DiGeorge syndrome is primarily caused by a deletion on chromosome 22 and presents with a range of symptoms. To aid in remembering the chromosome involved and some of the signs and symptoms, a mnemonic is used. These include cardiac abnormalities such as tetralogy of Fallot, abnormal facies with almond-shaped eyes and low-set ears, thymic aplasia leading to recurrent infections, cleft palate, and hypocalcemia/hypoparathyroidism causing short stature and seizures. Additionally, individuals with DiGeorge syndrome often have a degree of learning disability and are at an increased risk for psychiatric conditions such as depression, ADHD, and schizophrenia.

Genetic Conditions and Their Features

Genetic conditions are disorders caused by abnormalities in an individual’s DNA. These conditions can affect various aspects of a person’s health, including physical and intellectual development. Some of the most common genetic conditions and their features are:

– Downs (trisomy 21): Short stature, almond-shaped eyes, low muscle tone, and intellectual disability.
– Angelman syndrome (Happy puppet syndrome): Flapping hand movements, ataxia, severe learning disability, seizures, and sleep problems.
– Prader-Willi: Hyperphagia, excessive weight gain, short stature, and mild learning disability.
– Cri du chat: Characteristic cry, hypotonia, down-turned mouth, and microcephaly.
– Velocardiofacial syndrome (DiGeorge syndrome): Cleft palate, cardiac problems, and learning disabilities.
– Edwards syndrome (trisomy 18): Severe intellectual disability, kidney malformations, and physical abnormalities.
– Lesch-Nyhan syndrome: Self-mutilation, dystonia, and writhing movements.
– Smith-Magenis syndrome: Pronounced self-injurious behavior, self-hugging, and a hoarse voice.
– Fragile X: Elongated face, large ears, hand flapping, and shyness.
– Wolf Hirschhorn syndrome: Mild to severe intellectual disability, seizures, and physical abnormalities.
– Patau syndrome (trisomy 13): Severe intellectual disability, congenital heart malformations, and physical abnormalities.
– Rett syndrome: Regression and loss of skills, hand-wringing movements, and profound learning disability.
– Tuberous sclerosis: Hamartomatous tumors, epilepsy, and behavioral issues.
– Williams syndrome: Elfin-like features, social disinhibition, and advanced verbal skills.
– Rubinstein-Taybi syndrome: Short stature, friendly disposition, and moderate learning disability.
– Klinefelter syndrome: Extra X chromosome, low testosterone, and speech and language issues.
– Jakob’s syndrome: Extra Y chromosome, tall stature, and lower mean intelligence.
– Coffin-Lowry syndrome: Short stature, slanting eyes, and severe learning difficulty.
– Turner syndrome: Short stature, webbed neck, and absent periods.
– Niemann Pick disease (types A and B): Abdominal swelling, cherry red spot, and feeding difficulties.

It is important to note that these features may vary widely among individuals with the same genetic condition. Early diagnosis and intervention can help individuals with genetic conditions reach their full potential and improve their quality of life.

Elimination Disorders

Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.

Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.

Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.

Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.

The NICE guidelines require that before attempting clozapine, at least one second-generation (atypical) antipsychotic should have been tested. There is no mandate for a trial of a typical antipsychotic.

Antipsychotics in Young People

Antipsychotics are just as effective in children and adolescents as they are in adults. However, the rate of side effects in young people is higher than in adults. Clozapine is a beneficial second-line agent for treating children with refractory schizophrenia and some argue for its early use in first-episode psychosis. Before starting clozapine, a patient should have tried at least two different antipsychotics, with at least one being a second-generation (atypical) antipsychotic, according to NICE guidelines.

Pica: Eating Non-Nutritive Substances

Pica is a condition where a person persistently eats non-nutritive substances for at least a month. The name pica comes from the Latin word for magpie, a bird known for its large and random appetite. To be diagnosed with pica, the behavior must be developmentally inappropriate, not culturally sanctioned, and severe enough to require clinical attention. It is more common in young people than adults and is often associated with mental retardation.

There are various causes of pica, including mental disorders such as autism and schizophrenia, iron and zinc deficiency (although this is rare and not clear if it is a cause of effect), and pregnancy. The DSM-5 requires a minimum age of 2 before a diagnosis can be made. Pregnant women have been reported to experience certain forms of pica, such as geophagia (clay eating) and amylophagia (starch eating).

Pica affects both sexes equally and is estimated to occur in up to 15% of those with severe intellectual disability. However, aside from cases of autistic spectrum disorder of intellectual disability, pica usually remits by adolescence.

Pica: Eating Non-Nutritive Substances

Pica is a condition where a person persistently eats non-nutritive substances for at least a month. The name pica comes from the Latin word for magpie, a bird known for its large and random appetite. To be diagnosed with pica, the behavior must be developmentally inappropriate, not culturally sanctioned, and severe enough to require clinical attention. It is more common in young people than adults and is often associated with mental retardation.

There are various causes of pica, including mental disorders such as autism and schizophrenia, iron and zinc deficiency (although this is rare and not clear if it is a cause of effect), and pregnancy. The DSM-5 requires a minimum age of 2 before a diagnosis can be made. Pregnant women have been reported to experience certain forms of pica, such as geophagia (clay eating) and amylophagia (starch eating).

