 \200 Simple phobias Essence Excessive fear of an object or situation with distress and phobic av oidance. There may be anticipatory anxiety and exposure can precipi- tate a panic attack. Etiology Probable interaction of genetic in \202 uence, inhibited tempera- ment, parental in \202 uence and speci \201 c conditioning. Epidemiology Very common (10% in some studie s); 5:4 = 2:1. Comorbidity Depression; substance abuse. Subtypes Animal phobias; natural environment phobias (especially 5 \200\22310- yr-olds); bl ood/infection/injury phobias; situational phobias (e.g. lifts, closed spaces); other. 16_Semple_Chap16.indd 644 12/7/2012 3:49:03 PM SOCIAL PHOBIA, SIMPLE PHOBIAS, AND SELECTIVE MUTISM 645 Management \200 \200 Involve family and, if appropriate, others, e.g. teacher. CBT including desensitization, mo deling, contingency management, relaxation training, self-statements. Selective mutism (SM) Essence A consistent failure to speak in social situations in which t here is an expectation for speaking (e.g. at school) despite speaking in other situations. It has been considered both as an anxiety and an oppositional disorder. Epidemiology Rare, affecting 3 \200\2238/10 000 in the UK, unlike extreme shyness which is common in the \201 rst year at school. Slightly commoner in girls. Comorbidity Many children who develop SM have premorbid speech and language problems. Comor bidity with developmental delay/disorder, communication disorder, elimination disorders, an d anxiety disorders observed. Management Dif \201 cult to treat. There is a small evidence base for the use of behaviora l therapy, CBT, SSRIs, and individual psychotherapy. Involve family and school in treatment . 16_Semple_Chap16.indd 645 12/7/2012 3:49:03 PM CHAPTER 16 Child and adolescent psychiatry 646 Post-traumatic stress disorder1,2 Essence A syndrome characterized by a triad of symptoms: intrusive re-experiencing of a traumatic event; avoidance; and hyperarousal. Recognized in children since the 1980s. Symptoms variable in young children, but similar to adult pattern in older children (see b p. 390). Traumatic event Requires exposure to a situation or even t which is catastrophic or highly threatening. Epidemiology Prevalence varies according to age, but develops in approximately 3 \200\2236% of children exposed to a trauma. Most expos ed do not develop the disorder and those that are affected usually have a pre- existing vul nerability (i.e. \200\230an unnatural response to an unnatural event \200\231). Clinical presentation in young children Identi \201 cation of PTSD in children presents pa rticular problems, but can be improved by asking the child directly about their experiences . Do not rely solely on caregiver \200\231s history. Scheeringa criteria:3 Compulsive repetitive play representing part of the trauma and failin g to relieve anxiety. Recurrent recollections of the event. Nightmares, night terrors, and dif \201 culty going to sleep. Constriction of play. Social withdrawal. Restricted affect. Loss of acquired developmental skills, especially language regression and toilet training. Decreased concentration and attention. New aggression. New separation anxiety. \200 \200 \200 \200 \200 \200 \200 Depression is common in older children and adolescents. Note that post-traumatic stress symptoms which do not meet criteria for a diagnosis can sti ll be highly disabling and deserve attention in their own right. Comorbidity Common in PTSD with depression, anxiety disorders, and substance abuse frequent in adolescents. Behaviora l disorders common in young children. See Box 16.2 for NICE guidelines on treatment of PTSD . 16_Semple_Chap16.indd 646 12/7/2012 3:49:04 PM POST-TRAUMATIC STRESS DISORDER 647 Box 16.2 NICE guidance on treatment of PTSD in chil- dren and adolescents1 Interventions in the \201 rst month after a trauma Offer trauma-focused CBT to older chil dren with severe post-traumatic symptoms or with severe PTSD in the \201 rst month after the event. Interventions more than 3mths after a trauma \200 Offer children and young people a course of trauma-focused CBT adapted as needed to suit th eir age, circumstances, and level of development. (This should also be offered to those who have experienced sexual abuse.) For chronic PTSD in children and young people resulting fr om a single event, consider offering 8 \200\22312 sessions of trauma-focused psychological treatment. When the trauma is discussed, longer treatment sessions (90min) are usually nece ssary. Psychological treatment should be regular and continuous (usually at least once a we ek) and delivered by the same person. Do not routinely prescribe drug treatments for childr en and young people with PTSD. Involve families in the treatment of children and young peop le where appropriate, but remember that treatment consisting of parental involvement alone is unlikely to be of bene \201 t for PTSD symptoms. Inform parents (and where appropriate, children and young people) that apart from trauma-focused psychological interventions, the re is no good evidence for the ef \201 cacy of other forms of treatment, such as play ther apy, art therapy, or family therapy. 