Student Author: Asiphile Moyake

Specialist Advisors: Dr Papani Gasela and Dr Kaveshin Naido

Cover Image

This chapter covers the following topics:



It is defined as persistent inattentiveness, hyperactivity, impulsivity, disinhibition, and/or distractibility. These symptoms may all be transitory and part of normative developmental patterns (see ADHD related word cloud here). However, ADHD can be diagnosed if the symptoms impair daily living.

It is important to be able to recognise and manage ADHD because it is common, can be serious, can be persistent, is often stigmatised and is treatable.


The diagnosis is exclusively made on clinical grounds. The child must have:

The symptoms must also not be attributable to another cause e.g. medical condition, intoxication, emotional distress.

Table 10.1: Differential Diagnoses for ADHD

Differential Diagnoses

These psychiatric conditions can mimic ADHD:

  • Anxiety
  • Post-traumatic stress disorder (PTSD)
  • Bipolar mood disorder (BMD)
  • Depression
  • Psychosis
  • Autism spectrum disorder (ASD)
  • Oppositional defiant disorder (ODD)
  • Intellectual disability disorder (IDD)

Classification and Clinical Features

ADHD is classified as one of the following subtypes:

Table 10.2: Clinical Features of Inattentive- and Hyperactive-Type ADHD

  • Carelessness
  • Easily distractible
  • Difficulty listening when spoken to
  • Easily loses focus
  • Fails to complete tasks
  • Avoids tasks that require focus
  • Forgetful
  • Easily loses items
  • Fidgets
  • Squirms
  • Talks excessively
  • Has difficulty waiting his/her turn
  • Often runs and jumps around
  • Is unable to sit still or remain quiet for a reasonable amount of time
  • Often intrudes or interrupts others
  • Is over-familiar with strangers
  • Prone to accidents

These symptoms may manifest differently depending on the child’s age:

Associated features include:

The consequences of all this are that the child may have poor performance in school or sport, may become withdrawn, anxious or socially isolated and may be prone to accidents.

Clinical Assessment

It should consist of the following:

No additional tests are necessary to make the diagnosis, as it is made on clinical grounds according to the DSM-5 and ICD-10. However, rating scales are used as screening tools and are useful for monitoring symptoms at baseline and once treatment has been initiated. An example of this is the Swanson, Nolan and Pelham Rating Scale (SNAP IV), which is completed by both teachers and parents.

Psychiatric Assessment (Mental State Examination)

One must observe the relationship between the child and parent(s) in the consulting room. Often, due to difficulties related to ADHD, the parent-child relationship may be very strained.

During the consultation, the child may have difficulty sitting still and may make inappropriate interruptions. S/he may climb over furniture or leave the consultation early. One must observe how the parent performs limit-setting and enforces boundaries during the consultation.

For children on methylphenidate or other medication, it is important to ask whether the child has taken his/her medication that day and at what time it was taken. This may influence the clinical picture and whether ‘top-up’ doses of medication are needed.

Medical Assessment

One must exclude any comorbidities or other medical conditions that could better explain the patient’s symptoms.

One must measure and plot growth parameters e.g. height-for-age, weight-for-age. Blood pressure measurement, pulse monitoring and cardiac examination are also important, especially if the child is on stimulants.

If there is a family history of sudden cardiac death, one must do an ECG and consult with a paediatrician.

Figure describing Assessment Algorithm for ADHD
Figure 10.2: Assessment Algorithm for ADHD


The aims of treatment in the child with ADHD are to reduce symptoms, improve educational outcomes and reduce family and school-based problems.

Non-Pharmacological Management

It includes school and home-based behavioural interventions. The parents and teachers should, therefore, receive psychoeducation and the child should be referred to a mental health service, as behavioural interventions are effective in mild-to-moderate cases.

Parents should receive management training and support. They must be taught to constructively deal with their child’s behaviour, by teaching them how to positively reinforce desirable behaviours and extinguish misbehavior. This is a first-line intervention for younger children and mild cases of ADHD.

One must also liaise with the school and, if appropriate, ask for extra help for the student e.g. sit the child in the front of class, give short tasks, give extra time to complete assessments.


One may prescribe:


One should refer the child who:


Up to 60% of ADHD cases will continue into adulthood, however the symptoms may vary with time.


Children may suffer from anxiety disorders, such as separation anxiety disorder, specific phobia, generalised anxiety disorder, social anxiety disorder and panic disorder. Post-traumatic stress disorder and obsessive-compulsive disorder may also be diagnosed during childhood and adolescence. However, the DSM-5 no longer classifies these under anxiety disorders.


Fear is a reaction to a real threat, whereas anxiety is the cognitive, emotional and physiological reaction to a real or imagined threat. Both anxiety and fear can be adaptive. Many childhood anxieties are developmentally appropriate, thus it is important to keep the age and developmental stage of the child in mind. An anxiety disorder may be diagnosed when the anxious reaction results in psychic distress and/or interferes with daily functioning. The fears and anxiety are usually out of keeping with the child’s developmental stage.

