Childhoo

d Mental
Illnesses
Presenters:
Ang Jie Mei & Loy Lian
Wei
1
Learning Outcomes
At the end of this session, students are expected to:

● Understand the basic disorders in this group

● Recognize these disorders in clinical practice & basic treatments
● Assessment of children and families
● Diagnostic criteria of the disorders (developmental disorders, conduct
disorders, mental retardation, ADHD, other psychiatric disorders)
● Basic signs and symptoms of the disorder
● Classification of psychotic disorders
● Basic management principles of management

2
 Classification of Childhood
Psychological Disorders
Developmental Behavioural Psychoses
Learning Disorders Problems of childhood & Child schizophrenia
adolescence

Birth related Behaviour at home

Childhood autistic disorders Behaviour in school

Behaviour in society

Violence and crime

Attention Deficit
Hyperactivity Disorder
(ADHD) 3
 Types of Symptoms
Emotional Behavioural Developmental Relationship
Symptoms Symptoms Delays Difficulties
Anxiety Defiant behaviour Motor With adults

Fears Aggression Speech With other children

Obsessions Antisocial behaviour Play

Mood Eating disorders Attention

Sleep Withdrawn Bladder/ bowels

behaviour

Appetite Reading
4
Somatization Writing and Maths
Child and Adolescent
Psychiatry:
General Aspects
5
Epidemiology
● Prevalence of any psychiatric disorder in children & adolescents: 10 %

● 1 in 5 children may have mental health problem

○ Only 1 in 10 need specialist treatment

● 11 to 15 years old have the highest prevalence

● Girls: More likely to have emotional disorders

● Boys: More likely to have behavioural disorders

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Causes of
Childhood
Psychiatric
Disorders

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Causes of Childhood Psychiatric
Disorders
Genetics

● Heritability for most common psychiatric disorders: 50 to 80 %

Physical Disease

● Any physical disease can lead to psychological problems

● Particularly, brain disorders (especially birth injuries)

Social and Cultural Factors

● Influence from other children, teachers, people in the neighbourhood

● → Psychiatric disorders higher in areas of social disadvantage
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Causes of Childhood Psychiatric
Disorders
Family Factors

Children require ● Poor parenting: Neglect, abuse, poor

boundary setting, humiliation
● Stable and secure environment
● Conflict: Arguments within the family
● Love and care
● Prolonged absence or loss of a parent
● Provision of consistent discipline
● Parental illness: Physical or mental
health issues

● Care provided outside family home

9
Assessment of Children vs. Adults
1. Parents supply most verbal information in a young child
a. Should still be seen alone, without the parents at some stage

2. Flexible approach is required: Difficult to follow a set routine

3. Two members of multidisciplinary team needed to assess the child

4. Assessment may be done in outpatient clinic, school or the child’s

home

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The Interview
● Take a full psychiatric, general health, developmental and family history

● Parents, siblings and other relevant family members seen together

○ Should be made to feel as part of the solution rather than part of the
problem

○ Note pattern of interaction (Alliances, scapegoating, avoidance)

○ Note any difficulties communicating among family members

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Interviewing and Observing the Child
Start of the Interview

● Build a friendly atmosphere to win the child’s confidence

● Indirect and gradual approach

● General topics
○ To engage child’s interest
○ Pets, games and birthdays

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Interviewing and Observing the Child
● Older children:
○ Able to talk about problems and explain circumstances directly

● Younger children:
○ Need help, e.g. what would they ask for given three wishes
○ Imaginative play
○ Creative writing

● Behaviour:
○ Observe the child’s interactions with
■ Clinicians
■ Parents 14
Interviewing Other Informants
● Most important additional informant:
○ Child’s teachers
■ Classroom behaviour
■ Educational achievements
■ Relationship with other children
■ Relationship with teachers
■ Concern about home and/ or family

○ School visit may be needed to observe for classroom behaviours

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Physical Examination
1. Full general examination, esp. those presenting like an eating disorder

2. Thorough neurological screening, to exclude organic pathology

3. Height, weight, BMI, head circumference plotted on growth charts

4. Standard paediatric cardiovascular, respiratory, ENT, and abdominal

examinations

5. Evidence of congenital disorders, dysmorphism features

6. Evidence of neglect, or abuse

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Choosing an Appropriate Setting of
Care
Inpatient Care only when:

1. Treat a severe behaviour disorder

2. High risk of suicide or self-harm

3. For observation when diagnosis is uncertain

4. Separate from home temporarily

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Psychoeducation and
Self-Help Parenting Programmes
● Provide chance to child AND parents ● Teach parents techniques
to ○ Reward and encourage good
○ Discuss diagnosis behaviours
○ Learn about nature of disorder ○ Ignore and discourage bad
behaviours
● Identify stressors and strategize to
reduce them at
○ Family
○ Home
○ School 23
Child Protection and Child Abuse
Official* incidence statistics:
2 to 12 per 1000 children

Which is the most common?

1. Neglect (30 to 50%)

2. Physical abuse (15 to 30%)
3. Sexual abuse (10 to 20%)
4. Emotional abuse

● Physically disabled children are

3 times more likely to be abused

● Most vulnerable age: 0 to 3 years

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Physical Abuse (Non-Accidental
Injury)
● Deliberate infliction of injury on a child by any person having custody,
care or charge of the child

● Severe abuse e.g. causing fracture or cerebral haemorrhage, occurs in

1 in 1000 children

● Failure to prevent injury → Neglect, NOT abuse

● Discipline through hitting → Grey area

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Physical Abuse (Non-Accidental
Injury)
Detecting Abuse
● Injuries with no other
explanation
● Concern from relatives,
neighbours, teachers
● Rarely, coming forward of a
victim
Suspect physical of abuse
● Unusual nature of injuries
● Previous suspicious injuries
● Unconvincing explanations
● Delay in seeking help
● Incongruous reactions of carers
to injuries
● Fearful responses from child
● Evidence of distress( Social
withdrawal, regression, low self-
esteem, aggressive) 32
Physical Abuse (Non-Accidental
Injury)

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Physical
Abuse (Non-
Accidental
Injury)
Common factor

● Failure of normal
emotional bonding
between parent or
carer with the child

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Physical Abuse (Non-Accidental
Injury)
Management

Assessment of Injuries Fate of the child

● Specialist examination ● Sometimes, can be returned home

● Admission to paediatric ward ○ With close supervision
● Photographs and radiologic exam ● Temporary foster care
● Clear documentation ● Permanent alternative home

Subsequent action

● If non-accidental injury likely

○ Talk to parents
○ Examine other children
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Physical Abuse (Non-Accidental
Injury)
Prognosis

● High risk for

○ Delayed development
○ Learning difficulties
○ Emotional disorders
○ Behavioural disorders

● Difficulties rearing their own children

○ Some abuse their own children in the future

● Risk factor for almost every psychiatric condition in later life

● Strong association with suicide and self-harm

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Sexual Abuse
Includes ● More likely to report abuse when
○ Offender is a stranger
● Penetrative sex ○ Many offenders go unnoticed
● Touching of genitalia
● Exhibitionism ● Many are discovered during
● Production of pornographic material investigation of other symptoms
● Inciting children to engage in sexual ○ Urogenital/ Anal symptoms
practice together ○ Behavioural disorders
○ Emotional disorders
○ Inappropriate sexual behaviour
○ Pregnancy

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Sexual Abuse
● Not to make diagnosis without adequate evidence

● Investigate family, physical and psychologically.

