Child and adolescent mental health conditions

The mental health of children and young people in Ireland report, published by the Department of Health in April 2023, reported that 22 per cent of 15-19-year-olds in this country had a mental disorder. The percentage of young people who ever attempted suicide increased from seven per cent to 10 per cent in seven years from 2012 to 2017. Furthermore, 50 per cent of mental illness in adult life, excluding dementia, starts before the age of 15 years and 75 per cent starts before the age of 18.

A recent Vhi 360 Hot Topics session brought together experts in child and adolescent mental health from the Vhi 360 team to offer guidance to primary healthcare providers on diagnosing and treating young people with mental disorders.

First to speak was Dr Ngozi Oketah, consultant in general paediatric and adolescent medicine with a special interest in mental health at Children’s Health Ireland (CHI) Crumlin. Dr Oketah discussed the importance of early detection of mental health problems in children and adolescents.

She highlighted some of the more common mental health issues likely to present to primary care, including emotional disorders, attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), eating disorders, self-harm and suicide, conduct disorder and risk-taking behaviours.

Anxiety
At the top of the list of most common presentations are anxiety and depression, which account for almost two-thirds (63 per cent) of mental disorders in young people.

“During adolescence, lots of young people tend to feel more anxious about things. This is normal anxiety that we don’t want to pathologise, but when a young person is persistently worried and not able to stop themselves worrying, especially when it’s interfering with their day-to-day functioning, they could be missing school, not able to work or participate in their extracurricular activities, then this has become a bit more pathological and they need help because this type of anxiety won’t just go away,” Dr Oketah explained.

She pointed out that anxiety can manifest in several ways and may present as panic attacks or obsessive-compulsive disorder (OCD), which is characterised by recurrent and persistent thoughts, intrusive urges and/or compulsions and repetitive behaviours in response to obsessions. Alternatively, patients may present with generalised anxiety disorder (GAD), which is characterised by excessive anxiety about different things for more than six months and can be accompanied by restlessness, fatigue, irritability and sleep disturbances.

“We need to remember that anxiety can manifest with multiple physical symptoms,” she added. “Chest pain is very commonly. Recurrent abdominal pain is something we see very often as well. Constipation with soiling, especially in a child who previously had a normal bowel habit. Frequent headaches, dizzy spells and/or fainting episodes are common, especially with teenagers.”

One of the priorities in managing young people with mental illness is to prevent suicide. It is important to note that suicide is the fourth leading cause of death in 15-19-year-olds. Ireland has the fourth highest rate of suicide amongst adolescents aged 15-19 in the EU.

“That’s really high and something that I think about all the time, especially when I have young people in front of me,” Dr Oketah said. “While suicide is not necessarily 100 per cent preventable, it can be preventable.”

She highlighted the Ask Suicide-Screening Questions (ASQ) which can help identify young people at risk for suicide. ASQ is a set of four screening questions that takes 20 seconds to administer. It is designed for screening youth ages 8-24.

She also highlighted the modified teen patient’s health questionnaire 9 (PHQ-9M) as a valuable tool to assess the presence and severity of depressive symptoms in teenagers.

PHQ-9M specifically asks about suicidal thoughts and attempts, but it also examines for other symptoms of mental illness including depression, sleep disturbances, eating behaviours, concentration and restlessness.

“We need to think about what opportunities we have as healthcare professionals to support these young people, possibly preventing mental illness in adulthood if we can identify issues early,” Dr Oketah said.

ADHD
ADHD has a worldwide prevalence of 2.8 per cent in adults and approximately five per cent in children, according to World Health Organization figures. In the Irish population, the adult prevalence is 1.5 per cent and the prevalence in children is 4 per cent, according to research.

Dr Naazim Mohungoo is a child and adolescent psychiatrist with Vhi 360. Dr Mohungoo has previously worked with the Child and Adolescent Mental Health Services (CAMHS) in Dublin and has a special interest in ADHD.

He pointed out that ADHD can be difficult to diagnose in primary care as it shares a lot of features with other conditions, including ASD and learning disabilities.

For a diagnosis of ADHD, symptoms of hyperactivity or impulsivity and/or inattention should meet the diagnostic criteria in the DSM 5 or ICD11, and cause at least moderate psychological, social, educational or occupational impairment, based on interview and/or direct observation in multiple settings.

“We don’t usually go to the ADHD question until they’re about six years of age,” Dr Mohungoo said.

“There are a number of neurodevelopmental and developmental difficulties that could present and be masked as ADHD symptoms. All the different conditions need to be looked at before we jump to a diagnosis of ADHD.”

Differential diagnoses for ADHD include learning disorder, sleep disorder, oppositional defiant disorder, anxiety disorder, intellectual disability, language disorder, mood disorder, tic disorder, conduct disorder, ASD, and development coordination disorder.

Dr Mohungoo also pointed out that up to a third of children with ASD can have comorbid ADHD, highlighting the fact that some children may have more than one disorder.

He stressed the importance of early diagnosis, saying missed or late diagnosis can result in loss of potential, oppositional and conduct issues, mood disorders, substance abuse, self-harm and suicide.

Regarding management, Dr Mohungoo said: “We treat ADHD only, and I mean only, if ADHD is impacting on their functioning. I don’t think everybody with ADHD needs treatment.”

Non-pharmacological management includes ADHD-focused parental training and CBT for the young person with ADHD. First-line pharmacological treatment is still stimulants. Dr Mohungo’s practice is to ‘start low and go slow’.

He generally starts with a short-acting stimulant and titrates to a stronger agent or a longer-acting agent if tolerated and indicated.

Atomoxetine is the recommended second-line treatment after stimulants. It is a selective norepinephrine reuptake inhibitor and, as an antidepressant, it needs to build up in the body before benefits are seen. For this reason, it is not as popular as stimulants with patients, Dr Mohungoo said, although he added that children with ASD may tolerate atomoxetine better than stimulants.

Guanfacine is the newest ADHD medication on the market. It is an alpha-2a agonist that decreases heart rate and relaxes blood vessels, reducing blood pressure.

Guanfacine is thought to affect the part of the brain that controls attention and impulsivity. Research is emerging showing benefit in ADHD symptoms when guanfacine is combined with a stimulant.

Dr Mohungoo stressed the importance of referring children to the correct pathway. “If you refer them for an ADHD assessment and they wait to see us, and then I see them and I say no, it’s ASD, then they have to go on another list and wait. Try to get them on the right list at the start,” he said.

The presentations were followed by an engaging Q&A session, chaired by Dr Dáire O’Leary, consultant paediatrician, where the presenters were joined by Dr Lieselot Tampere, consultant paediatrician, and Regina Hardy, clinical nurse specialist in paediatric mental health.

Information
Vhi 360 Hot Topics is a series of educational webinars focused on key subjects of interest to support the primary care healthcare workforce in delivering improvements to patient care in primary care settings. These are conducted in partnership with MedCafe.ie.

A recording of the recent Vhi 360 Hot Topics in Child and Adolescent Mental Health Conditions Webinar can be found on www.medcafe.ie/webinars/825

This is an advertorial on behalf of Vhi 360 Hot Topics.