Akhenaton (1354 BC), Egyptian king If there is anything we wish to change in the child, we should \201 rst exam- ine it and see whether it is not something that could better be changed in ourselves. Carl Gustav Jung (1875 \200\2231961) 16_Semple_Chap16.indd 611 12/7/2012 3:48:59 PM CHAPTER 16 Child and adolescent psychiatry 612 Assessment 1: principles The biopsychosocial approach Understanding and managing successfully the mental and behavio ral problems of children depends upon the thoughtful consideration of all the biological, p sychological, and social factors that may play a role in the generation of symptoms. It is important to remember that several fac- tors may interact in a dynamic two-way fashion, giv ing rise to symptoms. The \200\230biopsychosocial approach \200\231 is useful at all stage s of the evaluation and intervention provided to a child. Children and families When a young person comes into contact with mental health services th ey are more likely to have been referred for help than to have sought help themselves. This is important to remember, since \200\230the patient \200\231 may have no say in their ref erral and this may have implications for the thera- peutic relationship. In addition, one i s rarely dealing with the young per- son alone \200\224they are usually dependent upon care givers, whether they are parents or other adults. Thus one is commonly confronted by a room full of people who may have differing experiences and interpretations of the young person \200\231s problems and of what is needed to improve the situation. The professional in this situation needs to be aware of the various dynam- ics and be vigilant in remaining objecti ve and non-partisan, while engaging with each family member. It is important to bear in min d that although the family has come hoping for help, they may also have feelings of failure or guilt related to their child \200\231s problems which one must be sensitive to. Who should attend the assessment Flexibility is important when assessing children and their families. Usually it is advisable to invite the child along with whoever lives in the fami ly home. The standard \200\230nuclear family \200\231 is far less common nowadays with sin gle par- ent and reconstituted families, kinship care, and professional foster care featuri ng prominently. It is helpful to \201 nd out who is in the room with you at the start of the assessment. Older adolescents may live away from home, perhaps alienated from their fam ilies. Thus sensitivity to individual circumstances is mandatory. Sometimes it is helpful f or other people to attend, e.g. the social worker, where this would aid in understanding a family \200\231s dif \201 culties, facilitate joined-up working, or support the family in attending and using the appointment. Communication A number of factors in \202 uence how one communicates with the family membe rs in the room, including: the level of the child \200\231s development; the presence of me ntal or physical disorder, e.g. autistic spectrum disor- der, deafness; and the language sp oken (an interpreter may be required). Developing skills for communicating well is essentia l for making a good assessment. 16_Semple_Chap16.indd 612 12/7/2012 3:48:59 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 614 Assessment 2: practice Starting the interview with the family \200 \200 Introduce yourself and clarify who is in the room with you. Allow the family to settle by e xplaining the purpose and duration of the appointment. If a one-way screen is in use explai n this. Discuss con \201 dentiality and the limits of this, particularly in relation to ch ild protection. Identify who will be sent copies of any letters produced following the asse ssment. It is common practice for letters to be copied to families if they wish this. Provi de age-appropriate toys and drawing materials to younger children. Establish \200\230rules \200\231, e.g. all toys are put away at the end of the session. Taking a history \200 \200 \200 Throughout the history, facilitate each person \200\231s participation. Obtain a descriptio n of the problem as each person sees it. Obtain the family history and construct a genogram . This is useful in gathering information about family members \200\231 relationships, upbr ingings, and mental and physical health. Enquire about school, hobbies, and peer relationsh ips. Take a developmental history for each child in the family. Particularly with adolescen ts, enquire about substance use and forensic activity. What has already been tried and have any other agencies been involved? Often there will be aspects of the history which either the child or the adults are unwilling to discuss in front of the other. It is important to allow individual time for a full history to emerge, while remembering that people often eit her know or suspect these secrets. \200 \200 Mental state and observations \200 Observe family functioning and interactions. Note patterns of communication, degree of warm th, power dynamics, alliances, etc. The mental state examination follows a similar pattern to that for adults, but with allowance for the child \200\231s level of development. It wil l be dif \201 cult to conduct a formal mental state examination on children under age 12, but one can comment on observable aspects, e.g. levels of activity and attention; physical and mental level of development; mood and emotional state; quality of social interaction; r esponse to boundary setting. Sometimes it is appropriate to carry out physical examination at this interview \200\224e.g. low weight anorexia \200\224usually have a parent/other chap erone present. 