Child & Adolescent Psychiatry in Primary Care

1. Child & Adolescent Psychiatry in Primary Care A symptom-based overview Dr Andrew Mowat

2. Epidemiology of Mental Health Dr Andrew Mowat

3. Symptomatology 4 patterns • Conduct Disorder • Emotional Disorder • Relationship Disorder • Developmental Disorder plus specific illnesses which occupy one or more of these domains Dr Andrew Mowat

4. Conduct Disorder “Disorders characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct” ICD-10 Dr Andrew Mowat

5. Conduct Disorder • Often confined to family • May be: • unsocialised (abnormal relationship with others) • socialised (normal relationships e.g. with peers) • Oppositional defiant • Commonly mixed with Emotional Disorder Dr Andrew Mowat

6. Conduct Disorder Management • Family Therapy • Social Support Dr Andrew Mowat

7. Emotional Disorder • Depression • 10% of 10-yr-olds “miserable” (parents report) • 40% of 14-yr-olds “miserable” (self-report) • Anxiety • Mania Dr Andrew Mowat

8. Depression • Childhood: boys = girls • Adolescence: boys << girls • Management • Drug Rx? • Therapy: • Family • Cognitive (individual) • School liaison Dr Andrew Mowat

9. Anxiety • Separation • Phobic • Generalised • School Refusal Dr Andrew Mowat

10. Phobias and all that…. • Agoraphobia F40.0 • Social phobias F40.1 • Simple phobia F40.2 • Obsessive-Compulsive Disorder F42 • Panic Disorder F41.0 • PTSD F43.1 Dr Andrew Mowat

11. OCD • Obsessive Compulsive Disorder • intrusive, repetitive thoughts • anxiety-provoking • ?abnormal 5HT transmission Dr Andrew Mowat

12. Mania • Very rare • Commonly misdiagnosed: • hyperkinetic disorder (childhood) • schizophrenia (adolescence) • First Rank symptoms may be prominent Dr Andrew Mowat

13. Relationship Disorder • Sibling rivalry • Elective mutism • Attachment Disorders • Reactive • Disinhibited Dr Andrew Mowat

14. Developmental Disorder • Pervasive Developmental disorders • Childhood Autism • Rett’s Syndrome • Asperger’s Syndrome Dr Andrew Mowat

15. Autism • Genetically-influenced • Neurodevelopmental impairment • onset before 3 years • Atypical variants • later onset • limited effect Dr Andrew Mowat

16. Autism • 3 Domains • Communication • Social interaction • Repetitive behaviour Dr Andrew Mowat

17. Asperger’s Syndrome • Problem areas • Social interaction • Restricted/Stereotyped interests • Differs from Autism • Normal cognitive & language development • Clumsiness • & tends to lead to depression later Dr Andrew Mowat

18. Hyperkinetic Disorders (ADHD) • Neurodevelopmental cause • Early onset • Boys > Girls • Show lack of persistence in activities requiring attention • Move from one activity to another without completing Dr Andrew Mowat

19. Attention 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 Dr Andrew Mowat

20. ADHD • Management • Behaviour modification • Cerebral stimulants: • Methylphenidate (Ritalin) • Tranylcypromine Dr Andrew Mowat

21. Ritalin • Amphetamine CNS stimulant • Must be used under Specialist supervision • Must be periodically withdrawn to verify still working • Controlled (Sched 2 MDA) drug • ADR: weight loss etc Dr Andrew Mowat

22. Substance Misuse • Glue/Solvents • Tobacco • Alcohol • Drug Dr Andrew Mowat

23. Eating 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” Dr Andrew Mowat

24. Anorexia Nervosa • Weight reduced by: • avoidance of food • overactivity • excessive exercise • appetite suppressants • laxatives/diuretics Dr Andrew Mowat

25. Anorexia Nervosa: complications Dr Andrew Mowat

26. Anorexia Nervosa: management • Aim to restore healthy weight and diet • Gradual work towards patient accepting need & responsibility for healthy weight • Hospital admission? • Behavioural therapy Dr Andrew Mowat

27. Bulimia Nervosa • Differs from Anorexia • Binge Eating • Purging • vomiting • laxatives, diuretics • Prevalence 0.5-1%, peak age in 20’s Dr Andrew Mowat

28. Bulimia Nervosa • Physical features: • salivary gland enlargement • erosion of dental enamel • calluses dorsum of hand (Russell’s sign) • metabolic disturbances • Management: • Behavioural therapy • ?SSRI Dr Andrew Mowat

29. Other specific disorders • Obsessive Compulsive Disorder F42 • Sleep Disorders • Trichotillomania • Tic • Enuresis • Encopresis Dr Andrew Mowat

30. Sleep 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 Dr Andrew Mowat

31. Tic disorders • Involuntary rapid, recurrent, non-rhythmic motor movements or vocal production • Gilles de la Tourette’s Syndrome • multiple tics • facial, limb • compulsive utterances • coprolalia • Treatment Dr Andrew Mowat

32. Enuresis • What is normal? • What investigations? • What therapy • Behavioural • Drug Dr Andrew Mowat

33. Summary • 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 Dr Andrew Mowat