# Textbook of Psychiatry/Disorders of Childhood & Adolescence
## Introduction

Children cannot be considered to be little adults. Child and adolescent psychiatry is a unique area and conceptualisations typical of adult mental health are often either not helpful such as the rubric of personality disorders, or fall short in terms of emphasis. For example whilst adult practitioners will consider the patient’s family, in childhood and adolescence the family may be a source of solutions that lead to symptom reduction, a barrier to change or indeed the cause of the child's presentation.
Child and adolescent psychiatrists conceptualise their patients and their patient’s challenges in a unique way. This focuses on the twin concepts of development, the changes that occur as part of growing up, and of the inter-relatedness of the child and those around them which as a shorthand can be called the systemic perspective.
To elaborate, a fundamental task of infants, children and adolescents is to grow and in so doing learn to regulate, or achieve mastery over physiological, behavioural and emotional systems such as the ability to sleep, eat, self-soothe and control the excesses of behaviour and impulsivity. As adults we do not, and cannot live life as "toddlers" and few adults would tolerate temper tantrums in their work colleagues. A developmental perspective allows the child and adolescent psychiatrist to know that stranger danger in a baby is normal and separation anxiety for the first few days of school is also within the normal limits. Similarly, the child and adolescent psychiatrist knows there should be a gradual improvement in the young boy’s ability to sit still and attend in class. Not to do so may suggest pathology. A grounding in what abilities and limitations to expect of children and adolescents, by age, gender and influenced by cultural expectation is essential to working in this area.
The content of some child and adolescent conditions demonstrate a developmental presentation pattern. For example, an underlying vulnerability to anxiety may become manifest in different ways across the child and adolescent developmental span. Of the anxiety-related presentations early issues include prolonged and excessive stranger danger; in the older child prolonged school-related separation anxiety. In pre-school children phobias often manifest as a fear of animals, in early school-age children as fear of the dark and/or burglars, school phobia around the age of entry to high school, in adolescence social phobia and late adolescence sees the onset of agoraphobia and panic disorder.
A systemic perspective emphasises that infants, children and adolescents are not "islands," indeed the very young cannot live without the care and protection of adults. Further, children develop within systems or social networks, most obviously the immediate and extended family and the school environment, the latter including peers and teachers. Included in such understandings will be culturally dependent rules such as how extended is the typical family. For example, is it the norm for grandparents to live with the child and parents; how open or closed is the family to non-familial influences such as the impact of religious or village leaders and the influence of the media. As well as the generally applicable culture within which the family sits there are patterns of interaction and belief which may be more individual to the particular family and not necessarily shared by their neighbours. The parents may be in conflict and the child caught in the middle. A parent may be chronically ill and the child adopting a carer role. Understanding of both individual family systemic issues and the wider cultural influences are important to the practice of child and adolescent psychiatry in a variety of ways. In terms of engagement for instance one must to know whether it is appropriate to conduct a home visit, how to address parents and grandparents and what sort of formulations are likely to make sense to the child and family. A systemic perspective is also important to management. This is universal in child and adolescent psychiatry, not restricted to cases where the treatment modality is family therapy. Clearly an intervention that contravenes a local or family belief is unlikely to be supported by the family, and is therefore unlikely to be successful.
Biological thinking, whilst in children less likely to lead to pharmacological interventions, is highly relevant to child and adolescent psychiatry. Biological constructs that may be important to a child's mental health presentation include a history of any pathological processes that may have affected the child’s developing brain. Examples include infections and toxic insults during pregnancy or anoxic brain damage during labour or the first minutes of life. The child and adolescent psychiatrist routinely takes a history about such issues, as well as considering the child's facial and body morphology for possible chromosomal or genetic abnormalities, and any evidence of developmental delay during the early years. Developmental delays may be circumscribed but more commonly may cross functional domains so a broad and comprehensive assessment is required. It will be found, for example, that many children with behavioural problems are also clumsy. Developmental problems, even though due to problems before or around birth, may not manifest themselves immediately. For example a lowered intelligence or specific learning or speech problems may not become obvious until the child enters the late preschool or early school period. In adolescence biological issues that arise are less likely to be developmental and more likely to be the adverse mental health effects of injury or misadventure, or related to the development of an acute or chronic medical illness such as diabetes or drug use and abuse.
Later in this chapter issues of disease classification relevant to child and adolescent psychiatry will be discussed. The preceding introductory comments may lead some readers away from classifications that are primarily categorical such as the ICD-10 and DSM systems. These classifications are important in child and adolescent psychiatry and facilitate good communication, research and service planning. However, child and adolescent psychiatrists are equally influenced by and comfortable with dimensional views of psychopathology. For example, where the child lies on a dimension of inattention is as important as is the question as to whether the child has Attention Deficit Hyperactivity Disorder. A dimensional view has the added benefit of potentially being less "pathologising" in that embedded in this approach is the understanding that healthy children also have a degree of "whatever it is" (i.e., inattention) but either have a more "healthy" amount or are more able to cope with it. With this perspective, rather than seeking cure of a categorical disorder, the child and adolescent psychiatrist will work to help the child and family move towards a more functional developmental trajectory. An example of this might be, in the case of a child with attention deficit, to attend more to the need to achieve education and less to the treatment of symptoms. This might, for instance, lead to the planning of a medication regime in a way which gives maximal attentional enhancement when the child is in school.
A useful dimensional nosology often used in child and adolescent mental health is the distinction between internalizing and externalizing symptoms. Formally derived from the scoring system of the Child Behavior Checklist (CBCL: Achenbach, 1991) and related measures, this terminology has now entered more general usage. Externalising symptoms are clearly witnessed or reported, obvious to an observer whereby the child will "externalise" an assumed feeling state, cognition or demonstrate lack of age-appropriate regulation. Typical symptoms include anger, aggression and hyperactivity. Internalising symptoms are less obvious, indeed may go unreported without appropriate questioning. Typical internalizing symptoms are depressed mood and specific and generalized fears.