16_Semple_Chap16.indd 614 12/7/2012 3:49:00 PM ASSESSMENT 2: PRACTICE 615 Interview with the child alone \200 It is usually helpful to offer to meet with the child alone, particularly for adolescents f or whom greater independence is developmentally appropriate. Establishing rapport and gaini ng the child \200\231s con \201 dence are primary objectives of the \201 rst interview. Young children should be invited to play, draw, etc. Clarify con \201 dentiality and excep tions to this again with the child, using age-appropriate language. Begin with subjects wel l away from the presenting problem (e.g. interests and hobbies, friends and siblings, schoo l, holidays). Progress to enquiring about the child \200\231s view of the problem, worries, fears, sleep and appetite, mood, self-image, peer and family relationships, experiences of bullying or teasing, abuse, persistent thoughts, fantasy life, abnormal experiences, suici dal thoughts, etc. (It may take more than one interview to obtain a full picture.) Gathering other information \200 Obtain consent to contact school for a classroom observation, meeting, or report from teach ers. Consult other caregivers, health professionals who have treated the child, social agen cies that have been involved with the child and/or family, and educational psychology if in volved. Consider using rating scales (e.g. Connor \200\231s Questionnaire, Moods and Feelin gs Questionnaire, CY-BOCS, K-SADS as indicated). It will sometimes be appropriate to reques t other assessments, e.g. speech and language, occupational therapy, neuropsychology, educa tional psychology, or to arrange physical investigations, e.g. hematology, chromosome studi es, EEG, CT. Formulation of the problem \200 Consider the problem in terms of biological, psychological, and social aspects, and identif y predisposing, precipitating, perpetuating, and protective factors. Use this along with a risk assessment to develop a management plan. Involvement of the family in this, and in its execution, is likely to be bene \201 cial. Consent/capacity/legislation \200 An assessment of a young person \200\231s capacity, and ability to give consent, is importa nt. Details of this vary across the UK. It is important to familiarize yourself with legisl ation around capacity and consent/refusal of treatment, as well as Mental Health and Childr en \200\231s Acts (if applicable) in your jurisdiction. 16_Semple_Chap16.indd 615 12/7/2012 3:49:00 PM CHAPTER 16 Child and adolescent psychiatry 616 Development An understanding of normal child development is essential to assess- ing and wo rking with children. Differentiating \200\230normal \200\231 from \200\230abnormal \200 \231 can be dif \201 cult in young people since they are subject to developmental change a nd thus \200\230normality \200\231 evolves and varies according to differing age. Furtherm ore, what is normal may vary according to the family, social, reli- gious, and cultural env ironment. Models of normal childhood experience and behavior that are based solely on the n orms of a particular society may be completely inappropriate in a different context. Having said this, there are a number of core \200\230norms \200\231 that transcend societal barr iers, and likewise there are a number of mental disorders that have been shown to exist wor ldwide. Assessing development In assessing a child \200\231s development it is helpful to consider the following areas which show signi \201 cant changes during development: \200 \200\230Theory of mind \200\231 is the ability to attribute beliefs, knowledge, and desire s to oneself, and to understand that other people also hold beliefs, knowledge, and desires which may differ from one \200\231s own. This allows the child to understand concepts such as deception, that others may hold different beliefs, and distinguishing fantasy from real ity. The pre-school child will rarely acknowledge their own or others \200\231 thinking. It is not until around age 10 that an awareness of different types of cognitive processes, e. g. memory, reasoning, comprehension, develops. Emotional development involves the skills of emotion differentiation, acceptable expression of emotion, and emotional containment/ conc ealment. Emotional and social development are closely linked. Social development including type of play (solitary, parallel, co-operative), friendships, social skills, and popularity . Cognitive development involves a number of mental processes including understanding, beli eving, calculating, reasoning, inference, and conceptualizing. Physical development includi ng the acquisition of motor and language skills. Moral development. Adolescence Adolescents deserve a special mention as their greater physical maturity can le ad one to have adult expectations of them. Adolescence is not just a blend of childhood and adulthood; it is a stage with unique biological and social characteristics of its own. Ado lescence is a relatively new social phenomenon, since the age of puberty has steadily dropp ed while educa- tion has become prolonged over the last few centuries. This means that, par ticularly in the developed world, individuals achieve physical and sexual maturity before t hey assume adult roles. Different sociocultural in \202 uences will inevitably also shape the normal adolescent presentation. 