 \200 \200 \200 \200 16_McClure_16.indd 575 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 576 Asking the dif \201 cult questions About sexual abuse See also b pp.801, 1002. Sexual and other forms of abuse are common speci \201 c and non-speci \201 c vulnerability factors f ors poor mental health and must be excluded as aetiological factors. The clinician \200\231 s task is to \201 nd an approach to asking about abuse that they are comfortable with and appear to the child to be comfortable with. One approach is a hierarchical set of question s. \200 \200 \200\230I ask these questions to all children I see. \200\231 Introductory comment: Ask child to respond to a broad, non-leading statement: tell me somet hing has happened to them that they wish had never happened. \200\231 Child \200\231s respo nse may be verbal or non-verbal af \201 rmation, denial, or looking perplexed; they may no t understand the question at all. Ask more speci \201 c questions: \200\230Some things ar e done by other people \200\231 or \200\230 are touched in places they wished t hey had not been touched. \200\231 Ask very speci \201 c questions: \200\230Some people a re touched in places like their private parts/vagina/penis (language depends on age, may al so point or draw picture), has this happened to you? \200\231 \200\230Some children Partial af \201 rmation or non-verbal cues that suggest possible abuse should be followed up during later appointments. One caveat is there are differ- ences between a purely forens ic and a clinical interview. In both settings open, non-leading questions are preferable. L ocal protocols will also guide assessments. About suicidal ideation and intent Clinicians must ask about suicidal thinking, especially in adolescents with any depressive features. Asking does not create or promote suicidal thi nk- ing. Again, a hierarchical approach is used effectively by many clinicians. \200 \200 Introductory comment: Ask adolescent to respond to a broad statement: \200\230Some young p eople tell me that they feel life is not worth living anymore. \200\231 Again look for resp onses that may be verbal or non-verbal af \201 rmation or denial. Ask more speci \201 c q uestions: to not be alive \200\231 or \200\230Some people think it would be better to be d ead. \200\231 Ask very speci \201 cally to clarify risk and extent of planning: thought of killing yourself? \200\231; \200\230Have you ever made a plan to kill yourself? \200\230 Have you ever lost control and started your plan? \200\231 \200\230I ask these questions to everyone I see. \200\231 \200\230Have you considered what it would be like \200\230Have you As above, partial af \201 rmation or non-verbal cues that suggest possible abuse should be followed up during later appointments. 16_McClure_16.indd 576 11/14/2012 3:42:46 PM ASKING THE DIFFICULT QUESTIONS 577 16_McClure_16.indd 577 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 578 Depression Loose usage of the words \200\230depression \200\231 and \200\230depressed \200\231 causes much con- fusion. They can refer to a mood, which may be appropriate, a sym ptom, or a mental disorder. Prevalence Approximately 10% of 10-yr-olds are reported by parents and teachers, and 20% of 14-yr-olds report themselves to be often miserable. However, the rate of diagnosable depre ssive disorder in a community sample of 11 \200\22316-yr-olds is closer to 3%. The discrepa ncy is due to those who suffer low moods, but do not meet full diagnostic criteria. Etiology Genes increase both the risk of developing depression and of experiencing negative life events. Post-pubertally females are twice as likely as males to become depressed and possible links to estrogen levels, either in utero or post-puberty, have been suggested. Fe males may also be more in \202 uenced by lack of positive relationships, close friendships , or a supportive peer network. Environmental factors include; early adversity and attachme nt dif \201 culties, negative or traumatic life events or abuse, death of a parent, drug a nd alcohol abuse, and bullying. Psychosocial factors include; social isolation and negative interpersonal relationships, poor academic achieve- ment, unstable family environment, par ental drug and alcohol abuse. Clinical features Diagnosis of depressive disorder requires that mood is persistently lower ed and accompanied by a loss of interest and enjoyment and/or increased fatigability for mo re than 2wks with a signi \201 cant effect on func- tioning. There should also be at least two of the following symptoms; \200 \200 \200 \200 \200 \200 \200 Reduced concentration and attention. Reduced self-esteem and self-con \201 dence. Ideas of guilt and unworthiness. Bleak and pessimistic views of the future. Ideas or acts of self-h arm. Diminished appetite. Disturbed sleep. Depressive disorders are frequently recurrent so it is always important to ask about past e pisodes. Dysthymia is a chronic enduring depressed state lasting for over a year, but without the intensity of a depressive episode. Amongst those referred to child psychiatric clinics, comorbidity is com- mon, e.g. conduct disorder, obsessive compulsive disorder. Management1 Initial assessment should identify: \200 \200 \200 Signi \201 cant risk of self-harm or suicide. Signi \201 cant lack of self-care or neglec t. Symptoms of manic episode or psychotic disorder. 