1 M http://publications.nice.org.uk/post-traumatic-stress-disorder-ptsd-cg26 1 Perrins S, Smith P, and Yule W (2000) The assessment and treatment of post-traumatic stre ss disorder in children and adolescents. J Child Psychol Psychiat 41: 277 \200\22389. 2 Yul e W (2001) Posttraumatic stress disorder in the general population and in children. J Clin Psychiat 63(Suppl. 17): 23 \200\2238. 3 Scheeringa MS and Gaensbauer TJ (2000) Post-traumat ic stress disorder. In Zeanah CH (ed), Handbook of infant health, pp. 369 \200\22381. New Y ork: Guilford Press. 16_Semple_Chap16.indd 647 12/7/2012 3:49:04 PM CHAPTER 16 Child and adolescent psychiatry 648 Obsessive \200\223compulsive disorder (OCD) Essence (see b p. 376) OCD is characterized by recurrent obsessions and/or compulsions that cause impairment in terms of time (>1hr/day), distress, or interference in functioning. Epidemiology Prevalence in adolescents 1 \200\223 3.6%. May occur as early as 5yrs of age and mean age of onset is 10yrs. Male predominance ( 3:2) in childhood, with equal gender distribution in adolescence. Mild subclinical obsessio ns and compulsions are common in the general population (4 \200\22319%) and disorder merges with normality. This is a persistent disorder which is often veiled in secrecy \200\224mea n delay to presentation is 2yrs. Etiology Genetic and non-genetic factors probably equally important. Only 15% have clearly identi \201 able precipitating factor. Clinical features \200 Obsessions: Common themes: contamination, harm coming to others, sexual, aggressive, religi ous. Compulsions: Common rituals include washing, checking, repeating, ordering, reassuranc e seeking. Rituals may involve parents and are part of normal development, especially in 3 \200\2237-yr age group. More likely to be OCD if the rituals or thoughts distress the child , they take up a lot of time and if they interfere with the child \200\231s everyday life. Multiple obsessions and compulsions common. Poor insight commoner in child cases. intrusive, repetitive, and distressing thoughts or images. repetitive, stereotyped, unnecessary behaviors. \200 Differential diagnosis Normal developmental rituals; Tourette \200\231s/tic disorder; depre ssion; ASD; eating disorder; psychosis. Comorbidity 70% have at least one comorbid disorder . Includes other anxiety disorders, ADHD, ODD, Tourette \200\231s syndrome, autistic spectr um disorders and mood disorders. Assessment \200 \200 Family and individual assessment where possible. Young person may be reluctant to discuss a spects of obsessions/ compulsions. Children \200\231s Yale \200\223Brown Obsessive Compulsi ve Scale may be useful both as rating scale and to obtain clear picture of obsession/ compu lsion. Screen for comorbidity. 16_Semple_Chap16.indd 648 12/7/2012 3:49:04 PM OBSESSIVE \200\223COMPULSIVE DISORDER 649 Treatment \200 \200 Consider guided self-help for mild impairment in \201 rst instance. If more severely affe cted, offer developmentally appropriate CBT and ERP (exposure response prevention) in group or individual format. Involve family where possible in planning and process of treatment, and school, etc., as necessary. Following multidisciplinary review, consider SSRI in additi on to CBT and ERP if no response. Monitor closely and advise of delay in onset of action of up to 12wks. After remission continue medication for 6mths then gradually withdraw. If SSR I fails, consider change to different SSRI/clomipramine. Need ECG prior to clomipramine tre atment. In specialist settings, augmentation with antipsychotic may be appropriate. Conside r inpatient care in most severe cases associated with major impairment and distress unrespo nsive to outpatient care. Also where there is signi \201 cant self-neglect or suicide risk . Absence of comorbidity and good insight increase chances of successful outcome. PANDAS1 (pediatric autoimmune neurological disorder associated with streptococcus) An autoi mmune syndrome associated with OCD and/or tic disorder, with pre-pubertal onset, characteri zed by episodic exacerbations of symptoms in association with evidence of Group A beta haem olytic streptococcal infection. 1 Swedo SE, Leonard HL, Garvey M, et al. (1998) Pediatric autoimmune neuropsychiatric disor ders associated with streptococcal infections: clinical description of the \201 rst 50 ca ses. Am J Psychol 55: 264 \200\22371. 