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Understanding Child and Adolescent Psychiatry

for Medical Students


January 2009

Dedicated
to
Professor Richard Harrington
(1956-2004)
Head of Department,
Child and Adolescent Psychiatry.
University of Manchester.

Central Manchester University Hospitals NHS Foundation


Trust

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Medical Student Handout
Introduction to the Department of Page No
Child and Adolescent Psychiatry – Prof Hill and Prof Green 4

1. Details of the course


Dr Latha Hackett and Dr Louise Theodosiou 5

2. Introduction to Child Psychiatry. 6


Dr Sandeep Ranote

3. Understanding and describing a case. 10


Dr. Samina Ahmed

4. Depression and emotional disorder 16


Dr. Sue Barrett

5. School Refusal 24
Dr. Soumitra Datta

6. Deliberate self harm 27


Dr. Louise Theodosiou

7. Conduct Disorder. 33
Dr. Prathiba Chitsabesan

8. Attention Deficit Hyperactivity Disorder 36


Dr. Prathiba Chitsabesan.

9. Adolescence. 39
Dr. Mischa N. C. Mockett

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10. Developmental disorders
I Learning disability 43
Dr Hilary Lloyd and Dr Latha Hackett
II Pervasive developmental disorder 48
Dr Latha Hackett

11. Psychosomatic disorders. 56


Dr Debra Bradley

12. Psychological aspects of physical illness. 60


Dr. Debra Bradley

13. Medication in Child and Adolescent Psychiatry. 65


Dr Louise Theodosiou.

14. References, Useful Addresses and Websites. 77


Dr Louise Theodosiou

15. Consultants in Child and Adolescent Psychiatrists in the 80


North West Region (Greater Manchester, Lancashire & Cumbria)

Compiled by Consultants and Specialist registrars in Child and Adolescent Psychiatry – January 2009
(To be revised June 2009)

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Child and Adolescent Psychiatry in the North West

We hope that you will find this booklet helpful. If you would like some clinical experience in Child
Psychiatry, then there are many opportunities here in the North West. We have enclosed at the end of
this booklet a list of the names and addresses of consultant child psychiatrists in the North West. Their
services offer a wide range of treatment modalities, so do not hesitate to ring up and find out what is
going on.

The North West region also has a number of specialised mental health services that may also be of interest.
There are inpatient facilities, which treat children and adolescents with severe mental disorders, at
Booth Hall, the McGuinness Adolescent Unit at Prestwich, the 16 – 17 Hope Unit in Pennine and the
Junction in Lancaster. In addition, the North West has one of only three specialised secure facilities for
adolescent offenders with mental disorders, the Gardener Unit at Prestwich Hospital.

Some of the consultants on the list are also able to take medical students for research or audit placements.
The Medical School will tell you who these Consultants currently are.

The Academic Department of Child & Adolescent Psychiatry has staff on three sites: Royal Manchester
Children's Hospital, Booth Hall Children's Hospital, and Prestwich Hospital. The department runs a large
research programme with particular interests in Clinical Trials, disorders of social development including
autism, severe adolescent disorders such as depression and self-harm, the provision of services (particularly
inpatient services), pre-school problems (particularly severe social relationship problems), and the
organisation of mental health services.

So, there are lots of opportunities here for learning about the psychiatry of childhood and adolescence, and
we are looking forward to seeing you.

Jonathan Hill and Jonathan Green


Professors in Child and Adolescent Psychiatry

January 09

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1. Child and Adolescent Mental Health services in the Northwestern Deanery

In every district there are multi-disciplinary and multi-agency teams. These are made up of Child and
Adolescent Psychiatrists, Clinical Psychologists and Child Mental Health practitioners from different
professional backgrounds such as nursing, social work, art therapy and occupational therapy. A list of
Consultant Child and Adolescent Psychiatrists and their addresses are included in the back of this handbook.

All the district general hospitals that you could be posted provide the opportunity for you to sign up with the
local Child and Adolescent Psychiatry service to attend clinics.

Additionally, a group of Manchester Child and Adolescent Psychiatrists, have produced a video for medical
students. Interviews between clinicians and child volunteers address conditions such as Autistic Spectrum
disorder, Attention Deficit Hyperactivity Disorder, depression, deliberate self harm, Conduct disorder and
Psychosomatic disorders.

This handbook contains information that will be useful in answering the PBL scenarios that you will use in
your groups. Important supplementary information will be provided in the Meet the Expert sessions that you
will attend during your training. For students with a special interest in this field, there are Child and
Adolescent psychiatrists who will be able to help you to undertake special study modules, research and audit
options.

This handbook has been compiled with contributions from Consultants and specialist registrars in Child and
Adolescent Psychiatry.

We hope that you find it helpful.

Dr Latha Hackett Dr Louise Theodosiou


Consultant in Child & Adolescent Consultant in Child & Adolescent
Psychiatry Psychiatry

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2. Introduction to Child Psychiatry
Dr Sandeep Ranote

This chapter aims to provide an overview of child and adolescent psychiatry (“CAP”), relevant to
undergraduates during their Children and Families module. It not only hopes to provide the basis of
preparation for the OSCE but also to generate interest in a relatively new and expanding speciality within
child health.

What Is Child And Adolescent Psychiatry?

Broadly, it is the management of emotions and behaviour lying outside the normal range for age and sex and
causing distress. In the short term it interferes with a child’s emotional development, social relationships and
academic progress. In the long term there is an important association with adult mental illness. In infancy
the child’s temperament and quality of relationship with the main carer (usually mother but reported to be
the father in 33% in U.K.) are important for their mental well being. Later, relationships with family and
peers (N.B. bullying) and school success become important factors. Early traumatic experiences including
separations, physical illness and developmental delay all increase the risk of childhood psychiatric disorder.
A developmental perspective must be taken.

How Do We Work?

You are required to undertake core training in psychiatry first, obtaining the Membership of the Royal
College of Psychiatrists (MRCPsych parts I, II and III) before proceeding to higher training as a specialty
trainee registrar in Child and Adolescent Psychiatry.

The service is delivered in a multidisciplinary style on an out-patient, day-patient or in-patient basis from
hospital departments or the community. Important members of the multidisciplinary team include,
psychiatrists, nurses, social workers, teachers, clinical psychologists, voluntary agencies e.g. NSPCC
and sometimes paediatricians, occupational and speech therapists.

Types of disorder

These are listed in the World Health Organisation 10th Revision of The International Statistical
Classification of Diseases (ICD 10). Chapter V of this international classification system is dedicated
specifically to mental and behavioural disorders. Children and adolescents can be affected by disorders more
typical of adults e.g. obsessive compulsive disorder, adjustment disorders, depressive episodes, anorexia
nervosa, sleep disorders, schizophrenia and substance abuse etc but there are conditions occurring first or
only in childhood (See Table 1).

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Table 1 -Adapted from ICD-10 Mental and Behavioural Disorders

BEHAVIOURAL AND EMOTIONAL DISORDERS WITH ONSET USUALLY


OCCURING IN CHILDHOOD AND ADOLESCENCE
Hyperkinetic Disorders
Conduct disorders
Mixed Disorder of Conduct and Emotions
Emotional Disorders with Onset Specific to Childhood
Separation Anxiety
Phobic Anxiety Disorder
Sibling Rivalry Disorder
Disorders of Social Functioning with Onset Specific To Childhood
Elective Mutism
Attachment Disorders
Tic Disorders
Transient Tic Disorder
Tourette’s syndrome
Other Behavioural and Emotional Disorders with Onset Specific to Childhood
Non-organic Enuresis
Non-organic Encopresis
Feeding disorder
Pica of infancy
DISORDERS OF PSYCHOLOGICAL DEVELOPMENT
Pervasive Developmental Disorders
Autism
Asperger’s Syndrome
Rett’s Syndrome
Specific Developmental Disorders of Speech and Language
Specific Developmental Disorders of Scholastic Skills
Specific Reading Disorder
Specific Spelling Disorder
Specific Developmental Disorder of Motor Function

Epidemiology

The main sources of information are from well known local population surveys: Isle of Wight, Inner London
Borough & Waltham Forest studies. These have shown that the prevalence of psychiatric disorder is twice as
high in inner city compared to rural children and that many children still go undiagnosed and untreated (See
Table 2).

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Table 2 – Rates of Significant Psychological Disorder illustrated

AGE GROUP RATE STUDY ASSOCIATION


Pre-School Overall – 22% Richman et al - Males > Females
Mod to severe Waltham Forest 2/3rds still had
behaviour problems Study (North East problems at 4 & 8
– 7% London) yrs old.
Middle – Overall rural– 6.8% Isle of Wight & Males > Females
Childhood Overall city – 13% Inner London ↑ risk of
Depression – 2.5% Borough Studies – psychological
Any physical Rutter et al problems if
disorder – 11.6% physical disorder
Epilepsy – 28% present
Adolescence Overall – 15-20% Various Studies Females > males
Depression – 4.5% Approx due to
↑ substance misuse, unclear definition
eating disorder, of adolescence &
DSH & depression developmental
changes

Aetiology

Although diagnosis is important, in “CAP” it is more useful to formulate the aetiology of the clinical
problem in understanding the individual case and this will be covered in more detail later in the book. The
aetiology of psychiatric disorders is multifactorial, divided into predisposing, precipitating and
perpetuating factors of a biological, social and psychological origin. Some factors are particularly relevant
to understanding children’s psychological problems.

1. Attachment & Bonding – derived from John Bowlby’s work. Development of the child’s first close
personal relationship, usually with the primary caregiver i.e. mother and/or father. This is very
important in determining the quality of subsequent relationships throughout the child’s life.
Attachment behaviours displayed around 6 – 7 months (stranger & separation anxiety). Separation
anxiety normally wanes over the pre-school years.

2. Temperament – individual differences between children in the style of their behaviour, thought to
be innate and largely genetically determined. Can be modified by experiences or environmental
influences. New York Longitudinal Study classified temperament in 3 groups (See below) and found
that those with “difficult” temperament had a 2-3 fold greater risk of behavioural problems.

Easy – regular rhythmicity of biological functions, positive approaches to novel situations, rapid,
positive adaptability to change, predominantly positive mood, mild intensity of emotional reaction

Slow to Warm up – negative, mild response to change, slow adaptability

Difficult – irregular, negative, withdrawing reactions to novelty, predominantly negative mood,


intense emotional reactions

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3. Families – Parents are key in a successful therapeutic outcome. Family factors important in
aetiology are: discordant relationships within the family, lack of emotional warmth, parental mental
illness, criminality in parent, large family size (small family size increases risk of depression).
Parenting style, described by Diana Baumrind, is also important (See Table 3).

Table 3 – Parenting style classification

Parenting Style Features Children Are


Authoritarian Autocratic, detached Compliant, withdrawn,
dependent, neurotic
Permissive Laissez-faire, indulgent Immature, lack of purpose,
increased risk of substance
abuse
Authoritative Parental authority & house Independent, assertive,
rules used, attend to child’s creative, friendly
view

Management

This is predominantly done on an out-patient basis, involving a multidisciplinary team, using psychological
and increasingly, pharmacological treatment approaches, and placing emphasis on the child’s social context
(family / carers, school etc).

References:

1. ICD 10 classification of Mental and behavioural disorders. Clinical descriptions and diagnostic
guidelines. World Health Organisation Geneva.
2. ICD 10 classification of Mental and behavioural disorders in Children and Adolescents – Multiaxial
classification of Child and Adolescent Psychiatric disorders World health organisation. Cambridge
University press ISBN 0 521 58133-8.
3. Rutter, M., Tizard, I. & Whitmore K (Eds) (1970) Education, health and behaviour, London:
Longman.
4. Cantwell, DP and Rutter, M. (1994) Classification: Conceptual issues and substantive findings. In
Child and Adolescent Psychiatry: Modern Approaches. 3rd edition. (M Rutter, E Taylor & L Hersov
eds) Blackwell Science, Oxford, PP 3-21.
5. Bowlby J (1980) Volume 1 Attachment. London Hogarth Press.
6. Thomas A, Birch HG, Chess S, Hertzig ME, Korn S (1963) Behavioural Individuality in early
childhood, New York University Press, New York.
7. Thomas A and Chess S (1980). The dynamics of psychological development. Brunner/Mazel, New
York.

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3. Understanding and Describing a case
Dr Samina Ahmed

Introduction
In Child & Adolescent Psychiatry it is important that the child’s difficulties be considered in the context of
his or her family, school, wider community and cultural background. Impact on the emotional, cognitive,
physical and behavioural wellbeing of the child should all be taken into account. Although diagnostic
categories can be useful, many young people present considerable co morbidity.

Assessment may begin before you meet with child and their family. You may wish to contact the referrer
for clarification regarding the problems, their presentation and the urgency of the situation. It may also be
helpful to ask about what strategies have already been tried to manage the child’s difficulties. It is crucial,
both from a legal and clinical perspective, to have parental consent for a psychiatric interview to take place.

The first interview with patient and their family


The first interview may take up to l½ hours. If possible, it can be most informative to assess the child and
both parents together. If assessing an adolescent you may wish to see the adolescent before seeing the
parents, alone, in order to give the message to the adolescent that you are there to try to help them rather
than side with their parents against them. This can also be a helpful strategy if the adolescent has attended
the appointment reluctantly, as it gives you a good opportunity to form a rapport with them and is beneficial
for the therapeutic alliance (Schowalter and King, 1991).

In some circumstances, for example, with a younger child, the patient may not wish to separate from their
parents at the first interview and you may need to make a further appointment for individual assessment of
the child.

During the interview with the parents you will have the opportunity to gain a sense of how the child’s
difficulties have impacted on the family, gain an account of the current problems from each parent and
explore the child’s developmental history in the context of the family.
Be aware that the accounts from different sources, and even at times from each parent, may differ greatly.
This is one of the reasons that so many different sources of information may be drawn upon as part of your
assessment. For example, children are more likely to report feelings and symptoms of low mood, including
suicidal thoughts and acts, of which the parents may be unaware (Kashani et al., 1985).

In summary, the first appointment should help the clinician have an appreciation of:

1. The presenting difficulties, their severity and impact on the family or wider society e.g. school.
2. What factors may have triggered, exacerbated or maintained the presenting problems.
3. The strengths of the family and child and whether they are motivated to working on the issues.
4. The expectations and ideas that the family have about being seen by CAMHS.

History taking
A good foundation for a thorough assessment is to take a detailed history. Sometimes it is not possible or
practical to obtain all of this information at the first interview and, in such cases, further appointments might
be offered.
Outlined below are the visual headings and suggested areas about which you may need to enquire. It may be
appropriate to spend more or less time on a specific area, dependent upon the nature of the referral:

1. Presenting complaint
Description – Why is help being sought now? Who instigated the referral?
Recent examples, focussing on precipitating factors, context and exacerbating and relieving factors.
When did it start?
Frequency
Severity
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Change of symptoms over time
What effect does it have?
What help was sought previously? How helpful was this?
What do they put it down to?

2. Recent behaviour and emotional state


Being disobedient, destructive, defiant, having temper-tantrums, telling lies, fire setting, stealing, taking
drugs or alcohol, smoking, solitary or accompanied involvement with the police, cruelty to
animals/young children.
Does this behaviour occur at home or outside?
How is it dealt with?
Happy or miserable, crying, often worries
Suicidal thoughts. Talking about or threatening suicide. Acts or thoughts of self-harm.
Routines, Rituals, obsessions, fussy or faddy behaviour.

3. Health, past medical history


Is he/she off school at all?
Generally healthy?
ROS: Asthma, headaches, stomach aches, eyesight, hearing, fainting, fits, absences
Childhood infections
Immunisations
Allergies, drugs, food
Eating difficulties: Food refusal, faddiness, feeding problems
Sleeping problems: settling, waking, nightmares, sleeping arrangements
Tics, mannerisms
PMH: Illnesses, operations, hospitalisations

4. Family structure and history

Draw family tree


Male Female

Deceased Deceased

Married

Divorced Separated

Identified patient

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Example of family tree

John Foster – 14 years old

Referred with difficulties socialising and aggressive behaviour

Fred Ada, 80 y
MI in 2006, Angina, Arthritis
at 83y

Eileen, 71y Geoff, 72y


Diabetes Arthritis
Edward, 51y Joseph, 53y
H/o Epilepsy H/o Learning
since c/hood Difficulties

Divorce, 2003

Sylvia, 39y Paul, 42y Kath, 41y James, 43y


Unemployed Housewife Factory Worker

John, 14y Kylie, 8y Joshua, 6y


Behavioural Tantrums
difficulties

It is usual practice to draw an arrow indicating the referred child, and also to draw a dotted line encircling
those living in the family home.

Persons in home:

Age, religion, occupation, education.


Current mental/physical illness.
Personality, seen by psychiatrist?
Contact with grandparents.
Details of parents own childhood and family support network.
Family history of psychiatric disorders or psychiatric treatment, alcoholism.
Family history of enuresis, epilepsy.
Any other illness in the family.
History of domestic conflict or violence and extent of childhood exposure to violence.

Family life and relationships

a) Parental relationships: how do they get on? How do they spend evenings, weekends? To what extent
do they both participate in childcare, discipline etc?
b) Parent-child interaction: closeness, description.
c) Child’s participation in family activities: helps at home etc.
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d) Rules and routines at home.

5. Personal history/developmental history

Pregnancy: planned, complications.


Delivery: spontaneous/induced, place, date, labour, presentation, mode of delivery, gestation, birth
weight, complications, resuscitation/SCBU.
Mother’s health during and after pregnancy, depression.
Neonatal period: breathing, feeding, convulsions, jaundice, and infections, how long in hospital?
Infancy: feeding, weaning, sleep pattern, placid or active, irritable, easy or difficult temperament. Any
behavioural difficulties eg tantrums as a toddler.
Milestones: sitting unsupported, walking unaided, first word with meaning, first 2 word phrases, and
comparison with siblings.
Bladder and bowel control: dry by day and night, bowel control.
Separations: apart from parents. How child reacted on separation for nursery/toddler playgroup.
Interactions with peers as a young child.

6. School

Present school –happy, progress, and contact with school


Attendance
Academic strengths & weaknesses.
Check with school.
Non-academic skills, independence
Social relationships, statutory assessment or involvement of Educational Psychologist.
Behaviour Support or learning support service.

Previous schools

Relationships – with other adults, with teachers, other children, opposite sex. Certain symptoms, such as
poor peer relations, are predictors of disorder (Cox and Rutter, 1985).

7. Social history

Home circumstances – description of the house, sleeping arrangements, community, overcrowding.


Other care arrangements – Child minder, baby sitter
Finances – any difficulties
Neighbourhood – description of area, house moves, community violence, neighbour disputes.

8. Personality/Temperament

Meeting new people – other adults, children, shy, clingy, how quickly does he/she adapt to change?
New situations – new places, new tools, explore or hand back.
Emotional expression – introvert, extrovert, generally happy/miserable
Affection & Relationships – how does he/she show feelings, affectionate, confiding, friendships:
school, at home.
Sensitivity – response to person/animal hurt, reaction if told off, did something wrong.
Interests, hobbies

Practicalities of the interview with the child

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The way in which you carry out the interview with the child will be largely determined by their age and
developmental level. In any case, it is important to try to put the child at ease by providing the right
materials (crayons, paper, books) and a safe and private environment.

It is important that you explain to the child that the interview is confidential and the limits of that
confidentiality.

It is usually easiest to initially try to engage the child by talking about subjects that they find interesting.
Once they have a sense of you as an adult that they can trust and speak easily to, it is then appropriate to
carefully move on to any more difficult or sensitive issues.

With much younger children, try to engage them in drawing a picture of their family or themselves and
tactfully ask questions based around the characters drawn. With an adolescent, the interviewer may involve more
direct questions and may be more akin to an interview in adult psychiatry.

Try to use more direct questions when eliciting factual information and more open questions when enquiring about
subjective experience.