● Young children: May need drawings or toys to illustrate

● Caution: NOT to suggest answers to child

● Inspection of anal and genialia region by paediatrician

● Specimens to be collected if intercourse is < 72 hours ago

● Aftermath of sexual abuse:

○ Secondary distress to child due to conflict
○ Abnormal sexual development
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Emotional Abuse
● Definition
○ Severe, persistent emotional neglect, verbal abuse, or rejection
○ Sufficient to impair a child’s physical or psychological development

● Most times, accompany other forms of abuse

● Parents require help → For own emotional problems

● Child needs
○ Counselling
○ If severe, period of separation
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Neglect
● Encompasses needs of physical, emotional, upbringing, safety or medical

● Occurs within
○ Family home
○ Institutions: Children homes or schools
○ Prenatally: maternal substance abuse

● Consequences of neglect:
○ Failure to thrive → Height, weight and developmental delay
■ In the absence of detectable organic cause

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Neglect

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Neglect
Physical Neglect Supervisory Neglect Emotional Neglect Cognitive Neglect

Inadequate food Inadequate parental Insufficient parental Insufficient attention

supervision attention to development of
● Intellect
Inadequate shelter Inadequate interest Failure to provide ● Speech
in child affection ● Neurological
Inadequate clothing Failure to provide
● Education
● Healthcare need
● Safe care place

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Learning Disability

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Learning Disability (LD)
Definition: Irreversible impairment of intelligence originating early in life,
associated with limitations of social functioning

● Alternative phrase: Mental retardation

● Efforts can be made to help to live as normal a life as possible

● Main interventions: Social and educational, NOT medical

○ Special schools
○ Sheltered work
○ Housing aid
○ Support for family and patient
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Learning Disability (LD)
● Not all individuals
with IQ < 70 have LD

● MUST impair function

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Intellectual Disability (DSM-5
Criteria) Replacement for mental retardation

Disorder with onset during the developmental period that includes both intellectual and
adaptive functioning deficits in conceptual, social, and practical domains.

The following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract

thinking, judgment, academic learning, and learning from experience, confirmed by both clinical
assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural
standards for personal independence and social responsibility. Without ongoing support, the
adaptive deficits limit functioning in one or more activities of daily life, such as communication,
social participation, and independent living, across multiple environments, such as home, school,
work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period. 46

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Causes of
Learning Disability
● Specific cause can be
identified in 80% of severe
cases

● Only 50% overall cases, a

cause can be determined

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Causes of
Learning Disability
● Specific cause can be
identified in 80% of severe
cases

● Only 50% overall cases, a

cause can be determined

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Emotional and Behavioural Problems
in LD
● May develop any common behavioural problems of childhood
○ Tends to occur at later age
○ Tends to last longer

● Severely disordered behaviour that threatens well-being of patient/ carers

○ Termed: Challenging behaviour
■ Aggression: Shouting, screaming, faecal smearing
■ Self-injury: Biting, cutting, burning, head banging
■ Stereotyped behaviours: Rocking, mannerisms, flapping
■ Hyperactivity
■ Anxiety
■ Social withdrawal 52
Emotional
and
Behavioural
Problems
in LD

53
Emotional
and
Behavioural
Problems
in LD

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Effects of Learning Disability on the
Family
● Parents may reject child at first, but rarely for a long time

● Due to diagnosis of LD usually not made after 1 yr old

○ Parents lose earlier hopes
■ → Period of bereavement, sadness, guilt, shame and anger

● Parents face lifelong hardship and social issues even after the acceptance to the
child

● Depression is common,
○ Parents, esp. in those who cannot work or socialize due to child’s needs
○ Siblings, due to reduced parental attention
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Interviewing Person with Learning
Disability
1. Simple questions
a. Avoid passive verbs, subordinate clauses, figures of speech, complex sentences

2. Allow adequate time

a. Do not appear impatient

3. Check answers to closed questions

a. Ask “Do you feel sad?” and check with “Do you feel happy?”

4. Avoid leading questions

a. Easily led due to wish to please others, rely on cues to communication, tends to say yes

5. Check with informant

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57
Down Syndrome
Learning Disability

● Degree of learning disability varies from mild to severe, with minority in the mild category

● Most are able to self-care with prompting by adolescence and live with their families

Temperament

● Usually affectionate and easy-going

● Most have some obsessional characteristics and behaviour

○ May be stubborn in daily routine

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Down Syndrome https://www.youtube.com/watch?v=AAPmGW-GDHA

https://youtu.be/NFmphpHS3Vg

Behaviour Problems

● Less frequent than in most other forms of LD

● Some may be chaotic and difficult to engage

○ Do very well with behavioural therapy

Ageing

● Signs of ageing appear prematurely

● Early changes of Alzheimer-like neuropathology found in brain at ages 40 or more

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Problems of Preschool
Children

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Common Disorders of Preschool
Children

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Temper Tantrums
● Normal btw 1 - 3 years ● Provoked by inconsistent discipline
○ Mostly mild in nature
● Reinforced unintentionally by excessive
● Abnormal when: Frequent or severe attention to child when tantrum occurs
tantrums
● Improves when parents set limit to child’s
● Triggers: behaviour
○ Frustration at not being understood ○ Enforce kindly but firmly
○ Desire for independence (Strapped ○ Pay less attention during tantrum
down to chair)
○ Hunger ● Investigate reason of inability to control
○ Tiredness child → Marital issue?
○ Needs attention

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Temper Tantrums

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Breath Holding
● Occur in 5% of child btw 2- 5 years ● Educate