16_Semple_Chap16.indd 616 12/7/2012 3:49:00 PM DEVELOPMENT 617 Biological factors de \201 ning adolescence include the achievement of sexual maturity as well as the physical and cognitive changes resulting from hormonal shifts which allow the d evelopment of new abilities. Social development is also accelerated with stronger peer rela tionships and in \202 uence. These physical, cognitive, and social changes lead to the ach ieve- ment of autonomy. Adolescence is also a time of identity formation which involves exp erimentation and which can lead to con \202 ict with authority. Abnormal adolescent develo pment is characterized by inability to adjust to these physical, sexual, and social changes , or by impaired development in these areas. I would there were no age between ten and three-and-twenty, or that youth would sleep out t he rest; for there is nothing in the between but getting wenches with child, wronging the a ncientry, stealing, \201 ghting. Shakespeare: The Winter \200\231s Tale, Act III Scene 3 16_Semple_Chap16.indd 617 12/7/2012 3:49:00 PM CHAPTER 16 Child and adolescent psychiatry 618 Resilience De \201 nition \200\230Resilience refers to the process of, capacity for, or o utcome of, successful adaptation despite challenging or threatening circumstances. \200\231 Masten et al. 1990. \200\230A resilient child can resist adversity, cope with uncertainty and recover more suc cessfully from traumatic events or episodes. \200\231 Newman 2002. Factors promoting resilience \200 Child: and male gender during, adolescence; higher IQ; good social skills with peers and ad ults; feeling of empathy with others; sense of humor; attractiveness to others; awareness o f strengths and limitations. Family: parental harmony; a valued social role, e.g. helping s iblings; where parental con \202 ict exists, a close relationship with one parent. support ive extended family; successful school Environment: experiences; valued social role, e.g. j ob, volunteering, helping neighbor; a close relationship with an unrelated mentor; membersh ip of religious or faith community; extra-curricular activities. easy temperament and good nature; female gender prior to, warm and supportive parents; good parent \200\223child relationship; The importance of resilience Children with mental health problems usually have historical a nd cur- rent adversities which are affecting their functioning. They will also have qualiti es in themselves, their families, or their environment which promote resilience \200\224the ir ability to \200\230bounce back \200\231 from adversity. The identi \201 ca- tion and p romotion of these qualities during assessment and management enhances the formulation and r ecognizes resources the child and family can draw on. Resilience is also important in understanding those children who do not develop psychopatho logy despite signi \201 cant stress and adversity. This has relevance for Tier 1 CAMHS pre ventative work, as the promotion of resil- ience factors in children may prevent or inhibit the development of mental disorder, e.g. emotional health cognitive behavioral therapy pro grams delivered on a whole class basis in schools. 16_Semple_Chap16.indd 618 12/7/2012 3:49:00 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 620 Attachment Attachment refers to the strong emotional bond that exists between a child and a caregiver. It develops through appropriate, sensitive parental responses to the child \200 \231s behavioral cues. It allows the child to develop understanding of his \200\230inner w orld \200\231 and how to understand the world around him. It is the foundation for safe sep aration and development of autonomy, and establishes beliefs about the value and reliabilit y of rela- tionships in the child \200\231s mind. The effectiveness of parental attunement per- manently in \202 uences the hypothalamic \200\223pituitary \200\223adrenal axis and t hus the baseline around which stress responses are modulated. This has lifelong implication s for emotional and behavioral regulation and mental health. Early satisfactory care is par ticularly important. Types of attachment \200 \200 Secure: Insecure avoidant: value relationships. Insecure anxious: relationships but sees th em as unreliable. Develops strategies for achieving attention. Insecure ambivalent: safety. Disorganized: relationships. child values relationships and is con \201 dent of self-worth. child appears emotionally independent, does