Normal early relationships

In the first 2 months of a baby’s life, infants are not fussy about who responds to their needs. From 3 to 6 months they become more selective, demanding comfort from one or two caregivers. By 6–8 months they are particular about who responds to their needs or holds them, especially when distressed, and show tearful separation anxiety if their main caregiver, usually the mother, is not there. If tired, fearful, unhappy or in pain, they will cling to her and be comforted by her presence as an attachment figure. At this time, the child learns to crawl, and so is able to leave a primary caregiver and possibly encounter danger. The development of attachment behaviour allows the infant to keep track of their parent’s whereabouts and resist separation. This close attachment relationship derives from social interaction and the mother’s sensitive responsiveness to the baby’s needs, not from any blood tie. It need not be with the biological mother, although it usually is. Its importance lies in it being:

This underscores the importance of having a young child’s parent ‘rooming in’ if admitted to hospital. Otherwise the child would be doubly distressed both by the absence of their attachment figure as well as by the threat of strange surroundings or procedures and by the stress of pain or illness.

If a young child is placed in strange, impersonal surroundings and separated from the mother for more than several hours, a triphasic acute separation reaction may set in (Fig. 23.1):

Recreating the original closeness can take weeks and is accompanied by a phase of irritability, misbehaviour and clinging. This can sometimes be seen when children who have been admitted to hospital as an emergency return home.

Children who have never had the opportunity for a close, secure attachment relationship in their early years are at risk of growing up as self-centred individuals who seek the affection and attention of others but have difficulty with close personal relationships and with learning to conform with social rules of conduct.

The selective clinging of early attachment behaviour diminishes over time so that in the second year of life children extend their emotional attachments to other family members and carers. By school age, they can tolerate separations from their parents for several hours. Children vary in their ability to do this depending on their temperament and social circumstances. For example, a child who is constitutionally apprehensive, who has an exceptionally anxious mother, or who has parents who threaten abandonment is likely to continue to cling to his/her mother for protection and comfort. A series of frightening events will tend to perpetuate clinging, which may persist well into middle childhood (age 5–12 years). This interferes with children’s capacity to learn how to cope with anxiety on their own (Fig. 23.2).

With entry into school, the importance of teachers and other children in shaping psychosocial development increases and their influence must be taken into account in understanding any schoolchild’s development.

Temperament

Children differ from each other in personality from birth, just as they do in physical appearance. This individuality in behavioural style or temperament is partly genetically determined. It is not fixed but changes slowly in the light of experience. It affects how other people deal with them.

A child born with a difficult temperament is prone to:

Such a pattern is a vulnerability factor for future emotional and behavioural problems. It may be hard for parents to maintain an affectionate relationship with a child who has a difficult temperament. Their self-confidence falters as they feel guilty that they have failed as parents. Such parents need support to maintain a positive, loving relationship with their child who will, if this can be done, soften and become easier to handle over a period of months. If parents lapse into irritable intolerance themselves, this is likely to maintain the child’s grouchy and unsatisfied manner and may lead eventually to low self-esteem or the development of behavioural problems.

Self-esteem

Children develop views and make attributions about themselves. Most children experience praise and success in enough areas of their lives to develop a sense of inner self-confidence and self-worth. Those who do not are at increased risk of developing emotional and behavioural disorders which in turn may breed further shame and failure. A child who does not consider him/herself worthwhile and valued by others will play safe and not attempt new activities or explore new situations because of a fear of failure. This restricts the development of coping skills and knowledge of the world generally. It may also be a vulnerability factor for depression and anxiety disorders. Children who lack a belief in their own worth may adopt extraordinary and problematic behaviours in order to attract the attention and acclaim of others. For instance, one child took to openly eating dog faeces because it attracted a crowd of amazed children around her. Repeated failure, academically or socially, will undermine self-esteem, as will some disorders themselves (dyspraxia, enuresis and faecal soiling in particular). An important source of low self-esteem, however, is the child’s parents, either because of their own low self-esteem or because of abuse (emotional, sexual or physical) and neglect.

Cognitive style

As children grow older, their thinking style evolves from one that is concrete to one that is able to cope with abstract thought. Below the age of about 5 years, thought is fundamentally egocentric, with the child being at the centre of his world (Box 23.2). During middle childhood, the dominant mode of thought is practical and orderly but tied to immediate circumstances and specific experiences rather than hypothetical possibilities or metaphors. Not until the mid-teens does the adult style of abstract thought begin to appear.

