Assessment \200 \200 Interview family and child. Observe child, preferably in more than one situation, e.g. clin ic and school. Collateral information from school, other involved parties. Rating scales ma y be useful, e.g. Connor \200\231s rating scale, Strengths and Dif \201 culties Questionna ire (SDQ). Screen for comorbidity. Physical examination including neurological examination. \200 \200 Management \200 \200 \200 Psycho-education. Medication ( Behavioral interventions, e.g. encouraging realistic expecta tions, positive reinforcement of desired behaviors (small immediate rewards), consistent co ntingency management across home and school, break down tasks, reduce distraction. School i ntervention. Treat comorbidity. Evidence base for dietary changes and \201 sh oils poor a t present. Voluntary organizations, e.g. ADDISS \200\224Attention De \201 cit Disorder Inf ormation and Support Service. b p. 628). \200 \200 \200 (cid:1)Controversy of ADHD The concept of ADHD has been criticized as medicalizing a social prob- lem. It is said to be over-diagnosed and that it undermines parents. The long-term b ene \201 ts of medication remain unclear. Nevertheless, there is recognition that symptoms can continue into adult life and that untreated, there are poor outcomes. Children and the ir families, who have experienced a good response to medication, usually want to con- tinue with it despite long-term uncertainty. 16_Semple_Chap16.indd 627 12/7/2012 3:49:01 PM CHAPTER 16 Child and adolescent psychiatry 628 Drug treatment of ADHD The currently available drug treatments for ADHD are symptomatic \200\224 they treat the core symptoms but do not cure them. 70% of affected chil- dren will show symptomatic response to medication, as demonstrated by: increased on-task behavior; r educed \201 dgeting, \201 nger-tapping, and inter- rupting; reduced impulsiveness; incr eased performance accuracy; reduced aggression; improved compliance; improved parent \200 \223child interactions; and improved peer status. Commonly prescribed drugs Methylphenidate A central nervous system stimulant licensed for t reat- ment of ADHD in children over 6yrs. Available as an immediate-release preparation las ting around 4hrs (Ritalin )), and as modi \201 ed release prepa- rations lasting 8 or 12h rs (Equasym XL , Concerta XL , Medikinet XL ). Modi \201 ed release preparations have t he advantage that medication does not need to be administered at school. Side-effects: abdo minal pain; nausea and vomiting; dry mouth; anxiety; insomnia; dysphoria; headaches; ano- r exia and reduced weight gain. Growth suppression may be a long-term outcome of high doses o ver long periods \200\224growth monitoring is advised. Atomoxetine (Strattera ) A non-stimulant NE reuptake inhibitor licensed for the treatment of ADHD. Taken once daily, providing 24-hr cover. May take up to 6wks to have a full effect . Side-effects: anorexia; dry mouth; nausea and vomiting; headache; fatigue; dysphoria. Dexamfetamine A central nervous system stimulant licensed for the treatment of ADHD in chil dren whose symptoms are refractory to other drugs. Side-effects are similar to those of met hylphenidate. Principles of prescribing in ADHD (NICE1) \200 The diagnosis of ADHD should be based on a comprehensive assessment conducted by a psychiat rist or a pediatrician with expertise in ADHD. It should also involve the child, parents, a nd carers, and the child \200\231s school, and take into account cultural factors in the ch ild \200\231s environment. Multidisciplinary assessment, which may include educational or c linical psychologists and social workers, is advisable for children who present with indica tions of signi \201 cant comorbidity. Drug treatment of ADHD should form part of a compreh ensive treatment program. A comprehensive treatment program should involve advice and suppo rt to parents and teachers, and could include speci \201 c psychological treatments. While this wider service is desirable, any shortfall in its provision should not be used as a re ason for delaying the appropriate use of medication. Drug treatment of ADHD should only be initiated by psychiatrists or pediatricians with expertise in ADHD, but continued prescribi ng and monitoring may be performed by GPs, under shared-care arrangements with specialists. The choice of drug should be guided by: the presence of comorbid conditions; the different adverse effects of the drugs; speci \201 c issues regarding compliance identi \201 ed fo r the individual child or