16_McClure_16.indd 578 11/14/2012 3:42:46 PM DEPRESSION 579 \200 Comorbid psychiatric disorder. Previous history of moderate or severe depressive episodes. When these are present, referral to a specialist child and adolescent men- tal health servi ce is appropriate First line treatment for mild depressive disorder with symptom duration less than 4wks Supp ortive therapy and psychoeducation about depressive disorders are effective \201 rst line interventions in 30% of children and adolescents with recent onset of mild to moderate dep ressive symptoms. Advice should be given on sleep hygiene, nutrition, activity, and exercis e. If there is no response to supportive management after 2 \200\2233mths, young people sho uld be referred to Tier 2/3 CAMHS services for more intensive psychological therapy. Treatment for moderate to severe depressive disorders Psychological therapies are recommend ed as \201 rst line treatments for treating child and adolescent depressive disorders. Re commended prac- tice is that a block of psychological therapy should be undertaken prior to consideration of antidepressant medication. Supported approaches are cognitive behavioral therapy (CBT) and interpersonal therapy. Brief fam- ily therapy may be effective in some ca ses. Response to treatment should be reviewed after 12wks If there is a good response to treatme nt the course of therapy should be completed and follow up should be provided for 12mths af ter remission of symptoms (or 2yrs if the patient has had one or more previous episode of d epression). Where there is a poor response to treatment after 12wks the assess- ment, formulation, and treatment plan should be reviewed and comorbid diagnoses considered and any signi \201 can t environmental factors investi- gated. If a diagnosis of depression remains, consider alte rnative psycho- logical therapy and/or antidepressant medication. The most commonly used me dications are the selective serotonin re-uptake inhibitor antide- pressants. Recently there has been concern about side-effects (including increased suicide) as well as ef \201 cacy . In the UK \202 uoxetine is the only medication that is currently recommended for use as an antidepressant in children. Tricyclics appear ineffective and should not be used. Prognosis Whilst recovery from a depressive disorder is likely, this may take months or in some cases years. Prognosis is worsened by increasing severity of disorder and by the prese nce of comorbid oppositional de \201 ant disorder. Even in those who have made a good reco very, further depressive epi- sodes are not uncommon. Prolonged follow-up is, therefore, wi se. Reference 1 National Collaborating Center for Mental Health (2005) Depression in children a nd young people. British Psychological Society. London: BPS. M http://guidance.nice.org.uk/ CG28/Guidance/pdf/ English. 16_McClure_16.indd 579 11/14/2012 3:42:46 PM CHAPTER 16 Child and family psychiatry 580 Suicide and non-fatal deliberate self-harm Suicidal thoughts are common; they become abnorm al when there is intent and/or plan when suicide is considered the only option. \200 Suicide the teenage years. It is the fourth commonest cause of death in the 15 \200\22319-y r age group (UK, 4 \200\2238 per 100,000) with a male:female ratio of 4:1. is far more comm on, with some 7% of Non-fatal deliberate self-harm those aged 15 \200\22316yrs having engag ed in an act of deliberate self-harm in the previous year, and 10% in an act of deliberate self-harm in their lifetime. Actual self-harm is more common in females, with a female:male ratio of reported self-harm in the previous year of 4:1. Thoughts of self-harm are also mo re common in females, with a rate of 22.4% girls and 8.5% boys. is very rare in pre-pubertal children, but incidence rises through Predisposing characteristics to completed suicide include: \200 Psychiatric disorder (such as conduct disorder, depression, substance misuse, ADHD and psyc hosis). Social isolation. Physical illness. Low self-esteem. \200 \200 Relevant family factors include a family history of abuse and neglect or of psychiatric ill ness and suicide, and family dysfunction. Methods of self-harm Those who kill themselves use a range of methods, most commonly: \200 \200 \200 \200 \200 drug overdose; inhaling car exhaust fumes; hanging; suffocating; shooting (in