Psychiatry: Safeguarding

• Safeguarding: Safeguarding — Your Duties | Types of Abuse and Warning Signs | Bruises, Bites and Burns | Abusive Head Trauma and Fractures | Investigating Suspected Physical Abuse | Sexual Abuse | Neglect and Emotional Abuse | Fabricated or Induced Illness | Exploitation and Online Harm | FGM, Forced Marriage and Radicalisation | Looked-After Children and Young Carers
• Consent and confidentiality: Consent and Parental Responsibility | Confidentiality and Young People
• Young people's health and mental health: Adolescent Health | Depression and Anxiety | Self-harm and Suicide Risk | Eating Disorders | ADHD | Autism | Learning Disability | Behaviour Problems, Psychosis and Transition
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🛡️ Safeguarding, consent and young people's mental health — safeguarding is everyone's responsibility. You don't need to be certain that abuse has happened — you need to recognise concern, record it and share it with the right people. Young people need to be seen alone for part of the consultation, and asked directly about mood, self-harm, relationships and safety.
Your four questions for every child: Does the story fit the injury and the child's development? Is anyone else at risk (siblings, other children)? Who has parental responsibility, and can this young person consent? Have I spoken to the young person on their own?

Safeguarding — Your Duties

• Key law and guidance (England):
  • Children Act 1989 — the child's welfare is paramount. Section 17 — child in need (services). Section 47 — enquiries when a child is suffering or likely to suffer significant harm.
  • Children Act 2004; Working Together to Safeguard Children (2023) — how agencies work together.
  • GMC: Protecting children and young people — every doctor must act on concerns, including about children of adult patients.
• What to do if you're worried:
  • Immediate danger — call the police (999); keep the child safe (admit to hospital if needed).
  • Listen to the child; don't ask leading questions; don't promise to keep secrets.
  • Record carefully — exact words used, who was present, times, a body map of injuries (measured, photographed by medical photography), what the carer says happened.
  • Discuss with a senior and the named or designated doctor or nurse for safeguarding — but don't delay a referral.
  • Refer to children's social care (by phone, then in writing within 48 hours), or the local multi-agency safeguarding hub (MASH).
  • Check if the child is known to social care or on a child protection plan.
  • Tell the parents you are making a referral — unless doing so would put the child (or others) at greater risk, or hinder a police investigation.
• Information sharing — consent is not needed to share information to protect a child from significant harm; share what is necessary, relevant and proportionate. Data protection law does not stop safeguarding.
• What happens next — strategy discussion, Section 47 enquiry, child protection medical, initial child protection conference; possible child protection plan (categories: neglect, physical, emotional, sexual abuse); court orders (emergency protection order, police protection) in urgent cases.
• "Was not brought" — use this rather than "did not attend" for missed children's appointments: the child depends on adults to bring them — repeated missed appointments may be neglect.

Types of Abuse and Warning Signs

• Four main categories — physical, emotional, sexual abuse and neglect (neglect is the commonest reason for a child protection plan in England).
• Other forms — domestic abuse (children are victims under the Domestic Abuse Act 2021), fabricated or induced illness, child sexual and criminal exploitation, FGM, forced marriage, radicalisation, modern slavery and trafficking, online abuse, bullying.
• Risk factors:
  • Child — babies (most serious injuries and deaths are in under 1s), prematurity, disability, persistent crying, looked-after children.
  • Parent or carer — domestic abuse, parental mental illness and substance misuse (the "toxic trio"), young parents, previous abuse, learning disability without support.
  • Environment — poverty, social isolation, overcrowding, unrelated adults in the home.
• Warning signs in the history (NICE CG89):
  • An explanation that is absent, vague, changing or doesn't fit the injury or the child's developmental stage.
  • Delay in seeking help.
  • Different stories from different carers; blaming a sibling or the child.
  • Repeated attendances with injuries, ingestions or vague symptoms.
  • The child discloses abuse.
• Warning signs in the child — fearful, withdrawn, "frozen watchfulness", over-compliant, sexualised behaviour, self-harm, running away, school decline, wetting or soiling.
• Warning signs in the parent–child interaction — hostile, rejecting, inappropriate expectations, unresponsive to the child's distress.