not self-worth depends on approval of others. Values values relationships but is cautious about their neither effectively self-suf \201 cient nor able to use Attachment styles are not \201 xed and can coexist. Parental attunement and style heavily in \202 uence attachment. Considering attachment in the psychiatric interview In addition to observations of the chil d \200\231s interactions with parents/ caregivers during the assessment interview, also con sider: \200 Factors that can affect parental attunement, e.g. parental mental illness, LD, substance mi suse, social chaos, domestic violence. Child \200\231s experiences, e.g. signi \201 cant s eparations, change of carers, abuse. Enquire about: understanding of \200\230inner world \200\231 (e.g. pain, hunger, satiety); outside world (e.g. social norms, awareness of dange r, stress regulation); explorative behavior (e.g. inquisitiveness, cognitive and motor skil ls); and understanding of relationships (e.g. bene \201 ts, communication, empathy). Disor dered attachment can closely resemble other disorders, e.g. ADHD, autism spectrum disorder (ASD). Furthermore, it increases the risk of many mental disorders developing. 16_Semple_Chap16.indd 620 12/7/2012 3:49:00 PM ATTACHMENT 621 Management of attachment problems Management is primarily aimed at improving attachment and therefore requires comprehensive assessment to determine what is required for attachment n eeds to be met. This may include health, social care, and education agencies. \200 \200 Build on strength and resilience in child and parent. Provide appropriate support and educa tion to parent. This could include behavioral management work, support groups, respite care , and help with parental mental health problems. Work with child may be helpful, e.g. reduc e stress, increase emotional awareness, and reduce temper. It is important to remember that individual work with the child will be far less in \202 uential than the successful modi \201 cation of primary relationships in improving attachment, and the consequent emotional and behavioral problems. Support and liaison with school. Treat mental disorder, e.g. ADHD , PTSD, depression. If the child \200\231s needs cannot be met, even with all support, it m ay be in the child \200\231s best interests to be accommodated away from the family home. \200 \200 Reactive attachment disorder This disorder re \202 ects a disturbed pattern of social rela tedness, is diag- nosed before age 5yrs, and may manifest as either inhibited or disinhib- ited subtypes. It represents the severe end of the spectrum of disordered attachment. 16_Semple_Chap16.indd 621 12/7/2012 3:49:00 PM CHAPTER 16 Child and adolescent psychiatry 622 An approach to behavioral problems Children, and to a lesser extent adolescents, often pres ent with behav- ioural problems rather than complaints of stress or depression. They may no t have the necessary level of development to recognize and then express these feelings; and they are often brought to services rather than referring themselves, therefore it is the o bservable problem, i.e. the behavior, that is presented. Differential diagnosis of various behavioral \200\230symptoms \200\231 Common behavioral p resentations include hyperactivity, inattention, separation problems, moodiness, peer/socia l problems, aggression/oppo- sitionality, sexually inappropriate behavior, regressed behavi or, somati- zation, tantrums, and rituals. Since individual \200\230symptoms \200\231 can occur in more than one disorder, it is wort h considering a differential diagnosis for the presenting behavioral symptom. It is also ex tremely important to differentiate a clearly maladap- tive behavior from one that is develo pmentally or situationally appropri- ate. \200\230Normal \200\231 behaviors also include t hose that form part of the child \200\231s expected testing and experimentation of the worl d. Assessment of behavioral disorders \200\224general principles \200 \200\224obtain a full description (from Identify the problem behavior/s parents, child, teachers, etc.) of the problem behavior/s. This should include the evolution of the behavior, a chronology of the child \200\231s typi cal daily activities, the setting in which the behavior occurs, its effects on family, scho ol, relationships, etc. and attitudes of others to the behavior/s. It is always appropriate to speak to the child alone (if possible) to establish his/her views, desires, and mental state. Determine the parental strategy the parents deal with the behavior/s. Do they agree with each other? This also includes information about their expectations, philosophy of par enting, interpretation of the behavior/s, moral, religious, and cultural views on parenting , etc. How do the parents react or respond to the behavior/s? How do they discipline or pun ish? What do they tolerate? Are they permissive or restrictive? Are they over-protective or uninvolved? Do they feel empowered or impotent, helpless, and incompetent as parents? How do they manage their frustrations, anger, etc.? What coping mechanisms do they have? Family history and dynamics of health, psychiatric