Coping with chronic or serious illness or adversities in childhood

Children can respond to adversity, including illness, in a number of ways:

• Cognitive response – can lie anywhere along the spectrum of over-acceptance to denial, with fluctuation over time. In over-acceptance, the child may allow the illness to overtake their life resulting in more impairment than is expected for level of symptoms, and high levels of anxiety about the slightest symptom. With denial, symptoms and warning signs may be ignored and treatment poorly adhered to.

• Emotional response – to diagnosis of illness and at times of relapse, may have similarities to a bereavement reaction or reaction to loss, with shock, denial, anger, followed by acceptance and adjustment (Fig. 23.3). Such responses to a serious illness are normal as long as the child proceeds through the phases.

• Behavioural response – young children tend to regress when stressed and behave younger than they actually are. A toddler may become overactive or clingy and display sleep and feeding difficulties. Regressive responses in older children predominantly manifest as problems with toileting, academic performance and peer relationships.

• Somatic response – can include expression of worry and distress through bodily symptoms such as recurrent abdominal pain.

Children suffering from chronic or serious illness are more vulnerable to mental health problems. This is related to:

This is a common problem in the toddler years. The child will not go to sleep unless the parent is present. Most instances are normal expressions of separation anxiety, but there may be other obvious reasons for it which can be explored in taking a history (Box 23.6), supplemented if necessary by the parents keeping a prospective sleep diary. Many cases will respond to simple advice:

If that advice does not resolve the problem, a more active intervention may be required. This involves parents imposing a graded pattern of lengthening periods between tucking their child up in bed and coming back after a few minutes to visit, but leaving the room before the child falls asleep, even if they are protesting. The object is to provide the opportunity for the child to learn how to fall sleep alone, a skill not yet developed. More refractory cases may require specialist referral.

Disobedience, defiance and tantrums

Normal toddlers often go through a phase of refusing to comply with parents’ demands, sometimes angrily (‘the terrible 2s’). This is an understandable reaction to the discovery that the world is not organised around them. They also become confused and angered by the fact that the parent who provides them with comfort when they are distressed is also the person who is making them do things they do not wish to do. This seems exceptionally unfair to them. That is one reason why children play their parents up but may be fine with others. All this can exhaust and demoralise parents, not least because many people offer advice or criticism (everyone thinks themselves an expert in the area of children’s development and behaviour). The points listed in Box 23.7 can be made.

Temper tantrums are ordinary responses to frustration, especially at not being allowed to have or do something. They are common and normal in young preschool children. If asked for advice, a sensible first move is to take a history, analysing a couple of tantrums according to the ABC paradigm (Box 23.8). Next, examine the child to identify potential medical or psychological factors. Medical factors include global or language delay, hearing impairment (e.g. glue ear) and medication with bronchodilators or anticonvulsants. If none are present, there are management strategies that can be adopted, some of which are shown in Box 23.9.

The easiest course of action is to distract the child or, if this cannot be done, to let the tantrum burn itself out while the parent leaves the room, returning a few minutes later when things quieten down (provided it is safe to leave the child alone). Obviously this should be done in a calm, neutral manner and certainly not accompanied by threats of abandonment. Tantrums which are essentially coercive (when a child is demanding something from a parent) must be met by a refusal to give in. They can often be forestalled by the simple expedient of making rules which the child can be reminded of before the situation presents itself. An alternative course is to use ‘time out’, which is a form of structured ignoring. The child in a tantrum is placed somewhere such as the hallway, where no-one will talk to him for a short time, e.g. 1 min per year of age. During this period they are ignored completely. Parents often expect this manoeuvre to produce a contrite child, complaining if it does not do so immediately. In fact, when used for tantrums, time out works according to different principles (not as a response to punishment but to the withdrawal of attention) and often takes several weeks to effect a gradual improvement. It may help to ask the mother to keep records to document this.

Disobedience can be dealt with by using a star chart to reward the child for complying with parental requests. The chart needs to be where the child can see it and it must be the case that the child knows what to do in order to get a star. It is wisest not to ‘fine’ the child by taking stars away once they have been earned. If the parent who is rewarding compliance by the child praises at the same time as giving the star, there may not be the need to tie stars with a material reward. However, if a tangible reward had been promised for a certain number of stars, it is important to follow through with this.