## Phenomenology
### Epidemiology

Population based surveys across numerous countries and cultural groups have recorded the prevalence of mental health disturbance in children and adolescents at between 15 - 20%. Methodological and design issues include whether the research was primarily parent report which finds higher rates of externalising disorders; child and youth self-report which provides better estimates of internalising disorders; or more robust designs which included information from multiple informants. General trends include higher rates of externalising disorders in males and of internalising disorders in females. Often, as is the case with depression, gender-based rates are similar in the pre-pubertal period. Post-puberty rates of depression are higher in females. Some conditions present at specific developmental stages, for example early onset psychosis is rare before the middle teenage years, or demonstrate a clear developmental relationship or progression. An example of the latter is the common trajectory from oppositional defiant disorder (ODD) in children to conduct disorder in adolescents.
It is probable there are many reasons for cross-cultural differences in the prevalence of specific conditions. One is that the prevalence of illness/disorder will be influenced by local conditions; anorexia nervosa is more common in affluent developed world. Another is the willingness to diagnose depends on culture; what was naughtiness in some western societies is now ODD or ADHD. With these caveats in mind useful prevalence estimates include a rate and diagnosable depressive disorder of approximately 3%, anorexia nervosa 0.5%, ADHD 6%, ODD and CD 6-10% (increasing with age) and autism 0.1%. Note one cannot simply add these prevalence figures and conclude that most children have a mental health problem. Conditions are often comorbid with one individual sometimes experiencing two or three mental health disorders.
Another consideration is impairment. Many symptoms such as mild anxiety, brief lowered mood or nightmares after a traumatic event are often normal. Key to the diagnosis and subsequent management plan is the impairment in daily functioning. If symptoms interrupt the child’s family or peer relationships, or impede their ability to attend and take advantage of school and other activities i.e., if symptoms either prevent normal function or normal development, then the presentation is more serious and worthy of an intervention. One measure of impairment is the disability adjusted life years (DALY) methodology. A recent application of this methodology to the child and adolescent mental health area suggests the impairment burden of neuropsychiatric conditions in children will double by the year 2020.