● Occurs when ○ Reassure parents that child is

○ Frustrated unlikely to be harmed by episode
○ Angry
○ Upset ○ Respond calmly

● Looks like a temper tantrum that is cut
short → Silence and breath holding →
Turn blue→ May lose consciousness
○ Avoid reinforcing the behaviour
with excessive attention
○ Attack usually disappear over time
when managed well

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Insomnia
● 20% children btw 1- 2 years take at least 1
hour to fall asleep or are repeatedly
wakeful for long periods during the night
● Most resolve within few months
● Severe, persistent problems → Parents’
response should be studied
○ May be maintaining behaviour by
■ Responding as soon as child
cries
■ Spending long periods at
bedside
■ Allow child to go to living room
■ Taking child to own bed
Improve insomnia with basic sleep hygiene
rules:
● Regular bedtime routine
● Cool, dark, quiet bedroom
● Calming activities before bedtime
(Reading, soft music)
● Reduce naps during daytime
● Reduce stimulants before bedtime, e.g.
food, drinks, activities
● Do not reinforce behaviour
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Feeding Problems
Food Fad and Food Refusals
● Picky when less chance to try wide ranges
of food or when parents are anxious about
child’s nutrition
● Offering alternative when refusing a type
of food is reinforcing the habit
● Ignore feeding problem as far as possible
○ To not offer alternative when
refuse to take certain type of food
○ To not persuade child to eat
Pica
● Often associated with behaviour
problems, autism or learning disability
● Reassure parents that child usually
improves with time
● Educate parents to
○ Keep non-edibles away from child
○ Reduce stressful situations for
child
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Disorders of Development
1. Pervasive developmental disorders
2. Gender identity disorders
3. Specific developmental disorders of speech and
language

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Pervasive Developmental Disorders
● Relatively common condition, characterized by deficits and delays in social and
communicative development, which are associated with restricted patterns of interest
and behaviour

● Includes the following

1. Autistic disorder
2. Asperger’s syndrome
3. Pervasive developmental disorder not otherwise specified (PDD-NOS, atypical autism)
4. Rett’s disorder (Rare)
5. Childhood integrative disorder (Rare)

● The phrase ‘autistic spectrum disorders’ (ASD) is widely used to describe all of the
conditions above, which may overlap to some extent.

● A child with PDD may have IQ that is subnormal, normal or above normal.

● Family members of child with autism may display autistic-like behaviour.

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Autistic Spectrum Disorders (DSM-5
Criteria)
A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history (examples are illustrative, not exhaustive):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and
failure of normal back-and forth conversation to reduced sharing of interests, emotions, or
affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example,
from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact
and body language or deficits in understanding and use of gestures; to a total lack of facial
expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from
difficulties adjusting behavior to suit various social contexts; to difficulties in sharing
imaginative play or difficulties in making friends; to absence of interest in peers.

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Autistic Spectrum Disorders (DSM-5
Criteria)
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two
of the following, currently or by history (examples are illustrative, not exhaustive):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or

nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking
patterns, greeting rituals, need to take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative
interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the

environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or
textures, excessive smelling or touching of objects, visual fascination with lights or movement).
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Autistic Spectrum Disorders (DSM-5 https://www.youtube.com/watch?v=j4PTf7LgsIE

Criteria)
C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned
strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected for
general developmental level.

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Autistic Spectrum Disorders

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Autistic Spectrum Disorders
Aetiology

1. Genetic factors
● Heritability of autism: 90%

● Risk of autism in a sibling of affected child: 2 to 20%

○ General population: 2%

● Higher risk of social, language, learning problems in relatives

○ Suggestive of autism being the severe end of general predisposition to
developmental difficulties

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Autistic Spectrum Disorders
Aetiology

2. Organic brain disorder

● Occurrence of seizures: 20% by the time of adolescence
○ Suggestive of underlying organic pathology in autism

3. Cognitive abnormalities
● Proposed core abnormality underlying ASD: Inability to judge correctly what others are
thinking
○ However, not present in all cases of ASD

➢ Abnormal parenting has not been shown to be a cause

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Autistic Disorder (Childhood Autism)
Classically characterized by difficulties in 3 areas and must be present by 3 years old.

Social Deficits Communication Deficits Restricted/ Repetitive Interests

Babies don’t like being held
Reduced eye contact
Unusual facial expressions
Speech may be totally absent (30%)
Difficulty in two way- conversations
May ask string of questions
Deep interest in ordinary items
● Spend majority of time with
these mundane items
● Washing machine, license
plates

Lack of gestures
Lack of empathy
Few peer relationships
Does not respond to affection
Does not value company of parents
Speech show unusual or asocial
quality
Common abnormalities:
● Echolalia
● Odd prosody (Unusually high
pitch/ stress/ rhythm/
intonation)
● Pronoun reversal (Referring
self as he/ she)
Reject other toys or imaginative play
Show stereotypies during stress:
● Hand- flapping, head rolling
Elaborate routine that is
● Resistant to change and
requires ‘sameness’
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Autistic Disorder (Childhood Autism)
Course and Prognosis

● About 2/3 of children meeting requirement for autism acquire some

useful speech, but some impairments do remain

● Most abnormal behaviours carry on until adulthood but may become

less socially impairing with time

● Only 10- 20%: Able to attend mainstream school

● Minority: Live independently and obtain work

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Asperger’s Syndrome
Condition where child has the characteristic impairments in social interaction and repetitive
behaviours or restricted interests that are seen in autism, but has normal speech and
intellectual abilities.

Typical presentation:

● Developmentally appropriate speech and language;

● Unusual use of language (e.g. prosody, abnormal rate/ rhythm/volume, novel words);
● Motor clumsiness;
● Unusually deep interest in one particular topic;
● Rigid behaviour and stereotypies;
● Social awkwardness or an eccentric social style; the child fails to read the other person’s
feelings, and often does not understand humour or irony;
● Difficulty in making close friends;
● Often shows an enhanced ability to rote learning formation about their special interests, or
perform at a high level in one particular activity.
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Asperger’s Syndrome
● Common comorbidities: Mood disorders and anxiety disorders (65% of
Asperger’s)

● Course and Prognosis

○ Many individuals learn and cope better by adulthood
○ Majority children can attend mainstream school
○ Most complete education and can work, especially in areas of
interest

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Autistic Spectrum Disorders
Assessment

● Autism Diagnostic Interview

● Autism Diagnostic Observation Schedule

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Autistic
Spectrum
Disorders

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Autistic Spectrum Disorders
Management

General

● Psychoeducation by PDD specialist

● Choosing school: Mainstream vs Special needs. School choice may change

over years as family needs change

● Parental support is important

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Autistic Spectrum Disorders
Management

Biological

● Atypical antipsychotics (Risperidone) shown to reduce aggression, tantrums,

stereotypies and self-injury.
○ Only when behavioural therapy failed, due to troublesome side effects

● Stimulants (Atomoxetine) for child with comorbid ADHD

● SSRIs for repetitive or obsessive behaviours

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Autistic Spectrum Disorders
Management

Psychological

● Reduce antisocial and troublesome behaviours: Intensive, focused behavioural

training programmes

● Education on transferring skills: Problem-solving, communication, self-control

● Speech and language therapy

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Gender Dysphoria
● Person experiences discomfort with the biological sex with which they were born to such
an extent that it becomes clinically significant distress or impairment in social, school, or
other important areas of functioning.