Aggressive behaviour

Small children can be aggressive for a host of reasons, ranging from spite to exuberance. Much aggressive behaviour is learned, either by being rewarded (often inadvertently) or by copying parents, siblings or peers. For example, many instances of aggressive, demanding behaviour are provoked or intensified by a parent shouting at or hitting their child. In such cases, it is the parent’s behaviour which needs to change. In most instances, the same principles as apply to tantrums are valid: make rules clear, stick to them, keep cool, do not give in and use time out if necessary. The latter can often be used on a 1–2–3 principle (Fig. 23.4). A tired or stressed child will be irritable and prone to angry outbursts, as will children whose communication skills are compromised by deafness or a developmental language disorder so that they are frustrated and exasperated. Optimistic reassurance that the child will spontaneously grow out of a pattern of aggressive behaviour is mistaken; once established, an aggressive behavioural style is remarkably persistent over a period of years. Thus, aggressive behaviour in children needs to be proactively managed. There are several evidence-based parenting programmes that are effective for teaching parents to manage aggression in their children. Parents should be encouraged to attend such programmes.

Autism

This is considered in Chapter 4.

Faecal soiling

It is abnormal for a child to soil after the age of 4 years. Thereafter, children who soil fall into two broad groups: those with and those without a rectum loaded with faeces. Because of this, it is important to ascertain whether there is faecal retention by abdominal palpation. The reasons why a child’s rectum becomes loaded are various, and commonly involve an interplay between constitutional factors and experience. Some children have a rectum that only empties occasionally, perhaps because of poor coordination with anal sphincter relaxation, and are thus more prone to developing retention. Superimposed upon this are a number of other factors:

Once established, a huge bolus of hard faeces may be beyond the capacity of the child to shift. Furthermore, a rectum loaded with hard or soft faeces (both are found) dilates and habituates to distension so that the child becomes unaware of the need to empty it. The loaded rectum inhibits the anus via the rectoanal reflex and stool may seep out with spontaneous rectal contractions beyond the child’s control. Soiling occurs in the child’s pants, which may then be removed and hidden out of shame.

Any reasons for faecal retention, such as an anal fissure, should be identified and treated, but the most important thing is to empty the rectum as soon as possible. The child and parents need to understand that retention is present and how it leads to incontinence.

A stool softener (macrogol) is given for a couple of weeks, followed, if necessary, by a stimulant laxative (docusate, sodium picosulphate or senna) and an osmotic laxative (lactulose). Sometimes an enema is required. Once the rectum is disimpacted, maintenance laxative therapy is maintained (see Fig. 13.14 for details). The child can be encouraged to defecate regularly in the toilet, which earns stars on a star chart. Such retraining may take a number of weeks while the distended rectum shrinks to a normal size. Throughout this period a regular laxative is usually needed. The stars may therefore need to be cashed in for tangible rewards such as extra pocket money in order to maintain the incentive.

In some cases, repeated soiling will have been such a humiliating experience for the child that they psychologically deny there is a problem and cooperation is doubtful. Other children find that their involuntary soiling allows them a measure of control over parents and they are reluctant to surrender an apparently useful weapon. Such cases may need psychiatric referral.

Soiling may occur in conjunction with an empty rectum for various other uncommon reasons. Some children have an urgency of defecation for apparently constitutional reasons and can only postpone defecation for a few minutes; they can be taken by surprise. Some children have neuropathic bowel secondary to occult spinal abnormality, usually associated with urinary incontinence. Similarly, diarrhoea can overwhelm bowel control. The child may have a general learning disability with a mental age below 4 years, so that expectations of social bowel control need to be revised accordingly. Lastly, the child may defecate intentionally as a hostile act. Such children may be entrenched in distorted relationships with their parents and may have other behavioural problems requiring psychiatric referral.

Tics

A tic is a quick, sudden, coordinated movement, which is apparently purposeful and recurs in the same part of the child’s body. It is not entirely involuntary in that it can be purposefully suppressed to some extent. About 1 in 10 children develop a tic at some stage, typically around the face and head – blinking, frowning, head-flicking, sniffing, throat clearing and grunting being the commonest. They are most likely to occur when the child is inactive (watching TV or on long car journeys) and often disappear when actively concentrating. They may worsen with anxiety but they are not themselves an emotional reaction. In most cases, there is a family history. These simple, transient childhood tics clear up over the next few months, although they may recur from time to time. They should be treated with reassurance in the first place.