### Clinical symptoms and classification

A major issue differentiating child and adolescent psychiatry from practice with adults is that the content of symptoms varies across the child and adolescent developmental span. Consider the example of depression. The symptoms displayed by older adolescents are often identical to the adult criteria for a major depressive disorder, for example a pervasively lowered mood, often with diurnal mood change, anhedonia, neurovegetative changes in sleep, appetite, weight and energy and typical depressive cognitions of helplessness, hopelessness and possibly suicidal thinking. This is very different from the picture seen in younger children. An eight year old, for example, can become profoundly depressed in mood without much in the way of depressive cognitions and is unlikely to report suicidal thinking. The very young child may seem sad without much verbal elaboration, relatively mute and markedly withdrawn with no pleasure in play or during other typical childhood activities. Uncertainties over whether a low mood in a younger child without significant depressive cognitions is the equivalent of a more adult type picture in an older adolescent, have, in the past, and perhaps in the present too, lead to difficulties in making valid diagnoses particularly in the younger age group.
Another group of disorders which show considerable variation with age are the anxiety disorders. Fear of the dark is so common in very young children as to be normal. However, with increasing age fears become more related to social interaction such as fear about being asked questions or giving presentations in class, difficulties talking to peers, or to adults when attempting to buy food, clothes or bus tickets. Similarly, age differences are seen in the anti-social domain; younger children rarely engage in assault with weapons or force others into sexual activity, these are features of conduct disturbance in older age groups.
Often clinicians will ask screening questions about typical externalising and internalising symptoms. Considering the former, disruptive young children are oppositional, defiant, easily angered, have prolonged or severe tantrums and actively defy authority figures. Older children and adolescents engage in aggressive behaviour: fighting, bullying, sometimes using a weapon, cruelty to animals or forcing others into sexual activity. They may also steal or vandalise property. The oppositional defiant behaviour seen at a younger age may also persist into adolescence. Other common behavioural presentations are inattentive and/or hyperactive behaviour which may occur in isolation or co-occur with aggressive or defiant behaviour. Children with these symptoms may demonstrate problems with their ability to maintain age-appropriate attention and concentration, problems controlling impulsivity or demonstrate hyperactive behaviour. "Age-appropriate" is a key construct in that there may be a considerable gap between this and the behaviour expected by parents. The latter can be either too permissive or inappropriately demanding for the child’s developmental stage. The symptoms are often prominent in classroom settings; they are of greater significance if they are present across numerous settings, typically including home and school. Hyperactive symptoms include the sense that child is always moving, cannot remain still even for an enjoyable activity and the behaviour may lead to dangerous play with risk of injury. Another group of behavioural presentations are the stereotypical, repetitive behaviors such as hand twirling or flapping or unusual mannerisms seen in children with autism and pervasive developmental disorders. Such behaviours have no functional significance, begin early in life and often persist. These behaviours should be differentiated from tics, for instance seen with Tourettes disorder or from medication side effects such as may be caused by some anti-psychotic medication. Autistic children may also demonstrate hyperactive and aggressive behaviours.
Internalising symptoms are often considered to be synonymous with anxiety and depressive symptoms. However, a broader definition is probably more useful. This would for example, include the body image disturbance typical of eating disorders. Many internalizing symptoms have been previously mentioned in this chapter. Childhood fears are common. In young children these are often poorly elaborated fearful feelings. With increased age they may be associated with cognitions typical of panic such as pre-event wishes to avoid the situation, or feelings that symptoms such as tachycardia are evidence of impending physical illness or death. Other common anxiety symptoms of children are obsessional thoughts, especially about germ’s or poisons, fears about school, and nightmares seen in Post traumatic stress disorder (PTSD). As with anxiety, depressive symptoms too change with age. In younger children they are not specific, and often take the form of a desire to withdraw and be alone and a general lowered mood. With age the child may become more pessimistic, hopeless and feel they are worthless or incompetent. From the mid-teen years onwards suicidal thoughts are common. These are of more concern if the thoughts are accompanied by detailed planning and a desire to enact the plan. In children and adolescents it is useful to identify the symptom of anhedonia (loss of the typical pleasure response). It is unusual for primary-school age children to avoid parties or activities and lose interest in interacting with friends. Adolescents can often describe an altered sense of pleasure; the younger child may not be able to describe this change. However, parents are often able to report this phenomenon as altered behavior – parents notice the child does not take as much pleasure in their usually enjoyed activities.
It is beyond the scope of this chapter to discuss all symptoms seen in child adolescent psychiatric practice. Many low prevalence conditions have typical or pathognomic symptoms such as eating non nutritious substances (Pica), being persistently mute despite normal speech and vocalisation apparatus, especially when outside the home environment (Selective Mutism), deficiencies in reciprocal social awareness and behaviours (Autism and Pervasive developmental disorder), tics, encopresis, enuresis and disturbances of attachment to name some. A comprehensive child adolescent mental health text is recommended to further study such conditions.
Attachment related symptoms are common and require some comment. Infants, including very young children are innately social and from birth demonstrate a repertoire of behaviours that promote attachment to parents, primary caregivers and other adults. Normal, adaptive, "secure" attachment behaviour is demonstrated by the infant maintaining suitable proximity to the parent, a willingness to explore the environment whilst repeatedly seeking assurance and a developing ability to self-soothe during brief periods of separation. Attachment styles where the infant is more anxious, ambivalent or disorganized include infants who are overly vigilant and excessively watchful, overly withdrawn or inconsistent in developmentally appropriate social interactions. Such behaviours are more likely to cause both current difficulties with establishing eating and sleeping and other routines, as well as the infant being more likely to develop mental health problems during later childhood.

