Child Adolescent Psychiatry in Primary Care

1. 21/09/2012 Dr Andrew Mowat 1 Child & Adolescent Psychiatry in Primary Care A symptom-based overview

2. 21/09/2012 Dr Andrew Mowat 2 Epidemiology of Mental Health Goldberg & Huxley�s 5 levels/4 filters: Prevalence is Goldberg & Huxley�s 5 levels/4 filters: Prevalence is

3. 21/09/2012 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 When children with mental health problems consult the Doctor, there are 4 broad groups of symptoms: often, the symptoms will overlap two or even three domains (the child with developmental delay who has conduct and emotional problems): Conduct Disorder: dissocial, aggressive or defiant conduct. Emotional Disorder: depression, anxiety, mania Relationship disorders: sibling rivalry, attachment disorders Developmental: delays, precocious behaviourWhen children with mental health problems consult the Doctor, there are 4 broad groups of symptoms: often, the symptoms will overlap two or even three domains (the child with developmental delay who has conduct and emotional problems): Conduct Disorder: dissocial, aggressive or defiant conduct. Emotional Disorder: depression, anxiety, mania Relationship disorders: sibling rivalry, attachment disorders Developmental: delays, precocious behaviour

4. 21/09/2012 Dr Andrew Mowat 4 Conduct Disorder �Disorders characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct� ICD-10

5. 21/09/2012 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 Conduct disorder seems to represent the most frequent and demanding of child mental health presentation, perhaps because it is a recurrent presentation. Mainly but not exclusively affecting boys, there is often a feeling of despair that �things have got so bad that I�ve had to bring him to you�. Children have frequently been in oppositional contact with other institutions � School, Police etc �and may have been referred �so that something can be done�. The disorder is often confined within the family, and may be seen as a way of achieving a desired change in family dynamics, on the part of the child. Behaviour is often successful in gaining attention, and in concealing other problems in relationships.Conduct disorder seems to represent the most frequent and demanding of child mental health presentation, perhaps because it is a recurrent presentation. Mainly but not exclusively affecting boys, there is often a feeling of despair that �things have got so bad that I�ve had to bring him to you�. Children have frequently been in oppositional contact with other institutions � School, Police etc �and may have been referred �so that something can be done�. The disorder is often confined within the family, and may be seen as a way of achieving a desired change in family dynamics, on the part of the child. Behaviour is often successful in gaining attention, and in concealing other problems in relationships.

6. 21/09/2012 Dr Andrew Mowat 6 Conduct Disorder Management Family Therapy Social Support Because conduct disorder cannot be seen in isolation from the rest of the family, it is best managed as a Family Problem. Therapeutic work, with other family members and a therapist, takes a great deal of time and persistence. The temptation not to see it through may undermine best efforts, and the delay in accessing services leads to great levels of frustration among families struggling on a day-to-day basis to contain the problem. Social support � provision of respite for parents, and activity for the child � may be seen as a reward for bad behaviour, and is unlikely to attract huge resources in a cash-limited Social Services Directorate. Therefore, in light of the likely failing of secondary health and social care services, patients are increasingly taking up time in Primary Care, where at least they have direct access to services. It is possible that better liaison between Health, Education, Legal and Social Care Agencies might foster more effective ways of providing Social Support, while waiting for assessment for further therapy.Because conduct disorder cannot be seen in isolation from the rest of the family, it is best managed as a Family Problem. Therapeutic work, with other family members and a therapist, takes a great deal of time and persistence. The temptation not to see it through may undermine best efforts, and the delay in accessing services leads to great levels of frustration among families struggling on a day-to-day basis to contain the problem. Social support � provision of respite for parents, and activity for the child � may be seen as a reward for bad behaviour, and is unlikely to attract huge resources in a cash-limited Social Services Directorate. Therefore, in light of the likely failing of secondary health and social care services, patients are increasingly taking up time in Primary Care, where at least they have direct access to services. It is possible that better liaison between Health, Education, Legal and Social Care Agencies might foster more effective ways of providing Social Support, while waiting for assessment for further therapy.