By the end of the interview you should have a reasonable idea about the child’s understanding of why they
are being seen and some idea of their emotional state.

Mental state examination

Appearance and behaviour: dress, physical appearance, motor activity, co-ordination, involuntary
movements, soft neurological signs.
Language: expression, comprehension, speech – spontaneity, quantity, rate, rhythm, and complexity.
Mood: subjective & objective, symptoms/signs of depression, suicidal feelings, anxiety, panic, anger,
aggression, and irritability.
Abnormal beliefs or experiences: thought content, hallucinations, delusions, worries, fears,
preoccupations, obsessions, fantasies or wishes.
Social response to interviewer: humour, rapport, eye contact, empathy, and co-operation, shy, confident,
any anxiety or distress.
Cognition: attention span/distractibility, draw-a-person test (note grip, handedness), write name, give days
of week, months of year, counting, simple arithmetic, orientation, memory, general knowledge, reading
skills/level of attainment.

Other sources of Information

Writing to school with consent from the individual with parental responsibility.
Undertaking school observations with appropriate consent.
Undertaking home observations.
Information from any other agencies involved with the child or family.

Multiaxial Diagnosis
In child and adolescent psychiatry we use the multiaxial classification to describe in shorthand the problems,
which the child is presenting with.
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The axes are as follows:

Axis I Psychiatric Diagnosis according to ICD 10.


Axis II Specific learning disability.
Axis III General learning difficulties.
Axis IV Medical diagnosis.
Axis V Abnormal psychosocial situations.

Formulation

Once all the information has been collected, it is possible to produce a formulation. This is a brief
description of the child’s presenting problems, any precipitating, predisposing or maintaining factors. It
helps to consider the factors under Biological, Psychological & Social categories.

FACTORS BIOLOGICAL PSYCHOLOGICAL SOCIAL


PREDISPOSING
PRECIPITATING
MAINTAINING
PROTECTIVE

The formulation is useful in helping to highlight areas for intervention and producing a management plan
with a description of the likely prognosis.

Other sources of Information

Following an initial assessment it is usual to seek information from any other professionals involved once
parental consent to do so has been obtained. This usually includes requesting a school report. It may also
involve liaison with Social Services or individuals from the Youth Offending Team, for example.

Further reading & References

1.Child Psychiatry – Goodman and Scott Part 1 – Assessment pages 1-21.

2. Child and adolescent Psychiatry Modern Approaches. Rutter, Taylor and Hersov. Third edition.
Chapter 2 Diagnostic appraisal

3. Child psychiatry. A developmental approach. Philip Graham. Assessment and diagnosis.

4. Schowalter JE, King RA (1991), The clinical interview of the adolescent. In: Textbook of Child and
Adolescent Psychiatry, Wiener JM, ed. Washington, DC: American Psychiatric Press, pp 74-77

5. Kashani JH, Orvaschel H, Burk JP, Reid JC (1985), Informant variance: the issue of parent-child
disagreement. J Am Acad Child Psychiatry 24:437-441

6. Cox A, Rutter M (1985), Diagnostic appraisal and interviewing. In: Child and Adolescent Psychiatry:
Modern Approaches, 2nd ed, Rutter M, Hersov L, eds. Oxford, England: Blackwell Scientific Publications,
pp 233-248

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4. Depression and Emotional Disorders
Dr Sue Barrett

Some of these disorders, e.g. separation anxiety disorder of childhood, are particular to children and/or
adolescents. Others show strong continuity into adulthood, e.g. depression.

Depressive disorders

• It is now recognised that depression can occur in children and adolescents


• But children differ from adults both in their ability to report symptoms and the fact that they experience
different symptoms more commonly.
• There are 2 main forms of affective (mood) disorder:
a) Unipolar = depression only
b) Bipolar = mania and depression (covered in the adolescence chapter)

Assessment
It is essential to speak to the child alone about their depressive symptoms and to confirm these by
speaking to the parents.
The parents often do not know the extent of a child’s symptoms and the child may feel inhibited talking in
front of his/her parents.

Symptoms of depression:
• Depressed mood
• Sleep disturbance/insomnia/hypersomnia
• Irritability
• Loss of energy
• Reduced concentration and attention/slowed thinking/indecisive/forgetful
• Disturbed appetite (more or less)
• Reduced self-esteem and self confidence
• Ideas of guilt or worthlessness
• Pessimistic view of future
• Suicidal ideas or acts

The following symptoms are known as somatic or biological symptoms:


Loss of enjoyment or pleasure (anhedonia)
Early morning wakening (2hrs before normally wake)
Diurnal variation in mood (usually worse am)
Weight loss due to loss of appetite
Loss of libido
Motor retardation or agitation
• A combination of symptoms must be present consistently over 2 weeks
• Severity of depression depends on the number and type of symptoms seen

More common in prepubertal children: somatic complaints (tummy ache and headache), psychomotor
agitation, separation anxiety, school refusal, and irritability

Less common in prepubertal children: sleep and appetite disturbance, guilt and hopelessness
More common in adolescents: hopelessness/helplessness, anhedonia, hypersomnia, irritability, use of
alcohol and drugs, reduced academic performance, antisocial behaviour in males

• Children who are depressed have other diagnoses too, about 50% also have an anxiety disorder and a
similar number conduct disorder

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Epidemiology
• Prevalence prepubertal children = 1-2%, M=F
Adolescents = 2-5%, F>M
Approx 10% depressed children are referred for treatment

Aetiology is Multifactorial
• Parental depressive disorder
a) Genetic factors, increased depression rates in family members of depressed children compared with
controls
b) Depression affects parenting skills, which may lead to children becoming depressed

• Biological factors
Much work in adults suggests abnormalities in brain neurotransmitter systems involving nor adrenaline
and serotonin. Children and adolescents respond to treatment with Selective Serotonin Re-uptake
Inhibitors (SSRI’s).

• Early adverse experiences


Early separation, loss of parent, lack of care, physical illness have all been found to be important in
predisposing to depression, both within childhood and into adult life.

• Recent life events and adversities


Life events, particularly loss, may precipitate depressive episode e.g. bereavement, parental separation,
loss of friends etc. adversities eg. Poor friendships, chronic illness in the family, poor housing, family
dysfunction etc can increase impact of life events

Treatment
• Outpatient/ inpatient/ day patient
• Liaison with school and other professionals
• NICE Recommends:
Enhanced education and recognition within primary care; Access to guided self-help and psychological
therapy for young people with mild depression; Specific outpatient psychological therapies (Cognitive
Behavioural Therapy, interpersonal or family therapy) at CAMHS for those with moderate depression;
Where there is inadequate response to psychological therapy, combined psychological therapy plus
Fluoxetine(an SSRI) is recommended. Cautious consideration of medication in under 12 years child due
to lack of evidence) Must warn about the potential for increased self-harm, suicidal behaviour, and
hostility; Options for 2nd line alternative SSRI’s are Sertraline or Citalopram; Tier 4 Specialist
consultation/inpatient care for high risk or refractory cases.
• Data from the Treatment for Adolescents with Depression Study states that “Fluoxetine alone or in
combination with CBT accelerates improvement of depression relative to CBT alone” and “adding
CBT to fluoxetine therapy minimizes persistent suicidal ideation and treatment-emergent suicidal
events.
• ECT is rarely used in this age group
• Tricyclic antidepressants are not effective in this age group
• Fluoxetine, Sertraline, & Citalopram do not have UK licence for use in children under 18 with
depression. See chapter 13.
.
Prognosis: for current episode is good but relapse rate is high

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Obsessive Compulsive Disorder (OCD)

Definition/Features
Condition in which there are repetitive intrusive thoughts (obsessions) and/or rituals (compulsions) that are
unwanted and interfere with function or cause marked distress

Common compulsions: washing, repeating, checking, touching. Common obsessions: concern with dirt,
thinking ‘something terrible might happen’, and concern with symmetry.

Secondary anxiety and depression are common. About 20% have premorbid obsessive personality. Parents
and siblings may get drawn into rituals and demands for reassurance.

Epidemiology
• 2% general population M=F, roughly half have symptoms before 15 years
• 0.5% adolescents M=F, symptoms may date back to preschool years
• prepubertally M>F

Differential Diagnosis
• Normal childhood rituals eg bedtime rituals, collecting behaviour, adolescent obsessions with idols
• Primary depressive disorder, Anorexia Nervosa, Schizophrenia: obsessions and compulsions can occur
• Mixed emotional disorders
• Autism: (see Pervasive Developmental Disorders chapter) ritualistic and repetitive behaviours are some
of the characteristic features of autism but are not ‘ego dystonic’ (unwanted and distressing)
• Tourette’s syndrome: commonly accompanied by OCD symptoms

Aetiology
Earlier enthusiasm for psychodynamic explanations, current theories emphasise biological and behavioural
basis:

Biological
• Neurological/neuroimaging studies of basal ganglia show structural/functional abnormalities
• Positive family history of OCD is common
• Tic disorders and OCD cluster in some families
• Serotonin is implicated, as SSRI’s are effective treatment

Behavioural
• Ethological theory: compulsions are fixed action patterns related to grooming and cleaning which have
escaped suppression from higher centres in brain
• Once initiated, rituals may persist as they reduce anxiety

Treatment
NICE Recommends
-Enhanced education & recognition in primary care
-Access to guided self-help packages for those with mild OCD
-Cognitive Behavioural Therapy (CBT) at CAMHS for those with OCD with significant functional
impairment
-Where there is inadequate response to psychological therapy, combined psychological therapy plus
SSRI is recommended.
-Options for 2nd line alternative SSRI’s or Clomipramine
-Tier 4 Specialist consultation/inpatient care for high risk or refractory cases

Licensed medications are Sertraline & Fluvoxamine (SSRI’s). Fluoxetine is recommended for OCD with
comorbid depression, but this is an unlicensed use (see Chapter 13)

18
• CBT: child keeps diary of compulsions, chooses easiest to tackle first and is helped by family and
therapist to avoid carrying out the compulsion: ‘response prevention’. Obsessions occurring without rituals
are harder to treat.
• Family Work: useful when family members drawn into rituals.

Prognosis
Disorder waxes and wanes but is remarkably persistent. Only a small minority fully recovered 2 to 5 years
later.

Emotional Disorders & Anxiety Disorders of Childhood

• In the past, children with socially incapacitating worries, fears or misery, along with somatic complaints,
were put together into the broadly defined category of ‘emotional disorders of childhood’ as they often
cluster together. ICD-10 and DSM-IV have split this category into specific anxiety and depressive
disorders. Not all children will fit into the criteria for a specific diagnosis and some might qualify for
several simultaneously.

• Many childhood emotional disorders seem to constitute exaggeration of normal developmental trends.

• Most children with emotional disorders will go on to be normal adults.

• ICD-10: Emotional Disorders with Onset Specific to Childhood


Separation anxiety disorder of childhood
Phobic anxiety disorder of childhood
Social anxiety disorder of childhood
Sibling rivalry disorder

• Children and adolescents can also get other anxiety disorders which are also seen in adults: generalised
anxiety disorder, panic disorder, post traumatic stress disorder (PTSD), dissociative disorders and
somatoform disorders (see later chapter).

Aetiology
• Anxiety disorders run in families- genetic effects and overprotective anxious parents producing anxious
children
• Early separation-Bowlby’s theories- anxiety often arises from threatened or actual separations from key
attachment figures
• Classical conditioning: a neutral stimulus can, by association with a frightening experience, become fear
evoking in itself
• Operant conditioning predicts subsequent avoidance of the stimulus (which blocks the chance for natural
exposure and extinction of the fear).
• Life events e.g. bereavement and adversities eg family conflict can be precipitants

Epidemiology of anxiety/emotional disorders


2-10% in studies, depends on definitions and assessment methods
F=M in prepubescents
F>M in adolescents
2nd most common childhood psychiatric disorder
Most common are: separation anxiety disorder, generalised anxiety disorder and specific phobias.

19
Separation Anxiety Disorder
Features
• Anxiety about separation from parents/other major attachment figures is normal & usually starts around
6 months and remains prominent during preschool years
• Usually wanes as child acquires ability to keep attachment figure ‘in mind’ and no longer need their
actual physical presence
• Disorder diagnosed when intensity of anxiety is developmentally inappropriate and leads to social
incapacity e.g. school refusal
• Child worries that parent may come to harm/leave and not return
• Child also worries re: themselves getting ill, lost, kidnapped or otherwise separated from parent
• Child commonly clingy even in own home, may refuse to sleep alone, nightmares

Epidemiology: 2-4% children affected

Treatment
Behavioural treatments operant techniques e.g. star charts to reward separation, graded exposure to
increasingly demanding separations
Cognitive therapy to teach coping self-statements
Family work parents can increase a child’s clinginess by: their own need to stay close to the child, their own
anxiety, their underestimates of child’s capability for independence

Prognosis
• some children have chronic mild separation anxiety with exacerbations e.g. precipitated by move of
school
• Separation anxiety may be replaced over the years by generalised anxiety or perhaps agoraphobia or
panic disorder

Generalised Anxiety Disorder


Features
• Occurs in adults and children
• Marked and persistent worriers who don’t consistently focus on any one object or situation
• Typical worries focus on future, past behaviour, personal competence
• Symptoms: self-conscious, can’t relax, tension, need reassurance, aches and pains

Epidemiology: 3% children, more adolescents. M=F. More in social class I&II.


Treatment: relaxation and cognitive therapy, medication not recommended

Course: often persists for years, may continue into adult life

Specific Phobias
Features
• Specific fears are very common in childhood and different fears peak at different ages e.g. fear of
animals peaks at age 2 to four years
• To be classified as a specific phobia the object or event must be abnormally intensely feared & avoided
or endured with intense anxiety.

Epidemiology
2-4% children and adolescents but most phobias are relatively mild
F>M for fears and phobias

Treatment: desensitisation, contingency management, and cognitive techniques


Course: mild fears are often transient, true phobias may persist into adulthood

20
Social Anxiety Disorder of Childhood
• Stranger anxiety is a normal phase of development up to 30 months
• Disorder is an exaggeration and undue persistence of normal phase associated with impaired social
functioning e.g. in peer relationships
• Good relationships with family and other familiar individuals
• Often meet criteria for generalised anxiety disorder

Course: may remain unassertive and socially impaired into adulthood or resolve spontaneously

Social Phobia
• Starts in mid-teens typically.
• Involves fear of public scrutiny and humiliation.
• May arise out of childhood shyness and inhibition.
• Responds to CBT and SSRI’s (used outside product UK licence)
• Anxiolytics rarely used

Panic Disorder
• Panic attack=severe, uncontrollable anxiety
• Typical thoughts: something terrible will happen to them e.g. heart attack, madness
• Typical somatic symptoms: sweating, tremor, palpitations, lump in the throat, pins and needles due to
over breathing, sensation of not being able to breath
• Attack can last from minutes to hours
• Key feature of the disorder: recurrent panic attacks & some panic attacks occur unexpectedly and
without any obvious precipitant.
• peak age of onset 15-19 years, rare in prepubertal children
• May be accompanied by agoraphobia
• Can run in families
• Responds to cognitive behavioural treatments and SSRI’s. Anxiolytics rarely used

Post-Traumatic Stress Disorder (PTSD)


Can develop in people of any age following a stressful event or situation (either short or long lasting) of an
exceptionally threatening or catastrophic nature, which is likely to cause distress in almost anyone. (e.g.
natural or manmade disaster, serious accident, being victim of serious abuse).
Predisposing factors such as personality traits or previous history of emotional disorder may lower threshold
for PTSD developing.

Features
• Re-experiencing: flashbacks, nightmares, repetitive & distressing intrusive images. In children: re-
enacting the experience, repetitive play, frightening dreams
• Avoidance: avoiding people, situations or circumstances, resembling or associated with the event
• Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability,
poor concentration
• Emotional Numbing: lack of ability to experience feelings, feeling detached from other people,
amnesia for significant parts of the event
• Comorbid depression, drug or alcohol use, can occur

Treatment
NICE Recommends:
-‘Debriefing’ should not be routinely offered to individuals who have experienced a traumatic event

21
-Where symptoms are mild & have been present for less than 4 weeks ‘watchful waiting’ is
recommended, with one month follow up
-Trauma-focused CBT should be offered to older children with severe PTSD symptoms in the first
month after the traumatic event
-Children & young people with PTSD should be offered a course of trauma-focused CBT adapted to
suit their age, circumstances & developmental level
-Do not routinely prescribe drug treatments for children & young people with PTSD

22
References

Allen AJ, Leonard H & Swedo SE (1995) Current Knowledge of medication for the treatment of Children
and Adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent
Psychiatry 34:976-986.
AACAP (1997), Practice Parameters for the assessment and treatment of children and adolescents with
anxiety disorders. J. Am Acad Child Adol Psychiatry 36 (10 Supplement): 69S-84S
Bernstein GA et al. Anxiety disorders in Children and Adolescents: a review of the past ten years. Journal of
American Academy of Child and Adolescent Psychiatry 35:1110-1119.
Emslie G, Rush A, Weinberg W, Kowatch R, Hughes C, Carmondy T, Rintelman J (1997), a double blind
randomised placebo-controlled trial of fluoxetine in depressed children and adolescents. Arch Gen Psych
54; 1031 –1037.
Harrington RC, Fudge H, Rutter M, Pickles A Hill J (1990), Adult Outcomes of Child and Adolescent
depression: I Psychiatric Status. Arch. Gen. Psych 47: 465-473.
Harrington R, Whittaker J, Shoebridge P & Campbell F (1998), Systematic review of efficacy of cognitive
behaviour therapies in Child and Adolescent depressive disorder Br Med J 316: 1559-1563.
Kutcher S (1997) Practitioner review: the Pharmacotherapy of adolescent depression. Journal of Child
Psychology and Psychiatry 38: 755-767.
March JS, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B,
Severe J. (2007) The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness
and safety outcomes. Arch Gen Psychiatry;64(10):1132-43.

NICE Clinical Guideline 28, Sept 2005: Depression in children & young people

CSM Guidance from Prof G Duff (regarding SSRI’s & depression) Dec 2003 & Dec 2004.

NICE Clinical Guideline 26, March 2005: Post-Traumatic Stress Disorder

NICE Clinical Guideline 31, November 2005: Obsessive-compulsive disorder

BNF for Children 2008

Further reading

Rutter, M. & Taylor, E., Child and Adolescent Psychiatry. Published by Blackwell Science. 4th Edition 2002

23
5. School Refusal
Dr Soumitra Shankar Datta

Introduction:
School refusal is currently understood as difficulty in attending school associated with anxiety (generalised
anxiety, separation anxiety or other emotional fears). It is a child-motivated refusal to attend school or
difficulties remaining in school for an entire day (Kearney, 2008). This includes children and young people
who do not attend school or want to leave school halfway in the day and also children who have regular
morning tantrums or avoidance behaviour with their care-givers to allow them to stay at home. This chapter
is specifically aimed at school refusal and does not cover children with truancy related school absenteeism.
School refusal is not a diagnosis. It is a heterogeneous problem with multifactorial origins.

The short term consequences include deteriorating academic problems, poor school achievements, difficulty
in peer relationships and family difficulties. In the longer run, school refusal at times can be an early sign of
adolescent onset anxiety problems and other psychological difficulties.

Epidemiology

School refusal may affect up to 5 % of all school aged children (King and Bernstein, 2001; Sewell, 2008).
Other reviewers have cited figures in the range of 1% to much higher (Kearney, 2008). The prevalence often
peaks at the transition years peaking at ages 5–7 years, then 11 years and again at around 14 years. It occurs
across all socioeconomic groups, and equally among boys and girls (Sewell, 2008).