Pica affects both sexes equally and is estimated to occur in up to 15% of those with severe intellectual disability. However, aside from cases of autistic spectrum disorder of intellectual disability, pica usually remits by adolescence.

The patient’s symptoms suggest that they have anorexia nervosa. Typically, the anemia that accompanies this condition is normochromic normocytic. It is crucial to note that if hypochromic microcytic anemia is present, it may indicate iron deficiency caused by hidden gastrointestinal bleeding.

Phenylketonuria is caused by a deficiency in the enzyme phenylalanine hydroxylase.

Niemann-Pick disease is a group of inherited diseases where lipids accumulate in the cells of the liver, spleen, and brain. Niemann-Pick Type C (NPC) is the most relevant type for psychiatric presentations, with about one-third of cases presenting in adolescence of adulthood. Symptoms include progressive ataxia/dystonia, cognitive decline, and atypical psychotic symptoms. There are four other types of Niemann-Pick disease, each with their own causes and symptoms. Type A and B have a lack of sphingomyelinase and present in early childhood of mid-childhood/adolescence, respectively. Type C has reduced sphingomyelinase activity and can present at any age, with symptoms including enlarged liver and spleen, learning difficulties, seizures, and slurred speech. Type D is a variant of Type C and has similar symptoms. Type E has reduced sphingomyelinase activity and presents in adulthood with similar symptoms to the other types.

The presence of conduct disorder alone does not alter the primary treatment recommendation for ADHD. Atomoxetine, which is less effective than methylphenidate, would only be considered if there is a concern about the potential for misuse of diversion.

ADHD (Diagnosis and Management in Children)

ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for the condition, with both recognising three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined.

Treatment for children under 5 involves offering an ADHD-focused group parent-training programme as a first-line option. Medication should only be considered after obtaining advice from a specialist ADHD service. For children and young people aged 5-18, advice and support should be given, along with an ADHD-focused group parent-training programme. Medication should only be offered if ADHD symptoms persist after environmental modifications have been implemented and reviewed. Cognitive behavioural therapy may also be considered for those who have benefited from medication but still experience significant impairment.

NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’. Methylphenidate of lisdexamfetamine is the first-line medication option, with dexamphetamine considered for those who respond to lisdexamfetamine but cannot tolerate the longer effect profile. Atomoxetine of guanfacine may be offered for those who cannot tolerate methylphenidate of lisdexamfetamine. Clonidine and atypical antipsychotics should only be used with advice from a tertiary ADHD service.

Drug holidays may be considered for children and young people who have not met the expected height for their age due to medication. However, NICE advises that withdrawal from treatment is associated with a risk of symptom exacerbation.

Schizophrenia in children is rare compared to adults, with a prevalence estimate of 0.05% for those under 15 years old. There are two classifications based on age of onset: early onset schizophrenia (EOS) when symptoms appear between 13-18 years old, and very early onset schizophrenia (VEOS) when symptoms appear at of before 13 years old. EOS and VEOS have atypical features compared to adult-onset schizophrenia, including insidious onset, more severe neurodevelopmental abnormalities, terrifying visual hallucinations, constant inappropriate of blunted effects, higher rates of familial psychopathology, minor response to treatment, and poorer outcomes. Preliminary data suggests that VEOS and EOS may be due to greater familial vulnerability from genetic, psychosocial, and environmental factors. Poor outcomes are most reliably linked to a positive history of premorbid difficulties, greater symptom severity (especially negative symptoms) at baseline, and longer duration of untreated psychosis. Age at psychosis onset and sex are not consistent predictors of outcome.

Both reactive attachment disorder and disinhibited social engagement disorder are associated with poor school performance, making it an unreliable factor for distinguishing between the two conditions. However, children with reactive attachment disorder typically exhibit more inhibited behavior similar to those with autism spectrum disorder, while children with disinhibited social engagement disorder tend to display more disinhibited behavior similar to those with attention deficit hyperactivity disorder.

Disorders resulting from inadequate caregiving during childhood are recognised by both the DSM-5 and the ICD-11, with two distinct forms of disorder identified: Reactive attachment disorder and Disinhibited social engagement disorder. Reactive attachment disorder is characterised by social withdrawal and aberrant attachment behaviour, while Disinhibited social engagement disorder is characterised by socially disinhibited behaviour. Diagnosis of these disorders involves a history of grossly insufficient care, and symptoms must be evident before the age of 5. Treatment options include video feedback programs for preschool aged children and parental training with group play sessions for primary school aged children. Pharmacological interventions are not recommended in the absence of coexisting mental health problems.

Depression in Young People: NICE Guidelines

The NICE Guidelines for depression in young people are limited to those between the ages of 5-18. For mild depression without significant comorbid problems of active suicidal ideas of plans, watchful waiting is recommended, along with digital CBT, group CBT, group IPT, of group non-directive supportive therapy. For moderate to severe depression, family-based IPT, family therapy, psychodynamic psychotherapy, individual CBT, and fluoxetine may be used for 5-11 year olds, while individual CBT and fluoxetine may be used for 12-18 year olds. Antidepressant medication should not be used for initial treatment of mild depression, and should only be used in combination with concurrent psychological therapy for moderate to severe depression. Fluoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks, and should be used as the first-line treatment. Paroxetine, venlafaxine, tricyclic antidepressants, and St John’s wort should not be used for the treatment of depression in children and young people. Second generation antipsychotics may be used for depression with psychotic symptoms, and ECT should only be considered for those with very severe depression and life-threatening symptoms.