Less commonly, the child has tics from which he/she is hardly ever free. They may be multiple, although there is fluctuation in the predominance of any particular tic and in overall severity. This is a chronic tic disorder which, if it includes both multiple motor tics and vocal tics such as hooting, yelping or swearing, is known as Gilles de la Tourette’s syndrome. These conditions tend to be persistent in the medium term, requiring medication (such as clonidine or risperidone) under specialist supervision.

Hyperactivity

Young children are characteristically lively, some more than others, by virtue of their immaturity. When their level of motor activity exceeds that regarded as normal, they may be termed ‘hyperactive’ by their parents. This is a judgement that depends upon the parents’ standards and expectations. The term can thus incorrectly be used as a complaint about a child who is normally active in overall terms but who can be cheeky and boisterous at times. Such a child is not hyperactive, but the parents need advice about how to handle unwanted behaviour.

In the true hyperkinetic disorder or attention deficit hyperactivity disorder (ADHD), the child is undoubtedly overactive in most situations and has impaired concentration with a short attention span or distractibility. Differences in diagnostic criteria and threshold mean that prevalence rates among prepubertal schoolchildren are variously estimated as between 10 and 50 per 1000 children, boys exceeding girls three-fold. There is a powerful genetic predisposition and the underlying problem is a dysfunction of brain neuron circuits that rely on dopamine as a neurotransmitter and which control self-monitoring and self-regulation.

Affected children are unable to sustain attention or persist with tasks. They cannot control their impulses – they manifest disorganised, poorly-regulated and excessive activity; have difficulty with taking turns; sharing; are socially disinhibited; and butt into other people’s conversations and play. Their inattention and hyperactivity are worst in familiar or uninteresting situations. They also cannot regulate their activity according to the situation – they are fidgety; have excessive movements inappropriate to task completion; lose possessions; and are generally disorganised. Typically, they have short tempers and form poor relationships with other children, who find them exasperating.

The children do poorly in school and lose self-esteem. They may drift into antisocial activities for a variety of reasons, partly because their behaviour drives parents, teachers and peers to use coercion and punishment, which is ineffectual or breeds resentment.

In addition to child psychiatric or paediatric evaluation, the child will usually need to be assessed by an educational psychologist.

First-line management in preschool children and school-aged children with mild to moderately severe disorder is the active promotion of behavioural and educational progress by specific advice to parents and teachers to build concentration skills, encourage quiet self-occupation, increase self-esteem and moderate extreme behaviour. Behavioural interventions similar to those embedded in parenting programmes are helpful. These involve having clear rules and expectations, and consistent use of rewards to encourage adherence and where appropriate, consequences to discourage unacceptable behaviour.

For those children in whom this is insufficient, hyperactivity responds symptomatically to several types of medication, although this is usually reserved for children older than 6 years of age. Stimulants such as methylphenidate or dexamphetamine and non-stimulants, like atomoxetine, reduce excessive motor activity and improve attention on task, focused behaviour. The usual approach is not to put the child on medication until behavioural and educational progress is actively promoted by the specific measures mentioned above. However, in severe cases with high degrees of impairment, simultaneous psychosocial and medical treatment may be required. It may be necessary to continue medication for several years, sometimes into adulthood. Yearly trial off medication is recommended to evaluate the need for continuing treatment. Specialist supervision is mandatory. Close liaison with the school is required throughout the years of treatment.

The role of diet in the cause and management of hyperactivity is controversial. Current evidence indicates that the sort of diet which aims blindly to reduce sugar, artificial additives or colourants has no effect. A few children display an idiosyncratic behavioural reaction such as excitability or irritability to particular foods. If this seems likely, trying the child on an exclusion of that particular food may be useful. In general, food and drinks with caffeine are not advised. Overzealous dietary exclusion can lead to malnutrition, especially in a child on stimulant medication that may already have the side-effect of appetite reduction.

Antisocial behaviour

Children steal, lie, disobey, light fires, destroy things and pick fights for various reasons:

When serious antisocial behaviour which infringes the rights of others is the dominant feature of the clinical picture and is so severe as to represent a handicap to general functioning, a diagnosis of conduct disorder is made. Children with conduct disorder may not have necessarily broken the law, although their behaviour excites strong social disapproval. They typically come from homes in which there are considerable discord, coercive relationships, limited boundaries that are inconsistently enforced, and poor supervision by adults. A milder form, characterised by angry, defiant behaviour to authority figures such as parents and teachers, is known as oppositional-defiant disorder (ODD).