Bruises, Bites and Burns

• "Those who don't cruise rarely bruise" — any bruise in a baby who is not independently mobile needs a safeguarding assessment.
• Normal accidental bruises — over bony areas at the front of the body (shins, knees, forehead, elbows) in mobile children.
• Bruises that suggest abuse:
  • On soft or protected areas — ears, neck, cheeks, eyes, torso, back, buttocks, inner thighs, genitals, hands and feet.
  • The TEN-4-FACESp rule — bruising to the Torso, Ears or Neck in a child under 4; any bruise under 4 months; bruising of the Frenulum, Angle of the jaw, Cheeks (fleshy part), Eyelids, Subconjunctivae; patterned bruising.
  • Patterned — fingertip marks (grip — upper arms, chest), hand slap marks (parallel lines), belt or cord loops, ligature marks.
  • Clusters, multiple bruises, bruises in a non-mobile child.
  • Petechiae on the face and neck (strangulation, suffocation).
• Torn frenulum in a baby — forced feeding or a blow; investigate.
• Human bites — oval or crescent marks; adult if the distance between canines is over 3 cm.
• Burns — immersion scalds with tide-lines, glove or stocking distribution, cigarette burns, contact burns with a recognisable shape (see the Paediatric Emergencies chapter).
• Conditions that mimic abuse:
  • Congenital dermal melanocytosis (previously "Mongolian blue spots") — blue-grey patches over the lower back and buttocks, present from birth, don't change over days — record at the newborn check.
  • Bleeding disorders (ITP, haemophilia, von Willebrand disease, vitamin K deficiency) — check FBC and clotting.
  • Impetigo (can look like cigarette burns), phytophotodermatitis, cultural practices (cupping, coining).
  • IgA vasculitis, meningococcal rash, Ehlers–Danlos syndrome.

⚠️ Safety Pearl: A small bruise in a young baby is often a "sentinel injury" — a warning before more serious abuse. Babies who have died from abuse often had earlier minor injuries that weren't acted on.

Abusive Head Trauma and Fractures

• Abusive head trauma (shaking or impact) — mostly babies under 1 (peak 2–4 months, when crying peaks):
  • Often no external signs.
  • Features — irritability, vomiting, poor feeding, drowsiness, seizures, apnoea, bulging fontanelle, enlarging head, collapse.
  • Classic findings — subdural haemorrhages, retinal haemorrhages (multiple, multilayered, extending to the edge of the retina), encephalopathy; often with rib or metaphyseal fractures.
  • High rates of death and lasting disability.
  • Prevention — advice for parents on coping with crying ("ICON — Infant crying is normal; Comforting methods can help; It's OK to walk away; Never, ever shake a baby").
• Fractures that suggest abuse:
  • Any fracture in a non-mobile baby.
  • Posterior rib fractures (squeezing) — highly specific.
  • Classic metaphyseal lesions ("corner" or "bucket-handle" fractures) — from pulling and twisting.
  • Skull fractures in infants (complex, multiple or bilateral), scapula, sternum, spinous processes.
  • Multiple fractures, fractures of different ages.
  • Femoral fractures in children not yet walking; humeral shaft fractures in young children.
• Abdominal injuries — liver, spleen, duodenal haematoma, pancreatic injury (raised amylase) with few external signs.
• Mimics — osteogenesis imperfecta (blue sclerae, dentinogenesis imperfecta, family history, wormian bones), rickets, birth injury (clavicle), copper deficiency (Menkes), glutaric aciduria type 1 (subdural haemorrhages), bleeding disorders.

