THE DISTRESSED YOUNG PERSON
• 7-20% children have mental health problems
• Child vs adolescent disorder = differences in ability to undertake positive adaptive behaviours and failing to
progress in expected fashion in one or more areas of development
PATHOPHYSIOLOGY OF CHILDHOOD DEVELOPMENT
Principles of development
i. Developmental tasks = competencies that need to be mastered at a critical period in the
developmental continuum
ii. Sensitive periods – undifferentiated neurons specifically sensitive to set of signals
a. More associated to mental health
b. Affect Attachment, affect modulation, anxiety regulation and behavioural
impulsivity
iii. Critical periods – optimal times in maturation to accomplish tasks
iv. Requires practice and anticipation
v. Brain remains sensitive to experiences throughout life – more sensitive parts include
the cortex which has increased plasticity
• Child’s early experiences (esp. between mother and infants) are critically important
Brain development
Critical periods Significance
Birth All brain cells present (except hippocampus)
Birth to 8 months Vision
Birth to 4 years Maths and logic
Birth to 10 years Language
Factors affecting Brain development.
Positive factors Negative factors
• Good family • Inadequate nutrition (e.g. folic acid – NTD)
experiences • Toxins during pregnancy (EtOH, thalidomide,
• Supportive rubella)
environments • Early experiences of deprivation
• Early social experiences (e.g stress)
• Visual defects
• Sensory deprived environments
TIMELINE OF PSYCHOPATHOLOGY IN CHILDHOOD
Early childhood Middle Late childhood
childhood
• Feeding and • Fears • Anxiety
sleeping issues • Fighting • Disturbed eating
• Minor aggression • Minor peer • Disobedience
• Separation anxiety relationships • Illicit drug use
• Temper tantrums • Nightmares • Moodiness
• Oppositional • Disobedience • Rebellion
behaviour
• School refusal
Childhood syndromes
Internalising disorders Externalising Specific developmental Pervasive developmental Other
disorders disorders disorders (PDD)
• Anxiety disorders (e.g. • ADHD – • Reading • Childhood autism • Eating disorder
separation, phobia, social hyperactive vs • Mathematics • Asperger’s • Elective mutism
anxiety, PTSD, OCD) inattentive
subtype • Communication • Rett’s syndrome • Enuresis
• Mood disorders
o Phonological • Childhood integrative disorder • Encopresis
• School refusal • ODD
o Expressive language • PDD NOS • Tic disorders
• Somatoform disorders • Conduct
o Receptive language • Gender identity
(unexplained physical Sx) • Truancy
e.g. conversion disorders o Landau-Kledffner disorders
syndrome (acquired
aphasia with epilepsy)
• Motor skills disorder
, EMERGENCY ASSESSMENT & Mx IN CHILD AND ADOLESCENT PSYCHIATRY
Hx Pearls
1) Reason for admission or referral?
2) Risk assessment -> danger of suicidal or out-of-control child
3) Does the child have an existing psychiatric disorder?
Ø Ice breaker topics – how’s school? Hobbies? Sports?
Music? Where do you live?
Ø How bad is it? – affect on ADL, restriction on social activities
Ø Their insight into their condition
4) Driving forces affecting development? Which is most likely?
Ø Biggest worry for a child is separation!!!!
Ø Biological
Ø Familial or sociocultural?
5) What resources available within child, family and the
community?
® consider the bio-psycho-social factors
6) Assess RF for suicide (SAD PERSONS): paranoia, disinhibition,
older, male, access to weapons, hx of unlawful behaviour or
violence, previous attempts, organised plans
7) ID protective factors:
Ø Coping skills - resilience, self-esteem
Ø Supports – family, dependents and community
8) Collateral Hx from 3rd parties (with parents alone and child alone)
Exam
Erikson vs Freud’s concepts about psychological development /
1) Create appropriate environment- well-lit, quiet, private, non- personalities:
stimulating, provide necessary sensory aids if needed
1) Freud believed that our personality is influenced internally
2) Simple exams – vitals, A-E through our libido (ego, superego) and mainly shaped by our
childhood esp. in our first 6 years
General Mx: 2) Erikson believed that our personality is dependent on our social
interactions and environmental changes which occur throughout
• ID what is going to hinder proper neurological development our life NOT just our childhood
• Non-pharm Mx – de-escalate and protect safety of others (explain
and reassure) – create a safe environment
• Aim to avoid idealisation to prevent repeated attendances
• If restrain required – should be planned, decisive, effective and
speedy
• Pharm Mx (last resort)
PHARMACOLOGICAL THERAPY IN CHILDREN
Main indications Goals Strategies
1. Epilepsy • Start LOW and GO SLOW • Change one drug / intervention at a time
2. ADHD • Aim for mono therapy but acknowledge • Give sufficient time 8-12 weeks
3. Obsession disorders o Development disorder • Consult senior colleague if prescribing
4. Depressive disorders o Severe mood disorders off-label
5. Tourette’s o Severe Sx which may warrant the need form than 1 • Clearly document all changes (i.e. target,
therapy rationale, plan, review, consent)
6. Nocturnal enuresis
• Allow sufficient time • Check adherence on each visit
• Always support prescription with adequate psychoeducation
(i..e. expected benefits, A/E, contingency plan) ® warn that
medication may be lifelong
• 7-20% children have mental health problems
• Child vs adolescent disorder = differences in ability to undertake positive adaptive behaviours and failing to
progress in expected fashion in one or more areas of development
PATHOPHYSIOLOGY OF CHILDHOOD DEVELOPMENT
Principles of development
i. Developmental tasks = competencies that need to be mastered at a critical period in the
developmental continuum
ii. Sensitive periods – undifferentiated neurons specifically sensitive to set of signals
a. More associated to mental health
b. Affect Attachment, affect modulation, anxiety regulation and behavioural
impulsivity
iii. Critical periods – optimal times in maturation to accomplish tasks
iv. Requires practice and anticipation
v. Brain remains sensitive to experiences throughout life – more sensitive parts include
the cortex which has increased plasticity
• Child’s early experiences (esp. between mother and infants) are critically important
Brain development
Critical periods Significance
Birth All brain cells present (except hippocampus)
Birth to 8 months Vision
Birth to 4 years Maths and logic
Birth to 10 years Language
Factors affecting Brain development.
