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.

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.

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.

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.

Hyperventilation associated with anxiety disorders often leads to paraesthesia, which is commonly felt in the hands, feet, and perioral region. If a person experiences rotational vertigo and tinnitus, it may indicate an organic disorder. On the other hand, raised systolic blood pressure may be associated with anxiety disorder, but not diastolic.

The presence of unexplained bruises on the upper limbs and retinal haemorrhage, which are indicative of ‘shaken baby syndrome’, are more likely to be a result of physical abuse rather than Munchausen’s syndrome by proxy.

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.

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.

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.

According to current evidence, there is no connection between autism spectrum disorder (ASD) risk and various environmental factors such as vaccination, maternal smoking, thimerosal exposure, and assisted reproductive technologies (Modabbernia, 2017).

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.

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.

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.

Genomic Imprinting and its Role in Psychiatric Disorders

Genomic imprinting is a phenomenon where a piece of DNA behaves differently depending on whether it is inherited from the mother of the father. This is because DNA sequences are marked of imprinted in the ovaries and testes, which affects their expression. In psychiatry, two classic examples of genomic imprinting disorders are Prader-Willi and Angelman syndrome.

Prader-Willi syndrome is caused by a deletion of chromosome 15q when inherited from the father. This disorder is characterized by hypotonia, short stature, polyphagia, obesity, small gonads, and mild mental retardation. On the other hand, Angelman syndrome, also known as Happy Puppet syndrome, is caused by a deletion of 15q when inherited from the mother. This disorder is characterized by an unusually happy demeanor, developmental delay, seizures, sleep disturbance, and jerky hand movements.

Overall, genomic imprinting plays a crucial role in the development of psychiatric disorders. Understanding the mechanisms behind genomic imprinting can help in the diagnosis and treatment of these disorders.

Females make up the vast majority of Rett syndrome cases.

Rett Syndrome: A Rare Neurodevelopmental Disorder

Rett syndrome is a neurodevelopmental disorder that is rare, affecting approximately 1 in 10,000 female births. Although it mostly affects females, there have been cases of males with the disorder. While the exact cause of the disorder is not known, it is believed to have a genetic basis, with mutations in the MECP2 gene (Xq28) being associated with the disorder. Monozygotic twins have been found to have complete concordance in cases of Rett syndrome.

The disorder has a unique presentation, with affected children experiencing a normal period of development until 6-18 months. After this period, they begin to develop problems with language, losing previously acquired speech. Purposeful hand movements are replaced with stereotypic movements, such as hand wringing, and ataxia and psychomotor retardation may occur. Other stereotypical movements, such as finger licking of biting and tapping of slapping, may also be seen. Head circumference is normal at birth, but growth begins to decelerate between 6-12 months, resulting in microcephaly. All language skills are lost, both receptive and expressive, and social skills plateau at developmental levels between 6-12 months.

Seizures are associated with Rett syndrome in 75% of those affected, and almost all affected children have abnormal EEG findings. Breathing problems, such as hyperventilation, apnea, and breath holding, are also seen. Children with Rett syndrome may live for well over a decade after the onset of the disorder, but after 10 years, many patients are wheelchair-bound with virtually no language ability. Additional features of the disorder include seizures, breath holding and hyperventilation, sleep difficulties, and issues with locomotion.

The most well-supported SSRIs for treating OCD in young people are sertraline and fluvoxamine, with sertraline having the strongest evidence base. Additionally, these are the only two SSRIs approved for use in young people with OCD in the UK.

POTS Study: Combination of CBT and Sertraline Best for Treating Pediatric OCD

The Pediatric OCD Treatment Study (POTS I) was the first randomized trial in pediatric OCD to compare the efficacy of sertraline, OCD-specific cognitive behavioral treatment (CBT), their combination, and a placebo control condition in treating children and adolescents with clinically significant OCD. The study took place in the United States and involved 112 participants who were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, of a placebo for 12 weeks.

The study found that all three active treatments (CBT alone, sertraline alone, and combined treatment) were significantly more effective than the placebo. The combined treatment was found to be the most effective, with a remission rate of 53.6%, followed by CBT alone (39.3%) and sertraline alone (21.4%). The study also found that combined treatment was less susceptible to setting-specific variations than CBT and sertraline alone.

The study concluded that children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor of CBT alone. The three active treatments were found to be acceptable and well-tolerated, with no evidence of treatment-emergent harm to self of others.

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.

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.