● Behave as children of the opposite sex do

○ Dress like them
○ Play their games
○ Prefer their toys
○ Use their verbal and physical mannerisms
○ All their friends are of the opposite sex

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Gender Dysphoria (DSM-5 Criteria) https://www.youtube.com/watch?v=wVT9jPbbSHE

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’
duration, as manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative
gender different from one’s assigned gender).

2. In boys (assigned gender), a strong preference for crossdressing or simulating female attire; or in girls (assigned
gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing
of typical feminine clothing.

3. A strong preference for cross-gender roles in make-believe play or fantasy play.

4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

5. A strong preference for playmates of the other gender.

6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong
avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys,
games, and activities.

7. A strong dislike of one’s sexual anatomy.

8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
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Gender Dysphoria
Prognosis and Outcome

● Significant proportion improve through adolescence and live rest of their lives
as their biological sex

● 2/3 have homosexual or bisexual orientation

● Minority will make the transition to the experienced sex.

● Associated with other psychiatric disorders: Depression, anxiety disorders

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Gender Dysphoria
Management

● Psychoeducation
○ Educating whole family about gender identity, normal and abnormal, establish that not
necessary to behave in a specific way for a specific sex

● Behaviour modification
○ Find other children where their biological sex who are less stereotypical (E.g. sporty girl, non-
physical more home-oriented boys)
○ Widen the child’s peer group and interests
○ Individual therapy in older child

● Cross-gender living
○ Allow child to live as opposite sex → Not to be decided lightly
○ Pubertal period may be very distressing → Physical changes unwanted (facial hair and menses)
○ GnRH to block puberty can be considered
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Specific Developmental Disorders of
Speech and Language
● Common, affecting 3-5% of children

● Factors for normal speech and language development

○ Reasonable quality hearing
○ Ability to understand what is being said
○ Ability to process what is being said
○ Ability to form and verbalize a response

● Family history of speech problems common in these children

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Specific Developmental Disorders of
Speech and Language
● Types of speech and language disorders
○ Specific speech articulation disorder
○ Expressive language disorder
○ Receptive language disorder

● Approximately half resolve completely by adulthood, the rest improve to varying

degrees

● Therapy done most effectively in usual environment (school) as compared to

structured therapy sessions
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Specific Learning Disorders (DSM-5)
A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following
symptoms that have persisted for at least 6 months, despite the provision of interventions that target those
difficulties:

1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and
hesitantly, frequently guesses words, has difficulty sounding out words).

2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand the
sequence, relationships, inferences, or deeper meanings of what is read).

3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).

4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences;
employs poor paragraph organization; written expression of ideas lacks clarity).

5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers,
their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math
fact as peers do; gets lost in the midst of arithmetic computation and may switch procedures).

6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or
procedures to solve quantitative problems).
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Specific Learning Disorders (DSM-5)
B. The affected academic skills are substantially and quantifiably below those expected for the
individual’s chronological age, and cause significant interference with academic or
occupational performance, or with activities of daily living, as confirmed by individually
administered standardized achievement measures and comprehensive clinical assessment.
For individuals age 17 years and older, a documented history of impairing learning difficulties
may be substituted for the standardized assessment.

C. The learning difficulties begin during school-age years but may not become fully manifest until
the demands for those affected academic skills exceed the individual’s limited capacities (e.g.,
as in timed tests, reading or writing lengthy complex reports for a tight deadline, excessively
heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected
visual or auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of
proficiency in the language of academic instruction, or inadequate educational instruction.
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315.00 (F81.0) With impairment in reading:

Word reading accuracy. Reading rate or fluency. Reading comprehension.

Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties characterized by problems with
accurate or fluent word recognition, poor decoding, and poor spelling abilities.

315.2 (F81.81) With impairment in written expression:

Spelling accuracy. Grammar and punctuation accuracy. Clarity or organization of written expression

315.1 (F81.2) With impairment in mathematics:

Number sense. Memorization of arithmetic facts. Accurate or fluent calculation. Accurate math reasoning.

Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties characterized by problems
processing numerical information, learning arithmetic facts, and performing accurate or fluent calculations. If
dyscalculia is used to specify this particular pattern of mathematic difficulties, it is important also to specify any
additional difficulties that are present, such as difficulties with math reasoning or word reasoning accuracy.
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Disorders of School-Age
Children and Teenagers

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Psychiatry disorders in older children
and adolescent
Children aged 5-13 years
● Anxiety disorders
● OCD
● Mood disorders
● Attachment disorder
● Somatization disorders
● Enuresis and encopresis
● Eating disorders
● Tics & Tourette's syndrome
● ADHD
● Conduct disorder
● Sleep disorders
Adolescent
● Depression
● Bipolar disorder
● Anxiety disorder + OCD
● Eating disorders
● Schizophrenia + other psychoses
● Deliberate self harm + suicide
● Somatoform disorders
● Substance abuse
● Conduct disorder
95
Anxiety disorder
● Definition: psychophysiological respond to a psychological threat
● Very common in childhood
● Female > male; lower socio-economic class> higher socio-economic class
● Types:
○ Separation anxiety disorder: 10-20% affected, preschooler
○ Social anxiety: preschooler
○ Panic disorder: only in adolescent

96
 Course and
Aetiology prognosis
● Genetics ● Likely to remit
○ Children with parents who have anxiety ● High risk to develop anxiety-related
disorders are 2-4x likely to develop problems / depression in adulthood
● Personality (50%)
○ Shy, hesitant, fearful in new situation
are at high risk
● Parent-child attachment
○ Insecure attachment, lack of
reassurance, support being provided
dom parent to child
○ Overly strict parenting→ child lack of
confident
● Parental anxiety disorder
○ Child learn from people who have
anxiety at home