Treating conduct disorder can be difficult. Parent management training programmes (such as Webster–Stratton and Triple P) have an excellent evidence base and are highly recommended as primary interventions. However, poor parental cooperation and motivation can result in minimal benefit. Where parents are unwilling or unable to take up parenting programmes, affected children can be offered individual or group-based interventions focusing on problem-solving skills and anger management. Although these interventions show benefit in research settings, affected children do not often have the level of motivation required to benefit in routine clinic settings. In the absence of a coexisting psychiatric condition responsive to medication, it is not considered standard clinical practice to use medication for conduct disorder in the UK.

Anxiety

Pathological anxiety exists in two forms: specific and general. In phobias there is fear of a specific object or situation that is excessive and handicapping and cannot be dealt with by reassurance. Most children have a number of irrational fears (the dark, ghosts, kidnappers, dogs, spiders, bats, snakes) which are common and do not usually handicap the child’s ordinary life. Some of these persist into adulthood. If they are so severe that the child’s ability to lead an ordinary life is affected, then treatment by cognitive behavioural therapy with graded exposure to the feared event may be indicated and is usually successful.

More diffuse general anxiety presents indirectly in childhood and it is uncommon for a child to complain directly about anxiety. Often, it is first manifest as physical complaints: nausea, headache or pain. It may take the form of health worries and the child repeatedly asks for reassurance that he is not going to die. Some children with generalised anxiety may develop unusual coping strategies that appear manipulative, in an attempt to gain control over their parents and the world in general. It may be a justifiable reaction to an event or situation, or be disproportionate. If the condition follows a recognisable precipitant such as a parental illness and the parents can be directed to provide comfort and support, prognosis is good. If it arises insidiously, specialist mental health referral is indicated.

School refusal

During the years of compulsory school attendance, a child may be absent from school because of illness, because parents keep the child off school or because of truancy in which the child chooses to do something else rather than attend school. In truancy, a child leaves to go to school but never arrives or leaves early. It is often accompanied by other behavioural difficulties. A few non-attendees at school suffer from school refusal, an inability to attend school on account of overwhelming anxiety. Such children may not complain of anxiety but of its physical concomitants or the consequences of hyperventilation. Anxiety may present as complaints of nausea, headache or otherwise not being well, which are confined to weekday, term-time mornings, clearing up by midday. It may be rational, as when the child is being bullied or there is educational underachievement. If it is disproportionate to stresses at school, it is termed school refusal, an anxiety problem with two common causes – separation anxiety from parents persisting beyond the toddler years and anxiety provoked by some aspect of school, true school phobia. These can coexist.

School refusal based on separation anxiety is typical of children under the age of about 11 years. It may be provoked by an adverse life event such as illness, a death in the family or a move of house. The child is unable to tolerate separation from their attachment figure without whom the child cannot go anywhere, including school. Treatment is aimed at gently promoting increasing separations from the parents (e.g. staying overnight with relatives or friends), while arranging an early return to school. Some adolescents with school refusal have a depressive disorder, but more usually there is an interaction between an anxiety disorder and long-standing personality issues such as intolerance of uncertainty.

True school phobia is seen in slightly older, anxious children who are frequently uncommunicative and stubborn.

The management of school refusal is shown in Box 23.10.

Educational underachievement

Children who achieve less well in school than expected are sometimes brought to doctors. It is important to evaluate parents’ and teachers’ expectations and ensure the child is actually able to rise to them. The services of an educational psychologist are indispensable. Core medical responsibilities include testing sight and hearing and attempting to elicit the cause of underachievement according to the list in Box 23.11. The topic is considered further in Chapter 4.

Cognitive style

The style of thought specifically associated with adolescence is formal operational (abstract) thought (Box 23.12), but this is acquired at various ages by different individuals during the teenage years, and a substantial minority do not develop it at all. Doctors are at a disadvantage here, as they have been selected by a series of examinations for excellence of their ability to manipulate abstractions and compare hypothetical predictions; they have often forgotten what it is like to think otherwise and communicate poorly with patients who still think concretely and practically (school-age children, about half of all teenagers and perhaps 1 in 5 adults). When interviewing adolescents, the skill is to avoid being patronising, while being sensitive as to whether abstract and reflective thought is solidly achieved. Using practical examples (not metaphors) and checking whether you have been understood will help to avoid the common problem of being faced with an adolescent who responds to questions with a sullen ‘don’t know’. This is considered further in Chapter 28.