countries whe re guns are easily accessible). The majority of non-fatal deliberate self-harm is through overdosing, gen- erally with anal gesics or prescribed drugs. Cutting is very common, particularly amongst adolescent girls. Unless the cutting is deep a nd over the site of major blood vessels, it should not be seen as necessarily linked to sui cide or attempted suicide. Those who cut describe it as easing a build-up of bad feelings, resolving emotional numbness, or sometimes as a form of self-punishment. Assessment Careful assessment should happen soon after the self-harm. It should include the young person, the family, and information from other sources such as the family doctor or social services. Initial assessment should identify: \200 \200 \200 Injuries from self-harm. Likely/potential effects of ingestion of substance. The child/youn g person \200\231s capacity to consent to or refuse treatment. 16_McClure_16.indd 580 11/14/2012 3:42:46 PM SUICIDE AND NON-FATAL DELIBERATE SELF-HARM 581 \200 Presence or absence of mental illness. Risk of further episode of self-harm. Appropriate medical treatment should be provided. A further separate interview should be co nducted with the child once the acute situation is stable. Take a general history and addre ss: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 History of act of self-harm. Circumstances leading up to self-harming behavior. Degree of s uicidal intent at time of deliberate self-harm. Intensity, frequency and duration of self-h arm thoughts. Behavior at time of overdose/self-harm. Impulsivity or planned nature of the self-harm episode. Help seeking or help avoiding behavior. Ongoing plans for further self-h arm or suicide. Previous history of self-harming behaviors. A full mental state assessment. A clinical interview with the parents should include: \200 \200 \200 \200 A corroborative history of events surrounding self-harm episode. An exploration of parental response to the episode of self-harm. An assessment of family functioning and support for the child. Identi \201 cation of symptoms suggesting a psychiatric disorder. Management First treat the physical effects of the self-harm episode and arrange a men- tal health assessment. Following risk assessment, make sure that appropri- ate levels of super vision are in place. Consider access to medication and other means of self-harm. If there a re signi \201 cant concerns about ongoing suicide risk, consider admission to an inpatient unit. If there are concerns about child protection, a referral should be made to social wo rk. Treat any comorbid psychiatric disorder. Management options for deliberate self-harm. Aims of intervention \200 \200 \200 \200 Address self-esteem issues. Improve interpersonal skills and address relationship dif \201 culties. Improve communication skills. Learn more helpful ways to communicate emotions. Family work Family support and counseling with more structured and intensive family therapy may be appropriate. School based interventions \200 \200 \200 Entire school programs focusing on self-esteem peer relationships. Peer support programs. D evelopment and implementation of anti-bullying policies in school. Prognosis 10% of those w ho self-harm will repeat within a year. A sig- ni \201 cant proportion will kill themselve s within 5yrs \200\2244% of girls and 11% of boys. 16_McClure_16.indd 581 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 582 Bipolar disorder The diagnosis of bipolar disorder (BiPD) in children and adolescents remai ns controversial due to concern about how best to operationalize and apply the diagnostic c riteria to children and young people in general and pre-pubertal children in particular. Prevalence There have been few epidemiological studies addressing this issue. All epidemiol ogical studies have reported mania as being very rare or non- existent in prepubertal child ren. A number of epidemiological surveys of 9 \200\22318-yr-olds estimated the prevalence o f mania to be between 0 \200\2230.6%. Large retrospective surveys of adults with bipolar di sorder have noted that onset before age 10 occurs in 0.3 \200\2230.5% of patients, although many more described mood symptoms (commonly depression) beginning in childhood. Over recen t years several groups in the US have proposed that early onset bipolar disorder is much mo re common than previously reported. A closer inspection of these cases (most of whom have A DHD and/or oppositional de \201 ant disorder) suggests that they do not in fact meet the f ull diagnostic criteria and that they are probably better charac- terised as having severe mood dysregulation. Clinical features Because of the controversy surrounding the recent increases in the diag- nosis of early onset bipolar disorder, and the symptom overlap with other disorders, clinic ians are recommended to reserve