Child Adolescent Psychiatry in Primary Care A symptombased
Child & Adolescent Psychiatry in Primary Care A symptom-based overview Dr Andrew Mowat 1 1/21/2022
Epidemiology of Mental Health Setting Prevalence per 1000 patients/yr 1 st Filter: Community “The decision to consult” 2 nd Filter: Primary Care “GP recognition” 3 rd Filter: Conspicuous morbidity “The decision to refer” 4 th Filter: Mental Illness Services “Admission to Psychiatric beds” 5 th Filter: Psychiatric Inpatients 260 -315 Dr Andrew Mowat 230 101. 5 20. 8 3. 8 -6. 7 2 1/21/2022
Symptomatology 4 patterns l Conduct Disorder l Emotional Disorder l Relationship Disorder l Developmental Disorder plus specific illnesses which occupy one or more of these domains Dr Andrew Mowat 3 1/21/2022
Conduct Disorder “Disorders characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct” ICD-10 Dr Andrew Mowat 4 1/21/2022
Conduct Disorder Often confined to family l May be: l – unsocialised (abnormal relationship with others) – socialised (normal relationships e. g. with peers) Oppositional defiant l Commonly mixed with Emotional Disorder l Dr Andrew Mowat 5 1/21/2022
Conduct Disorder Management l Family Therapy l Social Support Dr Andrew Mowat 6 1/21/2022
Emotional Disorder l Depression – 10% of 10 -yr-olds “miserable” (parents report) – 40% of 14 -yr-olds “miserable” (self-report) Anxiety l Mania l Dr Andrew Mowat 7 1/21/2022
Depression Childhood: boys = girls l Adolescence: boys << girls l Management l – Drug Rx? – Therapy: Family l Cognitive (individual) l School liaison l Dr Andrew Mowat 8 1/21/2022
Anxiety Separation l Phobic l Generalised l l School Refusal Dr Andrew Mowat 9 1/21/2022
Phobias and all that…. l Agoraphobia F 40. 0 l Social phobias F 40. 1 l Simple phobia F 40. 2 l Obsessive-Compulsive Disorder F 42 l Panic Disorder F 41. 0 l PTSD F 43. 1 Dr Andrew Mowat 10 1/21/2022
OCD l Obsessive Compulsive Disorder – intrusive, repetitive thoughts – anxiety-provoking – ? abnormal 5 HT transmission Dr Andrew Mowat 11 1/21/2022
Mania Very rare l Commonly misdiagnosed: l – hyperkinetic disorder (childhood) – schizophrenia (adolescence) l First Rank symptoms may be prominent Dr Andrew Mowat 12 1/21/2022
Relationship Disorder Sibling rivalry l Elective mutism l Attachment Disorders l – Reactive – Disinhibited Dr Andrew Mowat 13 1/21/2022
Developmental Disorder Pervasive Developmental disorders l Childhood Autism l Rett’s Syndrome l Asperger’s Syndrome l Dr Andrew Mowat 14 1/21/2022
Autism Genetically-influenced l Neurodevelopmental impairment l onset before 3 years l Atypical variants l – later onset – limited effect Dr Andrew Mowat 15 1/21/2022
Autism Ø 3 Domains l Communication l Social interaction l Repetitive behaviour Dr Andrew Mowat 16 1/21/2022
Asperger’s Syndrome l Problem areas – Social interaction – Restricted/Stereotyped interests l Differs from Autism – Normal cognitive & language development l Clumsiness – & tends to lead to depression later Dr Andrew Mowat 17 1/21/2022
Hyperkinetic Disorders (ADHD) Neurodevelopmental cause l Early onset l Boys > Girls l Show lack of persistence in activities requiring attention l Move from one activity to another without completing l Dr Andrew Mowat 18 1/21/2022
Attention Deficit Hyperactivity Disorder l Common Presentations – – l accident prone socially-dissociated relationships with adults aggressive disciplinary problems Associations – below-average intelligence or mild handicap – epilepsy – minor motor difficulties Dr Andrew Mowat 19 1/21/2022
ADHD Management l Behaviour modification l Cerebral stimulants: l – Methylphenidate (Ritalin) – Tranylcypromine Dr Andrew Mowat 20 1/21/2022
Ritalin Amphetamine CNS stimulant l Must be used under Specialist supervision l Must be periodically withdrawn to verify still working l Controlled (Sched 2 MDA) drug l ADR: weight loss etc l Dr Andrew Mowat 21 1/21/2022
Substance Misuse l Glue/Solvents l Tobacco l Alcohol l Drug Dr Andrew Mowat 22 1/21/2022
Eating Disorders l Anorexia Nervosa F 50. 0 “Deliberate weight loss resulting in a bodyweight more than 15% below the norm” l Bulimia Nervosa F 50. 2 “Repeated bouts of overeating and an excessive preoccupation with the control of bodyweight” Dr Andrew Mowat 23 1/21/2022
Anorexia Nervosa l Weight reduced by: – avoidance of food – overactivity – excessive exercise – appetite suppressants – laxatives/diuretics Dr Andrew Mowat 24 1/21/2022
Anorexia Nervosa: complications Cardiovascular Metabolic Gastrointestinal Renal Haematological Endocrine hypotension, arrhythmias Skeletal Neurological osteoporosis, bone maturation Dr Andrew Mowat hypothermia, hypoglycaemia constipation/diarrhoea, pancreatitis calculi, renal failure anaemia, pancytopenia ↓ LH/FSH (♀) ↓ Testosterone (♂) ↑ GH/cortisol (both) seizures, sleep disturbance 25 1/21/2022
Anorexia Nervosa: management Aim to restore healthy weight and diet l Gradual work towards patient accepting need & responsibility for healthy weight l Hospital admission? l Behavioural therapy l Dr Andrew Mowat 26 1/21/2022
Bulimia Nervosa l Differs from Anorexia Binge Eating l Purging l – vomiting – laxatives, diuretics l Prevalence 0. 5 -1%, peak age in 20’s Dr Andrew Mowat 27 1/21/2022
Bulimia Nervosa l Physical features: – salivary gland enlargement – erosion of dental enamel – calluses dorsum of hand (Russell’s sign) – metabolic disturbances l Management: – Behavioural therapy – ? SSRI Dr Andrew Mowat 28 1/21/2022
Other specific disorders Obsessive Compulsive Disorder l Sleep Disorders l Trichotillomania l Tic l Enuresis l Encopresis l Dr Andrew Mowat F 42 29 1/21/2022
Sleep Disorders l Sleepwalking – first ⅓ of sleep – low levels of awareness, reactivity, recall l Sleep (Night) Terrors – first ⅓ of sleep – terror, vocalisation, motility – limited recall l l Nightmares Hypersomnia Dr Andrew Mowat 30 1/21/2022
Tic disorders Involuntary rapid, recurrent, non-rhythmic motor movements or vocal production l Gilles de la Tourette’s Syndrome l – multiple tics l facial, limb – compulsive utterances l l coprolalia Treatment Dr Andrew Mowat 31 1/21/2022
Enuresis l What is normal? l What investigations? l What therapy – Behavioural – Drug Dr Andrew Mowat 32 1/21/2022
Summary l Most Childhood Mental Health problems are disorders of conduct or emotion l Many represent wider problems within the family l Family Therapy or Cognitive Behavioural Therapy more often successful, but take a great deal more time, than drug therapy Dr Andrew Mowat 33 1/21/2022
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