Presentation

School refusal generally has a gradual onset. It may follow a period of illness related absenteeism. Some
children present with multiple bodily aches and pains, nausea, abdominal pain or headache, in the morning
before school. These symptoms often improve after the child knows that they will be able to keep away from
school for the day. School refusal may be associated with overt symptoms of anxiety related to fear of tests,
teachers, bullying and life stage transitions. Some of the children may want to go to school but can’t gather
the courage. This is different from children who are truant, who do not show symptoms of anxiety, lack
interest in school work, do not abide by school norms and engage in delinquent behaviours (Sewell, 2008).

Aetiology

It is likely that children presenting with school refusal behaviour have a multi-factorial aetiology:
Child related factors: Children may want to avoid school because of fear of separating from care-givers or
parents. School refusal may be a manifestation of separation anxiety disorder. Children may be protective
towards their parents and perceive that their being at home would help them to ensure that their parents are
safe. They may also get more attention from parents when they avoid school. Although school refusal may
be related to anxiety, diagnostic studies have reported that children with school refusal behaviour often do
not have a psychiatric disorder. Their anxiety and avoidance behaviour may be related to psychological
processes and sub-threshold anxiety symptoms and not necessarily psychiatric disorders.

Family factors: Parental involvement is a key factor determining child’s school attendance and is commonly
linked to academic achievement. Parental psychopathology and alcoholism can have direct contributions to
the child’s mental health. Families of youths with school refusal behaviour are often marked by poor
cohesion and considerable conflict, enmeshment, isolation, and detachment. Other contextual risk-factors
have been linked to absenteeism such as parental divorce and maltreatment. Children and youths living in
disorganized, unsafe, or unsupportive neighbourhoods that include poor adult supervision of attendance are
at substantial risk for absenteeism.

24
School factors: Inadequate school climate can be a contributory factor. Poor school climate may be linked to
harsh disciplinary practices, rigid regulations, school curricula not meeting a child's individual needs, poor
pupil–teacher relationships, insensitivity to diversity issues, and poor attendance management practices.
Victims of bullies display higher rates of absenteeism than their peers (Kearney, 2008).

Assessment

Assessment of school refusal should include seeing the young person and liaising with parents and teachers.
It may be necessary to assess the young person in various settings e.g. clinic and home. A recent paper
(Sewell, 2008) describes some simple steps which may help clinicians in the assessment of school refusal
behaviour. The following steps are useful as a guide (adapted from Sewell, 2008):

1. Going through the child’s medical records can provide valuable insights. Physical illnesses such as
asthma are strongly associated with childhood anxiety disorders and also school refusal.
2. Clinician should attempt to understand the child’s emotional world such as fear of loss of a parent;
need to protect parent and fear of situations within school as bullying, tests, change of teacher etc.
3. A physical examination may be needed to reassure parents and children and address their concerns.
4. Clinician should get information about the child’s academic abilities and achievements, attendance
and functioning in school from teachers.
5. Structured questionnaires (e.g. Child Behaviour Checklist, Strength and Difficulties Questionnaire)
and feedback from parents and teachers may be useful, to compare the child’s metal state and
behaviours in school with that at home.

Management

The final goal of treatment is return to fulltime school/educational placement. A ‘rapid return’ strategy may
be useful if the period of absence is short. For longer refusal periods a gradual approach is advocated.
Clinicians need to work with parents and teachers and also understand the child’s anxiety and concerns.

Kearney in a recent authoritative review (Kearney, 2008) has discussed in details about various strategies
which may be useful in different situations with youth and children with school refusal behaviour. Useful
strategies in some of the common scenarios are summarised below (adapted from Kearney, 2008):

a) Refusing school to avoid difficult situations (e.g. tests)


• Educating regarding anxiety
• Relaxation training
• Learning problem solving skills
• Psychological treatment to modify irrational thoughts or fears
• Gradual re-exposure to school setting using a hierarchy

b) Refusing school to get attention from others (e.g. from parents)


• Empowering parents to use brief and clear commands
• Helping the family to set a morning routine prior to school
• Rewarding children for school attendance
• Forced school attendance in special circumstances
• Advanced planning of meetings between family members to discuss problems

c) Refusing school to get rewards outside of school (e.g. playing videogames sitting at home during
school time)
• Rewarding children for school attendance
• Disincentives for non-attendance and not rewarding any non-attendance
• Learning to say ‘no’ to peers (to refuse offers from peers to miss school)

25
d) Refusing school because of systemic problems (transitions, bullying etc)
• Encouraging better parent-teacher collaboration
• Anti-bullying measures
• Reducing violence
• Increasing positive school climate and making transitions easy for students
• Planning curriculum to meet diverse student needs

Prognosis:
A large majority of young people with school refusal will improve spontaneously or with parental
management. Longer periods of refusal especially if more than two years, occurring in adolescence, having
co-morbid depression and lower IQ are associated with a poorer prognosis (Elliott, 1999).

Conclusions

School refusal is an important public health and social problem which needs to be tackled by multi-agency
working and strategic partnership between health and education and between young people, their
parents/care-givers and professionals.

References

1. Elliott, J. G., 1999, School refusal: issues of conceptualisation, assessment, and treatment, Journal of
Child Psychology And Psychiatry, And Allied Disciplines, vol. 40, no. 7, p. 1001-1012.

2. Kearney, C. A., 2008, School absenteeism and school refusal behavior in youth: a contemporary
review, Clinical Psychology Review, vol. 28, no. 3, p. 451-471.

3. King, N. J. and G. A. Bernstein, 2001, School refusal in children and adolescents: a review of the
past 10 years, Journal of the American Academy of Child and Adolescent Psychiatry, vol. 40, no. 2,
p. 197-205.

4. Sewell, J., 2008, School refusal, Australian Family Physician, vol. 37, no. 6, p. 406-408.

26
6. Deliberate self-harm and suicide
Dr Louise Theodosiou

To cover 1) Suicide
2) Deliberate self-harm
a) Overdose
b) Cutting
c) Other destructive behaviours

Epidemiology
Both overdose and suicide are much less frequent in childhood than in adult life. Both increase in prevalence
during adolescence. 40% of overdoses in adolescence are taken when the patient is over 16.

Suicide McClure 2001 (England and Wales)


Increase in suicide rate for males 15-19 yrs
From 1970 – 1998
Decrease in suicide rate for females 15-19 yrs
From 1970 – 1998
No change in suicide rate for males 10-14 yrs
From 1970 – 1998
Decrease in suicide rate for females 10-14 yrs
From 1970 – 1998

Marr and Field 2001


Each year at least 16 children commit suicide due to bullying

Cotgrove (2005) posits that coroners can be reluctant to label younger deaths as
suicides
The gender ratio for completed suicides is 4:1

Overdose Green (2004) study of 5 – 15 year olds


Parent’s reports – 14% of children and young people had tried to harm selves
Compared with 2% who did not have emotional disorders.

Hawton & Fagg (1992)


estimated that 19000 – 20000 people less than 19 yrs old overdose and referred to
hospital/year
(Annual rate approx 10-14 yrs 105/100000
15-19 yrs 446/100000)

Big increase in 60s and 70s

Self-injury much less common presentation to hospital than overdose (ratio poisoning to injury =
approx. 9:1)
Gender ratio for self harm approximately 1:6 male to female

O’Connor et al 2009 examined the prevalence of self harm in Scottish adolescents in light of the fact that the
suicide rate for adults in Scotland is twice that for adults in England. They found that rates were similar to
those of adolescents in England. “Self harm was reported by 13.8% of the respondents. The majority (71%)
of those who had self harmed had done so in the past 12 months and girls were approximately 3.4 times
more likely to report self-harm than boys. In multivariate analysis, smoking, bullying, worries about sexual
orientation, self harm by family and anxiety were associated with self-harm in both genders.”

27
Method

Suicide males - hanging


females much more likely to use self-poisoning

The most common form of self harm is probably cutting or scratching, much of this behaviour is not
presented to hospital and is thus rarely counted in statistics (Cotgrove 2005). The most commonly recorded
form of self harm in the UK is self- poisoning (Hawton et al 1996)

Overdose drugs used in episodes of self-poisoning


(May use more than one)
Non-opiate analgesics 60%
Minor tranquillisers 15%
Antidepressants 8%
Others 26%
Paracetamol involved in 48% of overdoses

Deliberate self-injury Cutting wrist/arm 85%


Cutting elsewhere 9%
Jumping from height 3%
Gunshot/asphyxiation 4%
Other 7%

It has been argued that risky behaviours e.g. drug use and unprotected sex could be classified as self-injury.
These behaviours have been linked to similar risk factors to the above activities e.g. Ramrakha et al 2000.
O’Connor et al 2009 noted that “drug use, physical abuse, serious boy/girlfriend problems, self harm by
friends and low levels of optimism were also associated with self harm in girls.”

28
Background and precipitants

Suicide Overdose
Background Background
Family history – increased rates of Family history – increased rates of
psychiatric disorder in the family psychiatric disorder and overdose in the
family
Family Circumstances – nearly all Family Circumstances – often
subjects living at home with one or both disrupted, living with single parent,
parents at the time of death. living with no parent, or in care. Also
from US greater number of fathers
without college education.
Psychiatric Disorder – increased rates of Psychiatric disorder – depression, often
depression (commonest), anxiety, conduct comorbid for conduct disorder increased
disorders and substance misuse rates of distress and low mood
IQ – probably average but not achieving
full potential
Chronic problems – with parents, school
or boy/girlfriends. This group also had
increased rates of contact with helping
agencies.
Past acts of self harm found to increase
the risk (Shaffer 1996) (Hawton et al,
1998)
Substance misuse - alcohol and drugs Substance misuse - alcohol and drug
have a strong independent association use are associated with deliberate self
with suicide (Fombonne 1998, Appleby harm although the degree of risk is
et al 1999) unclear (Hawton et al 2005)
Family disruption and abuse Family disruption and abuse are
particularly in males (Fombonne 1998, associated with deliberate self harm
Appleby et al 1999)
Bullying – the suicide of 3 young people
in Norway as a result of bullying was
addressed in the influential 1993 work by
Olweus.
Precipitants (Shaffer) Precipitants
Disciplinary crisis Often a ‘last straw’ event –a row with a
Within 2 weeks of birthday. boy/girlfriend, disagreement with parents.
Small number precipitated by reading a Adolescents often feel overdose is in
novel. response to stress/distress. Commonly
Social isolation may be important adolescents feel lonely/unwanted or
Often discussed in the preceding 24 hours angry prior to overdose.
Often impulsive.

29
Management and Risk Assessment

NICE provides clear guidance for the assessment of children and young people who have self harmed:
• “All children and young people who have self-harmed should normally be admitted overnight to a
paediatric ward and assessed fully the next day.”
• The 2007 amendments to the Mental Health Act state that all patients under 18, both on a section
and voluntarily admitted must be accommodated in an environment that is suitable to their age
(subject to need).
• “All children and young people who have self-harmed should be assessed by healthcare practitioners
experienced in the assessment of children and adolescents who self harm.”
• These practitioners should trained to work with children and young people and to assess risk.
Regular supervision should be available and access to senior colleagues should be provided.

Risk Factors
Predicting OD from Predicting repeat OD Predicting subsequent
Community sample suicide
i) Female sex i) Conduct disorder i) Male sex
ii) Disrupted family ii) Unemployment ii) Older age
Background
iii) Suicidal ideation iii) Disturbed family iii) High suicidal intent
Background
iv) Psychiatric disorder iv) Psychiatric treatment iv) Psychosis
(Depression, substance
Abuse, conduct disorder
v) Previous attempt v) Hopelessness vi) Unclear reasons for
attempt
vi) Sexual Problems vi) Social isolation vi) Social isolation

What should a full psychiatric assessment cover?

Details of the overdose - especially those suggesting high suicidal intent:


Planning in advance
Precautions to avoid discovery
No attempts to obtain help afterwards
Dangerous method (or belief the method was dangerous)
‘Final acts’ e.g. notes

Full psychiatric, family, personal and social history (if there is no evidence of depression look for trigger
factors e.g. is the young person being abused)
Mental state examination – especially depression, current suicidal ideation,
Interview with parent or other caregiver absolutely vital.
Communicate with other involved professionals e.g. social worker
Possibly contact school (if permission is obtained)
Physical examination if not already done. (Obviously physical emergencies will have been excluded prior to
the full assessment process)

In 50% of adolescents discharged from A&E departments the documentation on suicidal status is
inadequate.

Other behaviours
30
Depressed young adults may engage in risky sexual behaviour (and substance abuse) because of feelings of
hopelessness, worthlessness, and disregard for self or in an attempt to self treat their depression. Ramrakha
et al, 2000.

Are adolescents serious when they take an overdose?


Only 16% are alone in the house – most have a family member nearby.
75% do not take all the medication they could and tell someone afterwards.
Only 20% attempt to conceal the act.
80% do not leave a note and take no precaution against being found.

BUT many adolescents still express/report the wish to die, feel the overdose was serious and that they had
taken enough to kill them.

Is there an easy classification into different risk categories?

No, but the PATHOS questionnaire has been developed. Scores correlate with depression, hopelessness,
long premeditation time and high suicidal intent. Identify an ‘of concern’ group.

1. Have you had Problems for longer than one month?


2. Were you Alone in the house when you overdosed?
3. Did you plan the overdose for more than Three hours?
4. Are you feeling hOpeless about the future: that things won’t get much better?
5. Were you feeling Sad for most of the time before the overdose?

Score 1 for each yes. Increasing concern with increasing score.


The small numbers that go onto suicide make prediction of the individual case very difficult. But
numerous studies e.g. Hawton 1988 have indicated that up to 15% of people who take overdoses
eventually kill themselves.

Outcome of overdose
Increased risk of mortality.
10% repeat in next 2-3 yrs (majority in following year)
Interpersonal problems tend to improve post overdose, as do school/work difficulties.

Treatment
NICE recommends that immediate treatment should include advising carers of the need to remove
medications or other means of self-harm available

Treatment of any underlying psychiatric disorder – e.g. depression is essential


Or ensuring that problems such as abuse/bullying/other difficulties in school are addressed

Interventions include family interventions/psychotherapy e.g. problem solving, cognitive behavioural


therapy, brief psychodynamic interpersonal therapy (shown to be effective in adults after overdose e.g.
Guthrie et al 2001.

NICE recommends that group psychotherapy should be offered to young people who self-harm on several
occasions. CAMHS departments across Manchester are currently participating in the ASSIST Trial -
Randomised trial of group therapy for adolescents who repeatedly harm themselves.

BUT – only 30-50% patients offered treatment after initial assessment return for it. Less likely if taken a
previous overdose. More likely if have more symptoms (especially mood-related ones) and if parents have a
positive attitude.

31
References

Green, H., McGinnity, A., Meltzer, H., Ford. T, & Goodman, R. (2004). Mental health of children and
young people in great Britain. The report of a survey carried out by the Office for National Statistics on
behalf of the Department of Health and the Scottish Executive.

Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E, Marino-Francis F,


Sanderson S, Turpin C, Boddy G, Tomenson B. (2001) Randomised controlled trial of brief psychological
intervention after deliberate self poisoning. British Medical Journal 21;323(7305): 135-8.

Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R, Gunnell D, Hazell P, van


Heeringen K, House A, Owens D, Sakinofsky I, Traskman-Bendz L. (1998) Deliberate self harm: systematic
review of efficacy of psychosocial and pharmacological treatments in preventing repetition. British Medical
Journal 15;317(7156):441-7. Review.

Hawton K & James A. (2005) Suicide and deliberate self harm in young people. British Medical Journal.
330, 891-894.

Hurry, J. & Storey, P. (2000) assessing young people who deliberately harm themselves. British Journal of
Psychiatry, 176, 126-131.

Managing deliberate self-harm in young people. Council Report CR64. March 1998. Royal College of
Psychiatrists, London. Email to the Royal College January 2009 revealed this had not been updated.

NICE (National Institute for Clinical Excellence) (2004). Self-harm: the short-term physical and
psychological management and secondary prevention of self-harm in
primary and secondary care. London: National Institute for Clinical Excellence.

O'Connor RC, Rasmussen S, Miles J, Hawton K. (2009) Self-harm in adolescents: self-report survey in
schools in Scotland. Br J Psychiatry;194(1):68-72.

Olweus D. Bullying at School: What We Know and What We Can Do. Cambridge, MA:
Blackwell Publishers, Inc; 1993.

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Suicidal Behavior
Journal of the American Academy of Child & Adolescent Psychiatry 2001; 40:24S-51S

Ramrakha, S. (2000) Psychiatric disorders and risky sexual behaviour in young adulthood: cross sectional
study in birth cohort. British Medical Journal

Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. (1996) Psychiatric
diagnosis in child and adolescent suicide. Archives of General Psychiatry 53(4):339-48.

2007 amendments to the 1983 Mental Health Act -


http://www.opsi.gov.uk/acts/acts2007/ukpga_20070012_en_1

32
7. Conduct Disorder
Dr Prathiba Chitsabesan

Definition
Repetitive and persistent pattern of dissocial, aggressive or defiant conduct
Two main types- Oppositional defiant disorder (younger children/milder
severity)
- Conduct disorder

Diagnostic Criteria
(ICD 10/DSM IV)

Oppositional Defiant Disorder – 6 month history of 4 of the following:


Often loses temper
Often argues with adults
Often defies adult requests or rules
Often deliberately annoys others
Often shifts blame to others
Often angry and resentful

Conduct Disorder - 12 month history of at least 3 of the following:


Often bullies, threatens or intimidates
Often starts fights
Has used weapons in fights
Physically cruel to people
Physically cruel to animals
Stealing with force
Fire setting
Destruction of property
Running away from home
Truanting

Types- Socialised (antisocial behaviour often with others)


Unsocialised (poor peer relationships)

Epidemiology
Prevalence – 7% boys and 3% girls
Most common reason for referral to CAMHS
Higher prevalence in inner city areas

Co-morbidity
High:
- Generalised and/or specific learning disability
- Attention deficit hyperactivity disorder (ADHD)
- Emotional disorders (depression/anxiety)
- Substance misuse
- Poor achievement in school
- Poor interpersonal relationships with peers and adults

Differential Diagnosis
- Cultural variation

33
- ADHD (symptom of impulsivity common in both)
- Adjustment disorder
- Generalised learning disability

Aetiology
Familial
- Genes – evidence from twin studies
- Child rearing practices (lack of supervision/ warmth)
- Attachment difficulties
- Parental psychiatric disorder
- Large families
- Low income

Child
- Temperament – impulsive
- Poor emotional regulation and coping strategies (anger management)
- Cognitive attribution bias (neutral acts perceived as hostile)
- Generalised/specific learning disability
- Developmental delays e.g language

Social
- Socio-economic factors (poor neighbourhoods- housing/overcrowding)
- Peer influences from other antisocial children
- School – poor support/exclusion

Prognosis
- Strong continuity of childhood antisocial behaviour into adulthood
- Increased risk of difficulties with relationships and employment as adults
Poorer prognosis with early onset, greater severity, delinquency, intrinsic risk factors and co-morbidity
particularly ADHD

Management
Assessment
- History and mental state examination
- Assess parenting practice and parent-child interactions
- Liaison with school – information on child’s behaviour, academic abilities and relationships
- Exclude other differentials including learning disability e.g psychometrics
- Assess for co-morbidity e.g depression

Treatment
Child
- Treat any co-morbid disorder e.g ADHD/depression
- Individual work - problem-solving skills training to improve anger management and develop
better coping strategies
- Group work - social skills training if difficulties with peer relationships

Family
- Parent management training (e.g Webster Stratton Parenting Gps)– most evidence for efficacy as
an intervention for young children (<8yrs) and recommended by NICE
- Attachment therapy for young children with attachment disorders e.g Parent Child Game for
children and parents

34
- Family Therapy – to understand and change family dynamics that may be contributing factors to
difficulties in management

School
- School liaison regarding any learning difficulties etc and strategies to manage behaviour

Combined
- Multimodal approach important
- Multi-systemic therapy – developed in the USA for children with delinquent behaviour
combines the above approaches. Effective but costly to implement.