16_Semple_Chap16.indd 649 12/7/2012 3:49:04 PM CHAPTER 16 Child and adolescent psychiatry 650 Eating disorders Eating disorders in children and adolescents include anorexia nervosa, bul imia nervosa, and their variants characterized by disturbed or inade- quate eating patterns associated with abnormal preoccupation with weight and shape. Many children present with c linically signi \201 cant disorder which does not \201 t diagnostic criteria. Children a nd adolescents may also present with other types of clinical eating disturbance, including: \200 Food avoidance emotional disorder: unaccounted for by other psychiatric disorder and in the absence of abnormal cognitions about weight/shape. They know that they are underweight, wo uld like to be heavier, and may not know why they \201 nd this dif \201 cult to achieve. Often have other medically unexplained symptoms. Can result in serious weight loss. Select ive eating characterized by long-standing restriction of types of food eaten: rarely harmfu l but can result in social dif \201 culties. Pervasive refusal: refusal to eat, walk, talk or engage in self-care \200\2311. Likely to require prolonged inpatient treatment. Eating disturbance may also be a feature of other disorders, e.g. depression, OCD; or part of a ph ysical disorder where there is a psychological component to presentation. food avoidance and weight loss a rare disorder de \201 ned as \200\230a profound and pervasive Anorexia nervosa (AN) Essence Self-induced weight loss associated with abnormal beliefs and preoccupation regarding weight and/or shape. ICD-10 and DSM-IV criteria are used (b p. 398 ), but the \200\230weight criterion \200\231 of BMI <17.5 is problematic in children and a dolescents who are still developing. A suggested alteration by the Royal College of Psychia trists Eating Disorders Special Interest Group is BMI below the 2nd centile. Epidemiology P revalence 0.3% in adolescent females. Lower rates in boys and pre-pubertally. Assessment \200 \200 \200 Family and individual \200\224often secrecy around behavior. Eating \200\224intake, weight control measures, attitude to weight/shape. Assessment of factors contributing to and maint aining disorder, e.g. acute life stress, obesity, parental weight concerns, peers, psycholo gical factors such as perfectionism and personal ineffectiveness. Comorbidity and risk. Ful l physical assessment and investigations as appropriate, e.g. bloods, ECG, bone density, ov arian ultrasound scan (USS). Motivation to change. \200 16_Semple_Chap16.indd 650 12/7/2012 3:49:04 PM EATING DISORDERS 651 Management Involves physical, psychological, educational, and social aspects and will usual ly require a multidisciplinary approach. \200 Treatment should normally involve whole family and the effects of AN on other family member s should be recognized. Restoration of healthy weight allowing further growth and developme nt, and treatment of physical complications. Provide education on nutrition and healthy eat ing. Carers should be included in any dietary education or meal planning. Patients should b e offered family interventions that directly address the eating disorder, and also individu al sessions to provide support, improve motivation, and address core maladaptive thoughts, attitudes, and feelings. Treat comorbidity. Note psychological symptoms often improve with weight gain. The balance of responsibility for treatment between parents and young people w ill vary according to the age of the young person. Nevertheless, where young people refuse necessary treatment, parental right to override this must be considered, as well as use of Mental Health Act legislation. Where the young person is at serious risk, e.g. through phys ical compromise or suicidality, or is not progressing in outpatient treatment, specialist i npatient or day patient care in age-appropriate settings should be considered. Liaison with school, e.g. graded return if has been absent. Relapse prevention. \200 Bulimia nervosa Essence Disorder characterized by recurrent binges and purges, sense of lac k of control and morbid preoccupation with weight and shape. Rarely occurs pre-pubertally, much commoner in girls, often comorbid with depression. Usually of normal weight. Managemen t \200 Work with family to establish clear structures and boundaries. Strike a balance between ind ividual work and family work. Adolescents with bulimia nervosa may be treated with CBT adap ted as needed to suit their age, circumstances and level of development, and including the family as appropriate. Address physical health concerns, e.g. due to frequent vomiting. No clear evidence to support drug treatments in this age group, but \202 uoxetine could be a useful adjunct in older adolescents. \200 1 Lask B, Britten C, Kroll L, et al. (1991) Children with pervasive refusal. Arch Dis Child 66: 866 \200\2239. 