this diagnosis for those who have clearly met the diagnosti c criteria for a manic episode. The symptoms with the best speci \201 city are; \200 \200 \200 \200 \200 \200 elevated mood; grandiosity/in \202 ated self-esteem; pressured speech; racing thoughts; de creased need for sleep; hypersexuality. Differential diagnosis Differential diagnoses include, schizophrenia, schizoaffective disor der, ADHD, conduct disorder, substance abuse, autism spectrum disorders, organic causes, e. g. acute confusional states, epilepsy (pre or post ictal confusional states) and medication side effects, e.g. akathisia due to neuro- leptics. Sexual, emotional, and physical abuse may present with hypervigi- lance, disinhibition, and hypersexuality. Management The current evidence for both drug and psychological treatments of bipo- lar dis order in children and adolescents is extremely limited and treatment should be carried out by specialist child and adolescent mental health services. The goals of therapy will includ e reduction in core symptoms, psycho-education, relapse prevention, and facilitating normal growth and development. 16_McClure_16.indd 582 11/14/2012 3:42:47 PM BIPOLAR DISORDER 583 Pharmacotherapy Most of the recommendations for the pharmacotherapy of BiPD in child- ren a nd adolescents are based on \201 ndings in adults. Neither the effective- ness nor the sa fety of anti-manic (this term is used as there is no agreed de \201 nition of mood stabili zer), antipsychotic and anticonvulsant medica- tions in early and adolescent onset bipolar disorder is not yet established. To date only lithium in licensed in the UK for treatment o f bipolar disor- der in those 12yrs and older. Prognosis Longitudinal studies show: \200 Children with ADHD do not have an increased risk of BiPD in later life. No studies have dem onstrated that pre-pubertal mania progresses to the classic adult disorder. Very low rates of conversion of depression to mania among pre- pubertal children. Adolescent onset BiPD te nds to have a relapsing and remitting course similar to adult presentations. Around 20% of adolescents who have an episode of major depression experience a subsequent manic episode b y adulthood. This is predicted by: \200 depressive episode of rapid onset with psychomotor retardation and psychotic features; fami ly history of affective disorder especially mania; history of mania or hypomania following antidepressant treatment. \200 Adolescents presenting with an initial manic episode show higher relapse rates (appr oximately 50% during 5yr follow-up). The presence of psychosis is associated with chronicit y. 16_McClure_16.indd 583 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 584 Anxiety disorders Diagnostic criteria One disorder is speci \201 c to children and adolesc ence: separation anxiety disorder (SAD). Other anxiety disorders that may occur in children and adolescents include: generalized anxiety disorder (GAD), panic disorder (with and with out agoraphobia), simple and social phobias, and post- traumatic stress disorder (PTSD). Sp eci \201 c physical and cognitive symp- toms are described for each disorder. Developmenta l principles apply. \200 Very young children experience \200\230stranger danger \200\231, later simple phobias, and SAD with the beginning of the school years. Middle childhood presentations include fears o f animals, the dark, burglars, and anxiety-related abdominal pain. A recrudescence or \201 rst presentation of SAD may occur at the onset of secondary schooling. Adolescents may experience social phobia, and panic with or without agoraphobia. Prevalence Rates vary by disorder. SAD and GAD are not uncommon presentations to tertiary c linics. Panic disorders are less common. Differential diagnosis Child abuse may present as an anxiety disorder. Anxiety and depressi on often co-occur and mood should always be assessed. Acting out behavior may be due to anx iety. Truancy must be differentiated from school refusal s to separation anxiety. Prominent physical symptoms, esp. without typi- cal anxiety-related onset (e.g. Monday morning stoma ch pains), should be investigated. Occasionally, you must decide \200\230who has the anxie ty \200\231, the child not wanting to go to school or the parent. Treatment CBT is the treatment of choice for anxiety disorders, general principles include the following: \200 Clarity of diagnosis and psycho-education of child and parents (over- investigation often c auses more anxiety). Helping child to face their fears, usually by hierarchical desensitiza tion. Rapid exposure techniques ( \202 ooding or implosion) are rarely used. Identi \201 cation of unhelpful, distorted, or maintaining cognitions, challenging these cognitions, an d practicing more functioning thinking. Skills acquisition, e.g. progressive muscle relaxat ion, guided imagery. Parents as motivators and behavioral coaches. Early relapse identi \201 cation. \200 \200 Medication is usually reserved for when there is either no response or only an incomplete r esponse to psychological therapy. The selective serotonin reuptake inhibitors (SSRIs) have been shown to have short term bene \201 t in the treatment of anxiety disorders, in childr en and adolescents. 