### Assessment

As previously mentioned, as a generalisation children live within a family context and so it is usual to begin with interviewing the whole family. If there are no biological parents then the child is seen with the usual caregivers; for orphaned children the child is seen with the adult responsible for their care. Again, the practitioner needs to be knowledgeable on the child's developmental stage and what are the usual capacities and competencies for a child of that age. Importantly, this includes knowledge of the communication style and ability that would be expected. Some practitioners are fortunate in that they have been personally exposed to caring for young children in non-clinical settings. If this is not the case the practitioner can be guided by the type of school activities that are typical for children of different ages and school grades. For example, very young children in the school setting are often engaged in creative activities. Play is the primary communication mode of young children. Older children will draw, colour in or engage in imaginary play with toy figures. Towards the end of primary school children will more readily engage in conversation, although will often give few details spontaneously. Guiding the conversation with drawings or timelines or an activities leads to greater richness of detail. Adolescents will usually engage in greater self reflection and prolonged conversation and are often seen before other family members to emphasise their progress towards individuation from the family. Cultural issues are important when considering what information should come from father or mother and whether children should be seen by themselves or only when other family members present.

### Pathogenesis

An approach seen across many areas of psychiatry is the biopsychosocial-cultural schema. This schema emphasises the child lives within a family, school, local environment context and there may need to be interventions at numerous parts of the individual and social ecology to achieve a successful outcome. Rather than consider biopsychosocial-cultural factors during the infant, child, early and late adolescent stages separately, this section will take an over-arching developmental view and integrate these various ecological influences at different stages of development.
A developmental approach acknowledges differences in the child's integration of biological, emotional, cognitive and behavioural systems and differences peer and family interactions across the life span. Developmental theory highlights it is the interplay of these factors that determines whether development approximates to the normal trajectory or whether deviation occurs. The later, if significant, is synonymous with the presence of symptoms and impairment. The "normal trajectory" does not imply there is a single pathway to a particular outcome. Critical aspects of the biopsychosocial frame are required, including for example an intact central nervous system, availability of at least one attachment figure and an environment with the potential of providing at least food and shelter. Other useful concepts in the developmental context are protective, resilience or vulnerability factors. We will refer to descriptors for the major development epochs: fetal, infant, child and adolescent periods, despite some conjecture about when difference stages begin and end. Developmental is, after all, continuous.
Biological fetal determinants of later mental health include toxic fetal environmental factors and the adverse effects of maternal malnutrition. Toxic effects can be from infections (e.g., rubella, herpes, human immunodeficiency virus, cytomegalovirus and toxoplasmosis); excessive maternal alcohol intake and deficiency states such as folate deficiency, the later commonly following malnutrition. Genes controlling major organogenesis are operant during the fetal period and toxic effects at this stage can be catastrophic including mal-development of the central nervous system. Although birth-weight may give some indication of the success and traumas of the gestational period it is a very coarse and non-specific marker. However, intrauterine growth retardation (measures of which include both birth-weight and gestational age) is a useful predictor of later hyperactivity, academic performance and possibly other outcomes. Important psychosocial factors during the fetal period include maternal perception of social support, the development of attachment to the developing fetus and whether the wider system such as father, grandparents and wider community are involved or supportive.
The infant phase is obviously influenced by persisting fetal factors. From a mental health perspective a psychological construct of major importance in this stage is attachment. Attachment theory has essentially either replaced or lead to profound modification of previously held psychodynamic and learning paradigms. Understanding of attachment has progressed with recent cognitive and developmental psychology research finding the infant’s competence is greater at an earlier age than previously thought. Early behaviours include the infant's ability to recognise their mother's voice in the hours after birth and preferential eye tracking around two months of age. One must remember attachment is not uni-directional but rather relates to the relationship between infant and primary caregiver. Attachment has both cross-sectional and longitudinal links with mental health. Up to 80% of the offspring of depressed mothers display insecure attachment. This attachment style is also related to the child’s delayed expressed language and cognitive development.