7. 21/09/2012 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 Depression surprisingly prevalent: Isle of Wight study showed 10% 10-yr-olds & 40% 14-yr-olds at least miserable. Presents differently at diff developmental stages: pre-school despair on separation. After 6, symptoms like adult. May present as school refusal, friendship difficulties, irritability, or somatic conversion: abdo pain, headache etc. Suicidal thoughts not usually acted upon til adolescence. Half of depressed children have another psychiatric disorder ie conduct or anxiety disorder.Depression surprisingly prevalent: Isle of Wight study showed 10% 10-yr-olds & 40% 14-yr-olds at least miserable. Presents differently at diff developmental stages: pre-school despair on separation. After 6, symptoms like adult. May present as school refusal, friendship difficulties, irritability, or somatic conversion: abdo pain, headache etc. Suicidal thoughts not usually acted upon til adolescence. Half of depressed children have another psychiatric disorder ie conduct or anxiety disorder.

8. 21/09/2012 Dr Andrew Mowat 8 Depression Childhood: boys = girls Adolescence: boys << girls Management Drug Rx? Therapy: Family Cognitive (individual) School liaison Presents differently at diff developmental stages: pre-school despair on separation. After 6, symptoms like adult. May present as school refusal, friendship difficulties, irritability, or somatic conversion: abdo pain, headache etc. Suicidal thoughts not usually acted upon til adolescence. Half of depressed children have another psychiatric disorder ie conduct or anxiety disorder. Drug Rx controversial: used more commonly in post-pubertal children. Family, cognitive therapies. School liaisonPresents differently at diff developmental stages: pre-school despair on separation. After 6, symptoms like adult. May present as school refusal, friendship difficulties, irritability, or somatic conversion: abdo pain, headache etc. Suicidal thoughts not usually acted upon til adolescence. Half of depressed children have another psychiatric disorder ie conduct or anxiety disorder. Drug Rx controversial: used more commonly in post-pubertal children. Family, cognitive therapies. School liaison

9. 21/09/2012 Dr Andrew Mowat 9 Anxiety Separation Phobic Generalised School Refusal 5-10% of all children may be affected to significant extent Separation anxiety: arising early childhood, fear of separation of unusual severity. persisting to developmentally-inappropriate extent. Associated with significant socail dysfunction. Simple phobias: attachment or transfer of anxiety to external thing or circumstance � dogs, weather, open spaces. Unlike fear of spiders, snakes, dark, which are socially-engendered norms. School attendance problems can be associated with any emotional disorder. May be caused by bullying, difficulties in learning/achieving. Headache or abdo pain in morning. May be unwittingly fostered by parent who themselves has separation anxiety or emotional/other problems. Rx: re-establish attendance with support. Remember that School Teachers are often hard-pressed to attain their own targets educationally, and may not share your perception that Health is a role in which they have a vital part!5-10% of all children may be affected to significant extent Separation anxiety: arising early childhood, fear of separation of unusual severity. persisting to developmentally-inappropriate extent. Associated with significant socail dysfunction. Simple phobias: attachment or transfer of anxiety to external thing or circumstance � dogs, weather, open spaces. Unlike fear of spiders, snakes, dark, which are socially-engendered norms. School attendance problems can be associated with any emotional disorder. May be caused by bullying, difficulties in learning/achieving. Headache or abdo pain in morning. May be unwittingly fostered by parent who themselves has separation anxiety or emotional/other problems. Rx: re-establish attendance with support. Remember that School Teachers are often hard-pressed to attain their own targets educationally, and may not share your perception that Health is a role in which they have a vital part!

10. 21/09/2012 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 Although phobia may lead to panic attack, judged separate from Panic Disorder: panic disorder is much more serious.Although phobia may lead to panic attack, judged separate from Panic Disorder: panic disorder is much more serious.

11. 21/09/2012 Dr Andrew Mowat 11 OCD Obsessive Compulsive Disorder intrusive, repetitive thoughts anxiety-provoking ?abnormal 5HT transmission Obsessions are repetitive intrusive ideas images and thoughts: although unwamted ?unpleasant, sufferer feels unable to resist. Associated with increase in anxiety, ritual and compulsions (ways of decreasing anxiety). � involve compulsions such as washing, cleaning or counting. Some similarities between OCD and anorexia nervosa.Obsessions are repetitive intrusive ideas images and thoughts: although unwamted ?unpleasant, sufferer feels unable to resist. Associated with increase in anxiety, ritual and compulsions (ways of decreasing anxiety). � involve compulsions such as washing, cleaning or counting. Some similarities between OCD and anorexia nervosa.