Investigating Suspected Physical Abuse

• Child protection medical by a senior paediatrician — full history and top-to-toe examination (including mouth, ears, genitals, scalp), growth, development, body map, photographs.
• In children under 2 with suspected physical abuse (RCPCH and Royal College of Radiologists guidance):
  • Skeletal survey (repeat limited views at 11–14 days — healing fractures become visible).
  • CT head — all under 1s (and older children with signs); MRI brain and spine later.
  • Ophthalmology review with dilated fundoscopy (retinal haemorrhages).
• Blood tests — FBC and film, clotting screen (including von Willebrand screen and factor levels), bone profile (calcium, phosphate, ALP), vitamin D, PTH, LFTs, amylase or lipase, U&E; urine toxicology if drowsy; consider genetic tests (osteogenesis imperfecta) and metabolic tests.
• Siblings — assess siblings and other children in the household, especially twins and under 2s (skeletal survey may be needed).
• Document everything contemporaneously; reports may be used in court.

Sexual Abuse

• Usually by someone known to the child (family member, friend, carer); most children have no physical signs.
• How it comes to light:
  • Disclosure — often partial or delayed; listen, record the child's exact words, don't question in detail (leave it to specialist interviewers).
  • Behaviour — sexualised behaviour inappropriate for age, self-harm, eating problems, wetting or soiling, withdrawal, running away.
  • Physical — anogenital pain, bleeding, discharge or injury; recurrent UTIs; sexually transmitted infections; pregnancy in a young teenager.
• STIs in children — gonorrhoea, syphilis, chlamydia, trichomonas or HIV outside the newborn period (and not explained by vertical transmission) are strongly suggestive of sexual abuse; anogenital warts and herpes need careful assessment.
• The law (Sexual Offences Act 2003):
  • Children under 13 cannot consent to sexual activity — it is rape. Always discuss with the safeguarding lead and usually refer.
  • Under 16 — sexual activity is illegal, but prosecution is not intended for consensual activity between peers of similar age. Assess for exploitation (age gap, coercion, gifts, alcohol or drugs, multiple partners, older "boyfriend").
• Examination — by a specialist paediatrician (or at a Sexual Assault Referral Centre, or a children and young people's sexual abuse service); forensic samples if within the time window; emergency contraception, STI screening and prophylaxis (including HIV PEP).

Neglect and Emotional Abuse

• Neglect — persistent failure to meet a child's basic physical or psychological needs:
  • Faltering growth (catches up in hospital or foster care), poor hygiene, unsuitable clothing, hunger.
  • Untreated health problems — severe dental decay, untreated head lice, uncontrolled asthma, missed immunisations, repeatedly "not brought" to appointments.
  • Lack of supervision — repeated accidents, ingestions, young children left alone.
  • Developmental delay (especially speech), poor school attendance.
  • Unsafe home — dirty, cold, no food, dangerous environment.
• Emotional abuse — persistent emotional ill-treatment: rejection, humiliation, threats, being made to feel worthless, witnessing domestic abuse, inappropriate expectations, over-protection, exposure to frightening situations.
  • Signs — low self-esteem, anxiety, withdrawal, aggression, attachment problems, developmental delay, self-harm.
• Neglect and emotional abuse often build up slowly — use a chronology to see the pattern; share information across agencies.

Fabricated or Induced Illness

• What it is: A parent or carer reports, exaggerates, fabricates or induces illness in a child, leading to harm (unnecessary tests, treatments, restrictions on normal life).
• Warning signs (RCPCH 2021 guidance — "perplexing presentations"):
  • Reported symptoms and signs not seen by others, or only when the carer is present.
  • Test results and examination that don't fit the reported symptoms.
  • Unusual response to treatment — treatments "don't work".
  • New symptoms appear when old ones resolve.
  • Seeking multiple opinions; insisting on more tests, specialist referrals or disability aids (wheelchairs, feeding tubes).
  • The child's daily life is restricted beyond what illness would explain (out of school).
  • Induced — poisoning (e.g. laxatives, salt, insulin, sedatives), suffocation (repeated apnoea), tampering with lines or samples.
• Management:
  • Consult a senior and the named doctor early; agree one lead consultant.
  • Review all records (chronology); verify reported diagnoses with other clinicians.
  • Don't confront the carer before discussion with safeguarding colleagues; refer to children's social care when harm is likely.
  • Toxicology on samples taken at the time of events (if poisoning suspected); careful observation.