16_McClure_16.indd 584 11/14/2012 3:42:47 PM ANXIETY DISORDERS 585 Prognosis Untreated anxiety disorders predict later internalizing conditions in girls and e xternalizing disorders in boys. Short-term outcome of treatment is positive, especially in conjunction with parental support. 16_McClure_16.indd 585 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 586 Post-traumatic stress disorder Prevalence No unitary prevalence \200\224all traumatic event s vary in threat exposure and individual responses vary by developmental stage, past experi ences, and competencies. Prevalence varies from 100% of children taken hostage to 10% after natural disasters. Girls may report more PTSD symptoms. Diagnostic criteria A range of psychopathology may be experienced following an emotionally traumatic event, dependent on pre-existing vulnerabilities, event expo- sure, and related l oss and grief. PTSD occurs as a response to an excep- tionally threatening or catastrophic event. This leads to: \200 Re-experiencing phenomena: memories. Persistent avoidance of reminders of the trauma. e.g. nightmares, \202 ashbacks, and intrusive And either: \200 Inability to recall, either partially or completely, some important aspects of the period o f exposure to the stressor, or; Persistent symptoms of increased psychological sensitivity and arousal: e.g. dif \201 culty falling or staying asleep, irritability or outbursts of a nger, dif \201 culty concentrating, hyper-vigilance, exaggerated startle response. Emotional numbing and detachment is also often reported. Age-speci \201 c symptoms Younger children often present as regressed with altered sleep a nd feeding routines; exhibiting clingy, anxious, or aggressive behavior; or engaging in pos t-traumatic play. Young children cannot report emotional numbing or detachment; parents rep ort these symptoms as a \200\230personality change \200\231. Differential diagnosis Other anxiety disorders including event-related phobias, GAD, OCD, or, if of lesser severit y, an adjustment disorder. Comorbidity with depression is common. If trauma is repetitive e xpect disruptive behaviors in boys and early evidence of personality dysfunction in teenage rs. Treatment If severe, treatment can be complex and take time. Interventions include cognitiv e strategies such as identifying and modifying dysfunctional schema, behavioral strategies including prolonged re-exposure, skills acquisition such as relaxation techniques, supporti ve therapy, and family interven- tions to monitor for secondary impairment and altered fami ly function- ing. Eye movement desensitization and reprocessing (EMDR) has a role. Psychoph armacology may provide some symptomatic relief. 16_McClure_16.indd 586 11/14/2012 3:42:47 PM POST-TRAUMATIC STRESS DISORDER 587 Prognosis Many children seem to be resilient to traumatic events, but long-term problems in cluding symptom chronicity, generalization of fears, and generalized impairment have been r eported \200\224especially if parents have been unable to help the child manage their traum a. A history of chronic, repetitive trauma, such as sexual abuse, is overrepresented in oth er men- tal health presentations including drug and alcohol abuse, bulimia. 16_McClure_16.indd 587 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 588 Obsessive compulsive disorder Diagnostic criteria \200 Obsessions: recurrent persistent thoughts, images or impulses that are distressing, time-co nsuming and functionally impairing. Young people recognize these thoughts as their own, and perceive them as unhelpful and at times senseless. Compulsions: to neutralize anxiety caus ed by the obsessional thoughts or images. Rituals and habits: in form and content to compul sions in OCD, but: \200 \200 \200 mental or physical behaviors, completed in an attempt present in 2/3 pre-school children. They are similar are less frequent and intense; do not impact on functioning; do not cause distress. A diagnosis of OCD requires symptoms to be present on most days for at least 2 successive w eeks and be a source of distress or interference with activities. Children are not required to have insight into the nature of their thoughts to meet the criteria for a diagnosis of OCD. Prevalence Prevalence of OCD in children and adolescents is estimated as 0.5%. This is lowe r than in the general population where estimates of prevalence vary between 1 and 3%. 