As is expected the childhood period continues the development of the infant period including the attachment pattern established at that time. The child period is a time of continued cognitive, speech, language and psychological development underpinned by continued synapse formation, continuous (CNS) reorganisation and maturation of neuronal circuits. It is a time of an increased sense of self-efficacy, competence and mastery of more complex social circumstances. Social development includes a move from solitary play to parallel and then cooperative play, with the locus of contact not solely restricted to the family home. Relationships with non-family individuals such as school friends become more common, complex and incorporate increasing imagination and fantasy. Peers and group membership become important and the experience of rejection by peers can have major consequences including development of anxiety and lowered mood. Indeed children can develop both depressive and anxiety disorders of a degree of severity which justifies professional intervention. Consequences can include impaired social relationships, diminished social support, diminished self-esteem and increased deviant behaviour. These can then in turn result in further deterioration of the child’s mental state with a resulting downward spiral. Conversely, childhood can be a time of an increased sense of self-efficacy, competence and mastery of more complex social circumstances such as interactions in the school domain.
Definitions of Adolescence vary are often culture bound. One could argue that adolescence, or at least its recognition as a significant developmental stage is a relatively recent phenomenon and one of most relevance to the affluent developed world. There are many societies where work, marriage and the taking on of adult type responsibilities, unfortunately including going to war, occur at ages where the typical western teenager is engrossed in adolescent experimentation and is very far from these things.
From a biological perspective the onset of adolescence is defined by the hormonal changes of puberty and the effects these changes have on body morphology including the development of secondary sexual characteristics. Behaviour is in part gender-specific with greater levels of aggression in males and depression in females. Biological influences during the adolescent stage are not limited to physiological maturational processes. Environmental toxins include exposure to illicit drugs and legal substances such as cigarettes, alcohol and inappropriate use of over-the-counter medication.
Psychological factors include increased capacity for self-reflective thinking and development of a more sophisticated sense of self. A more robust self-identity is related to the development of personal values with may include moral, political, sexual, religious or spiritual values as well as future educational and work aspirations. Much psychological development occurs within the context of the school environment.
To conclude this discussion on aetiology, it should be acknowledged that several factors are not development stage specific but rather are factors that are influential across developmental phases. The family's resources; financial, emotional and cultural, and social economic class (SEC) are influential developmental factors. Socioeconomic disadvantage and poverty have been linked to not only child and adolescent behaviour problems and conduct disorder but also more bio-behavioural processes such as the exposure of children to spoken and written language and the number of encouragements and discouragements given to the child during the early years. Note it is simplistic to ascribe causation to family SEC, rather this is a summary of a complex variety of constructs, for example may include parent mental health, parent availability, dislocation from extended family resources and access to other resources that enrich the child’s development.
Biological effects can be influential across the lifespan such as some genetic factors, for example the presence of a genetic mutation seen with Velocardiofacial syndrome or the persistence of problems caused by anoxic brain damage at birth. Parental influence is also a persisting developmental effect. For example parents who have a coercive parenting style will continue to demonstrate this parenting style unless helped to do otherwise. In turn coercive parenting is related to the development of oppositional defiant disorder and later conduct disorder.
Finally, the child and family’s culture must be considered in any aetiological formulation. Culture affects many of the determinants of health, as well as the construction of whether a given phenomenon is a health issue. For examples some cultures are more willing to acknowledge youth suicide. Whilst clearly effecting data and statistical analysis, at a personal level help seeking behavior for suicidal youth is likely to be effected by social views on this issue. Culture is often seen as a strong developmental continuity. However, for some countries in the developing world cultural change is rapid and has profound effects on children, an example being prolonged parental absence due to adults following employment opportunities in major cities.