Klinefelter’s syndrome is a condition that occurs when a male has one of more extra copies of the X chromosome in their cells. This extra genetic material interferes with male sexual development, causing the testes to function abnormally and reducing testosterone levels. This can lead to delayed of incomplete puberty, genital abnormalities, gynecomastia, reduced facial and body hair, and infertility. Additionally, individuals with Klinefelter’s syndrome may experience learning disabilities, delayed speech and language development, and a shy personality. The syndrome is typically caused by one extra X chromosome in each cell, but can also be caused by two of three extra X chromosomes. The severity of symptoms increases with the number of extra sex chromosomes. Some individuals with Klinefelter’s syndrome have the extra X chromosome in only some of their cells, which can result in milder symptoms. Lyonization, which occurs when there are multiple X chromosomes in a cell, is present to some degree in all individuals with Klinefelter’s syndrome.

Lyonization: The Process of X-Inactivation

The X chromosome is crucial for proper development and cell viability, containing over 1,000 essential genes. However, females carry two copies of the X chromosome, which can result in a potentially toxic double dose of X-linked genes. To address this imbalance, females undergo a process called Lyonization, of X-inactivation, where one of their two X chromosomes is transcriptionally silenced. The silenced X chromosome then condenses into a compact structure known as a Barr body, which remains in a silent state.

X-inactivation occurs randomly, with no preference for the paternal or maternal X chromosome. It takes place early in embryogenesis, soon after fertilization when the dividing conceptus is about 16-32 cells big. This process occurs in all somatic cells of women, but not in germ cells involved in forming gametes. X-inactivation affects most, but not all, genes on the X chromosome. If a cell has more than two X chromosomes, the extra Xs are also inactivated.

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.

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 Camberwell Family Interview for Measuring Expressed Emotion

The Camberwell Family Interview is a tool designed to assess the level of expressed emotion within families. This interview was created with the aim of identifying the emotional climate within a family, particularly in relation to individuals with mental health issues. The interview is structured and standardized, with a set of questions that are asked to each family member separately. The questions are designed to elicit information about the family’s emotional atmosphere, including levels of criticism, hostility, and emotional over-involvement.

The Camberwell Family Interview is a valuable tool for mental health professionals, as it can help them to identify families that may be at risk of exacerbating mental health issues in their loved ones. By measuring expressed emotion, mental health professionals can gain insight into the family’s emotional dynamics and work with them to create a more supportive and positive environment. The interview can also be used to track changes in the family’s emotional climate over time, allowing mental health professionals to monitor progress and adjust treatment plans accordingly. Overall, the Camberwell Family Interview is an important tool for understanding and addressing the emotional needs of families affected by mental health issues.

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.

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.

Kleine-Levin Syndrome: A Mysterious Condition

Kleine-Levin syndrome is a peculiar disorder that typically affects adolescent boys. It is characterized by an excessive need for sleep and an insatiable appetite when awake. The condition is also associated with emotional and behavioral issues such as irritability and aggression.

The onset of symptoms is sudden and can last for several days to weeks before disappearing. This is followed by a period of normalcy, only to be followed by another episode. This pattern can continue for years, but the severity of symptoms tends to decrease over time. During the periods between episodes, those affected appear to be perfectly healthy with no signs of physical of behavioral dysfunction. The media has dubbed this condition as Sleeping Beauty syndrome.

Despite extensive research, the cause of Kleine-Levin syndrome remains unknown. However, the prognosis is generally positive, with most individuals making a full recovery.

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, depression, learning disabilities, substance misuse, psychosis, and autism are frequently observed alongside conduct disorders.

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.

Both the ICD-11 and DSM-5 acknowledge the subtypes of ADHD that are predominantly inattentive, predominantly hyperactive-impulsive, and combined. To make a diagnosis, both require evidence of symptoms before the age of 12 and for at least six months. While DSM-5 specifies six of more symptoms from each category, ICD-11 only requires ‘several’ symptoms without specifying a number. If the hyperactive-impulsive subtype is present, symptoms of inattention are not necessary for a diagnosis. Instead, the diagnosis would be ‘Attention Deficit Hyperactivity Disorder, predominantly hyperactive-impulsive presentation’, as long as there is a persistent pattern of inattention symptoms and/of a combination of hyperactivity and impulsivity symptoms for at least six months.

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.

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.

Massed Negative Practice in the Treatment of Tourette’s Syndrome

Massed negative practice is a technique used to treat Tourette’s syndrome. It involves having the patient repeatedly perform their tic until they reach a level of fatigue. This technique is used to condition the patient’s response to their tic. By repeatedly performing the tic, the patient becomes desensitized to it, and the tic may eventually decrease in frequency of intensity. Massed negative practice is a behavioural technique that can be effective in managing the symptoms of Tourette’s syndrome.

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.

The genetic polymorphisms that are associated with the development of hyperkinetic disorder (ADHD) include dopamine transporter (DAT1) and dopamine receptor related (DRD4). On the other hand, DBP, DISC1, and NRG are polymorphisms that are relevant to schizophrenia, while APP is associated with Alzheimer’s disease. Additionally, the DISC1 gene is believed to increase the likelihood of developing bipolar disorder and major depressive disorder.