References
- Conduct Disorder in Children (NICE, 2006)
- Earls, F and Mezzacappa, E. (2002) Conduct and Oppositional Disorders. In Child and
Adolescent Psychiatry (M. Rutter and E. Taylor, Eds). Blackwell, pp 419-436.
- Hill, J and Maughan B (2001) Conduct Disorders in Childhood and Adolescence. Cambridge
University Press.

35
8. Attention Deficit Hyperactivity Disorder/Hyperkinetic Disorder
Dr Prathiba Chitsabesan

Definition
ADHD is a persistent pattern of inattention, hyperactivity and impulsivity that is more pronounced and
extreme than is typically observed in individuals at a similar stage of development.

UK – ICD 10 (Hyperkinetic Disorder although term ADHD more commonly used)


USA – DSMIV (ADD and combined type -ADHD)

Characteristic Features
1) Marked hyperactivity, inattentiveness and impulsivity allowing for child’s developmental age
2) Early onset (before 12 years of age) –recently changed from 7yrs following NICE (2008)
3) Chronic in nature -at least 6 months duration
4) Pervasive across different situations i.e home and school
5) Impaired functioning

Epidemiology
1-3% as per ICD definition and 5-10% with broader DSM-IV definition
Male: Female ratio is 3:1 in community samples and 7/8:1 in clinic samples
Girls – Less frequently referred/diagnosed
- More inattention/impulsivity than hyperactivity symptoms

Co-morbidity
Highly co-morbid:-
- Defiant, aggressive and antisocial behaviour which may warrant diagnosis of oppositional defiant
disorder or conduct disorder
- Peer rejection
- Impaired family relationships
- Low self esteem and possible depression, particularly in adolescence
- Generalised and/or specific learning disabilities e.g reading and spelling
- History of developmental delays e.g language and motor
- Motor co-ordination difficulties (dyspraxia)
- School failure and exclusion more common
- Greater association with both Tic Disorder and Obsessive Compulsive Disorder

Differential Diagnosis
- Learning disability – inattentiveness and hyperactivity significantly more common in children with
learning disabilities
- Attachment disorder/difficulties
- Conduct disorder- symptom of impulsivity common in both
- Emotional disorders – severe anxiety and mania can result in restlessness and inattentiveness
- Tic disorder/ Tourettes – restlessness common
- Autistic spectrum disorders – problems with restlessness and distractibility common
- Secondary to medical condition (e.g epilepsy or head injury)

Aetiology
- Neurobiological disorder
- Genetic factors- evidence from twin studies although complex inheritance
- Mechanism involves problems with dopamine transmission and particular areas of the brain
affected, including frontal lobe/basal ganglia

36
- Environmental factors may increase risk - e.g obstetric complications, exposure to
alcohol/drugs/toxins/medication in perinatal period, low birth weight
- Gene-environment interaction
- Symptoms may be exacerbated by certain food/drinks (additives/sugar)

Management
Assessment:- Specialist ADHD Service
- History – parent and child
ƒ HPC – motor activity (always on the go, fidgeting, can’t sit still), attention
(persistence in tasks, distractibility, forgetful), impulsivity (difficulty turn taking,
interrupts/intrudes)
ƒ Full history including developmental/school history
- Observation in clinic and at school
- School liaison for information on symptoms, academic ability, behaviour including relationships
- Rating Scales – Connors Questionnaire (Parents and Teacher Versions)
- Assess for co-morbidity
- Refer for further assessments if concerns about learning disability or developmental delays (e.g
psychometrics, speech and language and occupational therapy assessments)

Treatment:- Specialist ADHD Services with Primary Care Support


- Multimodal – involves child, family and other professionals
- Psychoeducation – child and family- provide age appropriate information
- School liaison – classroom strategies and support for any identified learning disabilities or
developmental delays
- Medication should form part of comprehensive treatment plan that includes education advice and
behavioural interventions

Behavioural Interventions
- Young person- Advice regarding strategies for sleep/improving organisation skills/ anger
management/ social skill difficulties etc as necessary.
- Parents – parent management advice e.g Webster Stratton Parenting Gps or individual work if
complex.
- School liaison – classroom strategies to limit impact of symptoms. Support for any identified
learning disabilities.

Medication
Types:- 1) Stimulants (Methylphenidate and Dexamphetamine)
-licensed for use in children (>6yrs)
- efficacy in about 2/3 of children
- controlled drugs – abuse potential for short acting preparations
-Side-effects – reduced appetite and sleep. Mood effects-short lived. V rare -cardiac/haematological side-
effects
- Monitoring – ht/wt, BP and P
Methylphenidate (most commonly used)
- Short acting preparation (lasts 3-4hrs) – e.g Ritalin and Equasy
- Long acting preparation (lasts 8 to 12hrs dependent on drug e.g Equasym XL, Concerta XL
and Medikinet XL)
Dexamphetamine (short acting preparation only)
- immediate effect

2) Atomoxetine – non-stimulant/non controlled drug


- licensed for use in children (>6yrs)
- delayed onset of action (6-8 weeks)
- 24hr effect
37
- similar efficacy to methylphenidate
- Side-effects- less effect on appetite/sleep. GI symptoms and v. rare – hepatic disorders
- Monitoring ht/wt, BP and P

3) Others-Clonidine (antihypertensive) and imipramine (tricyclic antidepressant)


-rarely used due to side-effects and not licensed for use in children

NICE Guidance (2008)


- Parent training programme should be offered first line for pre- school children and those with mild-moderate
symptoms
- MPH, dexamphetamine, atomoxetine equally efficacious
-Methylphenidate should be used as first line and atomoxetine second line medication
treatment, except in particular circumstances e.g co-morbidity and patient choice.
- Prior to medication treatment cardiac examination and ECG if abnormal findings or relevant
FH

Prognosis
- Hyperactivity decreases in adolescence
- For many, symptoms continue into adulthood (about 50%)
- If co-morbidity high – problems with employment/relationships
- Poorer outcome if associated with conduct disorder/delinquency (antisocial personality disorder
and substance abuse)

References
- ADHD- Diagnosis and management in children, young people and adults (NICE, 2008).
- Schachar R and Scott S (2002) Syndromes of Hyperactivity and Attention Deficit. In Children and
Adolescent Psychiatry (M. Rutter and E. Taylor, eds). Blackwell pp 399-418.

38
9. Adolescence
Dr. Mischa N. C. Mockett

Introduction
Adolescence is the period of life between childhood and adulthood. The World Health Organisation classes
adolescence between the ages of 10-19. In the United Kingdom there are some 7.6 million individuals in this
age group.
The period defined as adolescence sees rapid physical, psychological and developmental changes. It is
marked by an individual’s passage through puberty. The transition from childhood (with parents holding
responsibility) to adulthood (with individuality and autonomy) is not always an easy one. In addition to this,
young people are able to leave school and home at the age of 16 and traditionally CAMHS has worked with
people until this age. The mental health section of the National Service Framework for Children and Young
People and Maternity services has as its standard “All children and young people, from birth to their
eighteenth birthday, who have mental health problems and disorders have access to timely, integrated, high
quality, multi-disciplinary mental health services to ensure effective assessment, treatment and support, for
them and their families.” The need to address young people transitioning into adulthood is increasingly
recognised both in terms of legislation and healthcare provision.
Over the last 20 years mental health disorders have increased in this group. This comes in the context of an
increase of family disruption and breakdown, educational and work pressures and easier access to alcohol
and illicit substances.

Physical Development
Girls enter puberty earlier than boys with the mean age for the first signs of puberty being at 11.5 years
compared to 12 years for boys. The growth spurt occurs earlier in girls between a mean age of 11-12 years
compared to a mean age of 14 years in boys. The whole process can last between 1.5 years and five years for
physical maturation. In developed countries the age of puberty has dropped over the last century with better
nutrition and health, and currently the mean age of menarche has stabilised between the ages of 12.5 and 13
years.

Psychosocial Development
By the age of 15 adolescents have comparative cognitive abilities to adults. Through adolescence there is a
shift from accepting boundaries and rules set by others to setting them as an individual. Early adolescence is
marked by the concrete thinking of childhood, moving to abstract thinking in mid adolescence, followed by
complex abstract thought and the development of personal identity in late adolescence. These internal
physical and psychological changes interact with external environmental and social changes. With more
abstract thinking comes the ability to have capacity and give informed consent crucial in managing illness.
As puberty progresses individuals develop a sense of sexuality and body image which if impaired can
damage self esteem and mental well being.
The development of an adolescent’s individuality and autonomy must be balanced with the cultural aspects
of developed countries. Adolescents continue to require the physical and financial support of adults and,
while developing autonomy, continue to adapt to the rules and boundaries of the education system as well as
living as the charges of others. It is within this context that disharmony and conflict can occur with
adolescents having coping strategies that are not appropriate and emotions that are not easily expressed.

Sexual Health and Development


As adolescents pass through puberty they develop into sexual maturity. They can often engage in risk taking
behaviours, which can have common predisposing factors such as poor socioeconomic circumstances or
poor mental health. The adverse consequences of risk taking behaviour include sexually transmitted diseases
such as HIV as well as teenage pregnancy. The median age for first sexual intercourse for both sexes has
stabilised at 16 years. First sexual intercourse is often associated with unsafe sex and alcohol use with only
50% of adolescents engaging in the first sexual intercourse under the age of 16 using contraception. The
United Kingdom has the highest teenage pregnancy rate in Western Europe. Although teenage pregnancy
can be positive it is also associated with poor outcomes.

39
Available sexual health education and services are crucial in enabling adolescents to develop autonomy and
future choices.

Substance Misuse
Substance misuse refers to the whole group of substances tobacco, alcohol, inhalants and other drugs. As
already discussed adolescents often engage in risk taking behaviour. By the age of 11 years 1% of
adolescents smoke regularly and by the age of 15 years 24% smoke. By the age of 16 years some 30-50% of
adolescents report to having experimented with cannabis. By 16 years over 75% of adolescents have been
drunk at least once in their lives. Estimates of solvent abuse (glue sniffing and other inhalants) vary and can
be as high as 5% due to their availability. This behaviour is particularly risky due to fatalities occurring from
cardiac arrhthymias, laryngeal spasm and inhalation of vomit.
Adolescents with conduct disorders are more liable to become substance abusers and a combination of
conduct disorders and hyperactivity carries a particularly high risk.
Managing substance abuse requires an individual to change their behaviour. This requires open mindedness
and a non judgemental approach from professionals. Accurate information on the effects of drugs should be
given and strategies on minimising the harm associated with drug use. The overall aim is to facilitate a
process of change.

Capacity and Consent


Before the age of 16 professionals face ethical and legal uncertainty. When testing for capacity a young
person should be able to

• Understand the nature, purpose and necessity for a treatment


• Understand benefits, risks, alternatives and effects of non treatment
• Believe the information available to them
• Retain information long enough to make a choice
• Make a choice free from pressure

The legal definition of competence stands as


“as a matter of law, the parental right to determine whether or not the minor child below the age of 16 will
have medical treatment terminates if and when the child achieves sufficient understanding and intelligence
to understand fully what is proposed” (Gillick v West Norfolk and Wisbech Area Health Authority 1985)

If a young person lacks competence to make decisions parents have the legal power to consent on their
behalf.
Adolescents rate confidentially very highly. This must be approached in a sympathetic way and clearly
explained that information can be given and that it will not be divulged to others unless this is required by
law to protect the individual from risk of serious harm.

Other Mental Health Disorders That May Occur In Adolescence

Eating Disorders
The average weight changes through puberty are a 15kg increase for a boy and 14 kg for a girl.

Anorexia Nervosa
Diagnostic Criteria
¾ !5% below expected weight for age and height
¾ Deliberate dietary restriction sometimes combined with excessive exercise, appetite
suppressants and purging
¾ Intense fear of fatness
¾ Endocrine consequences including amenorrhea in post menarcheal females or delayed or
arrested puberty in early onset cases
Prevalence 0.1% in 11-15 years, and 1% in 16-18 years.
The female to male ratio is 10:1.
40
Aetiology- Complex multifactoral with possible contributing factors including genetic, biological,
psychological, familial and sociocultural.

Treatment
¾ Engagement crucial with family and patient.
¾ Weight gain using realistic targets through a structured plan of small regular meals.
¾ Mostly outpatient treatment although some may require inpatient
¾ Therapies including individual therapies, family therapy and behavioural therapy
Prognosis
¾ 50% recover
¾ 25% partly recover
¾ 25% chronic course

Bulimia Nervosa
Presentation
¾ Episodes of overeating in which the sufferer experiences a loss of control
¾ Usually followed by compensatory behaviours to avoid weight gain such as self-induced vomiting,
laxative abuse, excessive exercising.
¾ Body weight may be normal, low or overweight.
Prevalence rare pre-puberty,
1% in adolescence
Female to male ratio 30:1.
Treatment-Individual therapy consisting of cognitive behavioural work or group therapy usually in the out
patient setting
Prognosis - often episodic with remissions and relapses. Long term disturbed patterns of eating behaviour.

Psychosis
Psychosis refers to a cluster of symptoms and signs, the essential feature of which is the break down in the
appreciation of reality.
Differential diagnosis includes
¾ Psychotic depression
¾ Bipolar disorder
¾ Organic psychosis including delirium and substance induced disorders
¾ Schizophrenia

Schizophrenia
Very rare below the age of 7 years.
Peak time of presentation for males is 15-25 years and 25-35 years in females.
Although males are generally more vulnerable to early onset schizophrenia the sex ratio is reversed in the
11-14 age group, probably as girls are more likely than boys to be post pubertal.
Lifetime prevalence is 1%.
Aetiology complex and multifactoral including nuerodevelopmental, genetic and environmental factors.
Presentation
¾ Similar at all ages with hallucinations, delusions, thought disorder and negative symptoms such as
affective blunting and social withdrawal.
¾ Content of abnormal beliefs and perceptions are influenced by the individual’s developmental stage.
¾ Onset is often acute rather than insidious

Treatment- Comprehensive multi disciplinary approach.


¾ Antipsychotic medication. Newer aytypical antipsychotics are the first line treatment due to the risk
of side effects in younger people. They treat hallucinations and delusions and the newer drugs can
also have an impact on residual negative symptoms.
¾ Psychological. This can include psychoeducation into the illness. Family work including family
therapy can be crucial in enabling compliance, addressing parental loss and concern and reducing

41
expressed emotion a risk factor of relapse. Other therapies including cognitive behavioural therapy
can be beneficial.
Prognosis - About 20% will have one episode only with no ongoing impairment. Early onset generally has a
worse prognosis than adult onset. After a second and subsequent episodes recovery is often incomplete and
social functioning may gradually deteriorate.

References

• Viner, R. et al The ABC of Adolescence (A series of 12 articles published in the BMJ February to
April 2005)
• Goodman R. and Scott, S. Disorders in Adolescence in Child Psychiatry, Blackwell Publishing 2002
• Lask, B. Taylor, S. and Nunn, K. Practical Child Psychiatry The Clinician’s Guide BMJ Publishing
Group 2003
• The Royal College of Psychiatry Website, Surviving Adolescence - A tool kit for parents
• National Service Framework (NSF) for Children, Young People and Maternity Services
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH
_4089114

42
10. DEVELOPMENTAL DISORDERS
I Learning Disability
Dr Hilary Lloyd and Dr Latha Hackett

Development, the expectation of orderly change over time and with increasing maturity, is the backdrop
against which all child psychiatry is practised. Developmental disorders either represent incomplete
development, or represent deviations of development.

The term “developmental delay” is in frequent parlance, but is best avoided as “delay” implies that there
may be eventual “catch-up” which is usually not the case. IQ tests remain the best, albeit imperfect,
standardised measures of intellectual functioning available, but must be used in conjunction with
assessments of adaptive behaviour and clinical findings.

Terminology
There are many terms used to describe learning disability. ICD-10 uses the term “Mental Retardation”
which it defines as a condition of arrested or incomplete development of the mind, which is especially
characterised by impairment of skills, manifested during the developmental period, which contribute to the
overall level of intelligence (i.e. cognitive, language, social). Clinical, psychometric and social evidence of
impairments should be taken into account in the diagnosis. Intelligence is not a unitary characteristic, but is
assessed on the basis of a large number of more or less specific skills.

The most common terms are:-


• UK, Department of Health: Learning Disability
• UK, DFES: Learning Difficulties
• UK, RCPsych: Learning Disability
• WHO, ICD-10: Mental Retardation
• DSM-IV-R: Mental Retardation
• Ireland, DoH: Intellectual Disability

The IQ bands of severity (mild – moderate – severe - profound) used are different for health (ICD-10,
RCPsych) from those for DFES learning difficulties, leading to confusion between agencies [see Table].

Within health, in the UK, the preferred term is learning disability. It is a less stigmatising term than either
mental handicap or mental retardation. Learning disability may be defined as a generalised impairment in
intellectual functioning of a longstanding nature, associated with impairments in the domains of social and
self-help skills. “Learning disability” avoids the term “mental” (to distinguish it from mental illness from
which most people with learning disability do not suffer), and avoids the assumption of immutable handicap,
allowing for progress and the development of skills.

In the USA “Intellectual disability is the currently preferred term for the disability historically referred to as
mental retardation”. “The term intellectual disability (a) reflects the changed construct of disability
proposed by AAIDD and WHO; (b) aligns better with current professional practices that are focused on
functional behaviours and contextual factors; (c) provides a logical basis for individualized supports
provision due to its basis in a social-ecological framework; (d) is less offensive to persons with disabilities.”

IQ Severity - Severity -
Health – learning disability Education – learning difficulties
70-80 Within normal range Mild
50-69 Mild Moderate
35-49 Moderate Severe
20-34 Severe Severe
< 20 Profound Severe

43
Generalised and Specific Learning Disability

Generalised (global) – IQ 69 or below. The cut-off of IQ of 70 for the definition is used because 70 is 2
standard deviations below the mean. Defined in this way, approximately 2-3% of the population has a
generalised learning disability.

Specific learning disability, or specific developmental disorder (ICD-10): a particular (and statistically
significant) deficit in a developmental skill (reading, spelling, arithmetic, language) compared with the
child’s overall ability e.g. dyslexia, dsygraphia, dyscalculia, specific language disorder. Evidence consistent
with specific learning disability would be that formal tests of literacy or language abilities showed lower
attainments/skill level than would be predicted with overall IQ (and the discrepancy would be statistically
significant). A child may have more than one specific learning disability, and a category of “mixed
developmental disorder” exists in ICD-10.

Prevalence of generalised learning disability

IQ 50-70: approx. 2% of population

IQ <50: approx. 0.35% of population

Aetiology

Mild learning disability – often associated with family history of below average intelligence (polygenes
may exert effect), socio-economic deprivation, parental neglect. Specific medical aetiologies (genetic,
chromosomal, traumatic) may be relevant and identifiable in individual cases, but are absent in the majority
of cases.

Moderate – profound learning disability – often have an identifiable medical aetiology:


• Chromosomal anomaly (e.g. Down’s Syndrome, Cri-du-chat) in 40% (dysmorphism usually evident)
• Genetic disorder (e.g. Fragile X, Cornelia de Lange, Tuberous Sclerosis) in 15%
• Teratogenic effects, complication or pregnancy/delivery, failure of intrauterine development, (e.g.
foetal alcohol syndrome, birth trauma) in 10%
• Post-natal (acquired) – head injury etc (10%)
• Undetermined causes (25%)

Overall, the greater the degree of learning disability, the higher the rate of identifiable medical aetiology.