16_Semple_Chap16.indd 651 12/7/2012 3:49:04 PM CHAPTER 16 Child and adolescent psychiatry 652 Depression in children and adolescents Epidemiology 12-mth point prevalence 1% pre-pubertal , 3% post-pubertal. No sex difference pre-pubertal, commoner in females thereafter. Risk factors include Female, post-pubertal, parental history of depres- sion, personally un desirable life events resulting in permanent change of interpersonal relationships in frien ds or family, past history of depressive symptoms, high trait levels of neuroticism or emot ionality, ruminative style of thinking. Etiology Stress-vulnerability model useful in understanding development of depression. Vuln erability (genes, endocrine, early family factors) inter- acts with social stressors (pover ty, family discord, etc.) to provoke depres- sion at time of life stress. Clinical features \200 Mood changes: but as \200\230grumpy \200\231, \200\230irritable \200\231, or \200\230down \200\231; also anhedonia. Thought changes: reduced self-esteem, con \201 dence, concentration, and self-ef \201 cacy. Hopelessness, guilt, indecisiveness . Suicidal thoughts must be taken seriously. Rarely psychotic symptoms. Physical/behavioral changes: Fatigue, apathy, withdrawal, appetite and sleep change, aches and pains, self-har ming and suicidal behavior. Results in impairment of functioning \200\224school, social, fa mily, etc. unpleasant mood \200\224may not be described as sadness reduced energy, motivation, self-care. Course \200 Recovery: shortens duration of illness. 30% recurrence within 5yrs. 3% risk of suicide over next 10yrs. Chronic/recurrent illness signi \201 cantly impairing in all aspects of life. 20% will later manifest bipolar disorder. 10% at 3mths, 50% at 1yr, 70 \200\22380% at 2yrs. Treatment Comorbidity 50 \200\22380% meet criteria for additional non-depressive disorder including c onduct disorder/ODD, separation anxiety, OCD, ADHD, eating disorder, other anxiety disorder s. Differential Medical conditions; substance misuse; adjustment disorders; other psychiatr ic disorders. Assessment \200 Family and individual interviews. Assess whether depression is present, contributing factor s to development and maintenance, presence of comorbidity, suicide risk. Collateral from te achers, GP, social services, etc. Consider use of rating scales, e.g. Moods and Feelings Qu estionnaire. Physical examination and laboratory investigations as indicated. \200 \200 16_Semple_Chap16.indd 652 12/7/2012 3:49:04 PM DEPRESSION IN CHILDREN AND ADOLESCENTS 653 Treatment (NICE) Mild depression \200\224usually at Tier 1 or 2 \200 \200 Up to 4wks of \200\230watchful waiting \200\231 \200\224stay in contact with family. If sy mptoms continue offer 2 \200\2233mths of individual non-directive supportive therapy, group cognitive behavioral therapy (CBT), or guided self-help (GSH). If unresponsive refer for T ier 2/3 review and treat as for moderate \200\223severe. Moderate \200\223severe depression \200\224Tier 2 \200\2234 \200 Offer individual CBT, interpersonal therapy, or family therapy for at least 3mths as a \201 rst-line treatment. If unresponsive after 4 \200\2236 sessions multidisciplinary revie w and consider alternative/additional psychological therapy and pharmacotherapy. If unrespo nsive after further 6 sessions, comprehensive multidisciplinary review and consider alterna tive psychotherapy including child psychotherapy. Consider inpatient treatment if child/you ng person is at high risk of suicide, serious self-harm and self-neglect, or when required intensity of treatment (or supervision) is not available elsewhere, or for intensive assess ment. Pharmacotherapy/ECT Ensure that full discussion of rationale, delayed onset of action, time course and need to take regularly along with risks/bene \201 ts of drug takes place with family, and provide written information. Monitor for side-effects and bene \201 ts. There is limited evidence that all SSRIs/atypical antidepres- sants (including \202 uoxetine) m ay increase the risk of suicidal ideation and/ or behavior and increase the risk of discont inuation of treatment because of adverse events. Fluoxetine is the only antidepressant with a favor- able risk:bene \201 t ratio and should be prescribed \201 rst. Start at 10mg d aily, increase if necessary to 20mg after 1wk. Second-line recommendations are sertraline o r citalopram. TCAs, venlafaxine, and St John \200\231s wort are not recommended. Medication should be continued for at least 6mnths after remission then phased out over 6 \200\22312w ks. In psychotic depression consider augmentation with atypical antipsychotic. Only conside r ECT for young people (12 \200\22318yrs) with very severe depression and either life- thre atening symptoms or intractable and severe symptoms that have not responded to other treatm ents. Relapse and remission Monitor for 1yr regularly for \201 rst episode or 2yrs for recurren t episode. If at high risk of relapse consider follow-up psychotherapy as prevention, or to promote child and family \200\231s identi \201 cation and management of early warning sig ns. 16_Semple_Chap16.indd 653 12/7/2012 3:49:04 PM CHAPTER 16 Child and adolescent psychiatry 654 Suicide and self-harm in young people This section should be read alongside b p. 784 in the liaison chapter. Epidemiology Overall increase during the twentieth century, suicide now r epresents the third cause of death in adolescents (12% of mortality in this group). Complet ed suicide is commoner in males, however suicide attempts and deliberate self-harm (DSH) ar e commoner in females and include self-poisoning, cutting, and burning. Two important points: \200 Completed suicide is only the tip of the iceberg of suicidal behavior/ ideation. There is a very strong association between depression and suicidality. The combination of mood disord er, substance misuse, and conduct problems is particularly high risk. Factors increasing risk of completed/attempted suicide \200 \200 \200 \200 \200 Persistent suicidal ideas. Previous suicidal behavior. High lethality of method used and on going availability of lethal method. High suicidal intent and motivation, e.g. planning, st ated wish to die. Ongoing precipitating stresses, e.g. interpersonal con \202 ict, legal p roblems. Mental disorder: mood disorders, psychosis, substance misuse, conduct disorder, an xiety disorders, PTSD, eating disorders. Poor physical health. Psychological factors: impul sivity, neuroticism, low self-esteem, hopelessness. Parental psychopathology and suicidal b ehavior. Physical and sexual abuse. Disconnection from major support systems, e.g. school, family, work. \200 \200 \200 Prevention General measures include: \200 \200 \200 \200 \200 Screening and treating psychiatric disorders. Crisis lines/access to help. Education of par ents, the public, and the media. Intervene in cluster situations (e.g. several suicides in a school). Reduce access to means, e.g. limits on paracetamol purchase. 16_Semple_Chap16.indd 654 12/7/2012 3:49:05 PM SUICIDE AND SELF-HARM IN YOUNG PEOPLE 655 Self-harm Presentation with self-harm may indicate psychiatric disorder or signi \201 cant psychosocial problems. Many risk factors for self-harm are shared with those for suicide. Among adolescents who deliberately harm themselves, the factors that are most likely to be associated with a higher risk of later suicide include: \200 \200 \200 \200 \200 \200 \200 Male gender. Older age. High suicidal intent. Psychosis. Depression. Hopelessness. Having a n unclear reason for the act of deliberate self-harm. Management Parents have a responsibility to ensure the safety of their child. They should b e involved in the assessment and management planning. Sometimes young people will ask us no t to tell parents about their suicidal thoughts and acts. One should discuss this with them and try to persuade them otherwise, but ultimately one must inform the parents if risk is present. This exception to con \201 dentiality should have been explained at the start of the assessment. Management may involve the participation of several agencies: child and adult medical and m ental health services; social services; police; education; non-statutory agencies. \200 Usually admission to an age-appropriate medical ward to allow both medical treatment and a full psychosocial assessment. Mental health and risk assessment by a specially trained staf f member with ready access to psychiatric opinion. A minority will need inpatient psychiatr ic care. This should be in an age-appropriate unit. It is usually appropriate to refer on t o the local CAMHS if the family agrees to allow a fuller assessment and ongoing management. Where assessment reveals abuse issues, these need to be tackled according to local procedu re. 16_Semple_Chap16.indd 655 12/7/2012 3:49:05 PM CHAPTER 16 Child and adolescent psychiatry 656 Bipolar disorder in children and adolescents Epidemiology BPD is rare in prepubescent child ren; prevalence in adolescents is approximately 1%. Familial factors are important with a 4 times greater risk of mood disorder in offspring of parents with BPD. Presentation Will depend on the phase of the disorder. See b p. 652 for depres- sion. A hyp omanic/manic child may present as overactive, full of self-belief, grandiose, and challengi ng of authority. They are often irritable and can become aggressive or violent. Poor concen tration affects school perform- ance. Over-spending, sexual disinhibition and risk-taking b ehavior may feature. Psychotic symptoms may be present. Mixed affective states are also rec ognized. Diagnosis NICE recommends (M http://www.nice.org.uk/CG38): \200 That adult criteria are used but (i) mania must be present, (ii) euphoria must be present m ost days, most of the time (for 7 days), and (iii) irritability is not a core diagnostic cr iterion. Do not diagnose solely on the basis of a major depressive