Anxiety disorders are the most common psychiatric disorders in childhood and are associated with a poor quality of life, depression and social limitations. Often, children with panic disorders are labelled with treatment-resistant asthma.

Anxiety disorders are often comorbid with other anxiety disorders, depression or behavioural disorders, see related image here.

Classification and Clinical Features:

The child with anxiety will develop maladaptations, which are

Clinical features specific to the anxiety disorder are shown in the table.

Table 10.3: Clinical Features of Various Anxiety Disorders

Anxiety Disorder Clinical Features
Separation anxiety disorder
  • Developmentally inappropriate and excessive worry of being separated from caregiver/attachment figure which occurs outside the developmental phase of separation anxiety and is present for >4 weeks
  • May lead to school refusal
Selective mutism
  • Refusal/inability to speak in select situations (e.g. at school) which interferes with social relationships and educational achievement and is present for >4 weeks
Specific phobia
  • Disproportionate fear of a specific situation or object for >6 months
Social anxiety disorder
  • Excessive fear of social situations or being observed in public which is present for >6 months
Panic disorder
  • Unprovoked panic attacks and/or fear of having a panic attack (after excluding a medical cause) which is present for >4 weeks
  • Avoidance of public spaces, crowds or enclosed spaces for >6 months
Generalised anxiety disorder
  • Severe worry about everyday tasks or situations which is present for >6 months


Anxiety disorders may develop because of:

One must get a detailed history from the child and parents as the anxiety may be warranted for the child’s context e.g. abuse.


Non-Pharmacological Management

This may include:

Pharmacological Management

Medication is used in severe cases. One may prescribe:


The child should be referred to a child and adolescent psychiatry service if s/he has a poor response to treatment, s/he has psychiatric co-morbidities, there is a need for diagnostic clarification or there is no access to psychotherapeutic services at primary or secondary healthcare levels.


These children are at higher risk for anxiety disorders, mood disorders, suicidality and substance use disorders in adulthood.


Suicidality in children may be underestimated as it may be misinterpreted as the child or adolescent is ‘seeking attention’ or ‘acting out’. Unless otherwise specified, suicidality is a broad term that refers to the cognitions, activities or behaviour of persons seeking their own death, including thoughts/ideations, utterances, threats, plans, intent, actions or omissions.

Whereas, suicidal behaviour refers to any behaviour that is often intentional, potentially harmful or lethal to the child. It is the result of psychological pathology or a reaction to adverse life events. Suicidal behaviour may also be a reaction to abuse (physical, emotional or sexual), neglect or poor home circumstances. This needs to be explored in detail in a child or adolescent who presents with suicidality.

Criteria and Clinical Features

The criteria for suicidality include:

The child may present with a history of:

Associated Comorbidity

The child may have a psychiatric disorder at the time of the suicide attempt. Common comorbid conditions include:

The child may also have:


Management should be individually tailored and should consider risk factors specific to individual patients. One must:

The treatment plan should include psychotherapeutic, psychopharmacological and/ or social interventions to achieve relief from acute psychosocial stressors. However, the interventions employed will largely depend on the clinical services available.

Principles of Management

They include:

See related image here.


Hospitalisation is generally indicated if:

Ideally, inpatient treatment of a child should be in a secure child psychiatry ward or paediatric ward and ensure close supervision, monitoring and support of the patient.

Non-Pharmacological Management

The child should be offered psychotherapy – CBT and dialectical behavioural therapy (DBT). DBT adapted for use in adolescents with suicidal behaviour involves training in mindfulness, interpersonal skills, emotion regulation, and stress tolerance. The parents should be involved in the psychosocial interventions and strategies to improve the parent-child relationships implemented e.g. improving problem solving within the family, parenting techniques and communication skills. See related image here.


See the Disorders of Development chapter.


It is the voiding of urine into clothing or in bed after the age of 4-5 years i.e. intermittent urinary incontinence.


It may be clinically classified as:

Nocturnal enuresis may be primary (the child has never gained bladder control; more common) or secondary (the child had gained bladder control for >6 months but now has recurrent bedwetting). Nocturnal enuresis should not be over-investigated.


Causes or precipitating events include:


Evaluation should include:


It includes:

See related image here.


It is the (usually involuntary) voiding of faeces in inappropriate spaces (according to social or cultural norms) after the age of 4 years in a child who has obtained bowel control.


Causes include:


A detailed history must be taken and medical/organic causes excluded e.g. Hirschsprung’s disease, spina bifida, cord lesions, overflow incontinence in the chronically constipated patient.

Diagnostic Criteria

They include:


If a medical cause for the incontinence is found, it should be managed e.g. disimpaction and routine laxative therapy (polyethylene glycol, enemas) for the child with constipation. Behavioural therapy is effective (such as star charts). Parents must be educated on how to appropriately manage difficulties. The home circumstances must be assessed and prior history of traumatic events (including sexual abuse) elicited if present. The child should be referred to a child psychiatry and adolescent service if the encopresis is persistent.