Primary school aged children are most commonly affected by behavioural problems, while emotional problems are more prevalent among secondary aged children.

Epidemiology of Mental Health Disorders in Children and Adolescents

The Department of Health (DoH) survey titled The Mental Health of Children and Young People in England is the primary source of epidemiological data on children and adolescents aged 2-19. The latest survey was conducted in 2017 and involved over 9000 participants. The data was collected through interviews with the child, their parent, and their teacher (if school-aged).

The survey found that 1 in 8 children aged 5-19 had a mental disorder, with emotional disorders being the most common, followed by behavioural, hyperactivity, and other disorders such as ASD, eating disorders, and tic disorders. The prevalence of mental disorders has slightly increased over recent decades, with a rise in emotional problems since 2004.

Rates of mental disorders tend to be higher in older age groups, but there is some inconsistency with behavioural and hyperactivity types. For preschool children, 1 in 18 had at least one mental disorder, while for primary school children, 1 in 10 had at least one mental disorder, with behavioural and emotional disorders being the most common. Rates of emotional disorders were similar in boys and girls, while other types of disorders were more common in boys.

For secondary school children, 1 in 7 had at least one mental disorder, with emotional disorders being the most common. Among those aged 17-19, 1 in 6 had at least one mental disorder, with emotional disorders being the most common, mainly anxiety. Girls aged 17-19 had the highest likelihood of having a mental disorder, with nearly one in four having a mental disorder and 22.4% having an emotional disorder.

In summary, the epidemiology of mental health disorders in children and adolescents in England highlights the need for early intervention and support for emotional and behavioural problems, particularly in older age groups and among girls.

PANDAS: Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

PANDAS is a condition characterized by sudden onset of worsening of obsessive compulsive disorder (OCD) and tic disorders in children between the ages of 3 and puberty. It is associated with group A beta-hemolytic streptococcal infection, which can be confirmed through a positive throat culture of history of scarlet fever. In addition to psychiatric symptoms, PANDAS is also associated with neurological abnormalities such as physical hyperactivity and jerky movements that are not under the child’s control. The presence of these diagnostic features can help identify PANDAS in affected children.

Anorexia Nervosa and Morgan Russell Scale

The patient is exhibiting symptoms of anorexia nervosa, a serious eating disorder characterized by a distorted body image and an intense fear of gaining weight. To measure the outcome of treatment for anorexia nervosa, the Morgan Russell scale is commonly used. This scale consists of two scores: an average outcome score and a general outcome score, with a possible total of 12.

The average outcome score is based on the patient’s progress in five areas: nutritional status, menstrual function, mental state, sexual adjustment, and socioeconomic status. By assessing these areas, healthcare professionals can determine the effectiveness of treatment and make necessary adjustments to improve the patient’s overall well-being.

The Morgan Russell scale is a valuable tool in the treatment of anorexia nervosa, as it provides a comprehensive evaluation of the patient’s progress and helps healthcare professionals tailor treatment plans to meet the patient’s specific needs.

Risk Factors for ADHD

There are several risk factors associated with the development of ADHD. According to the NICE guidelines, these include maternal smoking, alcohol consumption, and heroin use during pregnancy, as well as low birth weight and fetal hypoxia. Additionally, severe early psychosocial adversity has also been identified as a potential risk factor for ADHD. This refers to experiences of significant stress of trauma during early childhood, such as abuse, neglect, of exposure to violence. These factors can have a lasting impact on a child’s development and may contribute to the development of ADHD symptoms. It is important for healthcare professionals to be aware of these risk factors and to provide appropriate support and interventions to children and families who may be affected.

PANDAS: A Disorder Linked to Streptococcal Infections

PANDAS, of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, is a condition that affects children who develop sudden onset of obsessive-compulsive disorder (OCD) and/of tic disorders like Tourette’s Syndrome after contracting strep infections such as Strep throat of Scarlet Fever. The National Institute of Mental Health (NIMH) has identified five criteria for diagnosing PANDAS, including the presence of OCD and/of tic disorder, pediatric onset of symptoms, episodic course of symptom severity, association with group A Beta-hemolytic streptococcal infection, and association with neurological abnormalities. The anti streptococcal DNAse B (Anti DNAse-B) titre is commonly used to determine if there is immunologic evidence of a previous strep infection. PANDAS is linked to basal ganglia dysfunction.

Elimination Disorders

Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.

Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.

Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.

Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.

The Royal College of Psychiatrists in London published a report in April 2004 on the role of mental health services in addressing child abuse and neglect. The report identifies neglect as the most common form of child abuse, followed by physical abuse, emotional abuse, sexual abuse, and fabricated or induced illness. The report emphasizes the importance of mental health services in addressing and preventing child abuse and neglect.