episode in a child with a family history of bipolar disorder, but follow up such children carefully. For older or d evelopmentally advanced adolescents, use adult criteria. Do not diagnose bipolar II ( child ren. \200 b p. 315) in younger adolescents or Differential diagnosis \200 ADHD or conduct disorder. Seek history of clear-cut episodes of elated mood, grandiosity, a nd cycles of mood. Mood cycles may also help distinguish BPD from schizophrenia. Substance misuse. Organic causes. Sexual, emotional, and physical abuse may manifest as disinhibition , hypervigilance, or hypersexuality. \200 \200 Comorbidity ADHD (70%), substance abuse (40%), ODD (40%), anxiety disorders (30%), Tourette \200\231s syndrome (8%), bulimia nervosa (3%). Outcome Early onset BPD has a poor outcome with 50% showing long- term decline in function. There is commonly a family history, sugges ting that this is a highly genetic form of BPD. The course is often chronic and less respon sive to treatment, with atypical and rapid-cycling features especially dif \201 cult to tr eat. Suicide risk is high with rates of completed suicide approximately 10%. 16_Semple_Chap16.indd 656 12/7/2012 3:49:05 PM BIPOLAR DISORDER IN CHILDREN AND ADOLESCENTS 657 Assessment: key areas \200 Individual and family. \200 Thorough developmental history, family history mood disorder, pattern of mood changes. Comorbidity. Impact of disorder on l ife \200\224family, friends, school, etc. Collateral information from school, etc. Physical examination and appropriate investigations. Level of risk \200\224suicide, exploitation, v iolence. Capacity/consent/legislation. \200 \200 \200 \200 \200 Management \200 Involve parents or carers in developing care plans so that they can give informed consent, support treatment goals, and help ensure adherence. Consider inpatient or day patient admis sion to age-appropriate services, or more intensive community treatment, for patients at ri sk of suicide or other serious harm. Acute mania Before starting (and thereafter) check hei ght, weight, and prolactin levels. Start at lower doses than for adults. If inadequate resp onse to antipsychotic can add valproate or lithium. Depression : if mild, monitor and suppo rt. If moderate to severe, offer psychological therapy \201 rst. If no response at 4wks c onsider \202 uoxetine starting at 10mg daily. If this fails, consider sertraline or cital opram. Consider augmentation with antipsychotic if psychotic symptoms present. Long term an tipsychotic that is associated with less weight gain and does not increase prolactin levels . As second-line, consider lithium for female patients and valproate or lithium for male pa tients. Psychological interventions include: psychoeducation and support to individual and family; more formal therapy, e.g. motivational interviewing, CBT; family therapy. Education and vocational training including school liaison, additional support, etc. Voluntary organ izations and support groups. : consider antipsychotic, valproate (not girls), or lithium. : need for long-term treatment? Consider atypical 16_Semple_Chap16.indd 657 12/7/2012 3:49:05 PM CHAPTER 16 Child and adolescent psychiatry 658 Psychosis Psychosis in adolescence is uncommon, and very uncommon in children. Diagnosis is on the basis of standard ICD-10 or DSM-IV criteria (b p. 178). Psychosis in children and adolescents Psychotic illnesses are rare in young children and pr esent a particular chal- lenge in both diagnosis and management. Very young children under 6yrs have preoperational cognitions and thus \200\230reality testing \200\231 is blurred b y a range of normal fantasy material. Imagined friends, transient hallucinations under stre ss, and loose associations may all occur within the normal spec- trum of development. Diffe rential diagnosis There are many causes of apparent psychotic symptoms in children and adol escents. This means that the assessment of a child with symptoms requires extreme care and thoroughness. Possible explanations include: \200 \200 Normal experience. Organic conditions (e.g. TLE, thyroid disease, brain tumor, Wilson \200 \231s disease, and substance misuse disorders). Mood disorders. PDD/autism. OCD. Schizophre nia. Language disorders. Dissociative disorders. Culture-bound syndromes. \200 \200 \200 \200 \200 \200 Schizophrenia Clinical features \200 \200 \200 \200 \200 More often insidious than acute onset. Associated with poor premorbid function with develop mental delays. Below average IQ. Negative symptoms often precede positive, and are prominen t. Comorbidity common \200\224conduct and developmental problems, substance misuse. Strong family history of schizophrenia/psychosis. Poorer outcome than adult-onset schizophrenia. P oor premorbid functioning, negative symptoms, \200\230disorganized \200\231 clinical prese ntation, and greater duration of untreated