Child and Adolescent Mental Health

Question 1

Depression

Answer 1

Depression is a disorder that causes persistent feelings of low mood, low energy and reduced interest. It can affect people of all ages, including children and adolescents. It is often triggered by life events, although it can happen without any apparent triggers.

Question 2

Depression presentation

Answer 2

Typical symptoms of depression include:

Low mood
Anhedonia, a lack of pleasure in activities
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding social situations (e.g. school)
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms such as abdominal pain
There are key points that need to be considered in assessing children and adolescents with depression. Particular attention needs to be given to the psychosocial contributors. It is important to ask question in private as well as taking a history with parents or others present.

Potential triggers (e.g. loss of a family member)
Home environment
Family relationships
Relationship with friends
Sexual relationships
School situations and pressures
Bullying
Drugs and alcohol
History of self harm
Thoughts of self harm or suicide
Family history
Parental depression
Parental drug and alcohol use
History of abuse or neglect

Question 3

Managing depression

Answer 3

Mild depression or low mood associated with a single negative event (e.g. loss of a family member) can be managed with watchful waiting and advice about healthy habits, such as healthy diet, exercise and avoiding alcohol and cannabis. Follow up within 2 weeks is advised.

NICE recommend referral to CAMHS for children with moderate to severe depression. CAMHS can then initiate:

Full assessment to establish a diagnosis
Psychological therapy as the first line treatment with cognitive behavioural therapy, non-directive supportive therapy, interpersonal therapy and family therapy
Fluoxetine is the first line antidepressant in children, starting at 10mg and increasing to a maximum of 20mg
Sertraline and citalopram are second line antidepressants
When the child responds to medical treatment, it should continue 6 months after remission is achieved
When they do not respond to medical treatment they may require intensive psychological therapy
Where there is follow up monitoring in secondary care, the mood and feelings questionnaire (MFQ) may be used to assess progress.

Admission may be required where there is high risk of self harm, suicide or self-neglect or where there may be an immediate safeguarding issue.

Question 4

Generalised anxiety disorder

Answer 4

Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms are present on a daily basis for months at a time.

Question 5

Assessing GAD

Answer 5

The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis
Assess for co-morbid mental health problems, such as depression and obsessive compulsive disorder
Assess for environmental triggers and contributors, such as family relationships, friendships, bullies, school pressures, alcohol and drug use

Question 6

Managing anxiety

Answer 6

The GAD-7 anxiety questionnaire can help establish the severity of the diagnosis
Assess for co-morbid mental health problems, such as depression and obsessive compulsive disorder
Assess for environmental triggers and contributors, such as family relationships, friendships, bullies, school pressures, alcohol and drug use

Question 7

Obsessive compulsive disorder

Answer 7

Obsessive compulsive disorder (OCD) is characterised by obsessions and compulsions.

Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore. Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind.

Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done. Often these compulsions are a way for the person to handle the obsessions. For example, checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. This is a normal behaviour, but in OCD the person may check every plug in the house 10 times before being able to go to sleep or leave.

There is a cycle in OCD: The obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety.

The obsessions and compulsions are present on a daily basis and are not something the person will enjoy or do willingly. They impact on other areas of life, such as their social life or other interests.

Question 8

OCD associations

Answer 8

OCD is strongly related to other mental health issues:

Anxiety
Depression
Eating disorders
Autistic spectrum disorder
Phobias

Question 9

Managing OCD

Answer 9

Mild OCD may be managed with education and self help resources.

More significant OCD may require:

Referral to CAMHS
Patient and carer education
Cognitive behavioural therapy
SSRIs medications (under the guidance of a CAMHS specialist)

Question 10

Autism Spectrum Disorder

Answer 10

Autistic spectrum disorder refers to the full range of people affected by a deficit in social interaction, communication and flexible behaviour.

The classification of autistic spectrum disorder was introduced in the diagnostic and statistical manual of mental disorders fifth edition (DSM-5), introduced in 2013. This took previous diagnoses such as Aspergers syndrome and autistic disorder and grouped them into one spectrum disorder, suggesting that the same disorder was responsible for the features of the condition and those affected fall somewhere along the spectrum.

The autistic spectrum has a significant range. On one end patients have normal intelligence and ability to function in everyday life but displaying difficulties with reading emotions and responding to others. This was previously known as Asperger syndrome. On the other end, patients can be severely affected and unable to function in normal environments.