Exploitation and Online Harm

• Child sexual exploitation (CSE) — a child is coerced or manipulated into sexual activity in exchange for something (attention, gifts, money, drugs, alcohol, a place to stay) or through threats:
  • Signs — older "boyfriend" or "girlfriend", going missing, unexplained gifts, money or phones, being picked up in cars, repeat STIs or pregnancy, alcohol or drug use, school absence, self-harm, changes in behaviour or appearance.
  • The young person may not see themselves as a victim.
• Child criminal exploitation and "county lines" — children used to carry and sell drugs across areas:
  • Signs — going missing, travelling to unfamiliar areas, unexplained money, new phones, injuries (stab wounds), carrying weapons, new friends who are older.
  • Knife injuries in young people — always consider exploitation and safeguarding.
• Modern slavery and trafficking — refer through the National Referral Mechanism (children don't need to consent).
• Online harm — grooming, sharing of nude images ("sexting"), sextortion (blackmail with images — a risk factor for suicide), cyberbullying, harmful content (self-harm, eating disorders), excessive screen use. Report via CEOP; "Report Remove" (Childline and IWF) helps remove images.
• Peer-on-peer abuse — sexual harassment, violence and coercive control in teenage relationships.

FGM, Forced Marriage and Radicalisation

• Female genital mutilation (FGM) — illegal in the UK (and to take a girl abroad for it):
  • Types — 1 (clitoridectomy), 2 (excision of the clitoris and labia minora), 3 (infibulation — narrowing of the vaginal opening), 4 (all other harmful procedures — pricking, piercing, cutting).
  • Mandatory reporting — health professionals in England and Wales must report to the police (101) when a girl under 18 tells you she has had FGM or you see signs of it. Also refer to children's social care.
  • At-risk girls — mother or sister has had FGM, from a practising community, planned extended trip abroad — safeguarding referral; FGM Information Sharing (FGM-IS) alert on the girl's NHS record; FGM Protection Orders.
  • Effects — pain, bleeding, infection, urinary problems, painful sex, difficult childbirth, psychological trauma.
• Forced marriage — illegal; marriage under 18 is illegal in England and Wales (from 2023). Signs — sudden withdrawal from school, family conflict, self-harm, extended trip abroad. Don't contact the family or use family members as interpreters; contact the Forced Marriage Unit.
• "Honour"-based abuse — treat as a safeguarding and police matter.
• Radicalisation — the Prevent duty: if worried that a young person is being drawn into terrorism, discuss with the safeguarding lead (Prevent referral; Channel programme).

Looked-After Children and Young Carers

• Looked-after children (in care — foster care, children's homes, kinship care):
  • Much higher rates of mental health problems, developmental delay, unmet health needs, missed immunisations, dental decay, exploitation.
  • Statutory health assessments — initial (within 28 days of entering care) and regular reviews.
  • Check who can consent (parents may keep parental responsibility; the local authority may share it).
  • Care leavers — support to age 25.
• Unaccompanied asylum-seeking children — trauma, infection screening (TB, hepatitis B, HIV), age assessment issues, trafficking risk.
• Young carers — children caring for a parent or sibling with illness, disability, mental health or substance problems — tiredness, school problems, isolation; identify and refer for a young carer's assessment.
• Children with disabilities — at higher risk of all forms of abuse and less able to disclose.
• Children in households with domestic abuse, parental mental illness or substance misuse — "think family" when treating adult patients.