12. 21/09/2012 Dr Andrew Mowat 12 Mania Very rare Commonly misdiagnosed: hyperkinetic disorder (childhood) schizophrenia (adolescence) First Rank symptoms may be prominent

13. 21/09/2012 Dr Andrew Mowat 13 Relationship Disorder Sibling rivalry Elective mutism Attachment Disorders Reactive Disinhibited Sibling rivalry unusual degree/persistence emotional disturbance following birth of younger sibling Elective mutism: emotionally-determined selectivity in speaking. Social anxiety, withdrawal, sensitivity, resistance. Reactive Attachment Disorder: persistent abnormalities in pattern of relationships associated with emotional disturbance, reactive to changes in circumstance (which, I think, means that child�s relationships with others e.g. siblings may be fairly normal until circumstances change e.g. parent returns, and behaviour and relationships suddenly change)(if my understanding is right, this must be phenomenally common, overlapping substantially with conduct disorder, or sibling rivalry). It is associated with neglect and/or abuse. Disinhibited attachment disorder: diffuse non-selective attachment behaviour � attention-seeking, inappropriate friendliness, poorly-modulated peer relationships (keep trying to be friends with peers who bully/reject).Sibling rivalry unusual degree/persistence emotional disturbance following birth of younger sibling Elective mutism: emotionally-determined selectivity in speaking. Social anxiety, withdrawal, sensitivity, resistance. Reactive Attachment Disorder: persistent abnormalities in pattern of relationships associated with emotional disturbance, reactive to changes in circumstance (which, I think, means that child�s relationships with others e.g. siblings may be fairly normal until circumstances change e.g. parent returns, and behaviour and relationships suddenly change)(if my understanding is right, this must be phenomenally common, overlapping substantially with conduct disorder, or sibling rivalry). It is associated with neglect and/or abuse. Disinhibited attachment disorder: diffuse non-selective attachment behaviour � attention-seeking, inappropriate friendliness, poorly-modulated peer relationships (keep trying to be friends with peers who bully/reject).

14. 21/09/2012 Dr Andrew Mowat 14 Developmental Disorder Pervasive Developmental disorders Childhood Autism Rett�s Syndrome Asperger�s Syndrome Abnormalities in social interaction and communication are common to all developmental disorders: restricted, stereotyped, repetitive repertoire of interests/activities/speech. Autism cover next slide. Rett�s: occurs in girls with normal early development followed by partial/complete loss speech, locomotion/hand dexterity skills. Aspergers: more later.Abnormalities in social interaction and communication are common to all developmental disorders: restricted, stereotyped, repetitive repertoire of interests/activities/speech. Autism cover next slide. Rett�s: occurs in girls with normal early development followed by partial/complete loss speech, locomotion/hand dexterity skills. Aspergers: more later.

15. 21/09/2012 Dr Andrew Mowat 15 Autism Genetically-influenced Neurodevelopmental impairment onset before 3 years Atypical variants later onset limited effect Autism believed to begenetically-influenced neurodevelopmental disorder. Abnormal or impaired development present BEFORE the age of 3. Characterised by 3 domains of abnormality (Later) BUT atypical presentation may include later onset or limited domain affected.Autism believed to begenetically-influenced neurodevelopmental disorder. Abnormal or impaired development present BEFORE the age of 3. Characterised by 3 domains of abnormality (Later) BUT atypical presentation may include later onset or limited domain affected.

16. 21/09/2012 Dr Andrew Mowat 16 Autism 3 Domains Communication Social interaction Repetitive behaviour The 3 characteristic domains of abnormality are: abnormal communication abnormal social interaction and restricted repetitive behaviours (body rocking, posturing, foot tapping etc)The 3 characteristic domains of abnormality are: abnormal communication abnormal social interaction and restricted repetitive behaviours (body rocking, posturing, foot tapping etc)

17. 21/09/2012 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

18. 21/09/2012 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 ADHD is a behavioural syndrome characterized by symptoms that may include chronic history of short attention span, distractibility, emotional lability, and impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired. � It is sometimes also named: hyperkinetic disorder, minimal brain damage, minimal brain dysfunction in children, minor cerebral dysfunction, or psycho-organic syndrome of children. ADHD is a behavioural syndrome characterized by symptoms that may include chronic history of short attention span, distractibility, emotional lability, and impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired. � It is sometimes also named: hyperkinetic disorder, minimal brain damage, minimal brain dysfunction in children, minor cerebral dysfunction, or psycho-organic syndrome of children.