If a medical cause for the incontinence is found, it should be managed e.g. disimpaction and routine laxative therapy (polyethylene glycol, enemas) for the child with constipation. Behavioural therapy is effective (such as star charts). Parents must be educated on how to appropriately manage difficulties. The home circumstances must be assessed and prior history of traumatic events (including sexual abuse) elicited if present. The child should be referred to a child psychiatry and adolescent service if the encopresis is persistent.


Psychotic Disorders

Psychosis in children is very rare. It is most often due to a general medical condition that produces psychotic features e.g. epilepsy, head trauma, inborn errors of metabolism, delirium. Medical causes of psychosis and the effect of illicit substances and substance withdrawal need to be ruled out before psychosis is diagnosed.

Childhood-Onset Schizophrenia (COS)

It is the onset of schizophrenia before the age 13 years, whereas early-onset schizophrenia (EOS) refers to the onset of schizophrenia before 18 years of age. It tends to develop in children aged 5-12 years.

Diagnostic Criteria

The diagnostic criteria for COS are the same as for schizophrenia in adults:

Perceptual disturbances are common. Auditory hallucinations are most common, however visual hallucinations are more common in children than in adults. Negative symptoms (amotivation, flat or blunted affect, poverty of speech and paucity of thoughts) and cognitive symptoms (impaired attention, memory and executive functioning) are very common and are usually the first to manifest (before hallucinations). Changes in mood, anxiety and agitation are also common.

Premorbid dysfunction, which may coexist, includes social withdrawal and isolation, disruptive behaviour problems, academic difficulties, speech and language problems, and cognitive delays.


Antipsychotic medication is the primary treatment for schizophrenia spectrum disorders in children and adolescents. Maintenance medication is required to improve functioning and prevent relapse. In young people with treatment-resistant schizophrenia spectrum disorders, a trial of clozapine should be considered. Psychotherapeutic interventions should be implemented in combination with pharmacological interventions.

On follow-up, one must:

Conduct Disorder


Conduct disorder is the persistent violation or defiance of age-appropriate norms, rules of society or expectations by a child over a 12-month period.


The child with conduct disorder will:

The child, caregivers and collaterals must be interviewed to obtain medical and social information. The above behaviours are displayed in the absence of a mood or psychotic disorder. It is particularly important to exclude abuse, maltreatment and neglect.


Children with conduct disorder may also have:


The mainstays of management are family and behaviour therapy as well as parenting skills training. The child should undergo educational assessment and be offered school and emotional support. Placement in a child and youth care centre should be considered a last resort

Tic Disorders


A tic is a sudden rapid, recurrent, non-rhythmic vocalisation or purposeless motor movement. The tics are absent during sleep and are exacerbated by stress.


The child may have:

Tic disorders may be classified as:


The child, family and teachers should receive psychoeducation and the former two provided with emotional support. The child should be referred to child and adolescent psychiatry services for habit reversal therapy and pharmacological intervention. The child may be started on a low-dose of a first-generation antipsychotic (e.g. haloperidol) or second-generation antipsychotic (e.g. risperidone).

Mood Disorders


Children with depression present slightly differently to adults with depression. The depression may be precipitated by bereavement or environmental stress (such as family break-up) and is often associated with anxiety disorders.

Clinical Features

The child may have:


Common comorbid conditions include:


One must perform a detailed assessment to exclude medical causes for this presentation e.g. vitamin B12 deficiency, hypothyroidism, sexually transmitted infections. Psychosocial stressors must be explored in detail with the child, caregivers and teachers and these stressors managed. A social worker referral should be performed, if necessary.

Family counselling should be performed, particularly psychoeducation surrounding the diagnosis. The child should be assessed for suicide risk and referred for psychotherapy, particularly CBT. Antidepressants may be started after excluding BMD and the child has been deemed a low suicidal risk

Mania and Bipolar Mood Disorder (BMD)

BMD can start in childhood but has higher prevalence rates in adolescence. They present with persistent and rapidly changing moods (depression and mania).

Clinical Features

The child may have:

Psychiatric Comorbidity

Comorbid conditions include:

BMD is associated with fractured family and peer relationships, poor academic performance, chronic mood symptoms or mixed presentations, psychosis, suicide attempts and hospitalisations.


One must assess if there is a family history of cardiac disease, diabetes or thyroid disease. Medical causes and the potential role of substances (both illicit and prescribed) must be excluded. A thorough physical examination should be performed, including height, weight, BMI and waist circumference. One should perform the following investigations:


The child and caregivers must be provided with psychoeducation and advised on the importance of sleep hygiene and routine. They should be referred to a child and adolescent psychiatry service for further management. With acute episodes, one may treat the patient with a mood stabiliser e.g. second-generation antipsychotic, lithium or anticonvulsant.