adolescent; the potential for drug diversion and/or misuse; the p references of the 16_Semple_Chap16.indd 628 12/7/2012 3:49:01 PM DRUG TREATMENT OF ADHD 629 child or adolescent and/or his parent or guardian. If there is a choice of more than one ap propriate drug, the drug with the lowest cost is prescribed. Caution is required in prescri bing for children and young people with epilepsy, psychotic disorders, or a history of drug or alcohol dependence. Careful titration is required to determine the optimal dose level a nd timing. The drug should be discontinued if improvement of symptoms is not observed after appropriate dose adjustment. Children should receive regular monitoring. When improvement has occurred and the child \200\231s condition is stable, treatment can be discontinued at intervals, under careful specialist supervision, in order to assess both the child \200\231 s progress and the need for continuation of therapy. 1 M http://www.nice.org.uk/cg72 16_Semple_Chap16.indd 629 12/7/2012 3:49:01 PM CHAPTER 16 Child and adolescent psychiatry 630 Autism spectrum disorders (ASD) Autism spectrum disorders are a group of lifelong developme ntal disor- ders characterized by their effect on social and communication skills as well a s by a restricted, stereotyped, repetitive repertoire of interests and activities. The spec trum ranges from clear-cut autism, to subtle variants, to traits found in the normal popula tion and includes the diagnoses of autism, Asperger \200\231s syndrome, and pervasive devel opmental disorder not otherwise speci \201 ed (PDD-NOS). Although 80% of individuals with child- hood autism have learning disability, about 80% of the population with autism spectr um disorders are of normal intellectual ability. (For a more detailed description of autism and other PDDs see Chapter 18, Learning disability, b pp. 758 \200\22361). Clinical features Dif \201 culties with social relationships \200 Few or no sustained re lationships. \200 Persistent aloofness or awkward interaction with peers. \200 Unusuall y egocentric with little concern for others or awareness of their viewpoint and limited emp athy or sensitivity. Lack of awareness of social rules. Problems in communication \200 Odd voice, monotonous and perhaps at an unusual volume talking at (rather than to) you with little awareness of your response. Language is super \201 cially good, but too formal, st ilted, or pedantic and with dif \201 culty in catching any meaning other than the literal. Impassive appearance with few gestures and abnormal gaze (i.e. limited non-verbal communic ative behavior). Awkward or odd posture and body language. Absorbing and narrow interests \200 \200 Obsessively pursued and unusually circumscribed interests. A set approach to everyday life that may include unusual routines or rituals; change is often upsetting. Comorbidity Depression; anxiety; bipolar disorder; psychosis; learn- ing disability; OCD; A DHD; tic disorders; dyspraxia; impaired cognition in various domains, e.g. perception, exec utive functioning; visual/auditory impairment; epilepsy. 16_Semple_Chap16.indd 630 12/7/2012 3:49:01 PM AUTISM SPECTRUM DISORDERS 631 Assessment \200\224key areas \200 History of problems, eliciting dif \201 culties in the domains (see features, b p. 630). L evel of distress and impairment in all aspects of life. Comorbidity. Cognitive ability. Imp act on parents/carers and sources of support. Obtain information from as many sources as po ssible. Referral for specialist assessment, especially speech and language. Also educationa l psychology (via school), occupational therapy, and physiotherapy as indicated. Observatio n of child. Consider use of diagnostic tools, e.g. Autism Diagnostic Interview \200\224 Rev ised (ADI-R); Diagnostic Interview for Social and Communication Disorders (DISCO); Developm ental Dimensional and Diagnostic Interview (3di). Medical investigation as appropriate, e.g . karyotyping, DNA, fragile X analysis, audiological examination, investigation for recogni zed aetiologies, e.g. tuberous sclerosis. Clinical \200 \200 \200 \200 \200 \200 In practice, the diagnosis is made by a variety of professionals including psychiatrists, p ediatricians, speech and language therapists and psycholo- gists. While a multidisciplinary approach to all cases is ideal, this is particu- larly important in complex cases. Management Effective management will be informed by thorough assessment of the individual c hild and family \200\231s needs and is likely to involve more