School refusal typically occurs when children are transitioning between schools, particularly from primary to secondary school, which usually happens between the ages of 10 and 13. It affects both boys and girls equally. The primary cause of school refusal is social anxiety, which arises from having to navigate new situations such as making friends on the playground and adapting to new teachers. It is important to note that school refusal is not related to a child’s academic performance.

Understanding School Refusal

School refusal is a common problem that affects 1-5% of children, with similar rates in both boys and girls. Although it can occur at any age, it is more common in children aged five, six, 10, and 11 years. Unlike truancy, school refusal is not a formal diagnosis and is characterized by severe distress about attending school, often manifesting as temper tantrums and somatic symptoms. Parents are generally aware of the absence, and there is no antisocial behavior present. Children with school refusal often have a desire and willingness to do school work at home, whereas those who are truant show little interest in school work in any setting.

The onset of school refusal symptoms is usually gradual and may occur after a holiday of illness. Stressful events at home of school, of with peers, may also cause school refusal. Presenting symptoms include fearfulness, panic symptoms, crying episodes, temper tantrums, threats of self-harm, and somatic symptoms that present in the morning and improve if the child is allowed to stay home.

Behavioural approaches, primarily exposure-based treatments, are used to treat school refusal. However, it is important to note that school refusal is not a diagnosis but a presenting problem that may be linked to other diagnoses such as separation anxiety disorder, generalized anxiety disorder, depression, oppositional defiant disorder, learning disorders, and pervasive developmental disabilities such as Asperger’s disorder, autism, and mental retardation.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

Depression in Young People: NICE Guidelines

The NICE Guidelines for depression in young people are limited to those between the ages of 5-18. For mild depression without significant comorbid problems of active suicidal ideas of plans, watchful waiting is recommended, along with digital CBT, group CBT, group IPT, of group non-directive supportive therapy. For moderate to severe depression, family-based IPT, family therapy, psychodynamic psychotherapy, individual CBT, and fluoxetine may be used for 5-11 year olds, while individual CBT and fluoxetine may be used for 12-18 year olds. Antidepressant medication should not be used for initial treatment of mild depression, and should only be used in combination with concurrent psychological therapy for moderate to severe depression. Fluoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks, and should be used as the first-line treatment. Paroxetine, venlafaxine, tricyclic antidepressants, and St John’s wort should not be used for the treatment of depression in children and young people. Second generation antipsychotics may be used for depression with psychotic symptoms, and ECT should only be considered for those with very severe depression and life-threatening symptoms.

The treatment recommendations for OCD are similar for both adults and young people, regardless of whether they have a learning difficulty of not. The first line of treatment is psychological therapy, such as self-help of CBT with ERP. If this is not effective, an SSRI can be used. It is important to note that having a learning difficulty should not prevent someone from accessing psychological therapy. While severe disabilities may limit access, tailored forms of CBT can still be effective for those with less severe forms of learning difficulties.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

Tourette’s Syndrome: Understanding the Disorder and Management Options

Tourette’s syndrome is a type of tic disorder characterized by multiple motor tics and one of more vocal tics. Tics are sudden, involuntary movements of vocalizations that serve no apparent purpose and can be suppressed for varying periods of time. Unlike stereotyped repetitive movements seen in other disorders, tics lack rhythmicity. Manneristic motor activities tend to be more complex and variable than tics, while obsessive-compulsive acts have a defined purpose.

Tourette’s syndrome typically manifests in childhood, with a mean age of onset of six to seven years. Tics tend to peak in severity between nine and 11 years of age and may be exacerbated by external factors such as stress, inactivity, and fatigue. The estimated prevalence of Tourette’s syndrome is 1% of children, and it is more common in boys than girls. A family history of tics is also common.

Management of Tourette’s syndrome may involve pharmacological options of behavioral programs. Clonidine is recommended as first-line medication, with antipsychotics as a second-line option due to their side effect profile. Selective serotonin reuptake inhibitors (SSRIs) have not been found to be effective in suppressing tics. However, most people with tics never require medication, and behavioral programs appear to work equally as well.

Linguistic Development and Risk Factors for Delayed Speech and Language

The development of language skills is an important aspect of a child’s growth. The prelinguistic period, from birth to 12 months, is marked by crying, babbling, and echolalia. From 6 to 12 months, a child responds to their name and can differentiate between angry and friendly tones. By 18 to 24 months, a child can use up to 40-50 words, mainly nouns, and starts to combine words in short phrases. By 36 to 48 months, a child has a vocabulary of 900-1000 words, can use plurals and past tense, and can handle three-word sentences easily.

However, there are risk factors associated with delayed speech and language development. These include a positive family history, male gender, twins, lower maternal education, childhood illness, being born late in the family order, young mother at birth, and low socioeconomic status. of these, a positive family history is considered the most reliable risk factor. It is important to monitor a child’s language development and seek professional help if there are concerns about delayed speech and language.