Severe Learning Disability v Mild Learning Disability: Associations


Mild LD Severe LD
IQ 50-69 Under 50 (≤ 49)
Social functioning Many have no or minor Invariably markedly
impairment impaired
Cause Organic pathology in Organic pathology in
minority. Polygenes and majority
environment appear to be
of greater effect
Family History Parents and siblings often Parents and siblings
of low IQ usually of normal IQ
Background Commoner in lower SES No particular SES skew
groups
Appearance Rarely dysmorphic Often dysmorphic
Medical issues Physical handicap unusual; Physical handicap
health generally normal; common; major health
44
life expectancy and problems frequent; life
fertility usually normal expectancy and fertility
low.
Psychiatric issues Spectrum of disorders PDD/ASD common;
similar to those in non-LD hyperkinesis; Self-
population, but more injurious behaviour.
frequent (e.g. ODD, CD,
ADHS, emotional MSE can be difficult to
disorders, Asperger’s); assess because of cognitive
MSE as in children difficulties and children
without LD; presentations often have limited or no
as in children without LD verbal ability.

Epidemiology of psychiatric disorders in learning disability

Various studies have estimated that at least 1 in 1000 of the general population in Great Britain has a degree
of learning disability of such severity/impact that they are likely to need specialist health services at some
point in their childhood. Approximately 40% of children in this group at any time will suffer from some
kind of psychiatric disorder. In an average health district of 300,000, this would amount to 120 children
having learning disability and psychiatric disorder.

Of those with mild LD (IQ 50-69):


• The psychiatric disorder has the same distribution as in the non-LD population
o Hyperkinesis/ADHD
o Conduct disorder
o Emotional disorders and social phobia
o Depression
o Asperger’s syndrome

Of those with severe LD (IQ < 50):


• The most common psychiatric disorders/clinical issues are:
o PDD/autism
o Severe social impairment
o Self-injurious behaviour
o Eating and sleep disorders

Current evidence and opinion suggest that autistic spectrum disorders become more common with
increasing severity of LD.

Psychotic disorders are not common in the child LD population (but do occur), especially pre-pubertally.
The child’s cognitive and communication difficulties may make clarification of psychopathology difficult.

ISSUES FOR ASSESSMENT/DIAGNOSIS/MANAGEMENT

1. Developmental/cognitive assessment. This is crucial because behaviour and emotional functioning


must be judged according to developmental level. Expectations of the child may be inappropriate,
leading to secondary social, psychological and psychiatric difficulties. The understanding of the
limitations and interpretations of psychometric assessment is essential.
2. Communication. Is a problem behaviour generated because the child is unable to communicate/be
understood otherwise (e.g. “no” or “leave me alone” or “I don’t like this”)? MSE of a child with
severe LD relies heavily on high quality and multiple-source observation and careful history-taking.
Accessing thoughts/percepts may not be possible. The examiner must modify his/her own language
to ensure it is as understandable as possible by the subject. Using pictures, play, signing may be
useful.
45
3. Exclusion of physical illness/pain. In children with limited means of communication, pain or acute
illness must be excluded as a cause of an alteration in behaviour (e.g. ear-ache, tooth-ache).
4. Behavioural phenotypes – some syndromes have behavioural phenotypes (rage, excessive appetite in
Prader-Willi).
5. Epilepsy – is of increased frequency in children with learning disability. Ictal behaviours need to be
recognised. Anti-epilepsy drugs are sometimes associated with adverse effects on behaviour.
Occasionally, psychosis may be induced by anti-epilepsy medication (e.g. vigabatrine, tiagabine).
6. Behavioural analysis – this relies on careful and detailed observation of behaviour, antecedents and
consequences, to understand the behaviour, identify triggers and reinforcers in order to inform a
management plan. Learning theory is very useful, but does not explain all challenging behaviour.
7. Family issues may be pertinent:
• “coming to terms”
• Inappropriate or dysfunctional parenting/management strategies
• Inappropriate expectations
• Life cycle issues (e.g. leaving home)
• Dependence/independence
• Attachment
• Parental and sibling emotional disturbance and/or family disharmony
• Vulnerability of LD child to abuse/scapegoating
• Burden of care/restrictions placed on family
8. Social factors
• Loss of earning for parents/carers
• Restricted opportunities
• Social isolation
9. Educational issues: understanding of the level of impairment/ability is essential. Inclusion vs special
educational provision debate. Availability of specialist teachers.

Treatments for psychiatric disorders in learning-disabled children

The following may be useful, according to clinical presentation:

Parent work, including adapted Webster-Stratton and Parent-Child Game methods.

CBT/social problem solving – may be useful in mild LD

Psychotherapy – mild LD (providing the child can use play and/or talking)

Behaviour therapy – can be difficult if there are multiple cares and professional involved with the individual
child (e.g. parents, respite carers, teacher, classroom assistant etc), as consistency is important. Parents may
not have personal resources to implement behavioural management successfully, and motivations are
important. When compliance is high, success, at least in the short-term, is good. Intensive home-cased
approach with much support is often needed, but not always available.

Psychopharmacology: a rapidly developing field


• Major mental illness – as in adults
• Hyperkinesis/ADHD – stimulants are often worth trying, but may be less effective in severe
LD, and some LD patients appear more sensitive to adverse effects
• Atypical anti-psychotics should be used with caution for agitation/hyperkinesis/aggression
(there is some evidence that children with LD may be especially susceptible to the
development of tardive dyskinesia). Long-term effects on developing brain are not known.
• There is a growing, but still relatively weak evidence-base that SSRIs may be useful in some
instances of high levels of aggression and/or anxiety in young people with LD

46
Treatment setting – most psychiatric disorders in children and adolescents with learning disability can be
safely and usefully assessed and treatment undertaken on an outpatient basis, but some cases need intensive
input, and, in cases of high risk (especially of aggression), an inpatient setting may be needed (occasionally
a secure setting is necessary).

Key Points
• Medical and educational terminology for severity of LD are different
• Children with LD are at increased risk of psychiatric disorder
• The spectrum of psychiatric disorder in mild LD is similar to that in the general child population.
• The spectrum of psychiatric disorder in severe LD is mainly PDD/ASD, Hyperkinesis/ SIB
• Medical aetiologies for LD are more commonly found in moderate-severe LD than in mild LD
• Physical illness or pain should be excluded as a cause of a change in behaviour in children with
limited communication
• Behavioural or emotional problems in a child with LD may be a manifestation of the child’s special
needs/disability/impairment not being understood
• Effective and necessary interventions may be social, educational, behavioural and/or
pharmacological (often a combination is needed)
• Parents may experience major difficulties in “coming to terms” with their child’s disability, and may
present at different points of developmental crisis/family life-cycle.

Further reading

Bouras, N (ed) (1999): Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental
Retardation. Cambridge University Press. Cambridge.

Corbett, J.A. (1979). Psychiatric morbidity and mental retardation. In Psychiatric Illness and Mental
Handicap (eds F.E. James & R.P.Snaith). London: Gaskell.

Council Report No: 123, Royal College of Psychiatrists: Psychiatric Services for Children and Adolescents
with a Learning Disability. September 2004.

Gillberg, C., Persson, E., Grufman, E., et al (1986) Psychiatric disorders in mildly and severely mentally
retarded urban children and adolescents: epidemiological aspects. British Journal of Psychiatry, 149, 68-74.

World health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines (ICD-10). Geneva: WHO.

47
10. DEVELOPMENTAL DISORDERS
II Pervasive Developmental Disorder (Autism Spectrum Disorder)
Dr Latha Hackett

This group of disorders is characterised by qualitative abnormalities in reciprocal social interactions and in patterns of
communication and by restricted, stereotyped repetitive repertoire of interests and activities. These qualitative
abnormalities are a pervasive feature of the individuals functioning in all situations, although they may vary in degree.
In most cases the development is abnormal since infancy and with only a few exceptions, the condition becomes
manifest during the first 5 years of life.

ICD X
F84 Pervasive developmental disorders.
F84.0 Childhood Autism.
F 84.1 Atypical Autism.
F84.2 Retts Syndrome.
F84.3 Other childhood disintegrative disorder.
F84.4 Overactive disorders associated with mental retardation and stereotyped movements.
F84.5 Asperger’s Syndrome.
F84.8 Other pervasive developmental disorder.
F84.9 Pervasive developmental disorder, unspecified.

DSM IV
PDD DSM IV CODES.

299.00 Autistic Disorders.


299.80 Rett’s Disorder
299.10 Childhood Disintegrative Disorder.
299.80 Asperger’s Disorder.
299.80 PDD Not otherwise specified (including atypical autism)

Autism (Pervasive Developmental Disorders/Autism Spectrum Disorder).

Pervasive developmental disorder is defined by the presence of abnormal and/or impaired development that is
manifest before the age of 3 years and characterised by the “triad” of:
1 Impairment/restriction of reciprocal social interaction.
2 Impairment/restriction in reciprocal communication.
3 Impairment/restriction of behaviour/imagination.

Clinical Presentation
1 Developmental delay/or deviant development.
2 Speech and language delay/deviant development.
3 Social abnormalities.
4 Behavioural abnormalities.

This condition is characterised by delay and deviation in the development of social relationships and language. In
addition they may likely show mannerisms, resistance to change, attachment to unusual objects and acute emotional
reaction of excitement or anxiety situations, which do not usually provoke such reactions.

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Behavioural Features

The baby is described as different from birth. He is slow to smile, unresponsive and passive and does not enjoy being
picked up. He will not put his arms up to be picked up, may wriggle and squirm. Likely to avoid eye contact, 2-3 yrs
prefers own company, when he is hurt does not go to parents for comfort. Slow to distinguish parents from others.
This can change as they grow older, show intense attachment to parents and distressed by their absence.

Social Impairment.
Poor social relationship, unable to understand another’s viewpoint. Aloof, indifferent, could be passive or active but
odd. Over formal, stilted. Sociable with one person but has problems with groups.

Communication Impairment.
Both in verbal and non-verbal delay and deviation in language development. Both comprehension and expression is
impaired. 50% do not develop speech. Echolalia, Neologisms, Pronominal reversal and highly sporadic language can
occur. Repetitive, one sided, formal, longwinded, literal and unusual metaphorical speech is a common feature in
children with PDD.

Impairment of Imagination.
Handles objects for simple sensations. Limited or no imaginary play, copies pretend play of others. No spontaneous
imitation play. Invents own imaginary world-rigid, stereotyped

Other features
Limited or no gestures, no finger pointing either for showing the adult his need or sharing some information with the
adult. Rapid flapping movements of the hands and arms, occurring when the child is excited or upset. Twirling of the
body and tiptoe walking. Examine objects by sniffing. Resistance to change, attachment to particular objects not
cuddly toys but bits of wire etc. Acute emotional reactions. Other behavioural symptoms include problems with
eating, drinking, sleeping, over-activity, distractibility, impersistance, soiling and wetting. General or specific learning
disabilities.

The presentation of Autistic Spectrum Disorder can be affected by associated disabilities that could be developmental,
physical or psychiatric. The overall level of ability, age, gender, personality and temperament, environment and
education.

Syndrome Overlapping with PDD (ASD)


ADHD, Obsessive Compulsive Disorder, Tourette’s syndrome, DAMP (Disorders of Attention, Motor Control and
Perception) Syndrome, Dyspraxia, Dyslexia and Developmental language Disorder.

Asperger’s syndrome

Relatively normal early development, the child is usually noted to lack warmth and interest in social relationships
round about the third year of life. Language is usually not delayed, but the quality of speech and often-laborious
exactitude in the use of language gives a pedantic quality to the child’s verbal output. They have social difficulties,
special interests; they are clumsy and have mannerisms.

Clinical presentation includes behaviour problems, unable to engage socially, school refusal, other emotional
disorders. They may also present with symptoms of attention deficit syndrome, depression etc.

Rett's Syndrome

In girls who have progressed normally for the first 1-2 years, but then regressed with the development of autistic
features associated with jerking or writhing, involuntary movements and abnormalities of muscular tone a diagnosis of
this condition should be considered. Female, early behavioural, social and psychomotor regression, loss of purposeful
hand skills with very characteristic hand wringing or hand washing movements and a failure of skull growth.

Epidemiology of PDD/ASD.

The prevalence of Autism was estimated at 2-5/10,000 to 10-20/10,000 if broader definitions were used. According to
49
the combined evidence from 16 acceptable population-based studies, the prevalence in children between the ages of
12-15 was though to be 8-12/10,000 (Wing 1993: Gillberg 1995). Asperger’s syndrome was about 36/10,000 (Ehlers
& Gillberg 1193, Gunnarsdottir & Magnusson,1994). Other Autistic-like conditions were thought to affect about
10/10,000.

Chakrabarti, S. and Fombonne E (2001) in their study showed the prevalence to be 62.6/10,000. The Report of
Medical research Council Autism Review, published 13th December 2001 reported that the prevalence is around
6/1000 in children.

Prevalence of Autism and related spectrum disorders (ASDs) is substantially higher than previously recognised. Baird
et al 2006 screened all children who had a diagnosis of ASD (n=225) or those judged at risk for being undetected
(n=1515) from a population of 56,946children aged 9-10 years. The prevalence of all ASDs was 116.1 per 10,000
(1.1%) . Of this prevalence of Childhood autism was 38.9 per 10,000 and all other ASDs 77.1 per 10,000.

The increase in prevalence over the years are thought to be due to better ascertainment, increased awareness,
recognising Autism in children with severe intellectual disability and ASD/Asperger’s in high functioning children.

Autistic traits are present in many children with severe disorders of attention, and in a substantial number of
individuals with mental retardation. Precise figures are unavailable for this group.

Proportion of ASD/PDD in different IQ ranges:


IQ :Percentage ((Wing et al).
0-19=86%,
20-49=42%,
50-69= 2%,
70+= 0.7%

Sex ratios: The boy girl ratio for Autism is 3-4:1 and in Asperger’s Syndrome 10:1.The difference might be
accounted for by a slightly different phenotype in boys as compared with girls, leading to under reporting.

Cognitions
Severe learning disabilities present in 40% of children with a diagnosis of ASD and mild to moderate impairments in
30% and 30% have normal intellectual functioning.

Asperger’s Syndrome: Verbal ability is often better than non-verbal skills. Relative inferiority on picture arrangement
and object assembly is a very common finding.

Underlying neuropsychological problems in Autism and its spectrum disorders.

1. Theory of mind or mentalising problem.


2. Diminished drive for central coherence.
3. Executive function deficits.

It appears that all three kinds of dysfunction may be present in many individuals with autism and its spectrum
disorders.

It is currently unclear which if any of this dysfunction might be regarded as the underlying core psychological
problem necessary and sufficient to cause autistic symptoms. Precursors of abnormalities in the three domains might
be decreased ability to share attention and to detect the direction of other people’s eye movement.

Associated medical conditions

Survey has shown 5-10% of all individuals with Autism have an underlying medical condition.

Tuberous sclerosis, Ito’s hypomelanosis, Phenylketonuria, rubella embryopathy and fragile X syndrome.
50
Asperger’s have less of these associated medical conditions.

About 1:3 of children with Autism develop epilepsy; half of them develop in the first 3 years of life the rest in
adolescence.

Autistic children have been found to have excess of complications of pregnancy.

Genetic factors:

In Autism and Asperger’s not specifically associated with other medical conditions genetic factors likely to play a
part. Twin studies suggest strong contributions to many cases of Autism. This does not explain all Autism and the
mode of inheritance. So far no twin studies in Asperger’s syndrome but clinical and family studies show that
hereditability/familiarity is also high in this group.
It is possible that Asperger traits could run in some families so a higher dose or additional brain damage would be
required for full-blown autism or Asperger’s syndrome.
Several groups have reported a link between manic depressive illness in some families and
Autism and Asperger’s syndrome.

Genetic counselling: The genetic risk is about 5% that a subsequent child will show autism. Greater risk for some
type of broader social-cognitive disorder of less seriously handicapping variety. Risk greater if offspring is male.
Unaffected sibling having an autistic child is very low, though available data do not provide exact figures for this risk.

Basic Neurobiology in Autism and its spectrum disorders

The frontal lobes, temporal lobes, brainstem and cerebellum have all been implicated in several different studies.

Hard Evidence
A. Amygdale in the temporal lobe there are too many cells, which are too small.
B. Purkinje cells in the cerebellum have been demonstrated to be reduced in number and to have abnormal dendrites.
MMR and link with Autism. There is no scientific evidence at present for a link between the administrations of
MMR as a causative factor for Child Autism.

Differential Diagnosis

1. Developmental or acquired language disorders


Desire to communicate by gesture and the capacity for social interaction is intact in children with
phonologically intact syntactic language disorders. But there is overlap in severe language disorders.

2 Mental retardation without autistic features.


Language and pretend play will be absent if mental age is under 12 months. Simple stereotypes are common.
The children are socially responsive in line with their mental age.

3 Mental retardation with Autistic features.


Many retarded children have a “triad” of impairment affecting (a) social interaction, (b) communication and
(c) play - varying degrees of repetitive and restricted behaviours. Only some of these children meet the full
diagnostic criteria for infantile autism, but many could be diagnosed as atypical autism.

4 Rett’s syndrome.
Occurs only in girls, may be confused with Autism. There is regression about 12 months accompanied by
deceleration of head growth; characteristic hand-washing stereotypes and restricted hand use, episodic over-
breathing and unproved laughter; progressively impaired mobility. They are appropriately socially responsive.
The disease is progressive and most are in wheel chairs by their late teens and die before 30.
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5 Neuro-degenerative disorders with progressive dementia.
These need to be considered when regression and autistic features appear after a period of normal or nearly
normal development. With time frank neurological impairments emerge and the child eventually dies.

6 Disintegrative disorder.
Also known as Hellers syndrome, it involves entirely normal development for 2-6 years followed first by a
phase of regression, often accompanied by marked anxiety and loss of bladder and bowel control, leading to a
life long severe mental retardation with pronounced autistic features.

7. Intense early deprivation.


Autistic features sometimes follow this. This has been evident in trans-nationally adopted children who had
suffered intense deprivation in their first year or two, of nutrition, physical care, cognitive and linguistic
stimulation and ordinary social interaction. Most of them do remarkably well within a few years of adoption,
but a small minority continue to have social and communicative impairments associated with intense
circumscribed interests and preoccupations with specific sensations. In many instances these autistic features
subsequently resolve.

8 Fragile X Syndrome.
This is commonly associated with behaviours that bear a superficial resemblance to autism - social avoidance
and poor eye contact are common but they seem to result from social anxiety rather than indifference.

9 Deafness.
They are typically sociable and keen to communicate by gesture. This is often suspected in autistic children
but careful history usually establishes that autistic children respond to sounds that interests them like the rustle
of a crisp packet.

OUTCOME
Long-term outcome is variable. Usually socially extremely restricted. 50% fail to achieve useful speech. Those 20%
who have normal to low normal intelligence have a better outcome. Many of them lead to an independent life.
Asperger’s syndrome the outlook is much better. Many of them present to Psychiatrist at the time of extreme social
stress, at adolescence and adult life.

Assessment

A full detailed neuro-developmental assessment is needed including a detailed family history. It is good practice to
have a comprehensive psychological testing.

1 Complete history - family and developmental history.


2 Individual assessment of the child over a period of time.
3 Assessment in the child’s familiar environment.
4 Assessment and observation of other disciplines including Clinical Psychology, Speech and language therapy
and education etc.
5 Physical examination and investigations.

The diagnostic formulation consists of whether the diagnostic triad is present, the type of social impairment, and the
level of ability and profile of skills and whether the child has other disabilities. If he has disabilities we would look for
an identifiable cause. Diagnosis is based on ICD 10 or DSM Subgroups.

Once the diagnosis is made, parents are supported by professionals, to help them to come to terms with the diagnosis
and its implications. These children’s educational needs need to be assessed. Parents also need practical support for
caring for these children with periods of respite care etc.
Management of Autism is multi-agency, multidisciplinary that includes Health Service

52
Professionals like Child & Adolescent Psychiatrist, Child Psychologists, Community
Psychiatric Nurses/Clinicians in CAMHS, Speech and language therapists, occupational therapists, and Local
Authority professionals like Social Workers and Educational Psychologists.