Anorexia nervosa

Dieting to slim is endemic among teenage girls. Part of the reason for this is the contemporary equation between thinness and attractiveness, an assumption prevalent in advertising and fashion. Resonant with this is the finding that most teenage girls (but very few boys) overestimate their body width and depth, perceiving and judging themselves as fatter than they actually are.

Slimming through self-imposed calorie restriction is usually self-limiting because the goal is achieved or because the girl gives up; hunger wins through. In some girls, however, the slimming process takes over and there supervenes what has been called a ‘relentless pursuit of thinness’, typically with a phobic horror of normal body weight and shape. This is anorexia nervosa, and the features are:

An affected girl will often deny hunger, reassure everyone that she is in the peak of health, exercise to lose weight and disagree fervently that she is too thin. She will be careless of her own emaciation and seem unconcerned that she is starving herself to death. To the bewilderment of her parents, she may cook for others and read cookery books avidly. She may well be deceitful to anyone she perceives as thwarting her in her quest. Thus, she will conceal her poor eating by secretly disposing of her meals or lying about her weight. Both before and during her illness she will show obsessional, perfectionist character traits; without these she would not have the capacity to establish herself as a persistent dieter. Indeed, she is likely to be described as having been quiet, compliant and hard-working, ‘the last person to develop anorexia nervosa’. Her parents will often present as nice people who avoid conflict.

As a result of starvation, her body develops a low metabolic rate with slow-to-relax tendon reflexes, reduced peripheral circulation, bradycardia and amenorrhea. Fine lanugo hair appears over her trunk and limbs. She does not lose pubic or axillary hair, although incompletely established puberty is delayed. Serum T₃ (triiodothyronine) may be low, giving rise to a false suspicion of hypothyroidism. Plasma proteins are sometimes low and ankle oedema not uncommon. Blood and urine levels of luteinising hormone and follicle-stimulating hormone are low and non-cyclical.

Some girls discover that self-restraint in carbohydrate intake can be bypassed by self-induced vomiting following repeated bouts of overeating and that further weight loss can be achieved by diuretics, and laxatives (in the belief that these will expedite food transit time and reduce absorption). This can cause wide fluctuations in weight and metabolic abnormalities such as hypokalaemia and alkalosis. This condition is bulimia which can occur at normal body weight or in association with low body weight as an ominous complication of anorexia nervosa. It tends to affect older rather than younger teenagers. Bulimia at normal body weight can be managed by encouraging a regular diet, monitoring this by a diary and providing individual or group cognitive behavioural therapy.

The prevalence rate among teenagers for anorexia nervosa is a little less than 1%, but the incidence rate may have increased over the last 50 years. The peak age of onset is 14 and girls outnumber boys by about 10 : 1. Bulimia is commoner, although prevalence rates vary widely, depending on the degree of severity. It also shows a markedly female preponderance and may also be becoming more frequent.

Chronic fatigue syndrome

Chronic fatigue syndrome (CFS) refers to persisting high levels of subjective fatigue, leading to rapid exhaustion on minimal physical or mental exertion. The term is broader and more neutral than the specific pathology or aetiology implied by myalgic encephalomyelitis (ME) or post-viral fatigue syndrome, which follows an apparently viral febrile illness. There is sometimes serological evidence of recent infection with coxsackie B or Epstein–Barr virus (EBV) or a hepatitis virus. Some cases have no history or evidence of a precipitating infection and there are no specific diagnostic tests. The clinical picture is somewhat diffuse and there are no pathognomonic symptoms. Myalgia, migratory arthralgia, headache, difficulty getting off to sleep, poor concentration and irritability are virtually universal. Stomach pains, scalp tenderness, eye pain and photophobia, and tender cervical lymphadenopathy are frequently encountered. Depressive symptoms are common and there is continuing debate as to how much of the clinical picture is physical and how much psychological. Usually parents insist on there being a physical cause and there is a risk that the doctor will carry out excessive unnecessary investigations. Most experienced doctors now regard the final clinical picture as resulting from both physical and psychological factors.

The majority of cases will remit spontaneously with time, but this takes months or sometimes years. Earlier recommendations of continuous rest have been shown to be unhelpful and can lead to secondary complications. The recommended treatment involves graded exercise therapy and/or cognitive behavioural therapy. Graded exercise therapy is usually provided by physiotherapists and aims to achieve gradual increase in exercise tolerance. If too much pressure is put upon the child, tantrums or mute withdrawal can occur. Argument about how much of the condition is physical and how much psychological is unhelpful. The parents and the child need continuing support to maintain as much of a normal life as possible, including school attendance. The mood of children with depressive symptoms may respond to antidepressant medication, but this is a treatment only for depressive symptoms and it is unlikely to result in alleviation of the fatigability. NICE guidelines are available.