Positive factors Negative factors
• Good family • Inadequate nutrition (e.g. folic acid – NTD)
experiences • Toxins during pregnancy (EtOH, thalidomide,
• Supportive rubella)
environments • Early experiences of deprivation
• Early social experiences (e.g stress)
• Visual defects
• Sensory deprived environments
TIMELINE OF PSYCHOPATHOLOGY IN CHILDHOOD
Early childhood Middle Late childhood
childhood
• Feeding and • Fears • Anxiety
sleeping issues • Fighting • Disturbed eating
• Minor aggression • Minor peer • Disobedience
• Separation anxiety relationships • Illicit drug use
• Temper tantrums • Nightmares • Moodiness
• Oppositional • Disobedience • Rebellion
behaviour
• School refusal
Childhood syndromes
Internalising disorders Externalising Specific developmental Pervasive developmental Other
disorders disorders disorders (PDD)
• Anxiety disorders (e.g. • ADHD – • Reading • Childhood autism • Eating disorder
separation, phobia, social hyperactive vs • Mathematics • Asperger’s • Elective mutism
anxiety, PTSD, OCD) inattentive
subtype • Communication • Rett’s syndrome • Enuresis
• Mood disorders
o Phonological • Childhood integrative disorder • Encopresis
• School refusal • ODD
o Expressive language • PDD NOS • Tic disorders
• Somatoform disorders • Conduct
o Receptive language • Gender identity
(unexplained physical Sx) • Truancy
e.g. conversion disorders o Landau-Kledffner disorders
syndrome (acquired
aphasia with epilepsy)
• Motor skills disorder
, EMERGENCY ASSESSMENT & Mx IN CHILD AND ADOLESCENT PSYCHIATRY
Hx Pearls
1) Reason for admission or referral?
2) Risk assessment -> danger of suicidal or out-of-control child
3) Does the child have an existing psychiatric disorder?
Ø Ice breaker topics – how’s school? Hobbies? Sports?
Music? Where do you live?
Ø How bad is it? – affect on ADL, restriction on social activities
Ø Their insight into their condition
4) Driving forces affecting development? Which is most likely?
Ø Biggest worry for a child is separation!!!!
Ø Biological
Ø Familial or sociocultural?
5) What resources available within child, family and the
community?
® consider the bio-psycho-social factors
6) Assess RF for suicide (SAD PERSONS): paranoia, disinhibition,
older, male, access to weapons, hx of unlawful behaviour or
violence, previous attempts, organised plans
7) ID protective factors:
Ø Coping skills - resilience, self-esteem
Ø Supports – family, dependents and community
8) Collateral Hx from 3rd parties (with parents alone and child alone)
Exam
Erikson vs Freud’s concepts about psychological development /
1) Create appropriate environment- well-lit, quiet, private, non- personalities:
stimulating, provide necessary sensory aids if needed
1) Freud believed that our personality is influenced internally
2) Simple exams – vitals, A-E through our libido (ego, superego) and mainly shaped by our
childhood esp. in our first 6 years
General Mx: 2) Erikson believed that our personality is dependent on our social
interactions and environmental changes which occur throughout
• ID what is going to hinder proper neurological development our life NOT just our childhood
• Non-pharm Mx – de-escalate and protect safety of others (explain
and reassure) – create a safe environment
• Aim to avoid idealisation to prevent repeated attendances
• If restrain required – should be planned, decisive, effective and
speedy
• Pharm Mx (last resort)
PHARMACOLOGICAL THERAPY IN CHILDREN
Main indications Goals Strategies
1. Epilepsy • Start LOW and GO SLOW • Change one drug / intervention at a time
2. ADHD • Aim for mono therapy but acknowledge • Give sufficient time 8-12 weeks
3. Obsession disorders o Development disorder • Consult senior colleague if prescribing
4. Depressive disorders o Severe mood disorders off-label
5. Tourette’s o Severe Sx which may warrant the need form than 1 • Clearly document all changes (i.e. target,
therapy rationale, plan, review, consent)
6. Nocturnal enuresis
• Allow sufficient time • Check adherence on each visit
• Always support prescription with adequate psychoeducation
(i..e. expected benefits, A/E, contingency plan) ® warn that
medication may be lifelong