97
Sign and
symptoms Treatment

Usually, combination of supportive approach,

education and CBT will be effective.
Benzodiazepine is not recommended 98
 Social anxiety
disorder disorder (social
● Definition: condition that is
characterized by significant distress /
phobia)
fear when a person is away from ● Experiencing extreme anxiety in social
home or from people to whom the situations where they perceived
individual has a strong emotional scrutinized, or embarrassed
attachment ● Eg: shy / anxious when speaking in
● More common in girls class, asking for something in shop,
● Severe enough to interfere with daily speaking to strangers
activities & social development ● Treatment: CBT, social skills training
○ School refusal, avoidance of leaving
house
● Initiated by a frightening experience
○ Admission to hospital
○ Insecurity in family
● Treatment: change overprotective
attitudes of parents and reassuring
99
children
symptoms of
emotional
behavior
● Communicate distress by complaining
repeatedly of physical symptoms for
which physical cause cannot be
found→ somatization (functional /
medically unexplained symptoms)
● Usually associated with stressful
circumstances / parental anxiety
● Common complaints: abdominal pain,
headache, limb pain, sickness
● Treatment:
○ Parents advised to convey sympathy but
not focus on the pain
○ Find way to reduce the pain without
taking analgesics→ relaxing music 100
Selective mutism
Assessment and management:
● Condition in which a person who is
normally capable of speech is unable
to speak in certain situation
● Has normal understanding of
language, often speak fluently at
home with familiar people but refuse to
do in some situation
● Present of at least 1 month, child has
no PDD or psychosis
● Age of onset: 2-5 years
● More common in girls
● TRO autism spectrum disorder,
developmental disorder
● early age treatment will improve
spontaneously
● Behavioral therapy→ patient in
comfortable environment and people,
gradually introduced a new person to
the child until get used to it
● Play or art therapy→ examine the
underlying reason
● Family therapy→ identify difficulties in
family relationship
● Speech and language therapy
101
Obsessive-compulsive
disorder (OCD)
● More common in girls
● Highly associated with tic disorders,
● Definition: common, chronic and long-
Tourette’s syndrome, and mood and
lasting disorder in which a person has
eating disorders
uncontrollable, reoccurring thoughts
● Management:
(obsessions) and behaviors
(compulsions) that he or she feels the
urge to repeat over and over.
● Adult vs child
○ Adult MUST be realize their thoughts
are unreasonable or excessive to meet
diagnostic criteria for OCD while
whildren is not required
○ Younger children do not have clear idea
of what they are trying to avoid whilst
performing a ritual, they may not be
able to fully describe the obsessions
they are experiencing 102
● Child should referred to child
psychiatrist if:
○ Moderate, severe or psychotic
depression
○ Mild depression which has not
responded to intervention in primary
care
○ Recurrence of depression after
recovery from a moderate to severe
episode
○ Self-neglect
○ Active suicidal ideation (require day /
inpatient treatment)
● All children and family should receive
adequate psychoeducation, self-help
materials and advices (diet, exercise,
sleep)
Treatment
● Mild
○ Supportive, Follow up in 2 weeks
○ Offer guided self-help or short course of
CBT if not improved
● Moderate to severe
○ Individual CBT, interpersonal therapy,
brief family therapy
○ Alternative form of therapy or
medications if no improvement after 12
weeks
○ medication in 12-18y/o: fluoxetine→
setraline / citalopram
○ Continue medication for at least 6
months after symptoms recede, slow
tapered to avoid withdrawal symptoms
○ Regular reviewed at least 12 months
after recovery
○ Avoid using medication in children
<12y/o
103
Unipolar depression
● Relatively common in childhood
● Diagnostic criteria in children have
slight differences with adult:
○ Core symptoms: remain low mood,
anhedonia, fatigue, irritable mood
○ Symptoms must be present at least 2
weeks and have a negative effect upon
functioning
○ Sleep is often disturbed (but no early
morning awakening)
○ Fail to gain weight
○ Physical symptoms: abdominal pain,
headaches, fatigue
● Prevalence:
○ Prepubertal: 1-2%
○ Adolescent: 3-8%
○ Male : female= 1:3 (in adolescent)
● Course and prognosis
○ Mild episode→ resolve 2-6 months but
high relapse; 5% become
chronic+recurrent proceed to adulthood
○ RF for chronicity→ severe depressive
episode, ongoing adversities, personality
disorder in child / parents, psychiatry
illness in parent, poor psychosocial
functioning
○ moderate-severe → 10-30x increased
risk of suicide
104
105
Post-traumatic stress disorder
● Definition: Severe psychological
disturbances following a traumatic
event, characterized by involuntary re-
experiencing of the event combined
with symptoms of hyperarousal,
dissociation and avoidance
● Frequently comorbid anxiety,
depression or ADHD.
● Management:
○ Trauma-focused cognitive behavioral
therapy (TF-CBT)
○ Medication is not recommended unless
significant comorbid depression→
fluoxetine

106
somatoform
disorders
● Definition: syndrome of prolonged
physical symptoms in the absence of
identifiable organic cause with
associated functional impairment in
the context of an identifiable stressor
● Extremely common for children to
express their distress
● Common complaints: abdominal pain,
headaches
● Comorbid anxiety or depressive
disorder are common
● Prevalence:
○ Peak age: 8-12 y/o
○ Common in girls 107
● Aetiology: ● Risk factors:
○ No one cause, Multifactorial
○ Children not mature enough to express
themselves verbally communicate
distress
○ Tend to focus on physiological bodily
sensation and misinterpret
● Aim of Assessment
○ To gather information
○ To exclude organic cause
○ To produce management plan

108
Management:
● Psychoeducation
○ Explain to child and family (cause which
could not found probably linked to
relevant psychological issues)
○ Low probability of serious illness
ensuing symptoms
○ Highlight improvement in family
communication, environment and
relationships help child to recover more
quickly
○ Teaching relaxation and problem solving
skills
○ Encourage to engage in social activities
● Family therapy
○ Helpful in addressing problems
● Individual CBT
○ Links between thoughts, feelings and
physical sensations
○ Adjust their abnormal illness behaviour
(eg: increase school attendance)
● Physical interventions
○ stomach ache→ hot water bottle
○ Joint problems→ physiotherapy
○ *Avoid medications
● Antidepressants
○ For comorbid anxiety or depression
○ SSRI→ fluoxetine (1st line)
109
 ● Sleep disturbances in childhood causes

