
- Every time (at least initially) • Allow tantrum to run itself out

Other aspects:
Education: Others:
• Can provide a framework for order, • Counselling of parents is
routines and structure important
• Understanding is difficult - try • Medication: not very useful.
physical prompting and visual Excitability may be reduced by
demonstration antipsychotics
• Teaching material has to be precise • Aggressive outbursts usually
and specific understood in terms of
• Help to develop any skills environmental factors

ASD can have challenging behaviours like headbanging if rituals change

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ID AND MENTAL ILLNESS:
3 x greater risk of mental illness and may present differently:
Depression:
Depressive/ suicidal ideas are rare and poorly planned – less likely to complain of low mood.
May notice an exaggeration of a need for sameness and observable anxiety
• Look for any family history of depression and observed behaviour:
- Diurnal mood or activity variation
- Agitation may lead to wandering
- Loss of appetite
- Sleep disturbance
- Speech or motor retardation

Mania/ Bipolar:

• Delusions are not as elaborate

• Family history of bipolar disorder (may help to distinguish from schizophrenia)
• Challenging behaviour
• Giggling
• Overactivity and excitement
• Inappropriate masturbation or exposure (disinhibition)

Schizophrenia:
Difficult to diagnose below IQ of 45 and is commoner with more severe ID. Tend to have
an earlier age of onset and less elaborate signs and symptoms:
Can present with: • Poverty of thought
• Fear • Delusions: less elaborate
• Withdrawal • Hallucinations: simpler and repetitive, may respond to
• Challenging behaviour unseen stimuli
(esp out of character) • Distinguish negative symptoms from developmental
history (deterioration from the previous level of
• Sleep disturbances functioning)
• Persecutory delusions and thought disorder less common

CAPACITY IN DECISION MAKING: assess capacity as normal with a MCA and depending on
the level of ID, you may need to consider providing information to individuals according to their
intellectual level, e.g. using pictures (Books Beyond Words is a good example)

EPILEPSY:
More likely in severe ID. Prevalence: School children: 0.6 %, mild ID: 3 - 6 %, at least
moderate ID: 44 % had epilepsy by age 22. Males: Females = 4: 1

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 • Fit frequency and psychotropic medications - may affect the seizure threshold
• Compliance can be an issue - inadequate control of fits - leading to polypharmacy
• Recording of fits may be difficult
• Need to assess side effects of medication
• Recognition of non-epileptic attacks
• Frequent attacks may cause over-protection by carers / parents
• Education of patient and carer - e.g. Emergency treatment of prolonged fits
• Social implications

Perinatal Psychiatry
Puerperium: the period of about six weeks after childbirth during which the mother's
reproductive organs return to their original non-pregnant condition.
- 10% of women suffer from a mental disorder postnatally
Confidential enquiries have shown that maternal suicide is a leading cause of maternal
death and that half of those could have been identified as at risk antenatally – all use very
violent methods- no second chances so need to identify early
RECOMMENDATIONS FOLLOWING THE MOST RECENT CONFIDENTIAL ENQUIRY:
1. All women should be screened at antenatal booking for a previous history of or
current psychiatric disorder.
2. All women with a previous history of serious affective disorder or other psychoses
should be referred in pregnancy for psychiatric assessment and management
3. Psychiatric services should have priority care pathways for pregnant and
postpartum women. These will include a lowered threshold for referral and
intervention, including admission and a rapid response time for women in late
pregnancy and the first 6 weeks following delivery.
4. Risk assessments of pregnant or postpartum women should be modified to take
account of risk associated with previous history, the distinctive clinical picture of
perinatal disorders and the violent methods of suicide.
5. Caution needs to be exercised when diagnosing psychiatric disorder if the only
symptoms are either unexplained physical symptoms or distress and agitation.
This is particularly so when the woman has no prior psychiatric history or when she
does not speak English or comes from an ethnic minority.
SCREENING:
Usually have a predictable course so community midwives are trained to screen all women
at antenatal booking for risk, but all clinicians should identify at risk people. They are best
managed in specialised services and should be referred. Who to refer:
• All women with previous or current: schizophrenia or psychosis, bipolar disorder,
postpartum psychosis, severe depression (received secondary care, psychiatrist)
• All women on mood stabilisers
• Any women with a family history of bipolar affective disorder or schizoaffective
disorder (or suicide) AND a personal history of any psychiatric disorder

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Examples:
If a pregnant lady presents with a mild-moderate
depressive episode (including self-harm history) to
the GP, initially try antidepressants. If this manages
her then fine leave it, if not then refer
Depressive/ puerperal psychosis: delusional beliefs
(baby or me is going to die). Should refer to a
psychiatrist (midwife refers to doctor to obstetric
consultant/ GP to refer)
History of counselling in primary care does not
require a referral. But need to find the details of the
counselling from the GP. Next steps = closely
observe her MH and arrange a psychiatric assessment
Gravida (pregnancies), Para (births), e.g. gravida 2 para 1 means 2 pregnancy and 1 birth

