9 Child and adolescent psychiatry9.5 Physical health and psychiatric disorder
9.5 Psychiatric disorder and physical illness in children
2 min read2 figures
Written by Resident Doctor Committee · Published
Distress expressed through the body
Children often voice distress through pain, fatigue or other physical symptoms. These symptoms are real and have physical, psychological and social causes.
Functional neurological disorder is diagnosed on positive clinical features, not on normal tests or a history of stress.
Chronic fatigue syndrome in young people
Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is diagnosed in a child or young person under National Institute for Health and Care Excellence (NICE) guidance when the core symptoms have lasted three months and no other condition explains them.
Post-exertional worsening points to ME/CFS, so do not assume that deconditioning keeps the fatigue going.
Outlook is better than in adults: most young people improve substantially or recover, whereas full recovery in adults is uncommon.
2021 NICE guideline | Treatment |
|---|---|
Recommended | A personalised energy management plan |
Remains an option | Cognitive behavioural therapy, as supportive treatment for symptom management |
Advised against | Graded exercise therapy, the Lightning Process, curative medicines, routine supplements |
School: a young person who values school should stay in it through flexible adjustments, such as a part-time timetable with rest breaks that respects the energy limit and keeps peer contact.
Physical disease mistaken for psychiatric disorder
Condition | Mistaken for | Points to the physical cause |
|---|---|---|
Hypothyroidism | Depression, slowing, falling attainment | Growth changes, cold intolerance, goitre |
Hyperthyroidism, usually Graves' disease | Anxiety, irritability | Tachycardia, tremor, heat intolerance, eye signs |
Wilson's disease | Mood, behavioural or cognitive disorder | Liver disease, dystonia, Kayser-Fleischer rings |
Anti-N-methyl-D-aspartate receptor encephalitis | Acute psychosis, agitation, catatonia | Rapid progression, seizures, dyskinesia, autonomic change |
Niemann-Pick disease type C | Antipsychotic-resistant psychosis, executive decline | Vertical supranuclear gaze palsy |
Absence epilepsy | Inattention | Brief impaired awareness, generalised 3 Hz spike-wave on EEG |
Obstructive sleep apnoea | Inattention, hyperactivity | Snoring, witnessed apnoeas |
Corticosteroids, montelukast, levetiracetam | New mood, sleep or behaviour change | Timing against the treatment |
Rapid onset, an unusual age, neurological signs, regression or cognitive decline should raise suspicion of a physical cause. Primary psychiatric illness can also begin acutely.
Epilepsy and brain injury
Lennox-Gastaut syndrome is a severe childhood epilepsy defined by multiple seizure types, slow spike-and-wave activity on the electroencephalogram (EEG) and cognitive impairment. Its accompanying psychiatric problems do not define it.
After mild traumatic brain injury, children and adolescents repeatedly show depression, anxiety, attention deficit hyperactivity disorder and conduct problems. Mania is not an established outcome.
Constipation
Functional (idiopathic) constipation accounts for the great majority of childhood constipation, and no organic cause is found.
Hirschsprung's disease is a congenital aganglionosis of the distal bowel and is usually diagnosed within the first two years of life.
Chronic illness, adherence and assessment
Missed treatment in adolescence is common and can be dangerous. Assess urgently whether self-harm, eating disorder behaviour or safeguarding concerns lie behind an omission that threatens health.
Assess capacity or competence for the actual decision under the law for the young person's age. Gillick is not the test for every 16 or 17-year-old.
Physical and psychiatric disorders can coexist, so do not pin every new symptom on the known diagnosis.