Sleep disorders direct -ve effect upon mood, behaviour

and cognitive function
○ children→ increased activity, irritability,
● Common encountered disorder: agitation, loss temper control
nightmares, night terrors, sleep ○ Adolescent→ at risk of psychiatric
walking problem if continually inadequate s;ee[
○ Adult→ slow in mental,
● Physiological of sleep between children
● Average sleep requirements at different
vs adult:
○ Total amount of sleep needed child > ages
adult
○ Circadian sleep wake cycle x trained
until 6-8 months
○ 5 y/o-puberty, sleep very sound at
night, very alert during the day
○ Adolescents increased daytime
sleepiness, sleep phase delayed→ stay
up late and lie during the morning

110
 ● Assessment: Nightmares
○ Record 24-hour sleep-wake pattern at
least one ordinary day ● Frightening dreams that cause child to
○ Sleep diary for 2-4 weeks wake up
○ To determine the usual routine and
● Child may distressed, take time to get
sleep disturbances
back to sleep
Insomnia ● Occur in REM sleep
● Common in childhood (5-6 y/o)
● 30% children of school age have either ● Frequent nightmare accompanied by
trouble getting to sleep or wake up daytime anxiety
repeatedly during the night ● No specific treatment, improve with
● Common cause: night time fears, time
separation anxiety, daytime napping,
worries, anxiety, depression, caffeine,
nicotine, alcohol
● Treat with discussing their worries or
fears

111
 Sleep walking
Night terrors
● Characterized by complex, automatic
● Sudden awakening, child sit upright,
behaviours occurring during sleep
screams loudly and has marked
● Child’s eye open, avoid familiar objects,
autonomic activation
appear agitated, not respond to
● Frantic motor activity leads to falling out
questions, difficult to wake (but usually
of bed + injury
led back to bed)
● Occurs few hours after going to bed,
● Lasts for few minutes
usually lasts about 5 minutes
● Common in age 5-12
● No specific treatment
● No specific treatment
● Seldom persists to adult life
● Advices protect child from injury by
fastening doors and windows securely,
barring stairs, removing dangerous
objects

112
Disorders of elimination→ functional
enuresis
● Prevalence:
● Definition: repeated involuntary ○ 10% @ 5y/o
voiding of urine, occurring after an age ○ 4% @ 4 y/o
at which continent is usual and in the ○ 1% @ 14 y/o
absence of any physical disorder ○ 0.5% @ adulthood
○ More frequent in boys
● Types:
○ Primary vs secondary ● Aetiology:
○ Nocturnal vs diurnal ○ Idiopathy
○ Delay maturation in nervous system
● Primary→ NO preceding period of
controlling bladder
urine continence
○ Family history of enuresis
● Secondary → preceding with period of
● Assessment:
urinary continence (commonly 6 ○ Determine primary or secondary
months) ○ Family history
● Regular daytime and nighttime ○ Any stressful situation
incontinence at 3-4 y/o→ 5 y/o taken as ○ Exclude primary cause→ Full
youngest age for diagnosis neurological examination, loaded colon,
113
spina bifida, perform urinalysis
● Synthetic antidiuretic hormone analogue
desmopressin (DDAVP) → reduce urine
production, but short term effect, relapse
when top taking
● TCA→ reduce bedwetting when given in low
dose, improve partially, relapse when stop, S/E,
114
accidental overdose, short term effect
Disorders of elimination→ functional
encopresis
● Definition: passed faeces in
● Treatment:
inappropriate places after the age at
○ Treat primary physical / psychiatric
which bowel control is usual disorder
● Diagnosed in a child >4 y/o, at least ○ Reassure parents that problems occurs
once a month for at least 3 months in other children and will improve in
● Common in boys > girls time
● Aetiology: ○ Avoid constipation (high fibre diet,
○ Idiopathy with learning disabilities adequate hydration, empty bowel with
○ Chronic constipation and overflow laxatives)
incontinence ○ Encourage normal bowel by sit on toilet
○ Structural malformation (eg: 5 minutes after each meal)
Hirschsprung's disease) ○ Encourage reward child for opening
○ Anal fissures bowels in appropriate place
○ Traumatic / unsettling events ○ Modify any stressful circumstances
○ Deliberate rebellion by child against
parents
○ Associated with anxiety / mood disorder
○ Associated with physical, sexual,
115
emotional abuse (extremely rare)
Disturbances of eating
habits or weight control
behaviour that results in
clinically significant
impairment of physical
health and or psychosocial
functioning

116
 https://www.youtube.com/watch?v=s51lAHCah7Q
Anorexia nervosa
● Characterized by extremely low body
weight, amenorrhea, distorted body
image, intense fear of gaining weight
● Onset 15-17 y/o
● Prepubertal onset→ onset before
menstruation
● Impact: pubertal development, family
relationships
● More likely to be male, less likely to
have other comorbid psychiatric
disorders
● Clinical feature:
○ Definite precipitating event (change of
school, bereavement) and short illness
course
○ Initial stages→ depression, irritability,
social withdrawals, school refusal, avoid
eating at mealtimes, excessive exercise,
laxative abuse, purging
○ Prepubertal children→ failure of gain
weight, cessation of growth, primary
amenorrhea (onset of menses will
delayed several years even recovered),
secondary sexual maturation absent
○ Patient do not express distorted body
image or definite valuation of
themselves but mention fearful of
menstrual periods, do not wish to grow
up
○ Comorbid depression and OCD 117
Diagnostic criteria
● A. Restriction of energy intake relative to requirements, leading to a significantly low body weight
in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is
defined as a weight that is less than minimally normal or, for children and adolescents, less than
that minimally expected.
● B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with
weight gain, even though at a significantly low weight.
● C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence
of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of
the current low body weight.

118
 Management
Assessment and investigation
● Can be treated as outpatient
● Refer to child psychiatrist relatively
● Intensive treatment needed when
urgently
severe emaciation, failure of outpatient
● Special attention should be pain for
treatment, guardians unable to manage
recent stressors
home re-feeding, admissions should
● Weight and height should be monitored
only be to facilities specifically for young
● BMI not reliable measure patient <16
people
y/o
● 1st line→ family therapy + home re-
● Pelvis USG monitor of uterus and ovary
feeding (Maudsley method)
● Individual therapy with CBT
● If child refuse, parental permission or
Mental Health Act 1983
● Medication indicated if comorbid
What to expect from treatment:
https://www.youtube.com/watch?v=XuHGvloVUSk
depression or anxiety