than one agency. \200 \200 Information (verbal and written) and support regarding the diagnosis. Liaison with educatio n services re appropriate support and school placement. The educational psychologist is wel l suited to provide advice in this area. Parenting programs speci \201 c to ASD. Adaptatio n of the child \200\231s environment, activities, and routines, e.g. visual timetabling. Co mmunication interventions. Treat comorbidity \200\224be aware that ASD may alter treatment approach and prognosis. Risperidone may be used for short-term treatment of signi \201 can t aggression \200\224monitor weight. Melatonin may help sleep disturbance where behavioral measures have failed. Wider family/sibling support including respite care, eligibility for bene \201 ts, and social work assistance. Inform about additional sources of information a nd support, e.g. National Autistic Society. \200 \200 16_Semple_Chap16.indd 631 12/7/2012 3:49:02 PM CHAPTER 16 Child and adolescent psychiatry 632 (Gilles de la) Tourette \200\231s syndrome Essence A developmental neuropsychiatric disorde r characterized by multiple motor and one or more vocal tics, present for at least a year, causing distress and impaired function. \200 Motor tics often begin between the ages of 3 and 8, a few years before the onset of vocal t ics. Typically, tics vary over time with more complex tics emerging after some years. Sever ity of tics waxes and wanes, with exacerbations often related to fatigue, emotional stress, and excitement. Tic severity usually peaks in early adolescence with most showing marked r eduction in severity by the end of adolescence. Coprolalia is strongly associated in the pu blic mind with this disorder, but is actually uncommon, and not required for diagnosis. Epidemiology 4:5 = 3:1. Prevalence is approximately 4 \200\2236/1000 in European and Asian populations. Etiology Thought to involve interaction of genetic and environmental factors. Multiple vulnerability genes implicated. Association with psychosocial stress well-known, a nd heightened HPA axis and NE system reactivity demonstrated. Other possibilities include g estational and perinatal insults, exposure to androgens, heat, fatigue, and post-infectious autoimmune mechanism (see PANDAS b p. 649). Comorbidity OCD and ADHD common; depression, a nxiety, learning dif \201 culties, ASD, migraines. Associated problems include sleep dif \201 culties, poor impulse control, and disruptive behaviors. Key aspects of assessment \200 \200 \200 Assess degree of interference with child \200\231s family, school, and social life. Careful perinatal, developmental, family, and medical history. Screen for associated dif \201 cul ties. Management \200 Psychoeducation for child and family, and lifestyle adjustment: what tics are, realistic ex pectations, stress reduction, caffeine reduction. Close liaison with school and educational interventions. Treat comorbidity. SSRIs may be helpful in comorbid OCD. Methylphenidate is no longer contraindicated in comorbid ADHD. Behavioral interventions \200\224habit reversa l training looks promising. Consists of awareness training, self-monitoring of tics, relaxa tion training, competing response training and motivational techniques. If tics are severe and impairing, consider medication, e.g. antipsychotics, A-adrenergics. Beware tendency of tics to wax and wane regardless of treatment. Information and support can be gained from th e Tourette Syndrome Association. \200 16_Semple_Chap16.indd 632 12/7/2012 3:49:02 PM OTHER TIC DISORDERS 633 Other tic disorders \200 Tics are sudden, rapid movements or vocalizations which occur in bursts. Tics are often und er partial voluntary control and can be suppressed for brief periods. They are frequently a ssociated with antecedent sensory phenomena including inner tension and premonitory urges, and tic performance may result in \202 eeting relief. Younger children may not experience these phenomena, or describe their tics as controllable. Chronic motor or vocal tic disorder More common than Tourette \200\231s syndrome, with a be tter long-term outcome. Transient tic disorder Motor and/or vocal tics are present transien tly for less than one year. Occurs in at least 5% of children. 