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

2. 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 )

3. 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)

4. 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.

5. Etiology

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

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

8. 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.

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. 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

19. 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).

20. 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.

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

22. Thank you
ANY FURTHER
QUESTIONS?

23. ANY FURTHER
QUESTIONS?