psychosis predict worse outcome. \200 Assessment: key areas \200 \200 \200 \200 \200 \200 \200 \200 Good engagement important. Detailed developmental history. History from multiple informants including family and school. Negative symptoms. Screen for comorbidity. Risk assessment. P hysical examination and medical investigations. Consider use of rating scale, e.g. K-SADS. 16_Semple_Chap16.indd 658 12/7/2012 3:49:05 PM PSYCHOSIS 659 Management \200 In-, day- or outpatient care? Will depend of complexity, level of risk, likely engagement/c oncordance, likely effect on child of being away from family. Care should be in age-appropr iate setting. Early intervention in psychosis services that have emerged across the UK, oft en extending down into the adolescent age group \200\224their input may be very useful. Med ication \200\224atypical antipsychotics favored over typicals. Side-effects still often pro blematic. Clozapine useful in treatment resistance. Age-speci \201 c evidence base limited . BDZs or antipsychotics may be useful in managing acute behavioral disturbance not respons ive to non-pharmacological measures. Supportive, psychoeducational and speci \201 c psycho therapeutic individual work, e.g. CBT, social skills training. Family support, education, a nd therapeutic work as appropriate. Manage comorbidity. Ongoing risk assessment and managem ent. Educational/vocational input, e.g. reintegration package to school, specialist educati on provision, supported college/work placements. Awareness of consent/capacity/legal issues . Varies across UK. Voluntary sector \200\224National Schizophrenia Fellowship, MIND. Acces s to bene \201 ts, etc. Thoughtful and measured transition to adult services. \200 \200 \200 \200 \200 \200 16_Semple_Chap16.indd 659 12/7/2012 3:49:05 PM CHAPTER 16 Child and adolescent psychiatry 660 Substance abuse in children and adolescents Substance abuse is increasingly common in young people. It affects 13% of adolescents referred to mental health services. The characterist ics of use and the approach to management can be different to those in adults. Comorbidity is common: conduct problems, depression and other emo- tional disorders, ADHD, eating disor ders. Types of use include: \200 Experimentation/exploration \200\224usually social, abou t adventure. \200 Social use \200\224social acceptance important. \200 Emotional/instru mental use \200\224for the \200\230high \200\231 or to suppress unpleasant feelings and de al with stress. Habitual use \200\224salience, tolerance, and negative consequences on life become prominent. Dependence \200\224full dependence syndrome ( b p. 542). Assessment: key areas \200 \200 \200 Involve family where possible. Substance \200\224types, routes, quantity, cost, context. Co nsequences of use \200\224family, friends, development, education, employment, physical and mental health, criminal activity. Attitude to referral \200\224Prochaska \200\231s theory of change. Link with other agencies, e.g. social services, education, youth justice. Risk \200\224to self, others, child protection. \200 \200 Management \200 Brief interventions may be suf \201 cient for young people with less severe substance misu se problems. Developmental stage and shorter history means rapid changes can be made. More severe problems are addressed by co-ordination of multiple agencies, e.g. mainstream CAMHS, social and education services. Structured treatment by specialist young people \200\231s s ubstance misuse treatment services is recommended for under-18s who have signi \201 cant s ubstance misuse problems (normally polydrug and alcohol misuse). This could include harm re duction interventions, psychosocial treatments (motivational therapies, cognitive behaviora l treatments, family-based supports and treatment) and occasionally pharmacological interve ntions. Again this occurs in the context of interventions to address all of the young perso n \200\231s health, social, family, and educational needs, and therefore involves multiple agencies. The involvement of a young person \200\231s family or those with parental respons ibility is considered good practice and may be required with regard to consent. 