16_Semple_Chap16.indd 633 12/7/2012 3:49:02 PM CHAPTER 16 Child and adolescent psychiatry 634 Language, learning, and motor co-ordination disorders Speech and language delay and disorde r A distinction is drawn between speech and language delay and disorder. Delay indicates th at speech and language acquisition is occurring at a slower rate, but in the expected seque nce. Disorder implies that speech and language development is not following the usual seque nce, suggesting speci \201 c dif \201 culties in an aspect of the language system that is impacting on the child \200\231s overall language development. Disorders include speci \201 c speech articulation disorder, expressive lan- guage disorde r and receptive language disorder. Both delay and disorder are commonly multifactorial in e tiology. They can impact on a child \200\231s learning and literacy, social development, an d emotional well-being and may initially present with behavior problems. Assessment by a sp eech and language therapist is indicated. Learning disorders Generally, the educational psychologist is ideally placed to identify an d advise on the management of these disorders. However, it is not unusual for the \201 rs t presentation of these disorders to be to CAMHS as behav- ioural problems. Reading disorder ( \200\230dyslexia \200\231) Dif \201 culty with reading, in most cases i nvolving a de \201 cit in phonological \200\223 processing skills. 4% of school-age childr en. Male predominance. There is often a family history of dyslexia. 20% have comorbid ADHD or CD. Management includes 1:1 remedial teaching, and parent involvement improves long-term outcome. Disorder of written expression Often coexists with dyslexia and manifests as dif \201 cult ies with spelling, syn- tax, grammar, and composition. Occurs in 2 \200\2238% of school-age children with a 3:1 male predominance. Dif \201 culties may \201 rst emerge with the sh ift from narrative to expository writing assignments. Mathematics disorder Female predominance and occurs in 1 \200\2236% of school-age children. Often associated with visuospatial de \201 cits and attributed to right parietal dysfunct ion. 16_Semple_Chap16.indd 634 12/7/2012 3:49:02 PM LANGUAGE, LEARNING, AND MOTOR CO-ORDINATION DISORDERS 635 Developmental co-ordination disorder (DCD) \200 DCD and dyspraxia are generally held to be synonymous and refer to an impairment of, or dif \201 culties with, the organization, planning and execution of physical movement with a d evelopmental rather than acquired origin. It can be comorbid with disorders of learning and behavior. Over half have attention dif \201 culties, of which a minority will meet criter ia for a diagnosis of DAMP: this disorder features De \201 cits in Attention, Motor contro l, and Perception and there are overlaps with ODD and ASD. Can impact on self-esteem, famil y and peer relationships and school life. DCD prevalence 6%, commoner in males. Premature a nd low birth- weight babies at increased risk. First presentation may be to CAMHS with beha vioral dif \201 culties. More usually seen in pediatrics and primary care. Assessment and input from occupational therapy and physiotherapy may be necessary. 16_Semple_Chap16.indd 635 12/7/2012 3:49:02 PM CHAPTER 16 Child and adolescent psychiatry 636 Enuresis The normal variation in the age of acquisition of bladder control makes it dif \201 cult to demarcate disorder. By age 5, only 1% children have trouble- some daytime wett ing. Nocturnal enuresis, however, continues to affect 15 \200\22322% of boys and 7 \200\223 15% of girls at the age of 7yrs. Primary (never dry) and secondary (previously dry) types a re distinguished. Enuresis can impact on self-esteem, family and peer relationships and res trict activities. There is a reduction in rates of enuresis with time but a small minority will continue to experience problems into adult life. Etiology Nocturnal enuresis has a str ong genetic component. Both psychosocial and pathophysiological associations have been demo nstrated. Diurnal enuresis is more likely to be associated with structural and functional d isorders of the urinary tract; and less likely to predict that other family members will ha ve shown enuresis. Management The majority of children will be managed in primary care, or by specialist enuresis clinics in the UK. Referrals to CAMHS are usually reserved for cases where enuresis is part of a wider disturbance of emotion and behavior, or where serious ps ychological consequences have developed in an enuretic child. \200 \200 \200 \200 Careful assessment will inform management. Psychoeducation of child and parents. Treat orga nic causes, e.g. structural abnormality, infection. Nocturnal enuresis: there is robust evi dence to support use of enuresis alarms. \200\230Night lifting \200\231, reward systems (e .g. star charts), and medication \200\224desmopressin, imipramine, oxybutynin \200\224may a lso be helpful. Diurnal enuresis: body alarms, watch alarm to remind child to use toilet, m edication, speci \201 c psychological approaches, e.g. anxiety management if related to fe ar of toilet. ERIC (Enuresis Resource and Information Center: org.uk) provides information and resources to improve childhood continence. Website and helpline. Includes enuresis and encopresis. M http://www.eric. 16_Semple_Chap16.indd 636 12/7/2012 3:49:02 PM ENCOPRESIS 637 Encopresis Again, determining what is abnormal is problematic, but soiling more fre- quentl y than once a month after the fourth birthday is regarded as an elimination disorder if it is not attributable to a general medical condition. Primary and secondary forms are recogni zed as for enuresis. Constipation and soiling are common presentations to pediatrics, with only a small minority being referred to CAMHS. These latter children tend to have signi \201 cant psychological problems in addition to soiling \200\224association with emotional abuse. There can be considerable impact on self-esteem, fam- ily and peer relationships, an d social activities. Most soiling will cease by age 16. Types of soiling \200 95% present with functional constipation with retention and over \202 ow. Both physical (p ersistent fecal loading leading to loss of sensation of rectal \201 lling, anal \201 ss ure) and psychological (toilet fears, fear of painful defecation) factors may be relevant. Never toilet trained. Frightened to use the toilet. Deliberately depositing feces in inappr opriate places. \200 \200 Management As most cases are likely to have multifactorial causes, a comprehensive biopsych osocial assessment is necessary to guide management. Possible elements of treatment include : \200 \200 Lifestyle changes, e.g. adequate \202 uid and dietary \201 bre. Education of child and family, and assistance to view child more positively. Medical management, e.g. laxatives. B ehavioral approaches, e.g. star charts. Family therapy, e.g. Sneaky Poo \200\224a narrative therapy approach that helps to unite the family against the problem of soiling, which is p ersoni \201 ed as the character \200\230Sneaky Poo \200\231. \200 \200 16_Semple_Chap16.indd 637 12/7/2012 3:49:03 PM CHAPTER 16 Child and adolescent psychiatry 638 Other behavioral disorders Sleep disorders Classi \201 ed as for adult sleep disorders (se e b p. 414). The main syn- dromes that manifest in children and adolescents are: nightmare disorder (b p. 446); sleep terror disorder (b p. 442); and sleepwalking disorder (b p. 444) . Management is the same as for adults. Feeding and eating disorders of infancy and early childhood1 Pica This is a common conditio n where there is persistent (>1mth) eating of non-nutritive substances at a developmentally inappropriate age (>1yr). Common substances are: dirt, stones, hair, feces, plastic, paper , wood, string, etc. It is particularly common in individuals with developmental disabiliti es and may be dangerous or life-threatening depending on the substance ingested. Consequenc es may include toxicity, infection, or GIT ulceration/obstruction. Typically occurs during 2nd and 3rd years of life, although young pregnant women may exhibit pica during pregnancy. Hypothesized causes include: nutritional de \201 ciencies; cultural factors (e.g. clay); psychosocial stress; malnutrition and hunger; brain disorders (e.g. hypothalamic problem). Rumination This is the voluntary or involuntary regurgitation and rechewing of partially di gested food. Occurs within a few minutes post- prandial and may last 1 \200\2232hrs. Regurg itation appears effortless and is preceded by belching. Typical onset 3 \200\2236mths of ag e, may persist for several months and then spontaneously remit. Also occurs in older indivi duals with LD. May result in weight loss, halitosis, dental decay, aspiration, recurrent re spiratory tract infection (RTI), and sometimes asphyxiation and death (5 \200\22310% of cas es). Causes include: LD; GIT pathology; psychiatric disorders; psychosocial stress. Treatme nt includes physical examination and investigations; behavioral methods; nutritional advice . 