For children and young individuals diagnosed with OCD of BDD, medication should be gradually discontinued if they have achieved remission, meaning their symptoms are no longer clinically significant and they are functioning normally, and this has been maintained for a minimum of 6 months. For adults, the recommended duration of remission before medication withdrawal is 12 months.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

Disruptive Behaviour of Dissocial Disorders

Conduct disorders are the most common reason for referral of young children to mental health services. These disorders are characterized by a repetitive and persistent pattern of antisocial, aggressive, of defiant conduct that goes beyond ordinary childish mischief of adolescent rebelliousness. Oppositional defiant disorder (ODD) shares some negative attributes but in a more limited fashion.

ICD-11 terms the disorder as ‘Conduct-dissocial disorder’, while DSM-5 recognizes three separate conditions related to emotional/behavioral problems seen in younger people: conduct disorder, oppositional defiant disorder, and intermittent explosive disorder. Conduct disorder is about poorly controlled behavior, intermittent explosive disorder is about poorly controlled emotions, and ODD is in between. Conduct disorders are further divided into childhood onset (before 10 years) and adolescent onset (10 years of older).

The behavior pattern of conduct disorders must be persistent and recurrent, including multiple incidents of aggression towards people of animals, destruction of property, deceitfulness of theft, and serious violations of rules. The pattern of behavior must result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

Oppositional defiant disorder represents a less severe form of conduct disorder, where there is an absence of more severe dissocial of aggressive acts. The behavior pattern of ODD includes persistent difficulty getting along with others, provocative, spiteful, of vindictive behavior, and extreme irritability of anger.

The prevalence of conduct disorders increases throughout childhood and is more common in boys than girls. The most frequent comorbid problem seen with conduct disorder is hyperactivity. The conversion rate from childhood conduct disorder to adult antisocial personality disorder varies from 40 to 70% depending on the study.

NICE recommends group parent-based training programs of parent and child training programs for children with complex needs for ages 3-11, child-focused programs for ages 9-14, and multimodal interventions with a family focus for ages 11-17. Medication is not recommended in routine practice, but risperidone can be used where other approaches fail and they are seriously aggressive.

The most prevalent type of tic disorder is transient tic disorder, which requires the patient to meet the overall criteria for a tic disorder, but with tics lasting no longer than 12 months. Tics may occur as a single episode of have periods of remission and relapse over several months.

Tourette’s Syndrome: Understanding the Disorder and Management Options

Tourette’s syndrome is a type of tic disorder characterized by multiple motor tics and one of more vocal tics. Tics are sudden, involuntary movements of vocalizations that serve no apparent purpose and can be suppressed for varying periods of time. Unlike stereotyped repetitive movements seen in other disorders, tics lack rhythmicity. Manneristic motor activities tend to be more complex and variable than tics, while obsessive-compulsive acts have a defined purpose.

Tourette’s syndrome typically manifests in childhood, with a mean age of onset of six to seven years. Tics tend to peak in severity between nine and 11 years of age and may be exacerbated by external factors such as stress, inactivity, and fatigue. The estimated prevalence of Tourette’s syndrome is 1% of children, and it is more common in boys than girls. A family history of tics is also common.

Management of Tourette’s syndrome may involve pharmacological options of behavioral programs. Clonidine is recommended as first-line medication, with antipsychotics as a second-line option due to their side effect profile. Selective serotonin reuptake inhibitors (SSRIs) have not been found to be effective in suppressing tics. However, most people with tics never require medication, and behavioral programs appear to work equally as well.

Munchausen’s syndrome by proxy, also known as fabricated or induced illness, is a rare form of child abuse where a caregiver, usually the mother, falsifies illness in a child by fabricating of producing symptoms and presenting the child for medical care while denying knowledge of the cause. It is most commonly seen in children under the age of 4, with symptoms including apnoea, anorexia, feeding problems, and seizures. The disorder is now recognized as ‘Factitious Disorder Imposed on Another’ in the DSM-5, with criteria including falsification of physical of psychological signs of symptoms, presentation of the victim as ill, and evident deceptive behavior. The perpetrator, not the victim, receives this diagnosis. Presenting signs of symptoms can take the form of covert injury, fabrication of symptoms, of exaggeration of existing symptoms. Symptoms are often subjective and easy to fake.

According to NICE guidelines from 2006, when prescribing an SSRI to children and young people with OCD, a licensed medication such as sertraline of fluvoxamine should be used. However, if the patient has significant comorbid depression, fluoxetine should be used due to current regulatory requirements.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

PANDAS: A Disorder Linked to Streptococcal Infections

PANDAS, of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, is a condition that affects children who develop sudden onset of obsessive-compulsive disorder (OCD) and/of tic disorders like Tourette’s Syndrome after contracting strep infections such as Strep throat of Scarlet Fever. The National Institute of Mental Health (NIMH) has identified five criteria for diagnosing PANDAS, including the presence of OCD and/of tic disorder, pediatric onset of symptoms, episodic course of symptom severity, association with group A Beta-hemolytic streptococcal infection, and association with neurological abnormalities. The anti streptococcal DNAse B (Anti DNAse-B) titre is commonly used to determine if there is immunologic evidence of a previous strep infection. PANDAS is linked to basal ganglia dysfunction.

