8.5 Perinatal, Child & Adolescent and Neurodevelopmental Mental Health
Key Takeaways
Postpartum psychosis usually starts within 2 weeks of birth, is strongly linked to bipolar disorder, and needs urgent admission, ideally to a mother and baby unit.
Baby blues affect up to 80% of mothers on days 3–10 and resolve within 2 weeks, whereas postnatal depression lasts longer and may need CBT or an antidepressant.
Fluoxetine is the first-line antidepressant for moderate to severe depression in children and young people, started by a specialist alongside psychological therapy (NICE NG134).
Methylphenidate is the first-line medicine for ADHD in children aged 5 and over after diagnosis by a specialist, with monitoring of height, weight, heart rate and blood pressure.
People with a learning disability are offered an annual health check from age 14, and reasonable adjustments are a legal duty.
Perinatal, Child & Adolescent and Neurodevelopmental Mental Health
Perinatal Mental Health (NICE CG192)
At booking and in the postnatal period, ask the Whooley questions (low mood and loss of interest over the past month) and the GAD-2; use the Edinburgh Postnatal Depression Scale or PHQ-9 if positive. Ask about past or present severe mental illness and family history of bipolar disorder or postpartum psychosis.
| Condition | Onset & Frequency | Features | Management |
|---|---|---|---|
| Baby blues | Days 3–10; up to 80% of mothers | Tearfulness, emotional lability, anxiety | Reassurance; resolves within 2 weeks |
| Postnatal depression | Within the first year; about 10–15% | Low mood, anhedonia, guilt about mothering, intrusive thoughts, poor sleep beyond the baby's needs | Guided self-help, CBT; antidepressant if moderate or severe (sertraline is commonly used in breastfeeding) |
| Postpartum (puerperal) psychosis | Usually within 2 weeks; 1–2 per 1,000 births | Rapid onset of mania, psychosis, confusion, rapidly changing mood | Psychiatric emergency: urgent assessment (within 4 hours) and admission, ideally to a mother and baby unit |
Warning
Highest-Risk Women: Women with bipolar disorder or a previous postpartum psychosis have a very high risk of postpartum relapse. They need a written perinatal mental health plan, specialist perinatal team input in pregnancy, and close monitoring in the first weeks after birth. Suicide is a leading cause of maternal death in the year after pregnancy in the UK.
Psychotropic Drugs in Pregnancy
- Valproate must not be used in women and girls able to have children unless they are in the Pregnancy Prevention Programme, and should be avoided in pregnancy (neural tube and other malformations, neurodevelopmental harm).
- Lithium in the first trimester is linked to cardiac malformations (Ebstein's anomaly); if continued, levels need close monitoring, especially at delivery.
- Decisions balance the risk of relapse against fetal risk and should involve a perinatal psychiatrist.
Depression & Self-Harm in Children and Young People (NICE NG134)
- Less severe depression: watchful waiting, then digital CBT, group CBT, group non-directive supportive therapy or group IPT.
- More severe depression: refer to child and adolescent mental health services (CAMHS) for individual CBT, interpersonal therapy for adolescents or family therapy.
- Antidepressants: fluoxetine is the first-line drug, used only after assessment by a specialist and in combination with psychological therapy; monitor closely for agitation and suicidal thoughts, especially early in treatment.
- Self-harm: every young person who self-harms needs a psychosocial assessment (NICE NG225), consideration of safeguarding (abuse, exploitation, neglect), involvement of parents or carers where appropriate, and a safety plan. Admission to a paediatric ward after significant self-harm by under-16s is common practice.
Attention Deficit Hyperactivity Disorder (ADHD, NICE NG87)
A neurodevelopmental condition with inattention, hyperactivity and impulsivity present in more than one setting (home and school), starting in childhood (DSM-5: several symptoms before age 12) and causing impairment.
- Diagnosis is made by a specialist (paediatrician, child psychiatrist or adult ADHD service) using history from several sources; there is no diagnostic blood test or scan.