Consent and Parental Responsibility

• Parental responsibility (PR):
  • Mother — always.
  • Father — if married to the mother at the birth (or later), or named on the birth certificate (births registered from December 2003 in England and Wales), or through a court order or agreement.
  • Others — adoptive parents, guardians, people with a child arrangements order (residence), the local authority (care order — shared).
  • Usually one person with PR can consent (except some major decisions such as circumcision where disputes go to court).
• Young people aged 16–17:
  • Presumed to have capacity to consent to treatment (Family Law Reform Act 1969); the Mental Capacity Act 2005 applies from 16.
• Under 16 — Gillick competence:
  • A child under 16 can consent if they have sufficient maturity and understanding to fully understand the proposed treatment, its risks, benefits and alternatives (Gillick v West Norfolk, 1985).
  • Competence is decision-specific — a child may be competent for one decision and not another.
  • Encourage involvement of parents, but it is not always required.
• Fraser guidelines — for contraception and sexual health advice without parental knowledge in under 16s. The young person:
  • Understands the advice.
  • Can't be persuaded to tell their parents (or let you tell them).
  • Is likely to begin or continue having sex with or without contraception.
  • Their physical or mental health will suffer without treatment.
  • It is in their best interests to give treatment without parental consent.
• Refusing treatment — a competent young person under 18 who refuses treatment can, in some cases, be overruled by the court (or a person with PR, though court involvement is advised) where refusal would lead to death or serious harm. Seek senior and legal advice.
• Emergencies — treat in the child's best interests if no one with PR is available and delay would cause harm.
• Parents refusing life-saving treatment (e.g. Jehovah's Witness parents and blood) — in an emergency give the treatment needed to save life; otherwise apply to the court (specific issue order).
• Disagreement between parents and doctors — mediation, second opinions, ethics committees; the court decides on best interests if no agreement.

Confidentiality and Young People

• Young people have the same right to confidentiality as adults — and are less likely to seek help if they fear parents will be told.
• Explain the limits at the start: "What you tell me stays between us, unless I'm worried that you or someone else is at risk of serious harm — then I'd need to share it, and I'd talk to you first."
• When confidentiality can be broken — risk of serious harm to the young person or others (abuse, exploitation, serious self-harm or suicide risk), a legal requirement (FGM, court order), or the young person agrees.
• Where possible, tell the young person before sharing, and share only what is needed.
• Sexual activity — under 13 always triggers a safeguarding discussion; 13–15 — assess for exploitation or abuse (consensual activity between similar-aged peers doesn't automatically need reporting).
• Records — young people's access to records; parents with PR may request access, but information can be withheld if the young person is competent and objects, or it would cause harm.

Adolescent Health

• Adolescence (about 10–24) — rapid physical, emotional and brain development; risk-taking; developing independence. Most long-term mental illnesses start before age 25.
• Good practice — see the young person on their own for part of every consultation (explain this is routine); use plain language; be non-judgemental.
• HEEADSSS psychosocial assessment:
  • Home — who lives there, relationships, safety.
  • Education and employment — attendance, performance, bullying.
  • Eating — body image, dieting, exercise.
  • Activities — friends, hobbies, social media, screen time.
  • Drugs — smoking, vaping, alcohol, cannabis, other drugs.
  • Sexuality — relationships, sexual activity, contraception, consent, exploitation.
  • Suicide and depression — mood, sleep, self-harm, suicidal thoughts.
  • Safety — violence, abuse, online risks, knife crime, driving.
• Chronic illness in adolescence — poor adherence is common (diabetes, asthma, epilepsy); address independence and identity; involve the young person in decisions.
• Sleep — body clock shifts later in adolescence; insufficient sleep affects mood and learning.
• Transition to adult services — plan from age 13–14 (NICE NG43); a named worker; joint clinics; don't transfer at a time of crisis.