30 \200\22350% of adults who have been diagnosed with OCD will have had symptoms before age 18 yrs. Onset is more common in boys pre-puberty and girls post-puberty. Treatment Age and developmentally appropriate psycho-education and guided self- help regard ing both the psychological and biological perspectives of OCD are essential components of t reatment for all children and young people. CBT (usually conducted in a 12-wk block of week ly therapy) and phar- macotherapy are effective and often required for more severe cases. F luvoxamine and sertraline are licensed for the treatment of OCD in children and adolescents . Prognosis The course of OCD may be acute or chronic. Longitudinal studies of adults who wit h a diagnosis of OCD suggest that prognosis is variable, but that most people fall into one of three patterns. 40% will recover and experience only mild symptoms, 40% will experience a \202 uctuating illness course with symptoms remitting and relapsing. 20% will develop chronic illness pattern. 16_McClure_16.indd 588 11/14/2012 3:42:47 PM ATTACHMENT DISORDER 589 Attachment disorder De \201 nition and diagnostic criteria The key feature of attachment d isorders is a pattern of abnormal social functioning that is apparent during \201 rst 5yr s of life, and is associated with a signi \201 cant disturbance in emotional functioning. These patterns persist into later childhood and adolescence in spite of changes in the chil d or young person \200\231s environment. Two patterns of attachment disorders are described ; Disinhibited attachment disorder Associated with an \200\230institutional \200\231 style o f care in early life, with care being provided by a number carers and the absence of a spec i \201 c primary care giver. The child is unduly friendly with strangers, does not seem to mind who looks after her/him, and forms super \201 cial relationships easily. Such childr en may be overactive, aggressive, show emotional liability, or poor- ly tolerate frustratio n. The incidence of disinhibited attachment disorder is not well characterized, but is rela tively low in the general population. Signi \201 cant rates of disinhibited attachment dis order are however, report- ed in children raised in institutional care from birth. Reactive attachment disorder These children fail to respond appropriately to social interac tions and dis- play a fearfulness and hypervigilance which is not responsive to reassur- an ce. Contradictory or ambivalent social responses may also be present. Parental abuse, negle ct, and severe maltreatment are highly signi \201 cant aetiological factors. The severity and duration of abuse or neglect in \202 u- ences the severity of the disorder. The preval ence of inhibited attachment disorder is low and not all children who experience signi \201 cant abuse and neglect will develop an inhibited attachment disorder. Differential dia gnosis Includes autism spectrum disorder, PTSD, ADHD, anxiety disorders, and selective muti sm. Treatment The focus of interventions is to ensure a secure nurturing care set- ting which p rovides consistent behavioral management and emotional responses. Infants and young childre n often have the capacity to alter their behavior in response to sensitive and emotionally responsive parenting. There is less evidence for signi \201 cant change in older children. Children with severe attachment disorders may require placement in a therapeutic residential unit. Prognosis Children with attachment disorders have signi \201 cant dif \201 culties with i nter- personal relationships and are at greater risk of developing mental health problems i n adolescence and adulthood. Duration of inadequate care is linked to outcome. Children who are placed with appropriate carers before age two have a better outcome. 16_McClure_16.indd 589 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 590 Schizophrenia Schizophrenia is characterized by disorders of thought, perception, mood, and sometimes posture. Peak onset is in young adult life. Prevalence in mid teens is 70.25% wi th equal numbers of males and females. Schizophrenia is very uncommon in the pre-pubertal c hild, when it does occur in this age group it is more common in boys. Causes There is a signi \201 cant genetic contribution with heritability estimates as high as 82 and \201 rst-degree relatives having a 12-fold increase in risk of developing the illness. Several pre- and perinatal factors also appear to be important. These include mate rnal infections, stressful events during pregnancy and obstetric complications. Clinical features The features of schizophrenia are complex. Refer to a standard adult psy- chiatric text for a more complete description of terms and their meaning. Onset may be ins idious or acute. Core features of schizophrenia include the following: \200 Thought disor der: thoughts inserted or removed from one \200\231s head or broadcast to others or disorga nized with abnormal speech