04/22/23Dr Andrew Mowat1
Child & Adolescent Child & Adolescent Psychiatry in Primary Psychiatry in Primary CareCare
A symptom-based overview
04/22/23Dr Andrew Mowat2
Epidemiology of Mental Epidemiology of Mental HealthHealthSettingSetting PrevalencePrevalence
per1000 patients/yrper1000 patients/yr1st Filter: Community“The decision to consult”
260-315
2nd Filter: Primary Care“GP recognition”
230
3rd Filter: Conspicuous morbidity“The decision to refer”
101.5
4th Filter: Mental Illness Services“Admission to Psychiatric beds”
20.8
5th Filter: Psychiatric Inpatients 3.8-6.7
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SymptomatologySymptomatology4 patternsConduct DisorderEmotional DisorderRelationship DisorderDevelopmental Disorderplus specific illnesses which occupy one or more of plus specific illnesses which occupy one or more of
these domainsthese domains
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Conduct DisorderConduct Disorder
““Disorders characterised by a Disorders characterised by a repetitive and persistent pattern repetitive and persistent pattern of dissocial, aggressive or defiant of dissocial, aggressive or defiant conduct”conduct”
ICD-10
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Conduct DisorderConduct DisorderOften confined to familyMay be:
– unsocialised (abnormal relationship with others)– socialised (normal relationships e.g. with peers)
Oppositional defiantCommonly mixed with Emotional Disorder
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Conduct DisorderConduct Disorder
Management
Family Therapy
Social Support
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Emotional DisorderEmotional DisorderDepression
– 10% of 10-yr-olds “miserable” (parents report)– 40% of 14-yr-olds “miserable” (self-report)
AnxietyMania
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DepressionDepressionChildhood: boys = girlsAdolescence: boys << girlsManagement
– Drug Rx?– Therapy:
FamilyCognitive (individual)School liaison
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AnxietyAnxietySeparationPhobicGeneralised
School Refusal
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Phobias and all that….Phobias and all that….
Agoraphobia F40.0Social phobias F40.1Simple phobia F40.2 Obsessive-Compulsive Disorder F42Panic Disorder F41.0PTSD F43.1
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OCDOCDObsessive Compulsive Disorder
– intrusive, repetitive thoughts– anxiety-provoking– ?abnormal 5HT transmission
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ManiaManiaVery rareCommonly misdiagnosed:
– hyperkinetic disorder (childhood) – schizophrenia (adolescence)
First Rank symptoms may be prominent
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Relationship DisorderRelationship DisorderSibling rivalryElective mutismAttachment Disorders
– Reactive– Disinhibited
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Developmental DisorderDevelopmental DisorderPervasive Developmental disordersChildhood AutismRett’s SyndromeAsperger’s Syndrome
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AutismAutismGenetically-influencedNeurodevelopmental impairmentonset before 3 yearsAtypical variants
– later onset– limited effect
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AutismAutism 3 Domains
Communication
Social interaction
Repetitive behaviour
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Asperger’s SyndromeAsperger’s SyndromeProblem areas
– Social interaction– Restricted/Stereotyped interests
Differs from Autism– Normal cognitive & language development
Clumsiness– & tends to lead to depression later
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Hyperkinetic Disorders (ADHD)Hyperkinetic Disorders (ADHD)Neurodevelopmental causeEarly onsetBoys > GirlsShow lack of persistence in activities
requiring attentionMove from one activity to another without
completing
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Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder
Common Presentations– accident prone– socially-dissociated relationships with adults– aggressive– disciplinary problems
Associations– below-average intelligence or mild handicap– epilepsy– minor motor difficulties
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ADHDADHDManagementBehaviour modificationCerebral stimulants:
– Methylphenidate (Ritalin)– Tranylcypromine
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RitalinRitalinAmphetamine CNS stimulantMust be used under Specialist supervisionMust be periodically withdrawn to verify
still workingControlled (Sched 2 MDA) drugADR: weight loss etc
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Substance MisuseSubstance Misuse
Glue/Solvents
Tobacco
Alcohol
Drug
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Eating DisordersEating Disorders
Anorexia Nervosa F50.0“Deliberate weight loss resulting in a
bodyweight more than 15% below the norm”
Bulimia Nervosa F50.2“Repeated bouts of overeating and an excessive preoccupation with the control of bodyweight”
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Anorexia NervosaAnorexia NervosaWeight reduced by:
– avoidance of food– overactivity– excessive exercise– appetite suppressants– laxatives/diuretics
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Anorexia Nervosa: complicationsAnorexia Nervosa: complications
Cardiovascular hypotension, arrhythmias
Metabolic hypothermia, hypoglycaemia
Gastrointestinal constipation/diarrhoea, pancreatitis
Renal calculi, renal failure
Haematological anaemia, pancytopenia
Endocrine ↓ LH/FSH (♀) ↓ Testosterone (♂) ↑ GH/cortisol (both)
Skeletal osteoporosis, bone maturation
Neurological seizures, sleep disturbance
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Anorexia Nervosa: managementAnorexia Nervosa: management
Aim to restore healthy weight and dietGradual work towards patient accepting
need & responsibility for healthy weightHospital admission?Behavioural therapy
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Bulimia NervosaBulimia NervosaDiffers from Anorexia
Binge Eating Purging
– vomiting– laxatives, diuretics
Prevalence 0.5-1%, peak age in 20’s
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Bulimia NervosaBulimia NervosaPhysical features:
– salivary gland enlargement– erosion of dental enamel– calluses dorsum of hand (Russell’s sign)– metabolic disturbances
Management:– Behavioural therapy– ?SSRI
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Other specific disordersOther specific disorders
Obsessive Compulsive Disorder F42Sleep DisordersTrichotillomaniaTicEnuresisEncopresis
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Sleep DisordersSleep Disorders Sleepwalking
– first ⅓ of sleep– low levels of awareness, reactivity, recall
Sleep (Night) Terrors– first ⅓ of sleep– terror, vocalisation, motility– limited recall
Nightmares Hypersomnia
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Tic disordersTic disordersInvoluntary rapid, recurrent, non-rhythmic
motor movements or vocal productionGilles de la Tourette’s Syndrome
– multiple tics facial, limb
– compulsive utterancescoprolalia
Treatment
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EnuresisEnuresisWhat is normal?
What investigations?
What therapy– Behavioural– Drug
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SummarySummary
Most Childhood Mental Health problems are disorders of conduct or emotion
Many represent wider problems within the family
Family Therapy or Cognitive Behavioural Therapy more often successful, but take a great deal more time, than drug therapy