Question 11

ASD features

Answer 11

Features vary greatly between individuals along the autistic spectrum. They can be categorised as deficits in social interaction, communication and behaviour. Features are usually observable before the age of 3 years.

Social Interaction

Lack of eye contact
Delay in smiling
Avoids physical contact
Unable to read non-verbal cues
Difficulty establishing friendships
Not displaying a desire to share attention (i.e. not playing with others)
Communication

Delay, absence or regression in language development
Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
Difficulty with imaginative or imitative behaviour
Repetitive use of words or phrases
Behaviour

Greater interest in objects, numbers or patterns than people
Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking.
Intensive and deep interests that are persistent and rigid
Repetitive behaviour and fixed routines
Anxiety and distress with experiences outside their normal routine
Extremely restricted food preferences

Question 12

Diagnosing ASD

Answer 12

Diagnosis should be made by a specialist in autism. This may be a paediatric psychiatrist or paediatrician with an interest in development and behaviour. A diagnosis can be made before the age of 3 years. It involves a detailed history and assessment of the child’s behaviour and communication.

Question 13

Managing ASD

Answer 13

Autism cannot be cured. Management depends on the severity of the child’s condition. Management involves a multidisciplinary team to provide the best environment and support for the child and parent:

Child psychology and child and adolescent psychiatry (CAMHS)
Speech and language specialists
Dietician
Paediatrician
Social workers
Specially trained educators and special school environments
Charities such as the national autistic society

Question 14

Attention deficit hyperactivity disorder

Answer 14

Attention deficit hyperactivity disorder (ADHD) is at the extreme end of “hyperactivity” and inability to concentrate (“attention deficit“). It affects the person’s ability to carry out everyday tasks, develop normal skills and perform well in school.

Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.

Question 15

Features of ADHD

Answer 15

All the features of ADHD can be part of a normal spectrum of childhood behaviour. When many of these features are present and it is adversely affecting the child, ADHD can be considered:

Very short attention span
Quickly moving from one activity to another
Quickly losing interest in a task and not being able to persist with challenging tasks
Constantly moving or fidgeting
Impulsive behaviour
Disruptive or rule breaking

Question 16

Managing ADHD

Answer 16

A detailed assessment should be carried out by a specialist in childhood behavioural problems before a diagnosis is made. Management should be coordinated by a specialist in ADHD. Parental and child education is essential. This includes education about parental strategies to manage the child.

Establishing a healthy diet and exercise can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician

Medication is an option after conservative management has failed or in severe cases. This should be coordinated by a specialist. Contrary to what you might think, they are central nervous system stimulants. Examples are:

Methylphenidate (“Ritalin“)
Dexamfetamine
Atomoxetine

Question 17

Eating disorders

Answer 17

Eating disorders stem from an unhealthy and distorted obsession with body image and food. There is a strong correlation with personality disorders, obsessive compulsive disorder, anxiety and other mental health disorders. Eating disorders are more common in girls. There seems to be a genetic component to the condition.

Question 18

Anorexia Nervosa

Answer 18

In patients with anorexia nervosa, the person feel they are overweight despite evidence of normal or low body weight. It involves obsessively restricting calorie intake with the intention of losing weight. Often the person exercises excessively and may use diet pills or laxatives to restrict absorption of food.

Features of anorexia nervosa:

Excessive weight loss
Amenorrhoea
Lanugo hair is fine, soft hair across most of the body
Hypokalaemia
Hypotension
Hypothermia
Changes in mood, anxiety and depression
Solitude
Cardiac complications include arrhythmia, cardiac atrophy and sudden cardiac death.

Question 19

Bulimia Nervosa

Answer 19

Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by “purging” by inducing vomiting or taking laxatives to prevent the calories being absorbed.

Features of bulimia nervosa:

Alkalosis, due to vomiting hydrochloric acid from the stomach
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux and irritation
Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
TOM TIP: There are some unique examination findings with patients that have bulimia, which makes it a popular spot diagnosis in exams. Look out for the teenage girl with a normal body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.

Question 20

Binge Eating Disorder

Answer 20

Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.

Binges may involve:

A planned binge involving “binge foods”
Eating very quickly
Unrelated to whether they are hungry or not
Becoming uncomfortably full
Eating in a “dazed state”

Question 21

Managing eating disorders

Answer 21

Patient and carer education is key to the condition. Management is centred around changing behaviour and addressing environmental factors:

Self help resources
Counselling
Cognitive behavioural therapy (CBT)
Addressing other areas of life, such as relationships and past experiences
Severe cases may require admission for observed refeeding and monitoring for refeeding syndrome.