Depression and Anxiety

• Common — about 1 in 5 children and young people aged 8–25 in England has a probable mental disorder; anxiety and depression increase through adolescence, especially in girls.
• Depression in young people — low mood or irritability, loss of interest, withdrawal from friends, falling school performance, sleep and appetite change, tiredness, physical complaints, self-harm, suicidal thoughts.
• Assessment — see alone; ask about self-harm and suicidal thoughts directly; look for causes and stresses (bullying, abuse, family conflict, bereavement, LGBTQ+ minority stress, online harm, substance use); physical causes (hypothyroidism, anaemia).
• Treatment (NICE NG134):
  • Mild — watchful waiting (about 2 weeks), then digital CBT, group CBT, group interpersonal therapy or supportive therapy.
  • Moderate to severe — refer to CAMHS; individual CBT, family therapy, interpersonal therapy or psychodynamic therapy.
  • Antidepressants — only after assessment by a specialist, alongside psychological therapy: fluoxetine first-line (ages 12–18; with caution in 5–11), then sertraline or citalopram.
  • Warn about increased suicidal thoughts early in antidepressant treatment; review closely (weekly at first).
• Anxiety disorders — separation anxiety (young children), specific phobias, social anxiety, generalised anxiety, panic disorder; school avoidance. CBT (parent-led in younger children); SSRIs in some (specialist).
• Obsessive-compulsive disorder — CBT with exposure and response prevention; SSRI.
• PTSD — after trauma; trauma-focused CBT (or EMDR).
• Emotionally based school avoidance — anxiety-driven non-attendance; early, joined-up support between school, family and health; gradual return.
• Support — school-based mental health support teams, NHS talking therapies for 16+ and 18+, Kooth and other online services, Childline (0800 1111), Papyrus HOPELINE247.

Self-harm and Suicide Risk

• Self-harm — intentional self-poisoning or self-injury, whatever the motive; common in teenagers (especially girls); often a way of coping with overwhelming feelings. Suicide is a leading cause of death in young people.
• Risk factors for suicide — previous self-harm, depression, hopelessness, psychosis, eating disorders, substance misuse, bullying, abuse, LGBTQ+ young people facing rejection, bereavement by suicide, exam or relationship stress, online harm (including sextortion), looked-after children, being in contact with the youth justice system, autism.
• Assessment (NICE NG225):
  • Treat physical injury or poisoning first (paracetamol levels in any overdose).
  • Psychosocial assessment by a mental health professional with CAMHS training — before discharge.
  • Don't use risk scales or tools to predict future suicide or self-harm, or to decide who gets treatment — focus on needs, safety and understanding.
  • Ask directly about suicidal thoughts and plans — asking does not increase risk.
  • Explore what's happening at home, school, online and in relationships; protective factors; safeguarding.
• Management:
  • A safety plan developed with the young person (warning signs, coping strategies, people to contact, making the environment safer).
  • Means restriction — advise parents to lock away medicines (including paracetamol) and sharp objects.
  • Many trusts admit under-16s to a paediatric ward for assessment and safety (follow local policy).
  • Follow-up with CAMHS; involve parents or carers (with the young person's knowledge); safeguarding referral if abuse or exploitation.
  • Treat the young person with compassion and respect — negative staff attitudes make repeat presentations less likely to seek help.

💡 Clinical Pearl: Asking a young person "Have you had thoughts of ending your life?" does not put the idea into their head. Most are relieved to be asked — and the answer shapes your safety plan.