patterns. Auditory commenting on his/her behavior. Delusions: ke eping with the patient \200\231s developmental or cultural context. Disorders hallucinations: external voices discussing the patient or \201 xed beliefs that are false not open to reason, and not in of posture: holding abnormal postures. Differential diagnosis Important differential diagnoses include affective psychosis (bipola r dis- order/psychotic depression), drug-induced psychoses, and psychoses sec- ondary to ot her organic conditions (see also b pp.956, 976), temporal lobe epilepsy, autism spectrum di sorder. Assessment As a schizophrenia-type psychosis can be caused by organic conditions, it is ess ential that signs of these be sought. Include full neurological exami- nation, and check fo r thyroid, adrenal, or pituitary dysfunction, and drug screen. Management Schizophrenia is often complex and dif \201 cult to treat. Children and adoles- cents will require both: \200 \200 Speci \201 c therapies, aimed at reducing the core symptoms. General therapies, relating t o the psychological, social, and educational needs of the child/young person and their fami ly. The aim is usually to deliver treatment on an out-patient basis, but it may occasionally be necessary to consider day or in-patient treatment. 16_McClure_16.indd 590 11/14/2012 3:42:47 PM SCHIZOPHRENIA 591 Traditional psychotherapies have little effect, but learning based thera- pies and those th at increase family support and reduce intrusive and criti- cal interactions can improve fun ctioning and decrease relapse rates. Antipsychotic medication, most commonly the newer atypical antipsy- chotics with preferable side-effect pro \201 les, is often effective. Relapses are fewer when families are suppor tive, but not intrusive or critical. The acute phase can progress to a chronic state with poor motiva- tion and inactivity. Cloz apine (an atypical antipsychotic drug) may amel- iorate this, but can cause agranulocytosis so ongoing blood monitoring is essential. Prognosis Prognosis is relatively good for a sin gle acute episode in a previously well functioning teenager. However, it is worse for insid iously developing ill- ness particularly in a child with pre-existing developmental dif \201 culties. The differentiation between schizophrenia and affective psychosis may be par- ticularly dif \201 cult and it is not uncommon for patients \200\231 diagnoses to switch between the two. 16_McClure_16.indd 591 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 592 Somatoform disorders and typical consultation \200\223liaison presentations This is a poorl y de \201 ned area with a whole host of overlapping terms, and confusions between descript ive terms and implied etiology. Some of the terms in common usage are: \200 Psychosomatic: include both illnesses brought on by stress, e.g. tension headache and physi cal symptoms secondary to psychiatric illness, e.g. hypothermia secondary to malnutrition i n anorexia nervosa. Somatoform are subdivided into: \200 \200 \200 \200 a very general and rather unhelpful term that can disorders: physical symptoms with no organic basis. These conversion disorders; chronic fatigue syndrome; pain syndromes, hypochondriasis; somatizati on disorder. Whilst many of these terms are entrenched, and so unlikely to disappear, the concept of som atoform disorders has been much criticized on the following grounds: \200 It implies a cause that is not demonstrable and often intuitively does not appear to be cor rect. It is often unacceptable to patients and parents and is therefore an obstacle to form ing a collaborative relationship. Its use may result in missing psychiatric or physical dia gnoses. There seems little relationship between this term and other diagnoses commonly appl ied to the same patients in non-mental health settings, e.g. irritable bowel, chronic fatig ue. \200 Conversion disorder See also b p.525. Conversion disorder is characterized by the presence of physical symptoms (e.g. paralysis, seizures, and sensory de \201 cits) or men- tal symp toms (e.g. amnesia), but without any evidence of physical cause. Previously called hysteria . Proposed underlying mechanism is transforma- tion of emotional con \202 ict into mental or physical symptoms. The postu- lated splitting off of mental processes from each other is referred to as dis- sociation. There may be secondary gain, e.g. when the child who is bei ng bullied at school develops paralysis, which keeps him at home. Conversion disorders are rare in childhood, particularly before the age of 8yrs. Treatment Principles of treatment include attempts to resolve any apparent emotion- al dif \201 culties, avoidance of unnecessary physical investigation, removal of secondary gain, and help in returning to normal life. Prognosis Generally favorable. Chronic fatigue syndrome See b pp.990 \200\223991 