Prognosis

● Rapid recovery 119

nervosa
● Definition: eating disorder
characterized by recurrent
episodes of uncontrolled
excessive eating (binges),
compensatory methods of
weight control and a fear
of becoming fat
● Extremely rare in
prepubertal
Diagnostic criteria
● A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
○ 1. Eating, in a discrete period of time (e.g., within any 2-hour
period), an amount of food that is definitely larger than what
most individuals would eat in a similar period of time under similar
circumstances.
○ 2. A sense of lack of control over eating during the episode (e.g.,
a feeling that one cannot stop eating or control what or how much
one is eating).
● B. Recurrent inappropriate compensatory behaviors in order
to prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, or other medications; fasting; or
excessive exercise.
● C. The binge eating and inappropriate compensatory behaviors
both occur, on average, at least once a week for 3 months.
● D. Self-evaluation is unduly influenced by body shape and
weight.
● E. The disturbance does not occur exclusively during episodes
120
of anorexia nervosa.
Attention deficit hyperactivity disorder
(Hyperkinetic disorder)
● Definition: persistent pattern of
inattention, hyperactivity and
impulsivity
● Long term may severely impact upon
child’s ability to achieve their
educational potential, causes difficulty
in managing social and home
environments, interfere with
interpersonal relationships and cause
problems in finding employment

121
Summary of diagnostic criteria:

● Core symptoms: inattention,

hyperactivity, impulsivity
● Symptoms started before age 7
● Symptoms present in at least 2
settings
● Must be definite of impaired
function
● Symptoms not caused or related
to another mental health disorder

122
Prevalence ● Aetiology

● Male: female= 3:1

Comorbidity

● Depression
● Tic disorder
● Anxiety
● Oppositional defiant disorder
● Substance abuse
● PDD

Differential diagnosis

● bipolar→ episodic, euphoria,

grandiosity

123
Prognosis

● During adolescent overactivity tends to

improve greatly
● General increase in self control helps in
reduce the inattention and
impulsiveness
● However those who do not lose
overactivity at high risk of conduct
disorder, antisocial behaviour and
juvenile delinquency
● Poor qualifications, unemployed,
involved in multiple road traffic
accidents serve a prison sentence

124
● methylphenidate→ 1st line uncomplicated
ADHD
● atomoxetine→ comorbid tics, Tourette’s,
anxiety disorders, substance misuse
● dexamphetamine→ reserved for those do not
125
improve on max tolerated dose for drugs above
Oppositional Defiant disorder
● Definition: recurrent pattern of
negativistic, defiant, disobedient and
hostile behaviour towards authority
figures
● Majority do not progress to more
serious psychopathology

126
 Diagnostic criteria
● A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness
lasting at least 6 months as evidenced by at least four symptoms from any of the
following categories, and exhibited during interaction with at least one individual who
is not a sibling.

Angry/Irritable Mood

○ 1. Often loses temper.

○ 2. Is often touchy or easily annoyed.
○ 3. Is often angry and resentful.

127
 Diagnostic criteria
Argumentative/Defiant Behavior

● 4. Often argues with authority figures or, for children and adolescents, with adults.
● 5. Often actively defies or refuses to comply with requests from authority figures
or with rules.
● 6. Often deliberately annoys others.
● 7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

● 8. Has been spiteful or vindictive at least twice within the past 6 months.

128
Diagnostic criteria
● B. The disturbance in behavior is associated with distress in the individual or
others in his or her immediate social context (e.g., family, peer group, work
colleagues), or it impacts negatively on social, educational, occupational, or other
important areas of functioning.
● C. The behaviors do not occur exclusively during the course of a psychotic,
substance use, depressive, or bipolar disorder. Also, the criteria are not met for
disruptive mood dysregulation disorder.

129
Conduct disorder
● Definition: persistent pattern of Prevalence
antisocial behaviour in which the
individual repeatedly breaks social ● ODD→ 3-16% < 16y/o
rules and carries out aggressive acts. ● CD→ 1-10%
● ODD + CD common reason for referral ● male:female=4:1
to child and adolescent mental health ● Onset of ODD→ <8 y/o
services (CAMHS) ● Onset of CD→ 10-15 y/o
● Become adult with antisocial personality ● Higher in lower socio economic groups
disorders
Comorbidity

● ADHD, learning disabilities, substance

abuse, PTSD, anxiety disorders,
depression, psychoses
130
 Diagnostic criteria
● A. A repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated, as manifested by the
presence of at least three of the following 15 criteria in the past 12 months from any
of the categories below, with at least one criterion present in the past 6 months:

Aggression to People and Animals

● 1. Often bullies, threatens, or intimidates others.

● 2. Often initiates physical fights.
● 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat,
● brick, broken bottle, knife, gun).
● 4. Has been physically cruel to people.
● 5. Has been physically cruel to animals.
● 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion,
● armed robbery).
131
● 7. Has forced someone into sexual activity.
Destruction of Property

● 8. Has deliberately engaged in fire setting with the intention of causing serious damage.
● 9. Has deliberately destroyed others’ property (other than by fire setting).

Deceitful ness or Theft

● 10. Has broken into someone else’s house, building, or car.

● 11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
● 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering: forgery).

Serious Violations of Rules

● 13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
● 14. Has run away from home overnight at least twice while living in the parental or
parental surrogate home, or once without returning for a lengthy period.
● 15. Is often truant from school, beginning before age 13 years.
132
● B. The disturbance in behavior causes clinically significant impairment in social,
academic, or occupational functioning.
● C. If the individual is age 18 years or older, criteria are not met for antisocial personality
disorder.

133
Differential diagnosis
● ADHD
○ Not show any specific behaviours
associated with ODD or CD
● Adjustment reaction to a specific
stressful event
○ Poor behaviour occur in first 3 months,
resolved by 6 months
● Mood disorders
○ Depression child mood is usually low,
associated with disturbed sleep and
anorexia
● Autistic spectrum disorder
● Learning disorders or specific
developmental disorders
● Dissocial / antisocial personality
disorder
○ Diagnosed from 17-18 y/o
○ Pervasive, severe lack of regard for, and
violation of the rights of others dating
back to mid adolescence
● Psychosis
○ Mental state examination should be
done
134
Aetiology
● Genetic ● Environmental factors
○ Positive family history ○ Precipitating event to cause disruptive
○ Present of monoamine oxidase behaviour on a background of genetic
promoter which polymorphism have and psychological vulnerability
been linked to ODD / CD; MAO enzyme ○ Eg: poverty-stricken, high crime
metabolizes neurotransmitters which neighbourhood. High unemployment
relate to aggressive behaviour
● Psychological risks
○ Adversely early experiences (poor
parenting, abuse)
○ Results in escalation of behaviour,
viscous cycle which negatively reinforce
child’s behaviour