Depression

Low mood can arise secondary to adverse circumstances or sometimes spontaneously. Depression as a clinical condition is more than sadness and misery; it extends to affect motivation, judgement, the ability to experience pleasure and provokes emotions of guilt and despair. It may disturb sleep, appetite and weight. It leads to social withdrawal, an important sign. Such a state is well recognised among adolescents, particularly girls, but occasionally affects prepubertal children. The general picture is comparable to depression in adults but there are differences (Box 23.13).

A diagnosis of depression depends crucially upon interviewing the adolescent on his own, as well as taking a history from the parents. Teenagers will, out of loyalty, often pretend to their parents that things are all right if interviewed in their presence. It is necessary to ask about feelings directly and to ask specifically about suicidal ideas and plans.

Treatment depends upon severity. Children with mild depression are managed initially in primary care and other non-specialist mental health settings. Many will recover spontaneously; hence a period of watchful waiting for up to 4 weeks may be appropriate. Alternatively, the child could be offered non-directive supportive therapy or guided self-help. However, if mild depression does not respond to these measures in 2–3 months, the child should be referred to specialist mental health services. Similarly, children with moderate and severe depression should be referred to specialist mental health services for more specific psychological intervention such as cognitive behavioural therapy, family therapy or interpersonal therapy. In all cases, any identified contributing factor such as bullying needs to be addressed. If psychological therapy for moderate or severe depression is insufficient after 6 weeks, then an SSRI (selective serotonin reuptake inhibitor antidepressant), fluoxetine, should be considered. Depressed young people who are suicidal may need admission to an adolescent psychiatric in-patient unit.

Self-harm

Like adults, young people who take overdoses do so for a variety of motives, of which suicide is the most serious one. For a high proportion, the overdose is a desperate gesture which may draw attention to a predicament perceived by them as irresolvable. Issues such as bullying or abuse should be considered. About half of teenagers who overdose are clinically depressed. Episodes of self-harm must be taken seriously as they carry significant risk of recurrence and suicide.

In those who have taken an overdose, a full psychiatric assessment is needed by a mental health professional. A useful adjunct in the assessment of suicide risk is the PATHOS score shown in Box 23.14; however, this needs to occur alongside a psychiatric assessment.

Drug misuse

Most teenagers are exposed to illicit drugs at some stage. A number will then experiment with them, some becoming habitual users. Usually, this is for recreational purposes, but a few use them to avoid unpleasant feelings or memories. A very small number become dependent, psychologically or physically. What is taken varies with culture and opportunity but alcohol and cannabis are common; solvents, LSD, ecstasy and amphetamine derivatives somewhat less so; and cocaine or heroin currently least prevalent, though their use is increasing. The addictive potential of the last two is the greatest and their dangers are well known.

Abuse implies heavy misuse. The signs vary with the agent but may include:

Doctors may be approached by parents worried that their adolescent child may be abusing drugs. An assessment will involve interviewing the adolescent, possibly combined with taking a urine sample for drug screening. Most areas have specific services for adolescents with drug and/or alcohol problems. These services usually take self-referrals so that young people with these difficulties can access them directly. Medical involvement is predominantly focused on users who have other psychopathology including depression, or with the physical consequences of intoxication or injection when these threaten health. Solvent abuse (mainly glue and aerosol sniffing) is quite widespread as a group activity of young adolescents in some areas. It can occasionally give rise to cardiac dysrhythmias, bone marrow suppression or renal failure, and any of these can cause death, as may a fall or road traffic accident when intoxicated. Cannabis and LSD use may trigger anxiety or psychotic disorders. Ecstasy taken at dances or raves can cause dangerous hyperthermia, dehydration and death.

Doctors need to ensure that any adolescent known to them who is thought to be using drugs knows the specific risks to health. Dependence is rare among teenagers and most likely to involve alcohol. The few who are using illicit drugs for respite from psychological distress need referral to a psychiatrist.

Psychosis

Psychosis is a breakdown in the perception and understanding of reality and a lack of awareness that the person is unwell. This can affect ideas and beliefs, resulting in delusional thinking where abnormal beliefs are held with an unshakeable quality and lead to odd behaviour. The connectedness and coherence of thoughts may break down, so that speech is hard to follow, leading to thought disorder. Perceptual abnormalities lead to hallucinations, where a perception is experienced in the absence of a stimulus.