## Treatment
### Pharmacotherapy

Prior to a discussion of pharmacotherapy it is prudent to discuss the decision-making process around the use of medication, especially given the rapid advances in this area and the array of medications now available. Whilst in some centers there is easy access to senior colleagues for advice, as a default strategy this is generally unsustainable and clearly does not work in regional hospitals or rural and remote settings. To this end practitioners need to be adept at accessing contemporary clinical practice guidelines from professional organizations (e.g., N.I.C.E.), Cochrane reviews, other published meta analyses and systematic reviews. Pharmacotherapy texts are often very informative, so too formularies that are often produced by government bodies; albeit care is required as some information can become out of date. The technology age has also made long distance communication available to many and so advice via email or phone can be obtained even if geographically remote. On-line discussion groups are also becoming more popular.
If these strategies do not provide the answer required then one should consider the conclusions of a seminal study in the area. Prior to accepting the findings of a seminal study the practitioner should determine whether the study is methodologically sound, has sufficient power, both genders and a range of ethnicities and social economic groups are included as participants thereby allowing generalization of findings into various practice settings. Finally, conclusions should be conservative in that they are consistent with the rigour of the methodology and strength of the analysis.
Various authors have published psychopharmacology practice advice relevant to children and adolescents. The over-arching principle is that medication prescription should only follow an adequate assessment and formulation. A broad formulation will determine whether there are ongoing causal or maintaining factors within the family system or local ecology. Many practitioners find the "predisposing, precipitating and perpetuating factor" heuristic helpful. An example being one should not prescribe medication for anxiety if the child is still being physically abused. In this case the treatment is to facilitate the provision of a safe environment. A prescribing generalisation is to start with a low dose. Child and parent compliance can be radically undermined by early adverse side-effects and so slowly increasing medication dose at the same time as predicting typical adverse events is prudent. Whenever possible dosage regimes should be dependant on the child's weight. There are adequate milligrams (drug) per kilogram (child weight) dosage schedules for stimulant medication, some atypical psychotics, tricyclic antidepressants such as Clomiprame for OCD and Sodium Valproate. Once a decision to prescribe is undertaken then the medication trial should continue, with regular monitoring, until an adequate dose has been trialed for an adequate period of time. Premature cessation creates uncertainty as to whether a certain medication is beneficial or not. If available and there are no financial constraints, new medications are preferable especially given their greater safety profile and fewer side-effects. Good prescribing needs to consider whether there are physical factors that influence the bioavailability of the medication such as concurrent liver or renal disease and in the patient with epilepsy some medications, especially anti-psychotic medication, can lower the fit threshold. Drug-drug interactions can occur, especially when drugs are combined which both affect these same neurotransmitter pathway.
When practicing child and adolescent psychiatry or behavioural paediatrics, there can be pressure from parents or teachers to increase medication dose beyond the usual parameters or too prescribe additional medications to obtain symptom control. This can be a serious problem in the overall management of the case. Family dysfunction including arguments between parents or the threat of school suspension is not a valid reason to increase the child's medication. There are persuasive research findings, for instance in the area of ADHD, that combining psychological interventions with medication is associated with lower medication dose. One assumes combined therapy can also decrease the number of medications required. Symptom deterioration is a reason to (a) review the diagnosis, (b) review barriers and maintaining factors, (c) look for new causal factors (d) review your therapeutic alliance with the child and family and (e) to consider comorbidity. The latter may be secondary to the original presentation, for instance a depressive illness in a teenager struggling with chronic anorexia nervosa. When these factors have been accounted for then increasing the dose or considering a second medication is reasonable. The prudent practitioner will also decide upon a small selection of medications with which they become very familiar with and prescribe preferentially. Use of a small number of medications allows greater knowledge of the typical dosage regime, side-effects and interaction profiles and also allows the practitioner to prepare and have ready access to patient information handouts.