16_McClure_16.indd 592 11/14/2012 3:42:47 PM SOMATOFORM DISORDERS 593 Recurrent non-organic abdominal pain See also b pp.310, 991. The child \200\231s complaints of recurrent abdominal pain are not found to have a physical basis. \200 710 \200\22315% of children at some point, usually Common, affecting between 5 and 12yrs (n o apparent gender or social class bias). There may be associated symptoms of other pains, n ausea, or even vomiting. Pains are usually episodic and relapsing though may be more persis tent. An uncommon variant is the periodic syndrome where episodes of pain are associated wi th vomiting, headache, and low grade pyrexia. This is thought by some to be a form of migra ine. Differentiation from organic pathology may be dif \201 cult. Features that may help includ e the diffuseness of the pain, the tendency not to be woken by it, pains elsewhere in the b ody, anxiety, and depression in child and parent, and the lack of positive \201 ndings on physical examination. Treatment Generally a combination of reassurance, education about the links between stress and the body, psychological treatment where appropriate and avoidance of unnecessary physic al investigation and treatment. Prognosis Short-term outcome is usually favorable though it is not known whether this is du e to or in spite of treatment. In the longer term further episodes of non-organic pain are found in a large minority of cases. Selective eating This is a condition of younger children that in most, though not all, reso lves in the teenage years. These children eat only a limited range of foods. In severe case s the restriction may be to only 3 or 4 foods. It is surprising that most children seem to ingest all the required nutrients in their very limited diet. To treat, a mixture of reassu rance and encourage- ment seems to be the best approach. More active intervention is indica ted when the child is malnourished and usually entails a gradual hierarchical desensitizati on program. 16_McClure_16.indd 593 11/14/2012 3:42:47 PM CHAPTER 16 Child and family psychiatry 594 Anorexia nervosa Epidemiology Anorexia nervosa is the third commonest chronic illness in te enage girls. Prevalence in the Western world is 70.5%. Whilst varying with age, a sex ratio of 9:1 (girls:boys) is fairly typical. Pre-pubertal cases are rare, but do occur. Bulimia nervosa is generally of youth onset. Causes Often unclear in individual cases; however, genetic pre-disposition, a perfectionist personality, and low self-esteem seem to be implicated. Dissatisfaction with weight and sh ape is relatively common in children as young as 8yrs and is presumably a vulnerability fac tor. The pathway into anorexia nervosa is through weight loss, either due to a desire to lo se weight or for some other reason such as depression/anxiety or, some- times, viral illnes s. Diagnostic criteria \200 Dietary restriction (may be accompanied by vomiting, exercise, laxative abuse, or other wei ght control methods) leading to signi \201 cant and unhealthy self-induced weight loss (e. g. to less than 85% of expected body weight for height or age or a BMI < 17.5) or to stunti ng of expected growth. Intense fear of gaining weight even when severely underweight. Body image distortion with dread of fatness. Amenorrhoea (may be \200 \200 p or s). In younger teenagers anorexic thoughts may often be either absent or hidden, e.g. fear of b ecoming fat may be absent because they \200\230know \200\231 they can control their weight . Individuals who exhibit signi \201 cant weight-losing behaviors, not explained by depres sion, a speci \201 c phobia, or physical ill- ness, may be referred to as having an atypic al eating disorder. Treatment The evidence-base for treatment is small. Management of anorexia ner- vosa in chi ldren and young people requires a team effort and virtually all cases will require intensiv e treatment with more than one therapeutic mo- dality. The key to success in individual tre atment is the engagement with the therapist rather than the type of therapy provided. Invol vement of the family through family therapy seems to be important. Treatment is likely to be lengthy and to involve attention to anorexic behaviors, to recogn izing and not acting on anorexic thoughts and feel- ings, and to returning to aspects of no rmal function such as school and home life. It is far preferable to work collaboratively wi th the young per- son. At times compulsory treatment (requires use of the Mental Health Act ) may be needed. Clearly, correction of dangerous weight loss or its secondary complica- tions may be urgent . Patients who are unable or unwilling to manage ade- quate oral nutrition may need nasogas tric feeding. In any rapid refeeding plan the risks of refeeding syndrome (b p.322) should be remembered. 16_McClure_16.indd 594 11/14/2012 3:42:47 PM ANOREXIA NERVOSA 595