Psychotic disorders include:

Both schizophrenia and bipolar affective disorder are rare before puberty, but increase in frequency of presentation during adolescence. In these disorders the psychotic symptoms occur in clear consciousness.

Investigations should include a urine drug screen, exclusion of medication-induced psychosis (e.g. high-dose stimulants or anticholinergic drugs), exclusion of medical causes (i.e. infection, seizures, thyroid abnormalities and sleep disorders) and dementia.

Where schizophrenia and bipolar disorder is suspected, urgent referral to a psychiatrist is needed for comprehensive assessment and treatment with antipsychotic medication, psycho-education, family therapy and, where appropriate, individual therapy. In the case of an organic psychosis the underlying cause needs to be treated promptly by the paediatric team, with help from mental health professionals as appropriate.

Cultural considerations

Many developed countries are increasingly ethnically diverse in relation to language, religion and culture. This diversity has many important clinical implications for child mental health. The first implication relates to the need to recognise the subgroup of young people who are refugees or asylum seekers. These children and their families have often experienced major traumatic events before arriving in their host country. They remain highly vulnerable to mental and social-economic adversities due to past and ongoing stressful experiences.

The second implication relates to well-recognised ethnic differences in the epidemiology of some psychiatric disorders. For example, among people of African and Caribbean origin living in Western European countries, there is a clear increase in the incidence of schizophrenia but a lower incidence of anorexia nervosa compared with the indigenous Caucasian population.

Another implication of culture relates to the presentation of psychiatric symptoms. It is well recognised that the content of obsessions in children with obsessive compulsive disorder is sometimes shaped by the child’s cultural and religious beliefs. This is also true of some delusions in young people with psychotic disorders. In these examples, understanding the child’s religious and cultural background is essential for making an accurate diagnosis.

There are also important cultural differences about normative behaviour in children and thresholds for help-seeking. Differences in the level of stigma attached to mental illness across cultures also influence parent’s help-seeking behaviour and access to child and adolescent mental health services.

The above implications suggest that cultural awareness and sensitivity are essential skills for all clinicians working or intending to work in ethnically diverse societies. The key message is that the presentation of psychiatric distress in children and young people may be coloured by their culture and language. It is therefore essential to avoid making assumptions about the significance of clinical information with cultural or religious meaning but instead to contextualise the information to the patient’s culture, for example, through the use of trained interpreters.

Assessment

It is best to interview both parents if possible. While doing so, consider the quality of their relationship and the parents’ mental state. Ask open questions where possible and feel able to ask directly about feelings. Assess the attitudes of the parents to the child. Obtain examples of the problem and estimate its frequency, severity, duration and the impact it has on both the child and family.

Interview the child and ask to see the older child alone as part of the assessment. Explain to the parents that you always like to have a few words with children on their own as they may have things they may feel too embarrassed to discuss with parents present. Assess the extent of the child’s suffering (they may be somewhat brazen and minimise this). Keep your questions very simple and specific, making sure the child understands what it is you want to know. This also applies to teenagers. Ask about use of drugs and alcohol, experience of abuse, thoughts of self-harm and suicide. Consider whether reports from school or other involved agencies might help. In many instances, it is worth asking the parents to keep a prospective record of the problem by means of a diary or chart which you can inspect in a few days’ time. Tell them what headings you want this under (such as ‘antecedents, behaviour and consequences’ for temper tantrums).

Treatment

Figure 23.5 shows an approach to managing a child displaying an emotional or behavioural problem. The process of making a referral to a child and adolescent mental health service (CAMHS) is most likely to succeed if the referrer has already taken some of the history and engaged the parents and child in an attempt to alleviate the problem. Many doctors, general practitioners and paediatricians in particular, are good generalists in child mental health issues and the mental health specialist should be seen as a specialist extension of their expertise, rather than a completely different sort of person.

In general, the management of children’s emotional and behavioural problems:

Often more than one intervention is required and treatments are combined and several professionals become involved. The main treatment interventions employed are described in Box 23.15.

Medication plays a comparatively small role, although particular instances for which there is evidence for their efficacy are the use of stimulant and non-stimulant drugs in hyperkinetic disorder (ADHD), neuroleptics in psychosis and antidepressants for severely depressed adolescents. There is sometimes a temptation to sedate a child who is causing a problem but this is rarely effective and ethically questionable.