Eating Disorders

• Types:
  • Anorexia nervosa — restriction of intake, low weight, intense fear of weight gain, distorted body image; mostly teenage girls (boys too). Highest mortality of any psychiatric illness.
  • Bulimia nervosa — binge eating with compensatory behaviour (vomiting, laxatives, excessive exercise); weight often normal.
  • Binge eating disorder.
  • ARFID (avoidant/restrictive food intake disorder) — restricted range or amount of food because of sensory issues, fear (choking, vomiting) or lack of interest, without body image concerns; common in autism; younger children.
• Physical signs of anorexia — weight loss or failure to gain weight with growth, bradycardia, low BP and postural drop, low temperature, cold blue peripheries, lanugo hair, delayed puberty or amenorrhoea, growth stunting, muscle weakness.
• Signs of vomiting — Russell's sign (calluses on knuckles), dental erosion, swollen parotids, low potassium with metabolic alkalosis.
• Medical risk assessment (RCPsych MEED guidance — Medical Emergencies in Eating Disorders):
  • % median BMI (BMI as a percentage of the median for age and sex) — under 70% is high risk; rate of weight loss.
  • Heart rate (very low — under 40 is red), BP (low or postural drop), temperature (under 35.5 °C).
  • Muscle strength — sit-up and squat-stand (SUSS) test.
  • ECG — bradycardia, prolonged QTc, arrhythmia.
  • Bloods — U&E, potassium, phosphate, magnesium, glucose, FBC, LFTs.
  • Admit to a paediatric ward if high risk — medical stabilisation.
• Refeeding syndrome — a dangerous shift of phosphate, potassium and magnesium into cells when feeding restarts: low phosphate (heart failure, arrhythmias, muscle weakness, seizures). Start feeding promptly (avoid underfeeding), monitor electrolytes daily at first and replace them; thiamine.
• Treatment (NICE NG69):
  • Anorexia — eating disorder-focused family therapy (FT-AN) is first-line in children and young people; CBT-ED or adolescent-focused psychotherapy as alternatives.
  • Bulimia — bulimia-focused family therapy; CBT-ED.
  • Refer early to a community eating disorder service; dietitian; monitor bone health (DEXA if low weight for over a year).
  • Detention under the Mental Health Act (with nasogastric feeding) if life is at risk and treatment is refused.

⚠️ Safety Pearl: A young person with anorexia can have normal blood tests and still be at high risk of death. Heart rate, BP, temperature, weight trend and muscle strength matter as much as bloods — and refeeding needs daily phosphate checks.

ADHD

• Attention deficit hyperactivity disorder — persistent inattention and/or hyperactivity–impulsivity that impairs functioning:
  • Symptoms before age 12, for 6 months or more, in two or more settings (home and school).
  • Boys more often diagnosed; girls often present later with inattention.
  • Associated with autism, learning difficulties, tics, anxiety, conduct problems, sleep problems; often runs in families.
• Diagnosis — by a specialist (paediatrician or psychiatrist); history from parents and school (rating scales such as Conners), observation; exclude hearing problems, absences, sleep apnoea, thyroid disease, trauma, learning disability.
• Management (NICE NG87):
  • Education for family and school; environmental changes (seating, short tasks, routines); behaviour support.
  • Under 5 — parent training programmes first; medication only with specialist advice.
  • 5 and over — medication if symptoms still cause significant impairment:
    • Methylphenidate first-line (short or long-acting).
    • Lisdexamfetamine if methylphenidate fails after a 6-week trial.
    • Atomoxetine or guanfacine if stimulants aren't tolerated or effective.
  • Before starting — heart rate, BP, height, weight, cardiac history (family history of sudden death, syncope on exercise — ECG and cardiology if present).
  • Monitoring — height and weight every 6 months (appetite loss, growth slowing), heart rate and BP; sleep; mood; tics; misuse or diversion of stimulants.
• Controlled drugs (stimulants are Schedule 2) — prescribing rules; DVLA advice for teenage drivers.

