04/22/23Dr Andrew Mowat1

Child & Adolescent Child & Adolescent Psychiatry in Primary Psychiatry in Primary CareCare

A symptom-based overview

04/22/23Dr Andrew Mowat2

Epidemiology of Mental Epidemiology of Mental HealthHealthSettingSetting PrevalencePrevalence

per1000 patients/yrper1000 patients/yr1st Filter: Community“The decision to consult”

260-315

2nd Filter: Primary Care“GP recognition”

230

3rd Filter: Conspicuous morbidity“The decision to refer”

101.5

4th Filter: Mental Illness Services“Admission to Psychiatric beds”

20.8

5th Filter: Psychiatric Inpatients 3.8-6.7

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SymptomatologySymptomatology4 patternsConduct DisorderEmotional DisorderRelationship DisorderDevelopmental Disorderplus specific illnesses which occupy one or more of plus specific illnesses which occupy one or more of

these domainsthese domains

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Conduct DisorderConduct Disorder

““Disorders characterised by a Disorders characterised by a repetitive and persistent pattern repetitive and persistent pattern of dissocial, aggressive or defiant of dissocial, aggressive or defiant conduct”conduct”

ICD-10

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Conduct DisorderConduct DisorderOften confined to familyMay be:

– unsocialised (abnormal relationship with others)– socialised (normal relationships e.g. with peers)

Oppositional defiantCommonly mixed with Emotional Disorder

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Conduct DisorderConduct Disorder

Management

Family Therapy

Social Support

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Emotional DisorderEmotional DisorderDepression

– 10% of 10-yr-olds “miserable” (parents report)– 40% of 14-yr-olds “miserable” (self-report)

AnxietyMania

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DepressionDepressionChildhood: boys = girlsAdolescence: boys << girlsManagement

– Drug Rx?– Therapy:

FamilyCognitive (individual)School liaison

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AnxietyAnxietySeparationPhobicGeneralised

School Refusal

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Phobias and all that….Phobias and all that….

Agoraphobia F40.0Social phobias F40.1Simple phobia F40.2 Obsessive-Compulsive Disorder F42Panic Disorder F41.0PTSD F43.1

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OCDOCDObsessive Compulsive Disorder

– intrusive, repetitive thoughts– anxiety-provoking– ?abnormal 5HT transmission

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ManiaManiaVery rareCommonly misdiagnosed:

– hyperkinetic disorder (childhood) – schizophrenia (adolescence)

First Rank symptoms may be prominent

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Relationship DisorderRelationship DisorderSibling rivalryElective mutismAttachment Disorders

– Reactive– Disinhibited

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Developmental DisorderDevelopmental DisorderPervasive Developmental disordersChildhood AutismRett’s SyndromeAsperger’s Syndrome

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AutismAutismGenetically-influencedNeurodevelopmental impairmentonset before 3 yearsAtypical variants

– later onset– limited effect

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AutismAutism 3 Domains

Communication

Social interaction

Repetitive behaviour

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Asperger’s SyndromeAsperger’s SyndromeProblem areas

– Social interaction– Restricted/Stereotyped interests

Differs from Autism– Normal cognitive & language development

Clumsiness– & tends to lead to depression later

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Hyperkinetic Disorders (ADHD)Hyperkinetic Disorders (ADHD)Neurodevelopmental causeEarly onsetBoys > GirlsShow lack of persistence in activities

requiring attentionMove from one activity to another without

completing

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Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

Common Presentations– accident prone– socially-dissociated relationships with adults– aggressive– disciplinary problems

Associations– below-average intelligence or mild handicap– epilepsy– minor motor difficulties

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ADHDADHDManagementBehaviour modificationCerebral stimulants:

– Methylphenidate (Ritalin)– Tranylcypromine

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RitalinRitalinAmphetamine CNS stimulantMust be used under Specialist supervisionMust be periodically withdrawn to verify

still workingControlled (Sched 2 MDA) drugADR: weight loss etc

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Substance MisuseSubstance Misuse

Glue/Solvents

Tobacco

Alcohol

Drug

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Eating DisordersEating Disorders

Anorexia Nervosa F50.0“Deliberate weight loss resulting in a

bodyweight more than 15% below the norm”

Bulimia Nervosa F50.2“Repeated bouts of overeating and an excessive preoccupation with the control of bodyweight”

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Anorexia NervosaAnorexia NervosaWeight reduced by:

– avoidance of food– overactivity– excessive exercise– appetite suppressants– laxatives/diuretics

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Anorexia Nervosa: complicationsAnorexia Nervosa: complications

Cardiovascular hypotension, arrhythmias

Metabolic hypothermia, hypoglycaemia

Gastrointestinal constipation/diarrhoea, pancreatitis

Renal calculi, renal failure

Haematological anaemia, pancytopenia

Endocrine ↓ LH/FSH (♀) ↓ Testosterone (♂) ↑ GH/cortisol (both)

Skeletal osteoporosis, bone maturation

Neurological seizures, sleep disturbance

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Anorexia Nervosa: managementAnorexia Nervosa: management

Aim to restore healthy weight and dietGradual work towards patient accepting

need & responsibility for healthy weightHospital admission?Behavioural therapy

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Bulimia NervosaBulimia NervosaDiffers from Anorexia

Binge Eating Purging

– vomiting– laxatives, diuretics

Prevalence 0.5-1%, peak age in 20’s

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Bulimia NervosaBulimia NervosaPhysical features:

– salivary gland enlargement– erosion of dental enamel– calluses dorsum of hand (Russell’s sign)– metabolic disturbances

Management:– Behavioural therapy– ?SSRI

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Other specific disordersOther specific disorders

Obsessive Compulsive Disorder F42Sleep DisordersTrichotillomaniaTicEnuresisEncopresis

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Sleep DisordersSleep Disorders Sleepwalking

– first ⅓ of sleep– low levels of awareness, reactivity, recall

Sleep (Night) Terrors– first ⅓ of sleep– terror, vocalisation, motility– limited recall

Nightmares Hypersomnia

04/22/23Dr Andrew Mowat31

Tic disordersTic disordersInvoluntary rapid, recurrent, non-rhythmic

motor movements or vocal productionGilles de la Tourette’s Syndrome

– multiple tics facial, limb

– compulsive utterancescoprolalia

Treatment

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EnuresisEnuresisWhat is normal?

What investigations?

What therapy– Behavioural– Drug

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SummarySummary

Most Childhood Mental Health problems are disorders of conduct or emotion

Many represent wider problems within the family

Family Therapy or Cognitive Behavioural Therapy more often successful, but take a great deal more time, than drug therapy