Child and adolescent psychiatry
Items test developmental thresholds, cross-setting symptom requirements, and which medications are actually approved and safe in children.
Core rules
- ADHD: at least six symptoms of inattention and/or hyperactivity-impulsivity for six months (five for older adolescents and adults), onset before age twelve, present in two or more settings. Stimulants (methylphenidate, amphetamines) are first-line; atomoxetine and alpha-2 agonists (guanfacine, clonidine) are alternatives, useful with comorbid tics or substance misuse risk. Monitor growth, blood pressure and sleep.
- Autism spectrum disorder: persistent social communication deficits plus restricted, repetitive behaviours or interests, with early onset causing impairment. Screen with M-CHAT; differentiate from language disorder, hearing loss and social pragmatic communication disorder.
- Depression in children: fluoxetine is approved from age eight and escitalopram from age twelve; the boxed warning concerns suicidality, so close monitoring after initiation is required.
- Disruptive mood dysregulation disorder requires chronic, non-episodic irritability with severe temper outbursts, onset before age ten; it is not a bipolar prodrome defined by episodes, which is the key contrast with mania.
- Tics and Tourette disorder: multiple motor and at least one vocal tic for more than a year; comorbidity with ADHD and OCD is the rule. Behavioural therapy (CBIT) is first-line; alpha-2 agonists or aripiprazole are pharmacological options.
- Elimination disorders: enuresis from age five, encopresis from age four, both after excluding medical causes.
Worked example
A nine-year-old boy has six months of inattention, loses homework, cannot sit still in class and at home, and has eye-blinking tics. This is ADHD plus a tic disorder; a stimulant is still acceptable, but an alpha-2 agonist or atomoxetine is a reasonable first choice given the tics, with behavioural parent training alongside.
Traps
Diagnosing ADHD from a single informant; labelling tantrums as bipolar disorder; starting an SSRI without a monitoring plan; forgetting that separation anxiety disorder can present as school refusal.