Self-harm is a common issue among young people, particularly girls, with rates appearing to have risen over the past decade. It is most likely to occur between the ages of 12 and 15 years and is associated with a range of psychiatric problems. Short-term management involves a psychosocial assessment and consideration of activated charcoal for drug overdose. Longer-term management may involve psychological interventions, but drug treatment should not be offered as a specific intervention to reduce self-harm. Risk assessment tools should not be used to predict future suicide of repetition of self-harm, but certain factors such as male gender, substance misuse, and parental mental disorder may be associated with a higher risk of completed suicide. It is important to seek professional help if you of someone you know is engaging in self-harm.

The condition associated with flapping hand movements is either Angelman syndrome of Fragile X, while hyperphagia is a symptom of Prader-Willi syndrome. Overlapping of fingers over thumb is seen in Patau syndrome, and pronounced self-injurious behavior is a feature of Lesch-Nyhan syndrome of Smith-Magenis syndrome. DiGeorge syndrome is typically caused by a deletion on chromosome 22 and presents with a variety of symptoms, including cardiac abnormalities (tetralogy of Fallot), abnormal facies (almond-shaped eyes, low-set ears), thymic aplasia (leading to recurrent infections), cleft palate, and hypocalcemia/hypoparathyroidism (resulting in short stature and seizures). Learning disabilities are also common in individuals with DiGeorge syndrome, and they may also be at increased risk for psychiatric conditions such as depression, ADHD, and schizophrenia.

Genetic Conditions and Their Features

Genetic conditions are disorders caused by abnormalities in an individual’s DNA. These conditions can affect various aspects of a person’s health, including physical and intellectual development. Some of the most common genetic conditions and their features are:

– Downs (trisomy 21): Short stature, almond-shaped eyes, low muscle tone, and intellectual disability.
– Angelman syndrome (Happy puppet syndrome): Flapping hand movements, ataxia, severe learning disability, seizures, and sleep problems.
– Prader-Willi: Hyperphagia, excessive weight gain, short stature, and mild learning disability.
– Cri du chat: Characteristic cry, hypotonia, down-turned mouth, and microcephaly.
– Velocardiofacial syndrome (DiGeorge syndrome): Cleft palate, cardiac problems, and learning disabilities.
– Edwards syndrome (trisomy 18): Severe intellectual disability, kidney malformations, and physical abnormalities.
– Lesch-Nyhan syndrome: Self-mutilation, dystonia, and writhing movements.
– Smith-Magenis syndrome: Pronounced self-injurious behavior, self-hugging, and a hoarse voice.
– Fragile X: Elongated face, large ears, hand flapping, and shyness.
– Wolf Hirschhorn syndrome: Mild to severe intellectual disability, seizures, and physical abnormalities.
– Patau syndrome (trisomy 13): Severe intellectual disability, congenital heart malformations, and physical abnormalities.
– Rett syndrome: Regression and loss of skills, hand-wringing movements, and profound learning disability.
– Tuberous sclerosis: Hamartomatous tumors, epilepsy, and behavioral issues.
– Williams syndrome: Elfin-like features, social disinhibition, and advanced verbal skills.
– Rubinstein-Taybi syndrome: Short stature, friendly disposition, and moderate learning disability.
– Klinefelter syndrome: Extra X chromosome, low testosterone, and speech and language issues.
– Jakob’s syndrome: Extra Y chromosome, tall stature, and lower mean intelligence.
– Coffin-Lowry syndrome: Short stature, slanting eyes, and severe learning difficulty.
– Turner syndrome: Short stature, webbed neck, and absent periods.
– Niemann Pick disease (types A and B): Abdominal swelling, cherry red spot, and feeding difficulties.

It is important to note that these features may vary widely among individuals with the same genetic condition. Early diagnosis and intervention can help individuals with genetic conditions reach their full potential and improve their quality of life.

Munchausen’s syndrome by proxy, also known as fabricated or induced illness, is a rare form of child abuse where a caregiver, usually the mother, falsifies illness in a child by fabricating of producing symptoms and presenting the child for medical care while denying knowledge of the cause. It is most commonly seen in children under the age of 4, with symptoms including apnoea, anorexia, feeding problems, and seizures. The disorder is now recognized as ‘Factitious Disorder Imposed on Another’ in the DSM-5, with criteria including falsification of physical of psychological signs of symptoms, presentation of the victim as ill, and evident deceptive behavior. The perpetrator, not the victim, receives this diagnosis. Presenting signs of symptoms can take the form of covert injury, fabrication of symptoms, of exaggeration of existing symptoms. Symptoms are often subjective and easy to fake.

ADHD is a prevalent disorder worldwide, with a prevalence of 7% in those under 18 and 3.5% in those over 18. It is more common in males, with a male to female ratio of 2:1 in children and 1.6:1 in adults. While some improvement in symptoms is seen over time, the majority of those diagnosed in childhood continue to struggle with residual symptoms and impairments through at least young adulthood, with an estimated persistence rate of 50%.

Obsessive compulsive disorder is no longer believed to be caused by strict parenting. The primary treatment is cognitive behavioural therapy, but selective serotonin reuptake inhibitors (SSRIs) may also be used, particularly for children over the age of 12. Boys typically experience onset of symptoms up to two years earlier than girls.