National Autistic Society is a useful resource available nationally, funded predominately by voluntary contributions
and by Local Authority. Parents and other professionals find the work of this society invaluable.

Treatment

There is no one treatment that provides a cure for Autism or its spectrum disorders. Early diagnosis, comprehensive
information, structured education and positive behaviour modification remain the most important cornerstones for all
intervention programmes. There are interventions available that can enhance communication and prevent secondary
behaviour problems. These are PECS (Picture Exchange Communication), Hanen, Early Bird, Child’s Talk, Lovaas,
TEACCH etc.

Medication, particularly for epilepsy, may be very important for some individuals, but the majority will probably be
better off without long-term pharmacological treatment, at least in the present state of our knowledge. Symptomatic
treatment of hyperactivity with stimulants could be used cautiously in some cases and sleep disturbance with
Melatonin has proved to be successful in some cases.

Further reading and information

• Advances in the Assessment and Management of Autism - ACPP Occasional Paper no. 13.
• Child Psychiatry Robert Goodman and Stephen Scott Blackwell Science.
• Rutter Child and Adolescent Psychiatry fifth edition, Blackwell publication. ISBN978 1 4051 4549 7.
• The National Autistic Society, www.nas.org.uk
• Loners- The life path of unusual children. Sula Wolff. Routledge ISBN 0-415-06665-4
• Autism and its spectrum disorders Christopher Gillberg Pages 73-96 in Psychiatric and behavioural disorders
in Developmental disabilities and mental retardation. Ed Nick Bouras.

Papers:

1. Practice parameters for the assessment and treatment of Children, Adolescents, adults with Autism and other
pervasive developmental disorders- AACAP OFFICIAL ACTION. J.Am Acad Adolescent psychiatry 38:12
Supplement December 1999.
2. Asperger syndrome and high functioning autism- Christopher Gillberg Review article, British Journal of
psychiatry 1998,172,200-209.
3. A screening instrument for Autism at 18 months of age: a 6-year follow up study. Baird et al. Journal of the
American academy of child and adolescent psychiatry 39.6 June 2000.
4. Ileal –lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorders in children. AJ
Wakefield et al The Lancet Vol 351 February 28 1998.
5. Measles, MMR and Autism the confusion continues. The Lancet Volume 355, April 22,2000. Number 9213.
6. Secretin: may not be effective in the treatment of autism. Khabir Ahmed. The Lancet Vol 354 December 18/25
1999.
7. Measles, mumps, rubella vaccination and bowel problems or developmental regression in Children With Autism.
Population Study. Taylor et al BMJ Vol 324 16th February 2002.
8. Time to look beyond MMR in autism research – The lancet editorial. The Lancet
Vol 359. February 23, 2002.
9. Practitioner Review: Diagnosis of Autism-Spectrum disorder in 2-3 years olds Tony Charman and Gilliam
Baird. Journal of child psychology and Psychiatry 43:3 (2002) pp 289-305.
10. Gillian Baird, Emily Simonoff, Andrew Pickles, Susie Chandler, Tom Lucas, David Meldrum, Tony Charman.
Prevalence of disorders of the autism spectrum in a popukation cohort of children in South Thames: the special
Needs and autism project (SNAP). Lancet, Volume 368 July 15th 2006.

53
The Red Flags for Autism

Communication Concerns.
• Does not respond to his/her name.
• Cannot tell me s/he wants.
• Language is delayed
• Doesn’t follow directions.
• Appears deaf at times.
• Seems to hear sometimes but not at others.
• Doesn’t point or wave goodbye.
• Used to say a few words but now doesn’t.
Social concerns.
• Doesn’t smile socially.
• Seems to prefer to play alone.
• Gets things for him/herself
• Is very independent.
• Does things ‘early’
• Has poor eye contact.
• Is in his/ her world.
• Tunes us out.
• Is not interested in other children.
Behavioural concerns.
• Tantrums.
• Is hyperactive/uncooperative/oppositional
• Doesn’t know how to play with toys
• Gets stuck on things regularly
• Toe walks
• Has unusual attachments to toys
• Lines things up
• Is oversensitive to certain textures or sounds
• Has odd movement patterns.

Absolute indications for immediate further evaluation

• No babbling by 12 months
• No gesturing (pointing, waving, bye bye etc) by 12 months
• No single words by 16 months
• No 2-word spontaneous (not just echolalic) phrases by 24 months.
• ANY loss of ANY language or social skills at ANY age.

(Filipek et al 1999 - National Autistic Society).

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11. Psychosomatic Disorders
Dr Debra Bradley

Somatisation

It is well recognised that all illnesses have both physical and psychological effects. Attributions about
physical symptoms can be seen as “normalising” or “pathologising”. A normalising attribution takes into
account environmental and psychosocial factors (eg I stayed up late last night and am worried about exams
next week – no wonder I have a headache) whereas a pathologising attribution looks for physical causes (eg
I have a headache – could it be a brain tumour).
The degree to which this occurs varies between individuals and from family to family.
It is also well recognised that anxiety about, and attention to, a symptom will increase its severity.
When physical symptoms are experienced in the absence of organic pathology (or their severity is much
greater than would be expected by clinical findings) this is described as somatisation or abnormal illness
behaviour. Somatisation is the process whereby an individual expresses psychological distress as somatic
symptoms.

Abnormal illness behaviour

The diagram below shows some of the factors that can contribute to the development of abnormal illness
behaviour.

55
Reduction in Restriction
External
fitness of activity
stress

Physical Symptoms Anxiety


Child
perceived
as delicate
Increased
sympathetic
nervous system
activity

Increased parental Increased


checking re awareness of
symptoms bodily
sensations

This diagram shows how anxiety on the part of both the child and their parents can perpetuate a cycle of
increased focus on physical symptoms. The child’s symptoms are real and can cause considerable distress
to the child and the family. The child receives additional parental attention as a result of suffering physical
symptoms and may also avoid difficult situations. Both of these effects will tend to reinforce the focus on
changes in bodily sensation and the labelling of these as worrying symptoms.

This diagram shows how anxiety on the part of both the child and their parents can perpetuate a cycle of
increased focus on physical symptoms. The child’s symptoms are real and can cause considerable distress
to the child and the family. The child receives additional parental attention as a result of suffering physical
symptoms and may also avoid difficult situations. Both of these effects will tend to reinforce the focus on
changes in bodily sensation and the labelling of these as worrying symptoms.

During assessment it is usually possible to identify additional external stresses at times when physical
symptoms are worse. These may be school related (eg exams, new class or bullying) or related to life events
or changes in the home situation.

56
A child’s reaction to physical symptoms will be affected by:

• The child’s temperament – children who show abnormal illness behaviour are often
described as having anxious, perfectionist, sensitive or insecure personalities. They are
more likely to cope with new or difficult situations by withdrawing and may have a history
of difficulties making friends.
• The child’s experience of illness – if a child has an experience of being unwell which they
found particularly difficult or unpleasant, this will increase their anxiety about becoming ill
in the future.
• The family’s attributional style – if the child’s family tend to pathologise rather than
normalise physical symptoms, the child is likely to be made more anxious about their
symptoms.
• The family’s experience of illness – if there is a family history of a particular illness the
family may be more worried by symptoms that are suggestive of the illness. For example a
child complaining of abdominal pain may cause great anxiety in a family where a
grandparent has recently been diagnosed as suffering from bowel cancer. Families may
also have had experience of doctors missing diagnoses or making wrong diagnoses.

General principles of management of abnormal illness behaviour


It is important to avoid the false dichotomy between “real illness” and symptoms that are “all in
the mind” or “made up”. It is imperative that the child and the family feel that their concerns have
been listened to and understood and that they are assured that the symptoms are real and are taken
seriously. The child and family should be given clear information that psychological stress can
and does cause real physical symptoms. If physical examination or investigation is indicated it
should be carried out promptly. Once necessary investigations have been carried out and found to
be normal this should be fed back to the family. At this point it is no further investigations should
be carried out unless the clinical picture changes significantly, as it is very difficult to engage a
family in psychological work if they are still awaiting results of further physical tests. In some
instances it can be helpful to have a joint consultation between the paediatrician and the child
psychiatrist. At such a meeting it is useful to go over results of any tests and to explain a joint
strategy for further management. The focus of ongoing work should be around how to cope with
symptoms and reduce their effect on daily activity rather than repeated detailed description of the
symptoms

Further management involves:


• An explanation about the effects of focusing on bodily sensation
• The recognition that physical symptoms are worse at times of increased stress. Getting
families to keep a diary of symptoms can be very useful in establishing aggravating factors.
• Teaching the child relaxation and distraction techniques
• Encouraging the child to increase their range of activities
• Discouraging parents from focusing on physical symptoms
• Encouraging parents to give additional attention to the child at times when they are well
and not complaining of symptoms
• Helping the child and parents to establish other means of communicating feelings or
distress
Forms of abnormal illness behaviour

Recurrent abdominal pain is a very common complaint particularly in middle childhood, affecting
between 10 – 25 % of children.

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Chronic fatigue syndrome

This is most frequently seen in adults but does occur in childhood. Onset is usually after a viral
illness. Affected children have mental and physical fatigue and may also complain of weakness
and unhappiness. They can miss considerable periods of time from school. A gradual programme
of graded rehabilitation recognising the physical and psychological aspects of the condition is the
best approach.

Dissociative disorders

These conditions are also known as conversion disorders or hysteria. The child may present with
an unexplained weakness of one or more limbs, a bizarre gait or funny turns. Symptoms that do
not fit expected anatomical or physiological patterns raise the suspicion that the symptom does not
have an organic basis. In the wider family or social circle there is frequently a history of someone
with similar symptoms. The symptom is best understood as the only way a child can cope with
their current situation. This may be as a result of unrealistic expectations of the child’s abilities or
can be a response to undisclosed abuse. It is important to gain as clear an understanding of the
child’s predicament as possible. Any underlying stress should be dealt with followed by a
programme of gradual physical rehabilitation.

Munchausen’s syndrome by proxy

In this uncommon condition, which can also be viewed as a particular form of child abuse, the
child is presented to doctors with fictitious illnesses. The parent (usually the mother) will present
the child with symptoms that they have deliberately fabricated. Parents may have a background in
nursing or other health professions. Symptoms may be fabricated by contaminating specimens, by
poisoning, by suffocation or by inducing fevers or skin rashes. The condition will be suspected if
the symptoms only occur when the child is in the care of the suspected carer. There are
considerable risks to the child as the abuse is both physical and emotional. In addition the child
may be subject to repeated hospital admissions and unnecessary investigations.

References

Eminson D M (2001) Somatising in children and adolescents. 1. Clinical presentations and


aetiological factors. Advances in Psychiatric Treatment, 7, 266-274.

Eminson D M (2001) Somatising in children and adolescents. 2. Management and outcomes.


Advances in Psychiatric Treatment, 7, 388-398.

McGrath P J and Goodman J E (1998) Pain in childhood. In P Graham McGrath P J and Goodman
J E (1998) Pain in childhood. In P Graham Cognitive-Behaviour Therapy for children and families
(pp 143-155) Cambridge University Press

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12. Psychological Aspects of Physical Illness
Dr Debra Bradley

Chronic illness

A chronic physical illness is defined as one that interferes with daily functioning for more than 3
months a year, or which causes hospitalisation for more than 1 month a year. By this definition
chronic physical illnesses occur in 10 – 20 % of the child and adolescent population. Most of these
conditions are relatively benign, causing little in the way of ongoing problems for the affected
children. However approximately 10 % of the population with chronic conditions (or 1 –2 % of
the total child population) are severely affected.

Children with chronic physical conditions are twice as likely to develop mental health problems as
healthy children. Children with a chronic condition affecting the central nervous system (eg
epilepsy or cerebral palsy) are five times as likely to develop a mental health problem.

The range of chronic childhood physical conditions includes:


• Asthma – affects 3 - 12 % of children
• Atopic dermatitis – affects 5 % of children
• Epilepsy – affects 0.5 % of children
• Cerebral palsy – affects 0.25 % of children
• Diabetes – affects 0.2 % of children
• Cystic fibrosis – affects 0.05 % of children
• Leukaemia – affects 0.05 % of children

Effects of chronic illness

Considering the range of conditions it is obvious that the effects of a condition will vary
depending upon various factors including:
• The child’s age at diagnosis
• The nature of the condition
• The effect on life expectancy
• The effect on physical appearance
• The nature of treatment and the restrictions that this imposes

These effects will in turn be affected by:


• The developmental stage of the child
• The child’s temperament
• The family’s perception of the condition
• The family’s experience of and attitude to illness
• Information given to the family at diagnosis and follow up

Diagnosis

Some conditions will be apparent at birth (or even pre-natally) while others may not manifest
themselves until well into childhood or adolescence. Whenever diagnosis occurs there is a period
of adjustment for the child and the family. For the parents this may include a grief reaction for the
loss of the “perfect child”. This is a similar reaction to that following a bereavement, and may
include periods of shock and denial followed by anger and sadness before eventual acceptance and

59
adaptation. For conditions that are diagnosed in later childhood the child may also go through a
similar process, as they realise the restrictions that the condition imposes on their future potential.
The child may go through a series of adjustments with increasing age and cognitive development
as they become aware of further implications of their condition eg around life long need for
treatment, future fertility and heritability.

Stage of development

Any condition will have different effects on the same child at different developmental stages. For
example a child who is diagnosed with insulin dependant diabetes at age 5 may have good diabetic
control throughout childhood. At this age they are likely to accept that their parents are
responsible for their diet and insulin administration. However with adolescence and a move to
greater autonomy the young person may resent the restrictions that diabetes imposes and their
diabetic control may become much worse. Families may require increased support at times of
transition from childhood to adolescence. This should provide input to the young person to
educate them about their condition and its treatment and to allow them gradually to take
appropriate control of their treatment. Parents may find it difficult to allow their child to take over
control of their treatment and require support around their anxieties at these times of transition.

Effects of chronic illness on the child


• Physical limitation – the condition may limit a child’s mobility or exercise tolerance. This
can lead to the child not experiencing the range of activities that healthy children
participate in. This may also affect the child’s range of, and opportunity for, social
interaction with other children.
• Stigma – some conditions are perceived as more stigmatising than others. Conditions that
affect physical appearance are often more stigmatising than those that do not. Other
conditions such as epilepsy and HIV infection can be associated with stigma.
• Treatment – some treatments cause significant restriction (eg postural drainage and chest
physio for cystic fibrosis) others may cause considerable distress due to pain, discomfort or
drug side effects.
• Hospitalisation – periods of time in hospital can cause significant problems for children.
Hospitalisation can cause disruption of relationships with family and with friends. Periods
of hospitalisation occurring in early childhood can disturb the process of attachment
between the child and its parents.
• Uncertainty re future – the child is likely to become increasingly aware with age of the
restrictions that their condition imposes on their range of choices for the future, ranging
from choice of occupation to their ability to live independently or even their life
expectancy.
• Education – schooling may be disrupted by periods of hospitalisation or exacerbations of
symptoms. Chronic illness may also lead to a lowering of educational expectations of the
child by family and teachers.

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Effects of chronic illness on the family
1. Parents
• Burden of care – much of the physical care for a child with a chronic condition will fall to
their parents. This may involve carrying out procedures that are distressing for the child
(eg blood sugar monitoring or insulin administration in diabetes) or that take considerable
time (eg physiotherapy exercises) or that cause disruption to normal family life (eg staying
with a child during hospital admissions)
• Anxiety re child’s illness – parents are likely to have considerable worries regarding their
child’s illness and it’s future course. This uncertainty can make planning for the future
difficult. Parents may have great anxiety about who will look after their child when they
are no longer able to do so.
• Restriction of activities – the range of normal family activities may well be affected.
Families may have difficulties using public transport and problems with access to leisure
activities. Problems with transport and accommodation may make taking a child with a
chronic illness on holiday impractical.
• Financial burden – the burden of care and the restriction of activities often lead to at least
one parent being unable to work. In addition to this there may be the expense of
adaptations, aids, special dietary requirements and transport to hospital.
• Overprotection – because of their sympathy for the child’s illness parents may find it hard
to discipline their child leading to overindulgence of the child and possible conduct
problems. They may also find it difficult to allow their child to experience the normal
range of activities and interactions with other children.
• Guilt – particularly in the case of inherited conditions parents may feel that they are to
blame for their child’s illness. Alternatively one parent may blame another for the child’s
illness.

2. Siblings
• Involvement in care – some of the burden of care may be taken on by siblings this can
cause them to have less time for homework or for social activities.
• Restriction of activities – siblings will be affected by all the factors that reduce the range
of activities available to their families.
• Embarrassment – siblings may also be subject to stigma and embarrassment about their
affected siblings condition. They may feel uncomfortable about bringing their friends
home.
• Guilt – siblings may feel guilt that they are not affected by the condition that affects their
sibling. They may resent the restrictions that their sibling’s illness imposes on their
family’s activities but feel very guilty about expressing these feelings.
• Decreased parental attention – siblings will almost by definition receive less parental
attention as a result of their sibling’s illness.

How to minimise harm


Problems for families with a child with a chronic illness can be helped by
• Ensuring families are receiving all benefits to which they are entitled – e.g. Disability
Living Allowance (DLA) which is a payment to which all families with children with
chronic conditions are entitled in recognition of the financial burden and additional expense
which families of children with chronic conditions experience.
• Respite care – can often be provided to families to allow them a break from onerous caring
duties or to enable them to take a holiday or to spend more time with their other children.

61
• Support groups – many families find meeting up with other families affected by the same
condition very helpful. There are many disease / condition specific groups which run local
or national support networks to put families in touch with one another.
• Support groups for siblings – many areas have groups for young people affected by
illness in a family member. These groups allow sharing of the experience of having an ill
parent or sibling.
• Genetic counselling – for conditions with a genetic cause parents should be referred for
genetic counselling for advice about risk of recurrence in future pregnancies. The young
person with the condition should also have access to age appropriate advice about
inheritance.

Hospitalisation
Effects of hospital stay
It has been recognised over the past 30 –40 years that children who were admitted to hospital
without their parents show a pattern of behaviour. This pattern of behaviour was described by
Bowlby. The initial stage is one of protest and distress. This is followed by a stage of general
misery, during which there may be disturbance of sleep pattern and refusal to eat. The final stage
is of detached resignation, during this stage the child will appear to be unconcerned even if the
parent visits.
In the longer term a child who has repeated admissions to hospital in early childhood is more likely
to develop emotional and behavioural problems in later life. The risk of this is increased by an
increased number of admissions or by an experience of longer admissions.

How to minimise harm


Problems associated with hospital admission can be reduced by:
• Preparation – for elective admissions the child can be taken to visit the ward and to meet
staff who will be involved in their stay. There is also an increasing range of children’s
books that describe the experience of a hospital stay. Many children’s wards have
produced their own information leaflet for families.
• Child friendly facilities – many children’s wards are decorated with bright colours and
children’s storybook characters. The importance of play facilities and play workers is
increasingly recognised. Rooms for procedures may be decorated in interesting ways with
lights or mobiles to distract the child.
• Open access for families – most children’s wards operate a system of open visiting for
families and have facilities for parents to stay in hospital with their child.
• Minimising discomfort – use of adequate analgesia during and after procedures will
reduce the distress to the child on the current occasion and therefore reduce anxiety prior to
any subsequent procedure. This includes the use of local anaesthetic cream prior to
venepuncture.
• Involving parents – staff on children’s wards can reduce the anxiety of the parents and
also the child by giving clear information about what will happen and when and by
ensuring that parents have an opportunity to ask questions about their child’s care.

Child psychiatry input into children with chronic physical illness

Child psychiatrists or psychologists may be asked to see children with chronic physical conditions
when it is felt that psychological factors are affecting the physical condition or its treatment. For
example non-compliance with treatment may be the result of a needle phobia or may be the
consequence of a depressive disorder. Psychological assessment can uncover the cause of any

62
non-compliance and treatment can be offered. Recognition and understanding of the factors that
underlie difficulties with treatment can improve compliance for the future.

