Child and Adolescent Mental Health prof. Elham Aljammas 19/3/2014

Adolescence Adolescence: transitional period between childhood and adulthood (11-22) Adolescents tend to develop these skills in areas of knowledge depth, but not in all subject areas )

Common presentations to GPs Attention Deficit Hyperactivity Disorder (ADHD) Autistic Spectrum Disorders Conduct disorders Depression Anxiety Obsessional-Compulsive Disorder (OCD) Eating Disorders Tic Disorders (inc Tourettes’s syndrome)

Predisposing risk factors Family factors including marital discord substance misuse criminal activities abusive or injurious parenting practices Individual factors including ‘difficult’ temperament brain damage epilepsy chronic illness cognitive deficits Environmental factors including social disadvantage homelessness low socioeconomic status poverty overcrowding social isolation There are a number of risk factors that can predispose children to conduct disorders. These factors can be associated with the family, the children themselves or be environmental.

Etiology

Attention Deficit Hyperactivity Disorder (ADHD) ADHD is a pervasive, heterogeneous behavioural syndrome characterised by the core symptoms of inattention, hyperactivity and impulsivity.

ADHD Methylphenidate, atomoxetine and dexamfetamine are recommended, within their licensed indications, as options for the management of ADHD.

Autistic Spectrum Disorder An intrinsic condition, ASD manifests core features which are pervasive and include deficits in: - Social communication - Social interaction - Social imagination Current prevalence of all ASD diagnoses: 1.6% Children with an ASD have a higher risk than peers of developing other mental health problems.

CONDUCT DISORDERS Conduct disorders are the most common reason for referral of children to mental health services They have a significant impact on quality of life for those involved, and, in the case of early onset (aggression at three years of age) outcomes for children are poor Many children do not receive support because of limited resources, high prevalence and difficulty engaging some families Early effective intervention is particularly important: recent research has established a neuro-developmental basis for this finding Refer to the full guidance, page 4 Quality of life Conduct disorders have a significant and detrimental impact on both the child and their family or carer(s). Children with conduct disorders are at high risk of experiencing future disadvantage through social exclusion, poor school achievement, long-term unemployment, juvenile delinquency and crime. They are also at high risk of having poor interpersonal relationships, leading to family break-up in adulthood, divorce and abuse of their own children Early effective treatment More than 60% of 3-year-olds with conduct disorders still exhibit problems at the age of 8 years if left untreated, and many problems will persist into adolescence and adulthood. Approximately half of the children diagnosed with conduct disorders receive a diagnosis of antisocial personality disorders as adults, with others being diagnosed with psychiatric disturbances, including substance misuse, mania, schizophrenia, obsessive-compulsive disorder, major depressive disorder, and panic disorder. This reinforces the importance of early treatment.

Conduct disorder and ODD Conduct disorder: repetitive and persistent pattern of antisocial, aggressive or defiant conduct and violation of social norms Oppositional defiant disorder: persistently hostile or defiant behaviour without aggressive or antisocial behaviour Oppositional defiant disorder, may be a precursor of conduct disorder. A child is diagnosed with oppositional defiant disorder when he or she shows signs of being hostile and defiant for at least 6 months. Oppositional defiant disorder may start as early as the preschool years, while conduct disorder generally appears when children are older. Oppositional defiant disorder and conduct disorder are not co-occurring conditions.

Associated conditions Conduct disorders are often seen in association with: attention deficit hyperactivity disorder (ADHD) depression learning disabilities (particularly dyslexia) substance misuse less frequently, psychosis and autism

Depression At any one time, the estimated number of children and young people suffering from depression: 1 in 100 children 1 in 33 young people Prevalence figures exceed treatment numbers: about 25% of children and young people with depression detected and treated Suicide is the: 3rd leading cause of death in 15–24-year-olds 6th leading cause of death in 5–14-year-olds Transition to Adult services, where appropriate, requires careful planning

Depression KEY SYMPTOMS ASSOCIATED SYMPTOMS persistent sadness, or low or irritable mood: AND/OR loss of interests and/or pleasure fatigue or low energy poor or increased sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame Mild Up to 4 symptoms Moderate 5-6 symptoms Severe 7-10 symptoms

Depression Anti-depressants should only be prescribed following assessment by a psychiatrist and only be offered in combination with psychological treatments First-line pharmacological treatment is fluoxetine* Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, Monitor for agitation, hostility, suicidal ideation and self-harm and advise urgent contact with prescribing doctor if detected Sertraline or citalopram* as second-line treatment Consider adding atypical antipsychotic if psychotic depression Continue for 6 months following remission, then phase out over 6–12 weeks

Anxiety Type of anxiety experienced by the child (social, generalised, panic, separation, specific phobia) and degree of impairment to functioning is important to detail in referral Cognitive Behavioural Therapy (CBT) and other behavioural approaches indicated for most anxiety disorders.

Obsessional-Compulsive disorder (OCD) Obsessive-compulsive disorder (OCD): characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress 1% of young people are affected – adults often report experiencing first symptoms in childhood Onset can be at any age. Mean age is late adolescence for men, early twenties for women

Obsessional-Compulsive disorder (OCD) All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology If CBT ineffective or refused - review and consider adding an SSRI Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD* Monitor carefully and frequently If successful, continue for 6 months post remission Withdraw slowly with monitoring

Anorexia nervosa Severe dietary restriction despite very low weight (BMI <17.5 kg/m2) Morbid fear of fatness Distorted body image (that is, an unreasonable belief that one is overweight) Amenorrhoea A proportion of patients binge and purge

Bulimia nervosa Characterised by an irresistible urge to overeat, followed by self-induced vomiting or purging and accompanied by a morbid fear of becoming fat. Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed. Selective serotonin reuptake inhibitors (SSRIs) and specifically fluoxetine, are the drugs of first choice for the treatment of bulimia nervosa.The effective dose of fluoxetine is higher than for depression (60 mg daily).

Tic Disorders (including Tourettes’s Syndrome) Presentation: Tics are involuntary, rapid, recurrent, non-rhythmic motor movements. Transient tic problems are very common in childhood, more common in boys, and a family history of tics is common.. Tourette’s syndrome is a constellation of multiple motor and vocal tics originating in childhood/adolescence and often persisting into adulthood.

Tic Disorders (including Tourettes’s Syndrome) Management: Psycho-social approaches Pharmocological approaches: - Haloperidol - Risperidone - Pimozide - Clonidine

Thank you ANY FURTHER QUESTIONS?

ANY FURTHER QUESTIONS?