SSRI medication may be used by a specialist in child and adolescent mental health.

Question 22

Refeeding Syndrome

Answer 22

Refeeding syndrome occurs in people that have been in a severe nutritional deficit for an extended period, when they start to eat again. Patients are at higher risk if they have a BMI below 20 and have had little to eat for the past 5 days. The lower the BMI and the longer the period of malnutrition, the higher the risk.

Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition. As the starved cells start to process glucose, protein and fats again they use up magnesium, potassium and phosphorus. This leads to:

Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload.

Question 23

Managing refeeding syndrome

Answer 23

Management will be according to the local protocol under specialist supervision:

Slowly reintroducing food with restricted calories
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balance monitoring
ECG monitoring may be required in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

Question 24

Personality Disorders

Answer 24

Personality disorder (PD) is an umbrella term that covers a number of variations of maladaptive personality traits that cause significant psychosocial distress and interfere with everyday functioning. It is characterised by patterns of thought, behaviour and emotions that differ from what is normally expected by society. It leads to difficult relationships, reduced quality of life and poor physical health.

Personality disorders are thought to result from a combination of genetic and environmental factors. Patients often have a history of early childhood trauma and difficult circumstances.

Question 25

Presentation of personality disorders

Answer 25

There are a wide range of symptoms and behaviours that can occur with personality disorders. Patients will vary in the symptoms they have. Symptoms can include:

Strong, intense emotions
Emotional instability
Anger
Low self esteem
Impulsive behaviour
Substance abuse
Poor sense of identity
Difficulty maintaining relationships
Risky behaviour, such as risky sex
Violence and aggression
Self harm
Suicide attempts

Question 26

Types of personality disorders

Answer 26

There are many different types of personality disorder. The classification is based on the dominant features. They fall under three main categories:

Anxious
Suspicious
Emotional or impulsive

Question 27

Anxious Personality Disorders

Answer 27

Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.

Dependent personality disorder features heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.

Obsessive compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen if these expectations are not met.

Question 28

Suspicious Personality Disorders

Answer 28

Paranoid personality disorder features difficulty in trusting or revealing personal information to others.

Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.

Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.

Question 29

Emotional / Impulsive Personality Disorders

Answer 29

Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.

Histrionic personality disorder features the need to be at the centre of attention and having to perform for others to maintain that attention.

Narcissistic personality disorder features feelings that they are special and need others to recognise this or else they get upset. They put themselves first.

Question 30

Managing personality disorders

Answer 30

Management of personality disorders can be difficult. The patterns of thinking and behaviours are deeply ingrained and are difficult to change. Patient and carer education is very important to help them understand the condition. Cognitive behavioural therapy (CBT) and psychotherapy is the key management option of choice. Supportive care can be provided during crises to help keep the patient safe.

There are no medical treatments recommended for personality disorders. Personality disorders can co-exist with other psychiatric problems (e.g. depression) where medications may be beneficial.

Question 31

Tourette’s and Tics

Answer 31

Tourette’s syndrome is characterised by the development of tics that are persistent for over a year. Tics are involuntary movements or sounds that the child performs repetitively throughout the day. These tics become more prominent when the person is under pressure or excited. The person may describe an overwhelming urge to perform the tic. This urge increases the more they suppress it. They feel they need to complete the tic, often several times, to get relief from that urge. These feelings are called premonitory sensations.

Tics often present around or after 5 years of age. They can be associated with OCD and ADHD.

Examples of Simple Tics

Clearing throat
Blinking
Head jerking
Sniffing
Grunting
Eye rolling

Examples of Complex Tics

Performing physical movements, such as twirling on the spot or touching objects
Copropraxia involves making obscene gestures
Coprolalia involves saying obscene words
Echolalia involves repeating other people’s words

Question 32

Managing Tourette’s and Tics

Answer 32

Usually tics will improve over time. Mild cases with no signs of underlying disease may only require reassurance and monitoring. Taking measures to reduce stress, anxiety and triggers can be helpful.

More severe or troublesome tics should be referred to a specialist. They may benefit from:

Habit reversal training
Exposure with response prevention
Medications may be tried in very severe cases, usually with antipsychotic medications
Co-morbid conditions such as OCD and ADHD may benefit from treatment.