1 Ellis CR (2006) Childhood habit behaviors and stereotypic movement disorder. Medscape. M http:// www.emedicine.com. 16_Semple_Chap16.indd 638 12/7/2012 3:49:03 PM ANXIETY DISORDERS: OVERVIEW 639 Anxiety disorders: overview Anxiety and fear are an inherent part of the human condition an d in times of danger are often adaptive. As a result of changing developmental and cognitiv e abilities during childhood, the content of normal fears and anxieties shifts from concern s about concrete external things to abstract anxieties. Anxiety disorders are characterized by irrational fear or worry causing signi \201 cant distress and/or impairment in functio ning and their rela- tive prevalence re \202 ects this shift in content. Thus speci \201 c disorders appear more common during speci \201 c stages of development. Epidemiology Anx iety disorders are among the most common psychiatric disorders in youth. Prevalence rates r ange from 5 \200\22315% with 8% requiring clinical treatment. Age of onset varies for each disorder. Separation anxiety disorder and speci \201 c phobia usually have onset in early childhood, generalized anxiety disorder occurs across all age groups, while obsessive \200 \223compulsive disorder, social phobia, agoraphobia, and panic disorder tend to occur in la ter childhood and adolescence. Aetiological that exhibits \200\230behavioral inhibition \200\231 (timidity, shyness, and emotional restraint with unfamiliar people or situations); insecure attachment; stressful or traumatic life events; high social adversity; over-prote ctive/critical/punitive parenting. Organic causes of anxiety Medical conditions: hyperthyro idism; cardiomyopathy; arrhythmias; respiratory and neurological diseases. Substances: alco hol; caffeine; cocaine; amfetamines; cannabis; SSRIs; LSD; ecstasy; etc. factors Genetic vulnerability; temperament Presentation of anxiety in children and adolescents \200 Particularly in children, it is dif \201 cult to obtain a history of cognitive, emotional, and physical symptoms. Often somatic symptoms are the only feature that the child will be able to readily describe. Nevertheless, with sensitive questioning, fears and worries can b e elicited. Behavioral presentations include overactivity, inattention, sleep disturbance, separation dif \201 culty, regression, school refusal, social withdrawal, aggression, ritu alistic behaviors, and somatization. General principles of management \200 Use ABC (antecedents, behavior, consequences) approach to help child and family understand what happens when the child feels anxious. Show how others \200\231 reactions are in \202 uencing anxiety. Stress reduction including relaxation. Psychoeducation re anxiety, e.g. co nnection between physical, cognitive, and emotional components. Age-appropriate CBT approac hes. \200 \200 16_Semple_Chap16.indd 639 12/7/2012 3:49:03 PM CHAPTER 16 Child and adolescent psychiatry 640 Separation anxiety disorder Characterized by increased and inappropriate anxiety around sep aration from attachment \201 gures or home, which is developmentally abnormal and results in impaired functioning. It occurs in about 3.5% of children and 0.8% of adolescents. Caus es Genetic inconsistent, or over- involved parenting; and regression during periods of stre ss, illness, or abandonment. Symptoms Anxiety about actual or anticipated separation from o r danger to attachment \201 gure; sleep disturbances and nightmares; somatization; and sc hool refusal. Comorbidity Depression; anxiety disorders (panic with agoraphobia in older ch ildren); ADHD; oppositional disorders; learning disorders; and developmental disorders. Nor mal separation anxiety Separation anxiety is a normal feature of development. Anxiety in a 2-yr-old who is being separated from his/her parent into the care of a stranger is normal s ince, at this developmental stage, the child may perceive the attachment \201 gure as the only source of safety. On the other hand, disabling separation anxiety in a 7-yr-old is co nsidered abnormal since the child has achieved a level of cognitive development at which he /she should have learned that many non- attachment \201 gures might be considered \200 \230safe \200\231. vulnerability; anxious, 16_Semple_Chap16.indd 640 12/7/2012 3:49:03 PM GENERALIZED ANXIETY DISORDER 641 Generalized anxiety disorder Essence Characterized by developmentally inappropriate and exc essive worry and anxiety on most days about things not under one \200\231s own control. Sev ere enough to cause distress and/or dysfunction. Affected children are often perfectionist and self-critical. Most common anxiety disorder of adolescence with approximately 4% preval ence in this group. More common in females during adolescence. Only one-third seek treatmen t. Symptoms Excessive