19. 21/09/2012 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

20. 21/09/2012 Dr Andrew Mowat 20 ADHD Management Behaviour modification Cerebral stimulants: Methylphenidate (Ritalin) Tranylcypromine

21. 21/09/2012 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 Ritalin (Methylphenidate Hydrochloride)(Novartis Consumer Health) is an amphetamine CNS stimulant licensed for treatment of Attention Deficit Hyperactivity Disorder. Its Product Licence clearly states that, firstly, it is to be used under the supervision of a Specialist and, secondly, that the diagnosis of ADHD must be made within the framework of guidance laid down in DSM-IV or ICD-10 classifications. � It can only be used as part of a comprehensive treatment programme, typically including psychological, educational and social measures aimed at stabilizing a child with the condition. � Legal Category: Controlled Drug (Schedule 2) Ritalin (Methylphenidate Hydrochloride)(Novartis Consumer Health) is an amphetamine CNS stimulant licensed for treatment of Attention Deficit Hyperactivity Disorder. Its Product Licence clearly states that, firstly, it is to be used under the supervision of a Specialist and, secondly, that the diagnosis of ADHD must be made within the framework of guidance laid down in DSM-IV or ICD-10 classifications. � It can only be used as part of a comprehensive treatment programme, typically including psychological, educational and social measures aimed at stabilizing a child with the condition. � Legal Category: Controlled Drug (Schedule 2)

22. 21/09/2012 Dr Andrew Mowat 22 Substance Misuse Glue/Solvents Tobacco Alcohol Drug Relatively frequent. Peer/cultural pressures. Once pattern established, easy to move from one to another. Treatment programmes aim at prevention � very intensive and difficult to treat once pattern established. More common in children with history of conduct disorder.Relatively frequent. Peer/cultural pressures. Once pattern established, easy to move from one to another. Treatment programmes aim at prevention � very intensive and difficult to treat once pattern established. More common in children with history of conduct disorder.

23. 21/09/2012 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� Anorexia: defined as Deliberate weight loss resulting in a bodyweight more than 15% below the norm. Bulimia defined as: �Repeated bouts of overeating and an excessive preoccupation with the control of bodyweight� Anorexia: defined as Deliberate weight loss resulting in a bodyweight more than 15% below the norm. Bulimia defined as: �Repeated bouts of overeating and an excessive preoccupation with the control of bodyweight�

24. 21/09/2012 Dr Andrew Mowat 24 Anorexia Nervosa Weight reduced by: avoidance of food overactivity excessive exercise appetite suppressants laxatives/diuretics In anorexia, weight can be reduced by: avoidance of food, overactivity, excessive exercise, appetite suppressants, laxatives/diuretics. Anorexics frequently prepare food for others, but rarely actually eat it themselves. Spend lots of time weighing themselves, or examining themselves in the mirror. Prevalence 0.5-1%. Female to male ratio 10:1 85% of sufferers adolescent. Anorexia carries a 5-15% mortality. In anorexia, weight can be reduced by: avoidance of food, overactivity, excessive exercise, appetite suppressants, laxatives/diuretics. Anorexics frequently prepare food for others, but rarely actually eat it themselves. Spend lots of time weighing themselves, or examining themselves in the mirror. Prevalence 0.5-1%. Female to male ratio 10:1 85% of sufferers adolescent. Anorexia carries a 5-15% mortality.

25. 21/09/2012 Dr Andrew Mowat 25 Anorexia Nervosa: complications Cardiovascular: brady/tachycardia, hypotension, ventricular arrhythmias Metabolic: hypothermia, hypoglycaemia, hypercholesterolaemia, altered pH Gastrointestinal: constipation or diarrhoea, fatty infiltration of liver: pancreatitis on refeeding. Renal: calculi, hypomagnesaemia, renal failure Haematological: anaemia, pancytopenia Endocrine: decr LH/FSH (?) decr Testosterone (?) incr GH/cortisol Skeletal: osteoporosis, delayed onset bone maturation (prepubertal) Neurological: seizures, decr REM sleepCardiovascular: brady/tachycardia, hypotension, ventricular arrhythmias Metabolic: hypothermia, hypoglycaemia, hypercholesterolaemia, altered pH Gastrointestinal: constipation or diarrhoea, fatty infiltration of liver: pancreatitis on refeeding. Renal: calculi, hypomagnesaemia, renal failure Haematological: anaemia, pancytopenia Endocrine: decr LH/FSH (?) decr Testosterone (?) incr GH/cortisol Skeletal: osteoporosis, delayed onset bone maturation (prepubertal) Neurological: seizures, decr REM sleep