Child psychiatrists and psychologists may also become involved if a child with a physical disorder
develops a psychiatric disorder. Major psychiatric illness is uncommon but emotional disorders
such as anxiety, depression and phobias occur more commonly than in healthy children.
Behavioural disorders such as conduct problems, attention difficulties and hyperactivity also occur
at an increased frequency.

References

Wallander J and Varni J (1998) Effects Of Pediatric Chronic Physical Disorders on Child and
Family Adjustment. Journal of Child Psychology and Psychiatry, 39, 29-46.

Mrazek D A (2002) Psychiatric Aspects of Somatic Disease and Disorders. In M Rutter, E Taylor
and L Hersov (Eds.) Child and Adolescent Psychiatry Modern Approaches. (4th Edition) (pp
810-827) Oxford : Blackwell Scientific Publications.

63
13. Medication in Child and Adolescent Psychiatry
Dr Louise Theodosiou

Very few psychoactive drugs are licensed for children. However the Medicines Act does not
prohibit the use of unlicensed medicines as it recognized that they might be needed. The General
Medical Council addresses the issue of prescribing medicines outside the terms of their licence in
their document Good Practice in Prescribing Medicines (2008). This states that “Currently
pharmaceutical companies do not usually test their medications on children and as a consequence
cannot apply to license their medicines for use in the treatment of children. The use of medicines
that have been licensed for adults, but not for children, is often necessary in paediatric practice.

When prescribing a medicine for use outside the terms of its licence you must:
a. Be satisfied that it would better serve the patient's needs than an appropriately licensed
alternative
b. Be satisfied that there is a sufficient evidence base and/or experience of using the medicine
to demonstrate its safety and efficacy. The manufacturer's information may be of limited
help in which case the necessary information must be sought from other sources
c. Take responsibility for prescribing the medicine and for overseeing the patient's care,
monitoring and any follow up treatment, or arrange for another doctor to do so (see also
paragraphs 25-27 on prescribing for hospital outpatients)
d. Make a clear, accurate and legible record of all medicines prescribed and, where you are
not following common practice, your reasons for prescribing the medicine.

For safety and medico-legal reasons, child psychiatrists prescribing drugs for children that they do
not usually use, will often consult with a suitably trained pharmacist, or a colleague with a special
interest in such prescriptions.
The physiological mechanism of action of psychotropics in children is thus largely unexplored.
Commonly used drugs are discussed below, and where possible the available evidence base for
their use in children is provided.

64
Antidepressants

* Not recommended in children


Antidepress Dose Side effects Licensed for Used for How Why
ants
Amitrypti- 150 – Anticholiner- Depression Depression Serotonic Cheap
line 200mg * ic Nocturnal Nocturnal reuptake Evidence that
In overdose – enuresis enuresis inhibitor it is the most
respiratory Clozapine Noradrenaline effective e.g.
depression induced reuptake Barbui &
arrythmia, hyper- inhibitor Hotopf
conduction salivation Anticholinergic
defects Antihistamine
Clomipra- 30 – Amitryptiline Depression Depression Amitryptiline Initial
mine 150mg * Phobic and Phobic and Serotonin
obsessional obsessional specific
symptoms symptoms effect but
Adjuctive Adjuctive major
narcolepsy narcolepsy metabolite is
treatment treatment not specific
Lofepramine 140 – Amitryptiline Depression Depression Amitryptiline Cheaper than
210mg * – but less SSRIs, less
severe dangerous
than other
tricyclics
Trazodone 150 – Amitryptiline Depression Depression Serotonin 2
300mg * – but less Especially Especially antagonism
severe with with Serotonin
Priaprism Insomnia Insomnia reuptake
blockade
Anticholinergic
Imipramine 25mg- Amitryptiline Nocturnal Nocturnal Amitryptiline Nocturnal
75mg enuresis enuresis enuresis
depending
upon age*
Nortriptyline 10mg – Amitryptiline Nocturnal Nocturnal Amitryptiline Nocturnal
50mg enuresis enuresis enuresis
depending
upon age*
Mirtazepine Initially Increased Depression Presynaptic
15mg up sleep and
to 45mg* appetite
Rarely
elevates liver
enzymes
Venlafaxine 75mg – Nausea Depression Serotonin and
150mg * headache noradrenaline
insomnia reuptake
inhibitor
Citalopram 20mg – Gastrointesti- Depression Serotonin Less lethal
60mg * nal Panic specific than
Anorexia disorder reuptake tricyclics
Insomnia inhibitor Apparently
Serotonin better
syndrome tolerated
Anorgasmia

65
Fluoxetine 20 – Citalopram Depression SSRI Long
This is the 60mg * Bulimia Half-life 72 duration of
only anti- Obsessive hours action can be
depressant compusive useful in
that can be disorder maintaining
used in Premenstrual plasma levels
children Dysphoric in patients
disorder taking meds
erratically
Fluvox- 100 – Citalopram Obsessive SSRI Evidence for
amine 300mg * compusive effectiveness
disorder in young
(OCD) people with
social
phobia,
separation
anxiety
disorder or
generalized
anxiety
disorder
Paroxetine 20 – Citalopram OCD SSRI
50mg * Post-
traumatic
stress
disorder
Panic
disorder
Social phobia
Sertaline 50 – Citalopram OCD SSRI
200mg *

Antidepressant Augmentation
Lithium is sometimes used to potentiate the effects of antidepressants. Lithium is dangerous both
in overdose and if the plasma level rises too high. Regular blood monitoring is needed. T3,
tryptophan can only be used by hospital specialists for patients with severe and disabling
depression of more than 2 years duration due to the fact that eosinophilia myalgia syndrome has
been reported. Although its use is limited, it can be of value even in patients with normal thyroid
function.

The safety of antidepressants in children

NICE published guidelines on depression in children and young people, this states that “In
December 2003, following a review by an Expert Working Group of the
Committee on Safety of Medicines (CSM), the CSM advised that, despite the lack of a marketing
authorisation for fluoxetine in the treatment of major depressive disorder in under 18s at that time,
the balance of risks and benefits for this drug was favourable. The CSM also stated that sertraline,
citalopram and escitalopram, paroxetine, venlafaxine and fluvoxamine should not be used as new
therapy. However, its advice was clear that child and adolescent psychiatrists are able to prescribe
selective serotonin reuptake inhibitors (SSRIs) other than fluoxetine in certain circumstances; for
example, where drug treatment is indicated but a patient is intolerant of fluoxetine.

NICE lists five steps in the treatment of children and young people with depression, the use of
medication is the fifth step, and NICE states that “Antidepressant medication should not be offered

66
to a child or young person with moderate to severe depression except in combination with a
concurrent psychological therapy. Specific arrangements must be made for careful monitoring of
adverse drug reactions, as well as for reviewing mental state and general progress; for example,
weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks
of
treatment.”

Antipsychotics

There are many long-term effects of taking the older antipsychotics for an extended period of time.
The available data has almost all been generated by its use in adults, and includes problems such as
osteoporosis. Many of the other side effects can be described with the label ‘extra-pyramidal
symptoms’. They include uncontrollable movements of the face, arms and legs. Parkinsonism,
acute dystonia, tardive dyskinesia are included in this group of symptoms. They can usually be
managed by lowering the dose of the neuroleptic drug, adding or increasing the dose of an
antiparkinsonian medication, or introducing other blocking drugs.
The new generation of atypical antipsychotics have not yet been in use long enough to generate a
lot of long-term data.
However there is also an increasing body of evidence to support the idea that psychosis itself may
be neurotoxic, and would certainly be damaging to a child’s academic career, social interactions
and self-esteem.
For students interested in understanding more about the practical applications of the use of
antipsychotics, a visit to the local child psychiatry In-patient unit is a way of obtaining more
information. (The McGuinness Unit can be found in Prestwich Hospital)

Challenging behaviour

The behaviour of children with severe learning difficulties or pervasive developmental disorders
can at times be very difficult to manage. Antipsychotics are sometimes used to help manage
challenging behaviour, although only very sparingly. Not only can the anticholinergic effects
paradoxically make behaviour worse, but also additionally the long-term effects of antipsychotics
on brains, which may be damaged, is not fully understood.
Conduct disorder can be very distressing for children and adults alike; it often contains a
component of destructive outbursts of anger. In adults who have difficulty regulating mood and
affect and the manifestation of these, antipsychotics can sometimes be an effective treatment.
Evidence is now slowly emerging of the effectiveness of antipsychotics in conduct disorder, but of
course it is vital to address the social and psychological aspects of conduct disorder and consider
medication as a very late intervention.

67
* Not recommended in children

Antipsycho- Dose Side effects Licensed for Used for How Why
tics
Haloperidol Child 25- Extra Pyramidal Schizophrenia, D2 Available IM
50mcg/kg Tardive other psychoses, Alpha 1 widely used
daily max dyskinesia Mania, short in the
10mg Neuroleptic term adjunctive treatment of
Malignant management of agitated
Syndrome psychomotor patients,
hypotension agitation and especially in
long term effect dangerously combination
of osteoporosis impulsive with
behaviour lorazepam
Chlorproma- 1-5yrs haloperidol Haloperidol M1 avoid IM as
zine 500mcg/ with childhood autism H1 hypotensive
kg 4-6 hr anticholiergic Alpha 1 still useful
max 40mg photosensiti- D2 orally due to
daily zation its
6-12 yrs antipsychotic
1/3 and anxiolytic
adult dose effects
max 75mg
daily
Thiorida- Associated with
zine rare reports of
arrythmia –
restricted for 2nd
line treatment of
schizophrenia in
adults
Sulpiride 200 – chlorpromazine Haloperidol Chlorpro high doses -
800mg * with porphyria mazine florid positive
symptoms,
low doses -
alerting effect
on withdrawn
patients with
schizophre-
nia
Trifluoper- 5mg chlorpromazine Chlorpromazine Chlorpro
azine starting mazine
dose – no
child/adult
maximum
Pimozide 2 – 20mg * chlorpromazine Chlorpromazine Tourette’s Chlorpro
ECG due to Monosymptoma- mazine
reports of sudden tic
death hypochondriacal
psychosis
Flupen- 12.5 – Chlorpromazine Chlorpromazine Mainte- Chlorpro-
thixol 100mg at nance, mazine
decanoate intervals of slow
14 – 35 release
days * depot
Haloperidol 50 – Chlorpromazine Chlorpromazine Chlorpro Chlorpro-
decanoate 300mg * mazine mazine

68
Antipsycho- Dose Side effects Licensed for Used for How Why
tics
Pipothiazine 50 – Chlorpromazine Chlorpromazine Chlorpro Chlorpro-
palmitate 100mg * mazine mazine
Zuclopen- 200mg – Chlorpromazine Chlorpromazine Chlorpro Chlorpro-
thixol 500mg * mazine mazine
decanoate
Clozapine 50 – use restricted by Chlorpromazine D1, 2, 3, 4 all atypicals
900mg * the Clozapine blockade are believed
monitoring 5HT to have less
service due to the blockade tardive
risk of M1 dyskinesia,
agranulocytosis H1 EPS and
Henderson found Alpha 1, 2 prolactin
an increase in increasing
diabetes effects
Olanzapine 10 – 20mg Increased Schizophrenia D1, 2, 3, 4 many
* appetite, mild blockade anecdotal
dispersible transient 5HT reports of use
tablet anticholinergic blockade in children
currently dizziness M1
available H1
IM
injection
coming out
Amisulpi- 400-800mg olanzapine Schizophrenia selective
ride * D2/D3
antagonis
m
Quetiapine 25 – olanzapine Schizophrenia D2
750mg * may prolong QT 5HT
interval H1
alpha 1, 2
Risperidone 2 – 16mg olanzapine acute and chronic Challen- D2,
child also insomnia psychoses ging 5HT
500mcg – behaviour alpha 1, 2
2mg

The controvertial Geddes paper (BMJ 2001) has reviewed the available evidence on side-effects in
antipsychotics and concluded that in comparable doses there is no advantage to the atypicals. This
ignores the question of tardive dyskinesia and osteoporosis however it was used to form the basis
of the NICE antipsychotic guidelines on prescribing in first time psychosis. This guidance is due
for review in December 2006, it does not address the use of antipsychotics in children and young
people.
Neuroleptic Malignant Syndrome is a risk factor for all antipsychotics, but is believed to be more
so for typicals
Haloperidol (IM and Oral) and chlorpromazine (oral) are the antipsychotics discussed in the Royal
College Guidelines on the management of the need for rapid tranquilization.
There is not yet specific guidance in the UK on the use of antipsychotics in children, although the
American Academy of Child and Adolescent Psychiatry has published guidelines. The college
seminars series also provides useful information.

69
Anxiolytics
The use of benzodiazepines in children for anxiolytic purposes is very unusual. The SSRI group of
antidepressants are becoming increasingly used in the management of anxiety phobias and post
traumatic stress disorder.

* Not recommended in children


Anxiolytics Dose Side effects Licenced for Used for How Why
Diazepam adult 2 – drowsiness anxiety or anxiety or specific
30mg and insomnia insomnia receptor site
child 1- lightheadedne acute alcohol acute
5mg ss withdrawal alcohol
available very addictive status withdrawal
IM oral, epilepticus status
IV, rectally febrile epilepticus
convulsions febrile
night terrors, convulsions
somnambu- night terrors,
lism somnambu-
lism
lorazepam 1 – 4mg * drowsiness Anxiety Anxiety absorbed
and insomnia insomnia more
lightheaded- status status effectively
ness epilepicus epilepicus IM than
very addictive diazepam
buspirone 5mg tds nausea Anxiety Anxiety Thought to Does not
50mg max dizziness act at share the
* headache specific addictive
5HT1A profile of the
receptors benzodiaze-
(response pines
may take up (not effective
to 2 wks) in controlling
their
withdrawal)

The BNF states that Benzodiazepines are useful for the short-term relief of severe anxiety. Other
members of the family include alprazolam, bromazepam, oxazepam and chlorazepate.
Chlordiazepoxide is a benzodiazepine with a very long half life – it is licenced as an adjunct in
acute alcohol withdrawal, additionally, if attempting to withdraw someone from another member
of the benzodiazepine family – it is recommended that they are converted to a comparable dose of
chlordiazepoxide and that this is then reduced.
The SSRIs initially increase anxiety, but once the antidepressant action kicks in, there is an
anxiolytic effect as well. Thus compliance can be increased by warning people of the initial
anxiety and subsequent relief.
Beta-blockers e.g. propranolol do not affect psychological symptoms of anxiety, but they do
reduce autonomic symptoms.

70
Hypnotics
Melatonin is often used to good effect at a dose of 2mg, for example in the management of
children with pervasive developmental disorders who are struggling to sleep.

* Not recommended in children


Hypnotics Dose Side effects Licenced for Used for Why
Nitrazepam 5 – 10mg * Diazepam Insomnia insomnia
Zopiclone 7.5mg * Bitter or Insomnia insomnia Lack the addictive
metallic taste effect of the
Gastrointestinal benzodiazepines
Zolpidem 10mg * Gastrointestinal Insomnia insomnia Lack the addictive
Depression effect of the
benzodiazepines
Chloral Adult 0.5 – 2g Gastrointestinal Insomnia insomnia Lack the addictive
hydrate Child – max 1g effect of the
benzodiazepines

Many other benzodiazepines e.g. flunitrazepam, flurazepam, loprazolam, lormetazepam and


temazepam are licenced for the use as hypnotics.
Promethiazine the antihistamine is popularly used as night sedation in children.

71
Bipolar affective disorders
Children and young people with acute mania are frequently treated in Tier 4 referral units.
Antipsychotic drugs are often used in the early stages of mania, the drugs listed below are used the
maintenance of adult patients with bipolar affective disorder.

* Not recommended in children


Antimanic Dose Side effects Licenced for How Why
Lithium Different Gastrointestinal Treatment and Inhibits
carbonate preparations Fine tremor prophylaxis of phosphoinositol
vary widely in Polyuria and mania, bipolar 2nd messenger
bioavailability polydipsia, also Recurrent system
* weight gain depression,
aggressive or
self-mutilating
behaviour
Carbamazepine 400mg – 1.6g 2nd line bipolar
used to treat in treatment
epilepsy in which seems to
children be particularly
effective in
controlling
rapid cycling
mania
Sodium 600mg – 2.5g Gastrointestinal
valproate daily Ataxia, tremor
used to treat weight gain
epilepsy in
children

Benzodiazepines may be useful in the early stages of manic episodes, as may antipsychotics. Some
people use depot antipsychotics for the maintenance of non-compliant bipolar sufferers, however
this use is controvertial given the higher rates of tardive dyskinesia seen in these patients. Given
that lithium has been shown to cause rebound mania if stopped suddenly, it is recommended that
when people are started on a course, they realise that the minimum time period is 2.5 years. Other
newer anticonvulsants are now being explored in the control of rapid cycling mood disorders.
NICE has published guidelines regarding the use of Olanzapine and Valproate in adult bipolar
disorder.

72
Hyperkinetic disorders also known as Attention Deficit Hyperactivity Disorder (ADHD)

The National Institute of Clinical Excellence produced a third set of guidelines for the treatment of
ADHD in 2008. The first set of guidance was a technology appraisal concerned mainly with the
use of methylphenidate in children, the 2008 guidance in contrast “makes recommendations for the
diagnosis and management of ADHD in children, young people and adults”. NICE states that:

“The first-line treatment for school-age children and young people with severe ADHD and severe
impairment is drug treatment. If the child or young person wishes to refuse medication and/or the
parents or carers reject it, a psychological intervention may be tried but drug treatments has more
benefits and is superior”.

NICE advises a pre-drug treatment assessment before starting medication. This should include
“full mental health and social assessment”, “full history and physical examination including
assessment of exercise syncope, undue breathlessness and other cardiovascular symptoms, heart
rate and blood pressure” “height and weight” “an ECG if there is a past history or family history of
serious cardiac disease” “risk assessment for substance misuse and drug diversion”.

NICE recommends “methylphenidate, atomoxetine and dexamfetamine” “within their licenced


indications”.

Methylphenidate is a centrally acting stimulant, it is also controlled drug not licenced for use in
children under 6 years. Methylphenidate controls the symptoms of ADHD for the duration of its
half life. The BNF for children lists the following in terms of common side effects “see under
Dexamfetamine Sulphate; also sleep disturbances, depression, confusion, attention-deficit
hyperactivity disorder aggravated, asthenia, anxiety, rash”. NICE states that “Common adverse
effects of treatment include insomnia, nervousness, headache, decreased appetite, abdominal pain
and other gastrointestinal symptoms, and cardiovascular effects such as tachycardia, palpitations
and minor increases in blood pressure.” Methylphenidate has been seen to contribute to low mood
and tearfulness in young people with learning disabilities. Height, weight and blood pressure
checks are also recommended. NICE encourages local authorities to draw up appropriate audit
schedules to monitor these physical checks.

Methylphenidate is available in both short (e.g. Ritalin) and long acting (e.g. Concerta, Equasym
XL and Medikinet) forms. The short acting forms have the advantage of starting to work very
quickly, this can be very useful, for example in the morning when a busy family is trying to get
ready for the day, additionally the fact that it has an average half life of four hours means that it is
quickly metabolised by children and young people. The fact that children and young people only
have to take tablets once a day is an advantage of the long acting forms, this reduces stigma e.g. in
school, reduces the likelihood of tablets being sold or stolen for abuse reasons and can enhance
compliance

Atomoxetine is a new treatment for ADHD. It is a selective norephinephrine reuptake inhibitor and
is not a controlled drug. Atomoxetine takes about 8 – 12 weeks to control the symptoms of ADHD.
Daily doses are necessary. The medication has a 24 hour duration of action and is usually taken
once daily. This can be a useful way of managing busy times in family life, as well as covering the
school day. There is no potential for abuse. The BNF for children lists the following in terms of
common side effects “anorexia, dry mouth, nausea, vomiting, abdominal pain, constipation,
dyspepsia, flatulence; palpitations, tachycardia, increased blood pressure, postural hypotension, hot

73
flushes; sleep disturbance, dizziness, headache, fatigue, lethargy, depression, anxiety, tremor,
rigors; urinary retention, prostatitis, sexual dysfunction, menstrual disturbances; mydriasis,
conjunctivitis; dermatitis, pruritus, rash, sweating”. The Medicines and Healthcare products
Regulatory Agency (www.mhra.gov.uk) states that the “overall balance of risks and benefits of
Strattera remains positive in the treatment of ADHD in children of 6 years and older and in
adolescents”. It also reports that seizures are a potential risk, that there are reports of QT
prolongation, concerns about an increase in suicidal thoughts and a risk of rare, but sometimes
severe, hepatic disorders.

