Key Facts

Child and adolescent mental health has become one of the most pressing healthcare challenges in the UK, with rising prevalence and significant unmet need. Early intervention is crucial for long-term outcomes.

Epidemiology

1 in 6 children aged 5-16 has a probable mental health disorder. Prevalence has increased from 1 in 9 (2017) to 1 in 6 (2022). Referrals to CAMHS have increased by >50% since 2019. Waiting times for CAMHS assessment average 3-6 months.

Aetiology

• Biological: Genetic predisposition, neurodevelopmental factors, physical illness
• Psychological: Adverse childhood experiences (ACEs), bullying, academic pressure, social media
• Social: Family dysfunction, poverty, parental mental illness, domestic violence, bereavement
• ACEs: Strong dose-response relationship — 4+ ACEs associated with significantly increased mental health risk

Pathophysiology

• Developing brain is particularly vulnerable to environmental stressors
• Chronic stress affects HPA axis, amygdala development, and prefrontal cortex maturation
• Critical periods for attachment, emotional regulation, and social learning
• Epigenetic changes from early adversity may have lasting effects on stress response systems

Common Presentations by Age

Pre-school (0-5):

• Attachment difficulties, emotional dysregulation, behavioural problems
• Developmental delay, ASD features

School age (5-12):

• Anxiety (separation anxiety, specific phobias, GAD)
• ADHD, conduct disorder
• Learning difficulties, school refusal

Adolescence (12-18):

• Depression, self-harm, eating disorders
• Social anxiety, OCD, PTSD
• Substance misuse, psychosis (FEP)
• Gender identity issues

Red Flags

• Self-harm or suicidal ideation — urgent CAMHS assessment
• Psychotic symptoms — rule out organic cause, urgent referral
• Significant weight loss/restriction — eating disorder assessment
• Disclosure of abuse — safeguarding referral
• School refusal >2 weeks — assessment needed
• Behavioural regression — consider trauma, abuse, or organic cause

Bedside

• SDQ (Strengths and Difficulties Questionnaire): Parent, teacher, and self-report screening tool (25 items)
• RCADS (Revised Children's Anxiety and Depression Scale): Self-report measure
• Risk assessment: Age-appropriate assessment of self-harm, suicide, safeguarding
• Developmental history: Milestones, school performance, social functioning

Bloods

• TFTs: If depression or mood disturbance
• FBC: Anaemia, baseline
• As guided by clinical presentation

Special Tests

• Cognitive assessment (WISC-V): If learning difficulty suspected
• ADOS-2: If ASD assessment indicated
• DIVA/Conners': If ADHD assessment indicated

Non-pharmacological

• First-line for most conditions: Psychological therapy
• CBT: Evidence-based for anxiety, depression, OCD, PTSD in CYP
• Family therapy: Eating disorders (FBT), conduct disorder, family conflict
• Parent training programmes: First-line for ADHD (pre-school), conduct problems
• School-based interventions: Whole-school approaches, anti-bullying, PSHE
• EMDR: For PTSD in CYP
• DBT-A: Adapted for adolescents with self-harm and emotional dysregulation

Pharmacological

• Depression: Fluoxetine 10-20mg OD — ONLY SSRI recommended for depression in CYP by NICE (CG28); specialist initiation
• Anxiety: SSRIs (specialist) if severe and CBT insufficient
• ADHD: Methylphenidate or lisdexamfetamine — specialist initiation (NICE NG87)
• Psychosis: Low-dose atypical antipsychotic — specialist only
• OCD: Fluoxetine or sertraline at higher doses — specialist
• General principle: Specialist initiation for most psychotropics in under-18s; shared care with GP

Referral Criteria

• Moderate-severe depression — CAMHS
• Self-harm — urgent CAMHS or A&E with liaison
• Suspected eating disorder — specialist ED service
• Suspected ASD/ADHD — neurodevelopmental pathway
• Psychotic symptoms — urgent CAMHS/EIP
• Safeguarding concerns — safeguarding referral (in parallel with any clinical referral)

• Early intervention significantly improves long-term outcomes
• 50% of lifetime mental illness starts before age 14
• Depression in CYP: ~60% respond to CBT or fluoxetine; combination most effective (TADS trial)
• ADHD: Persists into adulthood in ~65%; early treatment improves academic and social outcomes
• Conduct disorder: Without intervention, ~40% develop ASPD in adulthood
• Eating disorders: Earlier treatment = better prognosis (especially AN in under-18s)
• Self-harm: Increasing prevalence; ~15-25% repeat within 12 months

CAMHS Tier System

Adverse Childhood Experiences (ACEs)