16_Semple_Chap16.indd 660 12/7/2012 3:49:05 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 662 Child abuse 1: general issues1 In recent decades there has been growing awareness that the abuse of children can take many forms. All forms of child abuse involve the ele- ments of p ower imbalance, exploitation, and the absence of true consent. They may concern acts of com mission or acts of omission. Over recent times, domestic violence and parental substance mi suse have been rec- ognized as situations which should prompt concern for the protection of children from abuse. Categories of abuse Physical abuse includes hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. (Includes Munchausen syndrome by proxy \200\224see Box 16.3.) Neglect is the persistent failure to meet a child \200\231s basic physical/psychologi- cal needs, likely to result in serious impairment of the child \200\231s health and development . Includes failure to provide adequate: food, clothing, shelter and supervision; protection from harm or danger; and access to appropri- ate medical care. Also includes substance mis use during pregnancy. Emotional abuse persistent emotional maltreatment resulting in severe and persistent effect s on the child \200\231s emotional development. Includes denigration or rejection, emotiona l neglect, developmentally inappropri- ate expectations, repeated separations and mis-socia lization of the child. Other types of abuse are likely to result in emotional abuse. Sexual abuse involves forcing or enticing a child into sexual activity. This may include pe netrative and non-penetrative physical acts, and non- contact activities such as involving children in looking at or produc- ing sexual images, watching sexual activities or encourag ing children to behave in sexually inappropriate ways. Box 16.3 Munchausen \200\231s syndrome by proxy: factitious or induced illness syndrome (FI IS) \200 Part of a factitious syndrome that is manifest by a person feigning or inducing illness in a child (or others) in order to obtain medical attention. A form of child abuse in that it subjects the child to emotional abuse, unnecessary medical procedures, hospitalization or o ther treatments that are harmful to the child. Can be very dif \201 cult to detect as the perpetrating (and colluding) adult/s often deny and disguise their behavior. It is essentia l for professionals to be alert to it, especially where a child repetitively presents for m edical attention. Undetected, this form of abuse can result in very serious consequences (including fatality) for the child. 1 Adapted from HM Government (2006) What to do if you \200\231re worried a child is being a bused. London: HMSO. 16_Semple_Chap16.indd 662 12/7/2012 3:49:05 PM CHILD ABUSE 2: THE DUTY OF CARE 663 Child abuse 2: the duty of care All practitioners have a duty to safeguard and promote the welfare of children. It is important to remain alert to the possibility of abuse or neglect . The assessment of risk, and interventions to protect children, require a multidisciplinar y and multi-agency approach. In general, the duty to patients, including that of con \201 dentiality, is overridden by the duty to protect children. Referrals regarding possible abuse will usually be made to social services or the police. Making a child protection referral \200 Know how to access your local multi-agency Child Protection Procedures and follow them. It is good practice to discuss the referral with the child, as appropriate to their age and un derstanding, and with their parents, to seek agreement to the referral unless such discussi on would place the child at risk of signi \201 cant harm. It is not necessary to have agre ement to make the referral. Ensure that you carefully document all concerns, discussions, d ecisions made and reasons for these decisions. Discuss the situation with a senior colleagu e. Follow up oral communications in writing. Have as much information regarding the child a nd your concerns available as possible. Do not do anything which may jeopardize a police in vestigation, e.g. asking a child leading questions, or attempting to investigate the allega tions of abuse. \200 \200 Child abuse \200\224where does CAMHS \201 t in? \200 Being alert to abuse, responding to concerns expressed by individuals and families, and mak ing a child protection referral. Involvement in multi-agency discussion and planning for th e child. Post-abuse work with children and families (abusing and non-abusing). \200 Psychiatric outcome of chronic abuse Children who are abused have an extremely high rate of psychiatric disor- ders, both during the abuse and later on. Some of the most common disorders associated with previous abuse: PTSD Dissociative disorde rs Conversion disorders Borderline personality disorder Depression Paraphilias Substance ab use. \200 \200 \200 \200 \200 \200 16_Semple_Chap16.indd 663 12/7/2012 3:49:06 PM CHAPTER 16 Child and adolescent psychiatry 664 The looked-after-child (LAC) \200\230Looked after \200\231 is the term used to describe al l children in public care, including those in foster or residential homes, and those still with their own parents but subject to care orders. The majority have become \200\230looked after \200\231 because of abuse or neglect. Outcomes for LAC On leaving care, young people have signi \201 cantly poorer outcomes in t erms of education, employment, and physical and mental health. Teenage pregnancy, homelessn ess, and involvement in crime as both victim and perpetrator are increased.