worry; restlessness, irritability, and fatigue; poor concentration; s leep disturbances; muscle tension. In children: somatic symptoms (headache; stomach pains o r \200\230irritable bowel \200\231; rapid heartbeat; shortness of breath); nail biting and hair pulling; and school refusal. Comorbidity Very high rates \200\224up to 90%. Other anx iety disorders, depression, conduct disorders, and substance abuse are most common. Management \200 Good evidence for the use of CBT. This can be individual, group, or family-based, and it ma y be especially bene \201 cial for parents to be involved in children under 11 or when par ental anxiety is high. Psychoeducation regarding the nature and treatment of anxiety disord ers along with supportive listening and clari \201 cation. The formulation may indicate th e use of other psychosocial approaches. Although not supported by research evidence, use of SSRIs may be considered. 16_Semple_Chap16.indd 641 12/7/2012 3:49:03 PM CHAPTER 16 Child and adolescent psychiatry 642 Panic disorder/agoraphobia Essence Recurrent, unexpected panic attacks are the hallmark of this disorder, together with a period during which the child is concerned about having anot her attack and the possible consequences of an attack, and exhibits signi \201 cant behavi oral changes related to the attacks. These latter features are referred to as anticipatory anxiety. The \201 rst attack must be uncured. A panic attack is described as a discrete p eriod of increased fear peaking at about 10min and lasting about 30min to 1hr. Symptoms Swe ating, \202 ushing, trembling, palpitations and tachycardia, chest pain, shortness of bre ath and choking, nausea and vomiting, dizziness, paraesthesia, depersonalization and dereal ization, and a fear of dying. Note: in young children somatic symptoms predominate rather t han classic symptoms. Agoraphobia may or may not coexist with the disorder, but is usually present. The essential feature is anxiety about being in a situation in which escape would be dif \201 cult or help unavailable should a panic attack occur. This leads to avoidance of places or situations and may result in school refusal and separation anxiety. Epidemiolo gy Panic disorder has an estimated prevalence of 3 \200\2236% and is more common in females post-puberty. Peak onset is 15 \200\22319yrs. Comorbidity Depression, substance abuse, and other anxiety disorders (especially social phobia) are most common. Management As for gene ralized anxiety disorder. 16_Semple_Chap16.indd 642 12/7/2012 3:49:03 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 644 Social phobia, simple phobias, and selective mutism Social phobia Essence Extremely common and often undiagnosed. It is characterized by marked fear of one or more social or performa nce-related situations where the person is exposed to scrutiny and in which embarrassment m ay occur. Exposure to social situations usually causes an anxiety reac- tion (may be a pani c attack) that is distressing. Thus situations are either avoided or endured with discomfor t. This may lead to agoraphobia and in severe cases school refusal. Epidemiology Social Phobia (SP) is most common in adolescents with an estimated prevalence of 5 \200\22315% as opposed to only 1% in children. It is more common in girls and the aver age age of onset for both genders is 12yrs. Family studies demonstrate a 2x increased risk for SP in the relatives of SP probands, while twin studies show a 3x increased risk in mono zy- gotic twins. Comorbidity High rates of other anxiety disorders (especially GAD, simple phobia, and panic disorder) in approximately 30 \200\22360% cases, with mood disorders (20%) and substance a buse also frequent comorbidly. Prognosis Although the prognosis for treated SP is fair to good, comorbid conditions may pe rsist and hinder educational and social progress. Those who experience symptoms in 2 or mor e situations have a poorer outcome than those experiencing symptoms in a single situation o nly. Management \200 Good evidence for the use of CBT exists. This can be individual, group, or family-based, an d it may be especially bene \201 cial for parents to be involved in children under 11 or w hen parental anxiety is high. SSRIs should be considered where CBT alone has failed. Psycho education regarding the nature and treatment of anxiety disorders along with supportive lis tening and clari \201 cation. The formulation may indicate the use of other psychosocial a pproaches. \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 