Perinatal Psychiatry service: provides care for women with psych disorders
complicating pregnancy, childbirth and the postpartum period. They have specialist
knowledge including risk assessments and effect of treatment on the fetus and infant

Psychiatric Disorders in Pregnancy: Postnatal Psychiatric Disorders:

• More common in 1st trimester Up to 1/3 of deliveries are complicated by
• Generally mild and improve psychiatric morbidity
• Milder respond to psychosocial • 15-30% depression
interventions • 10% depressive episode
• First onset serious mental health illness • 3-5% moderate/severe depressive
is rare in pregnancy episode
• Depression& anxiety in the 3rd • 2% referred psychiatry
trimester may continue in the • 0.2% Psychosis
postpartum as postnatal depression

The Pinks The Blues

Normal phenomena in the first 48 hours 50-80% postpartum women experience.
postpartum, characterised by excitement Present about Day 5 (between Day 3 to
and a sense of euphoria. A woman may also 10). Attributed to hormonal changes in
present as mildly over talkative and overactive combination with physical and emotional
with some insomnia. exhaustion resulting in:
Though there is a slight risk of exhaustion, Emotional lability, tearfulness, mild anxiety and
the Pinks will resolve without any irritability. Presentation varies but generally
intervention. mild and not pervasive and last 48h
without any treatment

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DEPRESSIVE ILLNESSES:
Often with guilt and concerns about parental ability. Peak onset 2-4 weeks postpartum
and a secondary peak at 3 months. If previous severe depression/ postnatal depression then
50% risk. With prompt treatment, 2/3 of illnesses will resolve within 2-3 months. Without
treatment, it can take 6 months or longer to recover.
Symptoms are similar to depression at any other time: low mood, irritability, fatigue, early
morning waking, change in appetite, anhedonia, anxiety around the baby
- Rx: CBT and SSRIs (safe in breast feeding, particularly sertraline)

POSTPARTUM PSYCHOSIS AKA PUERPERAL PSYCHOSIS

Sudden onset of behavioural disturbances, hallucinations, delusions, fear and perplexity.
Risk is 0.2%, if bipolar or previous postpartum psychosis, risk is 50%:
- 50% present by day 7, 75% present by day 16 and 95% present by day 90
It is essential at-risk women are identified antenatally, so can effectively manage the risks-
99% are either bipolar (most) or schizoaffective disorder.
- Rx: Mother and Baby Unit for high intensity physical and psychological care:
antipsychotics and mood stabilisers.
Prognosis: good short term but significant morbidity and mortality

ANTENATAL ASSESSMENTS - BIRTH PLANS

Management must be proactive. A Birth Plan for each patient should be in place by 35
weeks gestation, this should include:
• Monitoring her mental health immediately following delivery
• A requirement for liaison between all health professionals
• Use of prophylactic medication, where appropriate
• Consideration of child protection
• Emergency contact details

MEDICATIONS IN PREGNANCY:
In Pregnancy Whilst Breastfeeding
• SSRIs and TCAs probably safe • Antidepressants are considered safe
• Avoid paroxetine in first trimester (cardiac • Avoid benzos can be sedating,
defects) or citalopram lorazepam has the shortest half-life so
safest.
• Avoid lithium

• Atypical anti-psychotics are safer

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Timing of psychiatric admissions: main
reason for the large peak is the sudden and
early onset of postpartum psychosis

DIFFERENCE BETWEEN EUPD AND BIPOLAR DISORDER:

EUPD (borderline PD): as with all PD generally starts in childhood/ adolescence, is a long
standing unstable mood not with clear episodes of illness like in bipolar disorder and no
single episode meet the threshold for mania or depression
Internal voices, 2nd person, telling patient to harm themselves (pseudohallucinations) are
very characteristic of EUPD and any other voices or comments should make you think of
something else
- Talking therapy is mainstay for EUPD: Stabilisation therapy, distress tolerance

Some Mental Health Act stuff: If got capacity and consent – T2 (section 42). If no
capacity or don’t consent – T3 (second doctor approved treatment). (Section 62) is
emergency treatment (continuing current treatment or something’s gone wrong). T2
specifies exactly within the BNF what the patient is willing to accept from doctors
medication wise. If anything falls outside of this but needs to be used in emergency, need T3
(section 62) and get 2 doctors to sign to use something outside of this limit

The Scoff Questionnaire:

Two or more positive answers are suggestive of anorexia nervosa or bulimia nervosa:
• 'Do you ever make yourself sick because you feel uncomfortably full?'
• 'Do you worry that you have lost control over how much you eat?'
• 'Have you recently lost more than one stone in a 3-month period?'
• 'Do you believe yourself to be fat when others say you are too thin?'
• 'Would you say that food dominates your life?

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