NICE identified only one published study directly comparing methylphenidate and atomoxetine, to
quote from NICE “This study reported no difference between the two drugs for hyperactivity or
clinical global impression. However, a finding of no difference on subjective outcomes is difficult
to interpret in the absence of a placebo group because it cannot be certain that drug effects were
successfully measured in either group.”.

NICE also discusses the use of Dexamfetamine, a central nervous system stimulant. NICE states
that it “is licensed as an adjunct in the management of refractory hyperkinetic states in children,
under specialist supervision. It is a Schedule 2 controlled drug and is not currently licensed for use
in children less than 3 years old.”

74
References
1. Barbui C, Hotopf M (2001) Amitriptyline v. the rest: still the leading
antidepressant after 40 years of randomised controlled trials. British Journal of
Psychiatry 178: 129-144.
2. BNF for children 2008
3. British National Formulary 2008
4. CG28 Depression in children and young people: NICE guideline.
http://www.nice.org.uk/page.aspx?o=cg028niceguideline
5. Henderson DC, Nguyen DD, Copeland PM, Hayden DL, Borba CP, Louie PM, Freudenreich
O, Evins AE, Cather C, Goff DC. (2005) Clozapine, diabetes mellitus, hyperlipidemia, and
cardiovascular risks and mortality: results of a 10-year naturalistic study. Journal of Clinical
Psychiatry; 66(9):1116-21.
6. National institute of Clinical Excellence - Attention deficit hyperactivity disorder - Diagnosis
and management of ADHD in children, young people and adults
http://www.nice.org.uk/nicemedia/pdf/CG072NiceGuidelinev4.pdf

7. Puri, B.K. & Tyrer, P.J. Sciences basic to psychiatry (Second Edition)
8. Practice Parameter for the Assessment and Treatment of Children and Adolescents With
Schizophrenia Journal of the American Academy of Child & Adolescent Psychiatry 2001;
40:4S-23S

Recommended Reading, reference books, web pages:-

College seminars series, seminars in child and adolescent psychiatry (second edition) edited by
Gowers S.G.

Jureidini JN, Doecke CJ, Mansfield PR, Haby MM, Menkes DB, Tonkin AL. (2004) Efficacy and
safety of antidepressants for children and adolescents. British Medical Journal. 328(7444):879-83.
Erratum in: British Medical Journal. 2004 May 15;328(7449):1170.

http://www.rcpch.ac.uk/publications/formulary_medicines/Unlicenced_Medicines.pdf - guidelines
on the use of unlicensed medication in children

Good practice in Prescribing Medicines (2006) http://www.gmc-


uk.org/guidance/library/prescriptions_faqs.asp

75
14. References, Recommended Reading and Useful Websites
Dr Louise Theodosiou.

Core Textbooks:

*Child Psychiatry Goodman, R. & Scott, S. (2005)


(2nd edn). London: Blackwell

*Seminars in Child and Adolescent Psychiatry Gowers, S


second edition College Seminars Series
Published By Gaskell, 1993
ISBN 0-902241-55-9

*Recommended reading.

For more in-depth information:

Child and Adolescent Psychiatry: Rutter, M. Taylor, E (Eds)


4th Edition

Finding the Evidence: A gateway to the Edited by Angela Scott, Mike Shaw and
literature in child and adolescent mental health Carol Joughin
second edition

Diagnostic Classification System:

Multiaxial Classification of Child and Adolescent Psychiatric Disorders


World Health Organisation, 1996
Cambridge University Press

(This book explains the principles of the multi-axial diagnostic framework in Child and Adolescent
Psychiatry and gives the criteria for each diagnosis.)

All textbooks are available in RMCH library. All or some of them would also be available in
departmental libraries and hospital libraries.

76
Websites

Specific Clinical Issues

• ADD Net UK www.btinternet.com/~black.ice/addnet


Information about UK support groups, news, events, and provides links to other relevant Internet
resources. In addition, it hosts an ADHD information library.

• Autism FAQ memo www.autism-resources.com/autism.faq.html


The site is in the form of a documentation of facts about Autism. Information is provided on the
definition of terms, book references, useful organisations and treatment programs.

• National autistic Society www.nas.org.uk


A useful source of information for professionals and parents/carers.

• (OASIS) www.udel.edu/bkirby/asperger/
On-line Asperger Syndrome Information and Support
Information is provided about related disorders, social skills, education, including links to research
papers and support groups.

• Eating Disorders Shared Awareness www.eating-disorders.com


Provides comprehensive information on a range of Eating Disorders. Resources include
definitions, causes, treatment, on-line support, relevant organisations and links to other Internet
sites.

• OCD Resource Centre www.ocdresource.com/


This web site is a useful resource for those inquiring about OCD. It provides information in terms
of its diagnosis, treatment and how to obtain help.

• Substance Misuse www.trashed.co.uk


Information is provided on a wide range of substances. Site produced by the Health Education
Authority.

• National Self Harm Network www.nshn.co.uk


Offering information and support.

• The National ME Centre and Centre for Fatigue Syndromes


www.nmec.org.uk/support.htm
Offers advice and information about ME and related illnesses.

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General Resources

• www.bma.org.uk (British Medical Association)


• http://bmj.bmjjournals.com/ (British Medical Journal)
• www.dh.gov.uk (Department of Health – point of access for white
papers)
• www.doctors.net.uk (Doctors Net – offers a link to the National Library of
Medicine as well a forum space that doctors can use to pose questions to
one another)
• www.drugs.gov.uk (The Home Office Website on the misuse of drugs – a
useful source of information on legislation, research and guidance)
www.fleshandbones.com - source of free revision aids for medical students
• www.gmc-uk.org (General Medical Council)
• www.ncbi.nlm.nih.gov/entrez/query.fcgi (The National Library of
Medicine – contains over 15 million medline citations)
• www.nice.org.uk (National Institute of Clinical Excellence)
• Royal College of Psychiatry Website www.rcpsych.ac.uk
Provides fact sheets relevant to Child and Adolescent Psychiatry and links to many other websites.

• Mental Health Information Source www.mhsource.com


The site informs of ‘what’s new’, including mental health news and site updates, provides links to
articles and on-line and off-line support. In addition, the site contains a symptom/disorder list
which provides information on individual disorders relevant to child and adolescent mental health,
including links to related sites.

• Mental health Net www.mentalhelp.net


Resources available include information about individual disorders and treatments, services, news,
books, journals and links to other relevant sites. A symptoms list provides access to information on
symptoms, treatment and on-line resources specific to childhood disorders. Alternatively
information relating to child and adolescent mental health problems can be accessed via an ‘index’
of ‘disorders, treatment and support resources’.

• Paediatric Development and Behaviour www.dbpeds.org


The site provides access to clinical and educational information including short articles for parents,
links to other relevant Internet sites, job and research opportunities and hosts a developmental and
behavioural paediatrics discussion list for professionals.

• Child Protection/Safeguarding Children


What to do if you're worried a child is being abused: summary –
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/Pub
licationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4007508&chk=mga3Dq

http://www.corc.uk.net/index.php?sectionkey=2
“The CAMHS Outcomes Research Consortium (CORC) is a collaboration between child and
adolescent mental health services (CAMHS) across the UK with the aim of instituting a common
model of routine outcome evaluation and analysing the data derived.”

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15. Consultant Child and Adolescent Psychiatrists in the North West Region

CONSULTANT Address Tel/Fax No:

ABBAS, S McGuinness Adolescent Unit, Prestwich Hospital, 772 3648 Tel


Bury New Rd, Prestwich, Manchester, M25 3BL 772 3593 Fax

AGARWAL, M. Red Oak-Child and Family Services 01524 842 266 Tel
Piccadilly, Scotforth, Lancaster, Lancashire, 01524 841 270 Fax
LA1 4PW
Meena.Agarwal@lancashirecare.nhs.uk

AHMAD, S The Mount, Whalley Road, Accrington, BB5 6AS 01254 226280 Tel
01254 396576 Fax

ALY, A Child & Adolescent Mental Health Service, 01772 644644 Tel
Shawbrook House, Balcarres Road, Leyland, 01772 641680 Fax
Preston, PR25 3ED
ahad.aly@centrallancashire.nhs.uk

ATKIN, L. Dept of Child Psychiatry, Carol Kendrick Centre , 0161 902 3400 Tel
Strattus House, Southmoor, Manchester M23 9XD 0161 902 3401 Fax
Louise.Atkin@cmft.nhs.uk

BAGADI, A Child & Family Centre, 70 Chapel Road, Sale, 969 3026 Tel
M33 1EG 976 3224 Fax
adam.bagadi@trafford.nhs.uk

BAILEY, S Gardener Unit, Prestwich Hospital, Bury New Road, 772 3666 Tel
Prestwich, Manchester, M25 3BL 772 3443 Fax
Nicola.Tattersall@bstmht.nhs.uk

BARRETT, S. Tree House Children’s Centre, Stepping Hill 4192055/2050/2053


Hospital, Stockport, SK2 7JE 419 2102 Fax
s.barrett2@nhs.net

BIRADAR, R. Child & Adolescent Mental Health Service, 01772 644644 Tel
Shawbrook House, Balcarres Road, Leyland, 01772 641680 Fax
Preston, PR25 3ED
rajeev.biradar@centrallancashire.nhs.uk

BOURNE, M Bickerstaffe House, 53 Garstang Road 01772 562547 Tel


Preston, PR1 1NA
Malcolm.Bourne@elht.nhs.uk

BOWMAN, F Child & Family Services Unit, Royal Bolton 01204 390659 Tel
Hospital, Minerva Road, Farnworth, Bolton, 01204 390660 Fax
BL4 0JR
frank.bowman@rbh.nhs.uk

79
BRADLEY, D. Reflections Child & Family Unit, Royal 627 8080 Tel.
Oldham Hospital, Rochdale Road, Oldham,
OL1 2JH
debra.bradley@nhs.net

CHIN, C Dept of Child Psychiatry, Fairfield General Hospital, 778 3526


Rochdale Old Road, Bury, BL9 7TD
cheechin@nhs.net

CHITSABESAN, P. Tree House Children’s Centre, Stepping 419 2050/2053 Tel


Hill Hospital, Stockport, SK2 7JE 419 2102 Fax
pchitsabesan@nhs.net

CHOWDHURY, N. Dept of Child & Family Psychiatry, Birch 01706 754349 Tel
Hill Hospital, Rochdale, OL12 9QB

CLARK, A F Gardener Unit, Prestwich Hospital, Bury New Road, 772 3666 Tel
Prestwich, Manchester, M25 3BL 772 3443 Fax
Andrew.Clark@bstmht.nhs.uk

DALEY, L Gardener Unit, Prestwich Hospital, Bury New Road, 772 3666 Tel
Prestwich, Manchester, M25 3BL 772 3443 Fax
Lynne.Daly@bstmht.nhs.uk

DAUD, L Reflections Child & Family Centre, Royal 627 8080


Oldham Hospital, Rochdale Road, Oldham,
OL1 2JH
laila.daud@nhs.net

DE BRUYNE, D, Preston CAMHS, Ellen House, 1-3 Ellen Court, 01772777344 Tel
Preston, PR1 7RH
Dianadebruyne@centrallancashire.nhs.uk

DUBICKA, B., The Junction, Piccadilly, Ashford Road, 01524 519700 Tel
Lancaster, LA1 4PW
Bernadka.Dubicka@lancashirecare.nhs.uk

DUFTON, I. Child & Family Services Unit, Royal Bolton 01204 390659 Tel
Hospital, Minerva Road, Farnworth, Bolton, 01204 390660 Fax
BL4 0JR
ian.dufton@rbh.nhs.uk

EARNSHAW, S. Westgate Centre for Children, 142-148 Westgate, 01695 50719


Sandy Lane, Skelmersdale, WN8 8LH

EMINSON, D M Child & Family Services Unit, Royal Bolton 01204 390659 Tel
Hospital, Minerva Road, Farnworth, Bolton, 01204 390660 Fax
BL4 0JR
mary.eminson@rbh.nhs.uk

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ERCAN, S. CAMHS, 155-7 Manchester Road, Higher Ince, 01942 775400 Tel
Wigan, WN2 2JA 01942 775403 Fax

FRASER, A Dept of Child & Family Psychiatry, Birch Hill 01706 754349
Hospital, Rochdale, OL12 9QB
alison.fraser@nhs.net

GREEN, J M Dept of Child & Family Psychiatry, Booth Hall 918 5025 Tel
Children's Hospital, Charlestown Road, Blackley, 918 5227 Fax
Manchester, M9 7AA
Jonathan.Green@manchester.ac.uk

HACKETT, L Department of Child & Adolescent Psychiatry, 248 9494 Tel


Winnicott Centre, 195-7 Hathersage Road, 225 9338 Fax
Manchester, M13 OJE
Latha.Hackett@cmft.nhs.uk

HARRISON, L Child & Adolescent Mental Health Service, 01772 644644 Tel
Shawbrook House, Balcarres Road, Leyland, 01772 641680 Fax
Preston, PR25 3ED
HILL, J University Place
Jonathan.Hill@manchester.ac.uk

HOLLY, L. Child & Family Therapy Service, Springleigh, 303 4902 Tel
Waterloo Road, Stalybridge, SK15 2AU 303 1809 Fax
louise.holly@penninecare.nhs.uk

HUGHES, S Dept of Child Psychiatry, Carol Kendrick Unit, 611 3131 Tel
1st Floor, Home 4, Withington Hospital, 611 4684 Fax
West Didsbury, M20 2LR
Steven.Hughes@cmft.nhs.uk

IMRAN, S McGuinness Adolescent Unit, Prestwich Hospital, 772 3648 Tel


Bury New Rd, Prestwich, Manchester, M25 3BL 772 3593 Fax

JAYSON, D Child & Family Centre, 70 Chapel Road, Sale 969 3026
M33 1EG
Dinah.Jayson@trafford.nhs.uk

KELSALL, M Dept of Child & Adolescent Psychiatry, Royal 922 2697


Manchester Children's Hospital, Pendlebury, 922 2351 Fax
Manchester, M27 4HA
Mary.Kelsall@cmft.nhs.uk

KEVERN, A The Junction, Piccadilly, Ashford Road, 01524 519700 Tel


Lancaster, LA1 4PW

81
KHOLI, G. The Hope Unit , Pennine House, Fairfield 01619188506 Tel
General Hospital,
Rochdale Old Road, Bury BL9 7TD

KRISHNAN, G Dept of Child & Adolescent Psychiatry, Royal 922 2108 Tel
(locum) Manchester Children's Hospital, Pendlebury, 922 2351 Fax
Manchester, M27 4HA

KROLL, L Dept of Child & Adolescent Psychiatry, Royal 922 2108 Tel
Manchester Children's Hospital, Pendlebury, 922 2351 Fax
Manchester, M27 4HA
Leopold.Kroll@cmft.nhs.uk

KUSHLICK A Child & Family Therapy Service, Springleigh, 303 4902 Tel
Waterloo Road, Stalybridge, SK15 2AU 303 1809 Fax
anna.kushlick@penninecare.nhs.uk

LIGHTSTONE, R Dept of Child Psychiatry, Fairfield General Hospital, 778 3526


Rochdale Old Road, Bury, BL9 7TD
rachel.lightstone@nhs.net

LLOYD, H Dept of Child & Adolescent Psychiatry, Royal 922 2131 Tel
Manchester Children's Hospital, Pendlebury, 922 2351 Fax
Manchester, M27 4HA
Hilary.Lloyd@cmft.nhs.uk

MARSHALL, R Department of Child & Adolescent Psychiatry, 248 9494 Tel


Winnicott Centre, 195-7 Hathersage Road, 225 9338 Fax
Manchester, M13 OJE
Ruth.Marshall@cmft.nhs.uk

MOCKETT, M Dept of Child & Family Psychiatry, Booth Hall 918 5024 Tel
Children's Hospital, Charlestown Road, Blackley, 918 5165 Fax
Manchester, M9 7AA
Mischa.Mockett@cmft.nhs.uk

MORRIS, T Dept of Child & Family Psychiatry, Burnley 01282 474800 Tel.
General Hospital, Casterton Avenue, Burnley, 01282 474802 Fax.
BB10 2PQ
Timothy.Morris@elht.nhs.uk

NANGIA, M Dept of Child & Family Psychiatry, Burnley 01282 474800 Tel.
General Hospital, Casterton Avenue, Burnley, 01282 474802 Fax.
BB10 2PQ
monica.nangia@elht.nhs.uk

OTTO, H. House Children’s Centre, Stepping Hill 4192055/2050/2053


Hospital, Stockport, SK2 7JE 419 2102 Fax
heinkeotto@nhs.net

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RANOTE, S CAMHS, 155-7 Manchester Road, Higher Ince, 01942 775400 Tel
Wigan WN2 2JA 01942 775403 Fax
sandeep.ranote@wwl.nhs.uk

ROSS, K FACTS, Prestwich Hospital, Bury New Road, 772 3811 Tel
Prestwich, Manchester, M25 3BL 772 3443 Fax
Kenny.Ross@bstmht.nhs.uk

ROUS, E. House Children’s Centre, Stepping Hill 4192055/2050/2053


Hospital, Stockport, SK2 7JE 419 2102 Fax
libby.rous@nhs.net

ROWSELL, M CAMHS, 155-7 Manchester Road, Higher Ince, 01942 775400 Tel
Wigan, WN2 2JA 01942 775403 Fax
mary.rowsell@wwl.nhs.uk

SANZ, L Windmill House, 150 Whitegate Drive, Blackpool 01253 655380 Tel
(locum) FY3 9ES 01253 761432 Fax

SHORTALL, A Dept of Child Psychiatry, Carol Kendrick Centre, 902 3400 Tel
Strattus house, Wythenshawe, 902 3401 Fax
Manchester
Anne.Shortall@cmft.nhs.uk

SUBBIAN, S Child & Family Therapy Service, Springleigh, 303 4902 Tel
Waterloo Road, Stalybridge, SK15 2AU 303 1809 Fax

SUTTON, A Dept of Child & Family Psychiatry, 248 9494 Tel


Winnicott Centre, 195-7 Hathersage Road, 225 9338 Fax
Manchester, M13 0JE
Adrian.Sutton@cmft.nhs.uk

THEODOSIOU, L. Emerge 16-17 CMHT, Millenium Powerhouse 2267457 Tel


140 Raby Street, Moss Side, Manchester, 2260329 Fax
M14 4ST
louise.theodosiou@cmft.nhs.uk

TRUMPER, A, Dept of Child & Family Psychiatry, Booth Hall 918 5227 Tel
Children's Hospital, Charlestown Road, Blackley, 918 5165
Manchester, M9 7AA
Anne.Trumper@cmft.nhs.uk

WHITTAKER J. Dept of Child & Family Psychiatry, Booth Hall 918 5026 Tel
Children's Hospital, Charlestown Road, Blackley, 918 5165 Fax
Manchester, M9 7AA
Jane.F.Whittaker@cmft.nhs.uk

11.1.09

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