Autism

• Autism — a lifelong neurodevelopmental condition with differences in:
  • Social communication and interaction — limited eye contact, pointing or shared attention; difficulty with conversation, understanding others' feelings or making friends; delayed or unusual language (echolalia).
  • Restricted, repetitive behaviours and interests — routines, distress at change, repetitive movements (hand-flapping, rocking), intense interests, lining up toys.
  • Sensory differences — over- or under-sensitive to noise, touch, textures (food), light.
• Signs to prompt referral (NICE CG128) — no babbling, pointing or gestures by 12 months; regression of language or social skills at any age (refer urgently); not responding to name; limited pretend play; unusual reactions; parents' concerns.
• Girls are often diagnosed later — better masking, quieter presentation (anxiety, eating problems, school refusal).
• Diagnosis — by a multidisciplinary autism team (history, observation such as ADOS, information from school); check hearing; look for co-occurring conditions.
• Co-occurring conditions — learning disability (in some), ADHD, anxiety, epilepsy, sleep problems, constipation, feeding problems (ARFID), depression; genetic causes (fragile X, tuberous sclerosis) — consider genetic testing (microarray, fragile X) especially with learning disability or dysmorphic features.
• Management (NICE CG170):
  • Support for the child, family and school — communication support (speech and language therapy), visual timetables, predictable routines, reasonable adjustments, an Education, Health and Care plan if needed.
  • Social communication interventions; parent programmes.
  • No medication for core autism features.
  • Treat co-occurring problems — melatonin for sleep (after sleep hygiene), treat ADHD and anxiety, constipation.
  • Behaviour that challenges — look for pain, illness, sensory overload or anxiety first; positive behaviour support; antipsychotics (risperidone or aripiprazole) only short term for severe aggression, with specialist monitoring.
• Hospital care — ask parents what helps; quiet rooms, reduced waiting, explain procedures visually; reasonable adjustments are a legal duty.

Learning Disability

• Learning disability — significantly reduced intellectual ability and difficulty with everyday activities, starting before adulthood:
  • Mild (IQ about 50–69), moderate (35–49), severe (20–34), profound (under 20).
  • Different from a specific learning difficulty (e.g. dyslexia, dyscalculia), where general intellect is normal.
• Causes — genetic (Down syndrome, fragile X, microdeletions), antenatal (alcohol, infection), perinatal (HIE, prematurity), postnatal (meningitis, head injury, untreated hypothyroidism or PKU), often unknown. Investigate with microarray, fragile X testing and others.
• Health inequalities — people with a learning disability die much younger than the general population, often from avoidable causes (respiratory infection, aspiration, constipation, epilepsy, cancer missed late).
• "Diagnostic overshadowing" — blaming new symptoms or behaviour change on the learning disability, and missing illness or pain.
• Good care:
  • Reasonable adjustments (Equality Act 2010) — longer appointments, easy-read information, a hospital passport, involving carers.
  • Annual health checks from age 14 with the GP; flag on the record.
  • Mental Capacity Act from 16 — support decision-making; best interests if lacking capacity.
  • Oliver McGowan Mandatory Training on learning disability and autism for health and care staff.
  • LeDeR — national review of deaths of people with a learning disability and autistic people.

Behaviour Problems, Psychosis and Transition

• Common behaviour problems in young children — tantrums, sleep problems, food refusal, toileting — usually part of normal development; consistent routines, praise and boundaries.
• Oppositional defiant disorder and conduct disorder — persistent defiance, aggression, rule-breaking, cruelty, stealing; linked to ADHD, learning difficulties, adversity and abuse. Parent training programmes (NICE CG158) and multi-agency support; screen for co-occurring problems.
• Attachment problems — after early neglect, multiple care placements; trauma-informed support.
• Selective mutism — speaks at home but not in school or other settings; an anxiety disorder; graded support.
• Tics and Tourette syndrome — see the Neurology and MSK chapter.
• Psychosis in young people — hallucinations, delusions, disorganised behaviour, social withdrawal, falling school performance; cannabis is a strong risk factor. Exclude organic causes (drugs, encephalitis, epilepsy, thyroid); refer urgently to early intervention in psychosis services.
• Bipolar disorder — rare before puberty; specialist care.
• Substance use — alcohol, cannabis, vaping, nitrous oxide, ketamine (bladder damage); brief interventions, young people's substance misuse services; think about exploitation and safeguarding.
• Mental Health Act — can be used for under 18s; admission must be to an age-appropriate environment; consider Gillick competence and parental involvement.
• CAMHS (Children and Young People's Mental Health Services) — tiered support from schools and primary care to specialist and inpatient care; crisis teams for urgent risk.
• Transition — plan the move to adult mental health or other services from 13–14 (NICE NG43); avoid gaps in care at 18.

Drug Reference Table

Spot the Diagnosis