problems, social and cultural circumstances, a nd support structures, it is also important to assess parental and sibling relationships, t he presence of any signi \201 cant stressors or losses, and how the problem behavior inter acts with family dynamics. Social behavior including social developmental, attachment behav ior, imaginary play, reading of social cues, relationships, and language use. School behavi or performance, peer and teacher interactions and responses, friendships, bullying, etc. \200\224it is important to \201 nd out how \200\224as well as gathering a full family history \200\224the evolution of the child \200\231s social behavior, \200\224attendance, changes in school, separation issues, 16_Semple_Chap16.indd 622 12/7/2012 3:49:00 PM AN APPROACH TO behavioral PROBLEMS 623 Child \200\231s health and development developmental milestones. Was the child planned, wan ted? How did siblings react? How did parents and siblings cope? Any post-partum problems? W as any professional support required? Also, child \200\231s temperament, illnesses, treatme nt, etc. Direct observation of parent \200\223child interaction it is important to note how the child behaves and how parents respond and interact with the child. If siblings can be present their behavior and interactions can also be evaluated. A home and/or school visit m ay add additional information about the behavior in these settings. Collateral information may be able to provide important input, and permission should be sought to contact and invo lve them where appropriate. \200\224pregnancy, birth, and \200\224during the interview \200\224teachers, extended family, and social services Management This will be informed by the assessment, but generally it is useful to help the child and family understand the thoughts and feelings contributing to the behavior. This ai ds in both reducing negative interpretations of the behavior and in helping to change the p roblem behavior. More speci \201 c management issues are addressed under topic headings. 16_Semple_Chap16.indd 623 12/7/2012 3:49:01 PM CHAPTER 16 Child and adolescent psychiatry 624 Conduct disorders The conduct disorders are characterized by a repetitive and persistent pa ttern of antisocial, aggressive, or de \201 ant behaviors that violate age- appropriate so cietal norms. Conduct disorders can be divided into con- duct disorder (CD) and oppositiona l de \201 ant disorder (ODD). Conduct disorder Epidemiology Commoner in boys and in urban populations. Prevalence 5 \200 \2237% in UK. Clinical features Aggression/cruelty to people and/or animals, destruction of property, dec eitfulness, theft, \201 re-setting, truancy and running away from home, and severe provoc ative or disobedient behavior. These behaviors result in signi \201 cant impact on family and peer relationships, and schooling. ICD-10 requires 1 or more feature at a marked level for over 6mths; DSM-IV requires 3 or more over 12mths, with 1 in last 6mths. Etiology/associations \200 Social disadvantage: homelessness, social isolation, high comm unity rates of deviancy, truancy, unemployment. Parenting: substance misuse, inconsistent a nd critical parenting style, parental con \202 ict, teenage pregnancy, single parenthood. Child: dif \201 cult/under-controlled temperament, attachment problems, and poor interpers onal relationships. poverty, low socio-economic class, overcrowding, parental criminality, parental psychiatric disorder and low IQ, neurodevelopmental problems, brain damage, epilepsy, Comorbidity ADHD; learning dif \201 culties (especially dyslexia); substance abuse; depres sion; anxiety disorder; autism spectrum disorders (ASD). Differential diagnosis adjustment disorder; ADHD; ASD; normal child (but parents/teachers h ave unrealistic expectations); PTSD; anxiety disor- der; depression; learning dif \201 cul ty; psychosis; subcultural deviance. Course and outcome \200 \200 Persistent disorder, particularly where onset is younger. Around half will receive a diagno sis of antisocial personality disorders as adults. Substance misuse, mania, schizophrenia, OCD, major depressive disorder, and panic disorder are also seen in adult life. There is an increased risk of early death, often by violent and sudden means. Increased risk of social exclusion, poor school achievement, long-term unemployment, criminal activity, and poor in terpersonal relationships including those with their own children. Assessment \200 \200 See family and child. Obtain a full history with collateral from school, social worker, and legal system. Identify causal, risk, and protective factors. Assess for comorbidity and ma ke a diagnosis. Formulate the problem and establish management plan. \200 \200 16_Semple_Chap16.indd 624 12/7/2012 3:49:01 PM CONDUCT DISORDERS 625 Management of CD This will be planned on a case-by-case basis, and is likely to require mul ti- agency communication and co-operation. Possible components include: b p. 667). NICE rec ommends group- \200 Parent management training ( based parent-training/education programs in children aged 12yrs or younger, e.g. Webster \200\223Stratton incredible years program, positive