### Psychotherapy

Psychotherapy with children and adolescents can be divided into individual, family and group approaches. Individual therapies are usually either psychodynamically informed or a cognitive- behavioural intervention, often with variations of cognitive or behavioural interventions depending on the age of the child, cognition being treated or the experience and training of the psychiatrist. Key elements across types of psychotherapy include therapy designed to be appropriate to the developmental stage of the child, all therapy being delivered within a family construct (not just "family therapy") and the therapist being suitably trained and their work is related to a known theoretical framework.
Behaviour therapy is usually symptom focused where the symptom is a problematic behaviour. Therapy is often brief, may involve the parent as a "coach" and helps promote desired behaviours and eliminate the problem behaviour. Whilst initially in the clinic or hospital, behaviour therapy works well in the real-world, addressing actual difficult symptoms such as agoraphobia or social phobia. Therapy tends to be practical, "here and now" and there is little emphasis on cognitions or dynamic insights. An example of behaviour therapy is "flooding" the child with separation anxiety disorder by assisting the parents to take the child to school and then leaving the children with teaching staff. Or if the same is done in a more gradual fashion then this may be more akin to desensitization. Cognitive behavioural therapy (CBT) expands on behaviour therapy by adding interventions that identify problematic thoughts or cognitive schema and introduces practices that directly challenge unhelpful thoughts and replace them with more helpful cognitions. There is considerably variation within CBT as regards the extent to which therapy focuses on behaviour, on cognitions or even on the underlying patterns of thinking and relating which form the fertile ground from which symptomatic thoughts and behaviours may arise. CBT is active, often "now" orientated and relies on out of session work by the child, often with parent assistance. Home work is a feature of CBT. Some CBT interventions are manualised and this greatly aides their formal research evaluation. Indeed the evidence base for many CBT programs is more robust than other forms of psychotherapy. There exist CBT packages for children who experience depression and different types of anxiety such as OCD, panic-agoraphobia and social phobia. It is perhaps the manualisaton, the growing evidence base and the relative brevity of these forms of therapy that may result in their rapidly increasing popularity over recent years.
Psychodynamic psychotherapy generally is longer term. While it is the existence of the presenting problem that is the stimulus for treatment, the therapy is generally more focused on helping the patient to gain insight, to understand the patterns in their thinking, feeling and relating which cause repeated difficulties and to be able to communicate in more healthy ways. Although the description of psychodynamic psychotherapy may resemble that of other therapies, for instance schema based cognitive behaviour therapy, it is marked out from these by its trade mark technology which is the focus on the way the patient relates to the therapist and to material from the patient’s unconscious mind. The focus on the "underlying" may be problematic if the therapy does not seem sufficiently relevant to the presenting symptom, but does have the potential for personal growth and resilience should symptoms recur at a later time. Dynamic approaches vary across the child and adolescent span. At younger ages therapist employ more creative techniques such a drawing and play.
Indeed Art and Play Therapy are generally psycho-dynamically informed and require further training and supervision. Longer term strategies have great value especially for seriously abused children and youth who are often in crisis and cannot make use of the structure inherent to CBT and the motivation required. With these individuals psychodynamically informed support and containment can be very helpful. With improvement the focus of psychodynamic therapy can alter from support to more insight oriented techniques or incorporate elements of CBT. There are many schools of family therapy and there are many differences between these. What they have in common is a perspective which brings to the foreground, not the inner world of the child or adolescent (though for some schools this remains important), but the relationships, communication patterns and shared beliefs within the family and other social systems within which the patient lives and functions. The developmental life cycle perspective is as integral to understanding families as it is to thinking about individuals. Some presentations can best be understood in terms of difficulties in negotiating family life cycle stages e.g., teenager becoming more independent and eventually leaving home and what this means for other family members and relationships. A narrative approach to family therapy might explore the way the family members understand their difficulties and whether there are alternative understandings which might lead to new possibilities. Family counselling and psychoeducation is also part of the repertoire of family interventions, often to help families cope with presentations that may be primarily biological not family dynamic in origin, for instance assistance coping with the behaviour of an autistic child. Confusion may arise with family therapy in terms of who is the patient. Some families bringing an identified patient are comfortable with the idea that the whole family is the patient and that all in the family will need to change. Others find this an alien concept and feel blamed when family therapy is recommended for a problem which, to them, resides within one member. It may be helpful to explore this and to address the issue of family being helped to help one of its members versus family being treated as the patient.

### Combined treatment

In the management of child and adolescent mental health presentations it is usual to begin with mono-therapy; usually in the form of one of the "talking" therapies. Across a range of approaches psychotherapy is not only helpful for symptom reduction but also enhancing resilience. Most treatment algorithms cite that for some conditions addition of a drug treatment can be beneficial. In this sense the medication is adjunctive to the primary psychotherapeutic interventions. For example addition of an SSRI medication to either Bulimia nervosa or OCD where psychological treatment alone produces insufficient benefit, is warranted and has an evidence base. Further, some studies, including those with ADHD, have concluded that combination of medication with psychotherapy decreases the ultimate dose of medication required. Combined treatments can also potentially lead to more rapid symptom reduction and be more cost effective.