It is important to note that while these side-effects are listed as very common, not everyone will experience them. It is also important to discuss any concerns of side-effects with a healthcare professional before making any changes to medication. Additionally, it is important to weigh the potential benefits of medication in treating ADHD symptoms against the potential side-effects.

In the case of a child with nocturnal enuresis who has already tried lifestyle measures and a reward chart without success, the next step in treatment would be to consider either prescribing desmopressin of trying an enuresis alarm. However, as the child is under 7 years old, the current first-line treatment would be to try an enuresis alarm before considering other options. Therefore, the best course of action in this scenario would be to try an enuresis alarm.

Elimination Disorders

Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.

Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.

Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.

Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.

Conduct disorders are defined by a consistent and recurring pattern of behavior that is defiant, aggressive, of dissocial. This behavior should be severe enough to violate social expectations that are appropriate for the individual’s age, and should not be mistaken for typical adolescent rebellion of childish mischief. The diagnosis is not based on isolated criminal of dissocial acts, but rather on a persistent pattern of behavior.

Night Terrors: Understanding the Condition

Night terrors, also known as pavor nocturnus of sleep terrors, are a common occurrence in children aged 3-12, with the majority of cases happening when a child is 3-4 years old. Both boys and girls are equally affected, and the condition usually resolves on its own during adolescence, although it can still occur in adults. These episodes typically last between 1 to 15 minutes and occur 1 to 3 hours after sleep has begun.

Night terrors are different from nightmares, which occur during REM sleep. Night terrors happen during the transition from stage 3 to stage 4 sleep, and children have no memory of the event the next morning. During a night terror, a child experiences intense crying and distress while asleep, usually around 90 minutes after falling asleep. They are unresponsive to external stimuli during this time.

Night terrors are distinct from nightmares in several ways. For example, there is no recall of the event with night terrors, while there may be partial recall with nightmares. Night terrors occur early in sleep, while nightmares occur later. Additionally, night terrors are associated with significant autonomic arousal, while nightmares have minimal arousal.

It is important to note that the information presented here is based on the Rechtschaffen and Kales sleep classification model developed in 1968, which is the classification used in the Royal College questions. However, in 2004, the American Academy of Sleep Medicine (AASM) reclassified NREM (non-REM) sleep into three stages, the last of which is also called delta sleep of slow-wave sleep.

Depression in Children and Adolescents

The first line of treatment for depression in children and adolescents is psychological therapy. If this approach is unsuccessful, fluoxetine is the preferred treatment. If fluoxetine is also ineffective, an alternative SSRI should be considered. However, there is limited data on which SSRI is most appropriate. These recommendations are based on the Maudsley Guidelines 10th Edition.

Atomoxetine is a suitable treatment option for individuals with Tourette’s and hyperkinetic disorder (ADHD) as it does not exacerbate tics, which is a common concern with other medications that affect the dopaminergic system. This is because atomoxetine is a highly selective noradrenaline reuptake inhibitor (NARI).

The highest correlation between maternal smoking and negative behaviors is found in externalizing problems such as ADHD and conduct disorder.

Prenatal Smoking and Risks for Offspring Psychiatric Problems

Prenatal smoking has been linked to various psychiatric problems in offspring, as reported by Indredavik (2007). The most consistent finding is the association between maternal smoking during pregnancy and attention-deficit hyperactivity disorder (ADHD) and conduct disorder. However, there are fewer reports on internalizing symptoms such as anxiety and depression. Additionally, there is one report suggesting an increased risk of autism associated with smoking exposure in utero. These findings highlight the potential risks of prenatal smoking on offspring mental health and emphasize the importance of smoking cessation during pregnancy.

Disruptive Behaviour of Dissocial Disorders

Conduct disorders are the most common reason for referral of young children to mental health services. These disorders are characterized by a repetitive and persistent pattern of antisocial, aggressive, of defiant conduct that goes beyond ordinary childish mischief of adolescent rebelliousness. Oppositional defiant disorder (ODD) shares some negative attributes but in a more limited fashion.

ICD-11 terms the disorder as ‘Conduct-dissocial disorder’, while DSM-5 recognizes three separate conditions related to emotional/behavioral problems seen in younger people: conduct disorder, oppositional defiant disorder, and intermittent explosive disorder. Conduct disorder is about poorly controlled behavior, intermittent explosive disorder is about poorly controlled emotions, and ODD is in between. Conduct disorders are further divided into childhood onset (before 10 years) and adolescent onset (10 years of older).

The behavior pattern of conduct disorders must be persistent and recurrent, including multiple incidents of aggression towards people of animals, destruction of property, deceitfulness of theft, and serious violations of rules. The pattern of behavior must result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

Oppositional defiant disorder represents a less severe form of conduct disorder, where there is an absence of more severe dissocial of aggressive acts. The behavior pattern of ODD includes persistent difficulty getting along with others, provocative, spiteful, of vindictive behavior, and extreme irritability of anger.

The prevalence of conduct disorders increases throughout childhood and is more common in boys than girls. The most frequent comorbid problem seen with conduct disorder is hyperactivity. The conversion rate from childhood conduct disorder to adult antisocial personality disorder varies from 40 to 70% depending on the study.