26. 21/09/2012 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 Aim of management has to be towards restoring a healthy normal bodyweight (BMI >17) in a gradual fashion, Patient must understand, accept and work towards importance of a healthy weight, and must assume responsibility for attaining/maintaining this. Hospital admission may be necessary if weight loss severe (<25% ideal bodyweight) or if serious chemical problem: hypokalaemia etc, and if severe depression/suicidal ideation Behavioural therapy: weight gain is rewarded by increasing mobility and privileges, and long-term cognitive therapy useful to remedy inappropriate link between feelings of low self-esteem, powerlessness, and perfectionist tendencies.Aim of management has to be towards restoring a healthy normal bodyweight (BMI >17) in a gradual fashion, Patient must understand, accept and work towards importance of a healthy weight, and must assume responsibility for attaining/maintaining this. Hospital admission may be necessary if weight loss severe (<25% ideal bodyweight) or if serious chemical problem: hypokalaemia etc, and if severe depression/suicidal ideation Behavioural therapy: weight gain is rewarded by increasing mobility and privileges, and long-term cognitive therapy useful to remedy inappropriate link between feelings of low self-esteem, powerlessness, and perfectionist tendencies.

27. 21/09/2012 Dr Andrew Mowat 27 Bulimia Nervosa Differs from Anorexia Binge Eating Purging vomiting laxatives, diuretics Prevalence 0.5-1%, peak age in 20�s Bulimia: repeated bouts of overeating and an excessive preoccupation with control of bodyweight, differs from anorexia in that weight is normal or increased. 2 main prongs of the illness: binge eating followed by purging of some sort � by self-induced vomiting, or by use of laxatives or diuretics. Prevalence, which peaks in 20�s, is 0.5-1%.Bulimia: repeated bouts of overeating and an excessive preoccupation with control of bodyweight, differs from anorexia in that weight is normal or increased. 2 main prongs of the illness: binge eating followed by purging of some sort � by self-induced vomiting, or by use of laxatives or diuretics. Prevalence, which peaks in 20�s, is 0.5-1%.

28. 21/09/2012 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 Unlike anorexia, bulimia sufferers experience intense craving for food. Episodes of bingeing and purging precipitated by feelings of depression, loneliness, boredom, anxiety. Usually CHO-rich �forbidden� foods, followed by intense guilt/self-loathing. Bulimic sufferers more likely then anorexics to self-injure. Management: some evidence that SSRIs help, but mainstay of management is behavioural therapy.Unlike anorexia, bulimia sufferers experience intense craving for food. Episodes of bingeing and purging precipitated by feelings of depression, loneliness, boredom, anxiety. Usually CHO-rich �forbidden� foods, followed by intense guilt/self-loathing. Bulimic sufferers more likely then anorexics to self-injure. Management: some evidence that SSRIs help, but mainstay of management is behavioural therapy.

29. 21/09/2012 Dr Andrew Mowat 29 Other specific disorders Obsessive Compulsive Disorder F42 Sleep Disorders Trichotillomania Tic Enuresis Encopresis

30. 21/09/2012 Dr Andrew Mowat 30 Sleep Disorders Sleepwalking first ? of sleep low levels of awareness, reactivity, recall Sleep (Night) Terrors first ? of sleep terror, vocalisation, motility limited recall Nightmares Hypersomnia Sleepwalking usually starts in childhood, occurring at times of stress. Usually occurs in stages 3 & 4 of sleep (within first few hours of onset). Small repetitive movements. Can negotiate barriers, may represent danger. Sleepwalkers can carry out complex purposeful tasks. Often FH. Management � avoid stressors, avoid medication if possible. Night terrors occur in slow wave sleep (stage 4) � onset within a couple of hours of sleep. Partial arousal accompanied by intense fear (physiological responses � tachycardia, hyperventilation, perspiration). Can be triggered by external (noise) or internal (febrile, head injury, drugs) factors. Nightmares usually occur in REM sleep, emotional & physiological arousal but loss of muscular tone which explains frequent observation of being unable to move as wakes. Frequently recalled on waking, but often a little confused. Hypersomnia � excessive sleep associated with somnolence during day. Narcolepsy (sleep attacks, associated with sleep drunkenness on wakening) often begins in adolescence. Pt goes straight from awake ? REM sleep. Associated HLA DR2. Can be managed with Methylphenidate or tranylcypromineSleepwalking usually starts in childhood, occurring at times of stress. Usually occurs in stages 3 & 4 of sleep (within first few hours of onset). Small repetitive movements. Can negotiate barriers, may represent danger. Sleepwalkers can carry out complex purposeful tasks. Often FH. Management � avoid stressors, avoid medication if possible. Night terrors occur in slow wave sleep (stage 4) � onset within a couple of hours of sleep. Partial arousal accompanied by intense fear (physiological responses � tachycardia, hyperventilation, perspiration). Can be triggered by external (noise) or internal (febrile, head injury, drugs) factors. Nightmares usually occur in REM sleep, emotional & physiological arousal but loss of muscular tone which explains frequent observation of being unable to move as wakes. Frequently recalled on waking, but often a little confused. Hypersomnia � excessive sleep associated with somnolence during day. Narcolepsy (sleep attacks, associated with sleep drunkenness on wakening) often begins in adolescence. Pt goes straight from awake ? REM sleep. Associated HLA DR2. Can be managed with Methylphenidate or tranylcypromine