parenting program (Triple P). It sets out criteria that such programs should demo nstrate. Individual-based programs are recommended only in situations where there are parti cular dif \201 culties in engaging with the parents, or a family \200\231s needs are too c omplex to be met by group programs. Functional family therapy. Multi-systemic therapy \200 \224family-based, including school and community. Highly resource-intensive, but good outco mes (Box 16.1). Child interventions \200\224social skills, problem-solving, anger managemen t, con \201 dence building. Treat comorbidity. Address child protection concerns. \200 \200 Oppositional de \201 ant disorder (ODD) Essence An enduring pattern of negative, hostile, and de \201 ant behav- iour, without serious violations of societal norms or the rights of others. Behavior may occur in one situation only (e.g. home) and tends to be most evident in interactions with familiar adults or peers. Epidemiology More common in boys and in childhood rather than adoles- cence. Prevalence 2 \200\2235%. Outcome A fourth show no symptoms later in life but many progress to CD and/or substance ab use. Management Same management principles as for CD (see above). Box 16.1 Prevention strategies and policy implications \200 Pre-school child development programs parents and families at risk and instituting home vis its and support. School programs classroom enrichment, home visits, and parent and teacher training. Community programs through their involvement with social agencies and institute i nterventions such as enhanced recreation programs, parent training, and adult mentoring of youth. Social and economic restructuring improve family and community stability. \200\224identifying \200\224identify children at risk and institute \200\224identify children and adolescents to reduce poverty and to 16_Semple_Chap16.indd 625 12/7/2012 3:49:01 PM CHAPTER 16 Child and adolescent psychiatry 626 Attention de \201 cit hyperactivity disorder (ADHD) ADHD is characterized by the three cor e symptoms of inattention, hyper- activity, and impulsiveness. DSM-IV recognizes 3 subtypes : a combined sub- type where all 3 features are present, an inattentive subtype (ADD), and a hyperactive-impulsive subtype. The DSM-IV de \201 nition of severe combined- type ADHD i s similar to the ICD-10 de \201 nition of hyperkinetic disorder. Symptoms should be at dev elopmentally inappropriate levels, be present across time and situations for at least 6mnth s, and starting before age 7. 5% of UK school children would meet DSM-IV ADHD diagnostic cr iteria, 1% would meet criteria for ICD-10 hyperkinetic disorder. It is at least 4 times com moner in males. Etiology 80% of cases are genetically inherited and risk of ADHD in sibling s is 2 \200\2233 times increased. Rates are increased in low birth-weight babies and babies born to mothers who used drugs, alcohol, or tobacco during pregnancy, following head injur y, and in some genetic and metabolic disorders. Differential diagnosis Age-appropriate beha vior in active children; attachment disorder; hearing impairment; learning dif \201 culty; a high IQ child insuf \201 ciently stimulated/challenged in mainstream school; behavioral disorder; anxiety disorder; medication side-effects (e.g. antihistamines). Comorbidity ADH D is highly comorbid with 50 \200\22380% of children having a comorbid disorder, including: speci \201 c learning disorders, motor- co-ordination problems, autism spectrum disorder, tic disorders, CD, ODD, substance abuse, anxiety, depression, bipolar disorder. Clinical features of ADHD \200 Inattention not to listen, fails to \201 nish tasks, poor self-organization, loses things , forgetful, easily distracted, and avoids tasks requiring sustained attention. Hyperactivi ty or feet, leaves seat in class, runs/climbs about, cannot play quietly, \200\230always o n the go \200\231. Impulsiveness interrupts others, intrudes on others. Careless with detail, fails to sustain attention, appears Most evident in structured situations, \201 dgets with hands Talks excessively, blurts out answers, cannot await turn, Problems associated with ADHD \200 Short-term: sleep problems, low self-esteem, family and peer relationship problems, reduced academic achievement, and increased risk of accidents. Longer term: development of comorbi d problems (see Comorbidity), reduced academic and employment success, increased criminal a ctivity, and antisocial personality disorder. ADHD symptoms may persist into adulthood (20 \200\22330% with full ADHD syndrome and 760% with 1 or more core symptoms). Impulsivity \200\223hyperactivity remits early, while inattention often persists. Studies show a patter n of psychopathology, 16_Semple_Chap16.indd 626 12/7/2012 3:49:01 PM ATTENTION DEFICIT HYPERACTIVITY DISORDER 627 cognition, and functioning in adults similar to that in children and adolescents. A poorer prognosis is associated with social deprivation, high expressed emotion, parental mental il lness, predominantly hyperactive-impulsive symptoms, CD, learning dif \201 culty, language disorder. 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 