NICE recommends group parent-based training programs of parent and child training programs for children with complex needs for ages 3-11, child-focused programs for ages 9-14, and multimodal interventions with a family focus for ages 11-17. Medication is not recommended in routine practice, but risperidone can be used where other approaches fail and they are seriously aggressive.

If a patient presents with both treatment resistant psychosis and executive dysfunction, it may be worth considering Niemann-Pick disease. Additionally, if a patient experiences treatment resistant anxiety symptoms accompanied by tachycardia, a pheochromocytoma should be considered. In cases where a patient exhibits personality changes and attentional issues in adulthood, along with irritability, aggression, and jaundice, it may suggest a mixed presentation of Wilson’s disease.

Niemann-Pick disease is a group of inherited diseases where lipids accumulate in the cells of the liver, spleen, and brain. Niemann-Pick Type C (NPC) is the most relevant type for psychiatric presentations, with about one-third of cases presenting in adolescence of adulthood. Symptoms include progressive ataxia/dystonia, cognitive decline, and atypical psychotic symptoms. There are four other types of Niemann-Pick disease, each with their own causes and symptoms. Type A and B have a lack of sphingomyelinase and present in early childhood of mid-childhood/adolescence, respectively. Type C has reduced sphingomyelinase activity and can present at any age, with symptoms including enlarged liver and spleen, learning difficulties, seizures, and slurred speech. Type D is a variant of Type C and has similar symptoms. Type E has reduced sphingomyelinase activity and presents in adulthood with similar symptoms to the other types.

The genetics involved in this condition are complex and do not adhere to a straightforward Mendelian pattern of inheritance. Individuals with this condition typically have limited social play skills and may experience difficulties with language. Despite a desire to form friendships, they may face challenges in doing so.

Autism Spectrum Disorder (ASD) is a lifelong disorder characterized by deficits in communication and social understanding, as well as restrictive and repetitive behaviors. The distinction between autism and Asperger’s has been abandoned, and they are now grouped together under the ASD category. Intellectual ability is difficult to assess in people with ASD, with an estimated 33% having an intellectual disability. ASD was first described in Europe and the United States using different terms, with Leo Kanner and Hans Asperger being the pioneers. Diagnosis is based on persistent deficits in social communication and social interaction, as well as restricted, repetitive patterns of behavior. The worldwide population prevalence is about 1%, with comorbidity being common. Heritability is estimated at around 90%, and both genetic and environmental factors seem to cause ASD. Currently, there are no validated pharmacological treatments that alleviate core ASD symptoms, but second-generation antipsychotics are the first-line pharmacological treatment for children and adolescents with ASD and associated irritability.

Depression in Young People: NICE Guidelines

The NICE Guidelines for depression in young people are limited to those between the ages of 5-18. For mild depression without significant comorbid problems of active suicidal ideas of plans, watchful waiting is recommended, along with digital CBT, group CBT, group IPT, of group non-directive supportive therapy. For moderate to severe depression, family-based IPT, family therapy, psychodynamic psychotherapy, individual CBT, and fluoxetine may be used for 5-11 year olds, while individual CBT and fluoxetine may be used for 12-18 year olds. Antidepressant medication should not be used for initial treatment of mild depression, and should only be used in combination with concurrent psychological therapy for moderate to severe depression. Fluoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks, and should be used as the first-line treatment. Paroxetine, venlafaxine, tricyclic antidepressants, and St John’s wort should not be used for the treatment of depression in children and young people. Second generation antipsychotics may be used for depression with psychotic symptoms, and ECT should only be considered for those with very severe depression and life-threatening symptoms.

Childhood Fear: Normal Development

It is normal for children to experience fear and anxiety as they grow and develop. According to Marks’ ‘ontogenetic parade’ theory, children’s fears follow a predictable pattern throughout their development. In the preschool years, children may fear imaginary creatures, animals, strangers, and their environment. As they enter middle childhood, fears of physical danger, bodily injury, and school performance become more prominent. During adolescence, fears about social evaluations and interactions become more common.

Gullone’s research in 1999 identified specific fears that are prominent at different ages. For example, towards the end of the first year, children may fear strangers, heights, and separation anxiety. In preschool years, fears of being alone, the dark, and animals are common. During the school years, children may fear bodily injury, illness, social situations, supernatural phenomena, failure, and criticism. Finally, in adolescence, fears about death, economic and political concerns may persist.

Overall, fear and anxiety are a normal part of child development, and parents and caregivers can support children by acknowledging their fears and helping them develop coping strategies.

ADHD is a prevalent disorder worldwide, with a prevalence of 7% in those under 18 and 3.5% in those over 18. It is more common in males, with a male to female ratio of 2:1 in children and 1.6:1 in adults. While some improvement in symptoms is seen over time, the majority of those diagnosed in childhood continue to struggle with residual symptoms and impairments through at least young adulthood, with an estimated persistence rate of 50%.

Atomoxetine has been found to enhance sleep in children diagnosed with hyperkinetic disorder, although it may take several weeks to observe any noticeable changes (unlike methylphenidate, which produces an immediate response). Unlike stimulants, it does not affect the dopaminergic system and is not linked to abuse of many of the side effects associated with stimulants, such as stunted growth of decreased appetite. It can also be prescribed in conjunction with stimulants.