135
Course and prognosis
● Usually stable throughout childhood
● Early CD (<8 y/o), 50% will develop
antisocial personality disorder in
adulthood
● Adolescent onset will severe in teenage
years but 85% have minor problems
during 20s
Assessment and management
● General: child does not feel their
behaviour s unreasonable and resistant
to interventions from health services
● psychoeducation→ need to understand
own behaviour, how it impacts and how
they would change
● Remedial teaching in school helpful
● Can be trained in behavioral
management techniques which can
reinforce work being done at home
136
Management (cont’d)

● Pharmacotherapy
○ Medication SHOULD NOT be the 1st line
○ SSRI ( appropriate use of stimulants)--> decrease symptoms in children with comorbid
ADHD / depression
○ In adolescent with severe aggression / violent outburst, atypical antipsychotic→ reduce
behaviour
○ Depot injections
● Psychological treatments
○ Psychological therapy→ 1st line management
○ Group sessions to teach parents
○ Promote good behaviour, positive relationship, setting clear rules and commands,
remaining calm and managing difficult situation
○ Systemic family therapy→ anger management, interpersonal skills training

137
138
139
140

Tics and Tourette’s syndrome
Tics
● Definition: sudden repetitive, non-rhythmic,
stereotyped motor movement or vocalization
involving discrete muscle groups.
● Classified as simple or complex; motor or vocal
OR transient / chronic, lasted for >12 months
● Extremely common, simple motor tics found
in 1-2% of children
● Associated with many behavioral, learning,
psychiatry disorders
● May cause great distress to both child and
family, have negative impact upon self
esteem, peer relationships and school
performance
Echolalia, palilalia, coprolalia:
https://www.youtube.com/watch?v=FK2vt
01laN4
● Simple tics→ typically sudden, brief,
meaningless movements or sounds that
usually involve only one group of
muscles. Common examples include
neck jerking, eye blinking, grunting,
snorting, or throat clearing
● Complex motor tics → typically more
purposeful appearing movements that
last for rather longer. Examples include
facial movements, jumping, touching, or
even self-harming.
● Complex vocal tics→ words and
phrases, and may include repetition of
what was just heard or said (echolalia and
palilalia) or socially inappropriate phrases
● (coprolalia). 141
Tics (cont’d)
● Number of tics, frequency, severity and
nature vary widely and able to suppress
the tic for short period
● May triggered / worsened by
excitement, fatigue, visual cues
Tourette’s syndrome
● Clinical feature
○ Motor tics appear in early life (3-8 y/o),
initially simple tics (blinking)→ complex
movement (licking)
○ Vocal tics (grunting, sniffing) almost
universal
○ Antisocial tics→ echolalia, palilalia
echopraxia
○ Severity peaks at 20 y.o
○ Some able to suppress tics for a short
time
○ Usually exacerbated by anxiety,
boredom, fatigue, excitement,
○ May reduced by sleep, alcohol, calming
surrounding
● Prevalence
○ Onset 4-6 y/o
○ Common in male > female
○ Not vary between races and
socioeconomic 142
143
Differential
diagnosis Aetiology
● Abnormal movements due to ● genetics→ 1st degree relatives 15-20%
neurological or neuropsychiatric ● neuroimaging→ reduce volume of
disorder caudate nucleus, increased volume of
○ Sydenham’s chorea, HUntington’s prefrontal cortex, cortico-striatal
disease, Wilson’s disease, tuberous pallidothalamo-cortico circuit (controls
sclerosis
suppression of unwanted movements
● Abnormal movements caused by
and find controls
medications
● Dopamine dysregulation→ efficacy to
○ Antipsychotic, anti epileptic
reduce tics
● ADHD
● autoimmunity→ antibodies produced
against streptococcus cross- reacting in
basal ganglia

144
Assessment
● Check for and treat any underlying
comorbid conditions
● Educate and reassure child and family
● Detailed neurological and
ophthalmological survey looking for
signs of other neurological conditions
Management
● psychoeducation→ provide stress free
environment
● Pharmacological treatments→ most
effective treatment but have adverse
effect
○ Antipsychotic
○ Alpha-2 agonists
○ Atypical antipsychotics
○ Local injections of botulinum toxin
● Psychological treatments
○ Cognitive behavioral therapy
145
Disorders of adults also seen in
adolescent

146
Bipolar disorder
● Rare before puberty, increases in
incidence rapidly in adolescent (mean
age 20 y/o)
● Young people do not show classical
alternation between depression and
manic episode
● Mixed episode are quite common →
rapid cycling
● Younger presentation, poor family
relationships, psychosis, family
history→ poorer the diagnosis
● Adolescent mania 50% relapse within 5
years

147
Suicide and deliberate self harm
● Most common comorbidities→ mood
disorders, alcohol, substance abuse,
anxiety disorder, eating disorder,
chronic physical diseases
● DSH→ act with a non fatal outcome,
which is undertaken with intention of
causing harm to self
● Females 4x likely to self harm

148
Assessment
● PE→ FBC, PCM and salicylate levels, ECG,
● History taking→
○ circumstances leading up to the DSH;
○ whether the child aimed to end their life;
○ frequency, intensity, and severity of
self-harm thoughts;
○ was the act planned; if so, how?
○ did the child seek help immediately, or
try to avoid discovery of the act?
○ are they still actively suicidal or thinking
about self harming again?
○ background: previous DSH, mental,
and physical disorders;
○ current psychosocial functioning (home
relationships, peer relationships,
bullying, school performance
Management
● Keep child safe
● Can treated as outpatient
● Indication for inpatient:
○ Active suicidal ideation
○ Intent, young person not able to promise
not to harm themselves
○ Psychosis
○ Impulsivity
○ Lack of suitable home environment
● Treatment:
○ Individual therapy→ depressed teenager
○ Dialectical behavioral therapy→
borderline personality disorder
○ Family therapy→ address relationships
problems + improve communication
● medication→ reduce suicidal behaviour
○ SSRI, lithium
○ *regular monitoring patient’s mental
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Schizophre
nia Substance abuse
● Rare in children ● Example
● <18 y/o→ early onset schizophrenia
○ Cannabis
● < 13 y/0→ very early onset schizophrenia
● Usually have strong family history ○ alcohol
● Treatment same as adult
○ Medication
○ Psychoeducation
○ Psychological treatments
○ Family therapy
● ALWAYS MONITOR SIDE EFFECT (weight
gain, extrapyramidal movements)
● Early onset→ poor outcome
● Associated with reduced IQ, increased
cognitive deficits, increased negative
symptoms, less likelihood of independent
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living, hold down employment
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Juvenile delinquency
● Definition: failure of young person to
obey the law
● Most common at 15-16 y/o, males
● Management
○ Emphasis on secondary prevention
rather than punishment
○ Involve social, educational,
psychological, psychiatric services

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