31. 21/09/2012 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 Tic disorders involve Involuntary rapid, recurrent, non-rhythmic motor movements or vocal production. The worst form is Tourette�s syndrome (Gilles de la Tourette 1857-1904, French Neurologist) Treatment: Haloperidol, behavioural therapy ?????Ritalin Tic disorders involve Involuntary rapid, recurrent, non-rhythmic motor movements or vocal production. The worst form is Tourette�s syndrome (Gilles de la Tourette 1857-1904, French Neurologist) Treatment: Haloperidol, behavioural therapy ?????Ritalin

32. 21/09/2012 Dr Andrew Mowat 32 Enuresis What is normal? What investigations? What therapy Behavioural Drug Involuntary voiding inappropriate for patients mental age unrelated to organic problem. Therefore need to have clear idea what parents/carers expect. Primary or Secondary event? When did siblings become dry? Other indications of delayed development? Other indications of organic pathology. Probably reasonable to check urine culture on every individual, and to perform ultrasound on any found to have blood, protein, casts or cells. Extremely useful to involve Health Visitors at early stage: firstly, to look for signs of delayed development, over longer period than standard consultation allows. Secondly, to reinforce the behavioural approach to management: star charts, bed changing, buzzer etc. Short courses of tricyclics (Tofranil [imipramine] very useful)Involuntary voiding inappropriate for patients mental age unrelated to organic problem. Therefore need to have clear idea what parents/carers expect. Primary or Secondary event? When did siblings become dry? Other indications of delayed development? Other indications of organic pathology. Probably reasonable to check urine culture on every individual, and to perform ultrasound on any found to have blood, protein, casts or cells. Extremely useful to involve Health Visitors at early stage: firstly, to look for signs of delayed development, over longer period than standard consultation allows. Secondly, to reinforce the behavioural approach to management: star charts, bed changing, buzzer etc. Short courses of tricyclics (Tofranil [imipramine] very useful)

33. 21/09/2012 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 Most Childhood Mental Health problems are disorders of conduct or emotion. They arise for complex reasons, often unperceived by the participants themselves. Time to achieve resolution is often foreshortened by pressure from parents, schools and other outside agencies, and therapy may be ineffective unless a strong engagement is achieved with the individual wanting to improve the situation. Many represent wider problems within the family. The prevalence of single-parent families may firstly be linked to the rising prevalence of Child Mental Health problems, and secondly may shorten the time between incidence and presentation. The other agencies who dealt with behavioural problems before � Schools, Welfare agencies, Law enforcement agencies � are coming under increasing pressure to pass these problems onto Health agencies. Family Therapy or Cognitive Behavioural Therapy are more often successful, but take a great deal more time, than drug therapy. In a world where giving one person treatment intrinsically denies someone else that same treatment, we have to be sure firstly that we select the right patient and, secondly, that the resources are distributed to help as many people as possible. Most Childhood Mental Health problems are disorders of conduct or emotion. They arise for complex reasons, often unperceived by the participants themselves. Time to achieve resolution is often foreshortened by pressure from parents, schools and other outside agencies, and therapy may be ineffective unless a strong engagement is achieved with the individual wanting to improve the situation. Many represent wider problems within the family. The prevalence of single-parent families may firstly be linked to the rising prevalence of Child Mental Health problems, and secondly may shorten the time between incidence and presentation. The other agencies who dealt with behavioural problems before � Schools, Welfare agencies, Law enforcement agencies � are coming under increasing pressure to pass these problems onto Health agencies. Family Therapy or Cognitive Behavioural Therapy are more often successful, but take a great deal more time, than drug therapy. In a world where giving one person treatment intrinsically denies someone else that same treatment, we have to be sure firstly that we select the right patient and, secondly, that the resources are distributed to help as many people as possible.