- Under 5: ADHD-focused parent training first.
- Children aged 5 and over and young people: ADHD-focused support and environmental adjustments (school), then methylphenidate as first-line medication; lisdexamfetamine if a 6-week trial of methylphenidate has not helped; atomoxetine or guanfacine as alternatives.
- Adults: lisdexamfetamine or methylphenidate first-line.
- Before and during stimulants: record height, weight, heart rate and blood pressure (stimulants suppress appetite and growth and raise heart rate and BP), ask about cardiac symptoms and family history of sudden death, and monitor regularly. Stimulants are controlled drugs and affect driving rules.
Autism
Persistent differences in social communication and interaction with restricted, repetitive behaviours and interests and sensory differences, present from early childhood. Red flags include lack of joint attention or pointing by about 12–18 months, absent babbling or social smiling, and loss of language or social skills. Diagnosis follows multidisciplinary assessment (NICE recommends starting within 3 months of referral). There are no medicines for the core features; support focuses on communication, education and environmental adjustments, while coexisting conditions (ADHD, anxiety, epilepsy, sleep problems, learning disability) are treated. Distressed behaviour should prompt a search for pain, illness or sensory triggers.
Learning Disability
A significant impairment of intellectual functioning (IQ below about 70) and adaptive functioning that starts in childhood. Causes include Down's syndrome, fragile X syndrome, fetal alcohol spectrum disorder and perinatal brain injury.
- Annual health checks are offered from age 14 in England.
- Clinicians must make reasonable adjustments (Equality Act 2010), such as longer appointments and easy-read information, and assess capacity for each decision under the Mental Capacity Act.
- Beware diagnostic overshadowing (attributing new symptoms to the learning disability) and inappropriate psychotropic prescribing (the STOMP programme aims to stop overmedication).
- The LeDeR programme reviews the deaths of people with a learning disability and autistic people to reduce avoidable deaths.
Other Childhood Presentations
- Conduct disorder: persistent antisocial or aggressive behaviour; group parent training programmes are first-line.
- Tic disorders and Tourette's syndrome: motor and vocal tics for more than a year; behavioural therapy for troublesome tics.
- Anxiety in children (separation anxiety, selective mutism, school refusal): CBT-based approaches with parent involvement.
Gender Incongruence
Some people experience gender incongruence (a mismatch between experienced gender and sex registered at birth), which may cause distress (gender dysphoria). Doctors should be respectful (using the person's chosen name and pronouns), assess and support mental health, and refer to NHS gender services for specialist assessment. For children and young people, NHS England children and young people's gender services provide holistic multidisciplinary care, and since 2024 puberty-suppressing hormones are not routinely prescribed to under-18s for gender incongruence outside research. Confidentiality, capacity and safeguarding principles apply as for any other healthcare decision.
A 27-year-old woman with bipolar disorder gave birth 6 days ago. Her partner reports that she has not slept for 2 days, is talking rapidly, believes the baby has been swapped, and her mood changes from elated to tearful within minutes. What is the most appropriate management?
Advise her to stop breastfeeding, rest and sleep in a separate room
Start sertraline 50 mg daily and refer her for perinatal CBT
Emergency psychiatric admission, ideally to a mother and baby unit
Reassure her partner that these are baby blues and review in 2 weeks
A 15-year-old boy has had moderate to severe depression for 4 months despite 6 sessions of individual CBT in CAMHS. The psychiatrist decides to add an antidepressant. According to NICE NG134, which drug should be offered first?
Citalopram
Fluoxetine
Amitriptyline
Venlafaxine
An 8-year-old boy has been diagnosed with ADHD by a community paediatrician. Parent training and school adjustments have not been enough, and medication is planned. What must be recorded before starting methylphenidate?
Electroencephalogram and MRI brain to exclude epilepsy
Serum ferritin, thyroid function and a coeliac screen only
A 12-lead ECG and echocardiogram for every child before treatment
Height, weight, heart rate, blood pressure and cardiac history
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