A teenage girl with low body mass index due to restricting food intake

Anorexia nervosa (AN) is an eating disorder that is characterized by restriction of energy intake leading to significantly low body weight, an intense fear of gaining weight or persistent behavior that interferes with weight gain, and disturbance in the way one’s body weight or shape is experienced. Because many patients with AN attempt to conceal their efforts to lose weight and minimize their symptoms, obtaining information from a caregiver is an important part of the assessment. A medical history and physical examination must be completed to assess medical stability, including review of vital signs, electrocardiogram, and laboratory studies. Medically unstable patients require a medical admission for refeeding and stabilization, including monitoring for refeeding syndrome. Pharmacotherapy should not be used as the primary treatment for patients with AN. The most evidence-based psychotherapy approach for children and adolescents is family-based treatment (Maudsley family therapy).

Excessive, uncontrollable worries

Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that is difficult to control. The worry is accompanied by at least one of restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance. Anxiety may present with crying episodes, temper tantrums, and irritability in children. Compared to adults, youth are also more likely to report somatic complaints associated with anxiety such as gastrointestinal upset, headaches, and sweating. Psychotherapies for GAD include cognitive behavioral therapy (CBT) and parent guidance to decrease accommodating behaviors. Pharmacotherapy options include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs).

Repeating, counting, and touching to prevent harm

Obsessive-compulsive disorder (OCD) is characterized by obsessions and/or compulsions that are time-consuming or cause clinically significant distress or impairment in functioning. Obsessions are recurrent and persistent intrusive, unwanted thoughts, urges, or images that cause marked anxiety or distress. Examples of obsessions include worrying about germs, the feeling things need to be “just right,” worrying about bad things happening, and disturbing thoughts or images about hurting others. Compulsions are repetitive behaviors or mental acts that an individual feels compelled to perform in response to an obsession or according to rules that must be applied rigidly. Examples of compulsions include washing, checking, tapping, ordering, and repeating. Young children may not be able to articulate the aims of these repetitive behaviors or mental acts. Selective serotonin reuptake inhibitors (SSRIs) are the first-line class of medications used to treat OCD in children and adolescents. Exposure and response prevention (ERP) therapy is the gold standard psychotherapy treatment for OCD.

A teenager who spends hours scrutinizing her skin

Body dysmorphic disorder (BDD) is an obsessive-compulsive and related disorder characterized by a preoccupation with a perceived defect or flaw in physical appearance that is not observable or appears slight to others. Individuals with BDD engage in repetitive behaviors or mental acts in response to appearance concerns such as comparing, excessive grooming, skin picking, mirror checking, or reassurance seeking. Females are much more likely to be affected and the disorder typically begins in adolescence. Many patients do not divulge their symptoms to medical providers unless specifically asked. The first-line medication class for BDD is selective serotonin reuptake inhibitors (SSRIs). Patients with BDD tend to require relatively high doses of SSRIs, and a relatively longer trial duration of 12 to 16 weeks is required to determine response. Research on the most effective psychotherapeutic treatments remains limited; however, cognitive behavioral therapy (CBT) may be a reasonable approach.

An adolescent with new-onset inattention

Cannabis use disorder is defined as a pattern of use that includes at least two signs or symptoms of problematic use. Cannabis is the second most commonly used psychoactive substance by adolescents. Cannabis use is associated with significant impairments in multiple cognitive domains, although even one week of abstinence can result in improved cognitive functioning. Cannabis use, particularly of products containing high concentrations of tetrahydrocannabinol (THC), increases the likelihood of developing schizophrenia. N-acetylcysteine (NAC) may be helpful for decreasing cravings and the risk of relapse. The most effective therapy modalities for cannabis use disorder are motivational enhancement therapy, contingency management, cognitive behavioral therapy (CBT), and family-based therapy.

Recurrent episodes of intense fear, shortness of breath, racing heart, and sweating

Panic disorder consists of recurrent, unexpected panic attacks accompanied by persistent worry about future attacks and/or a maladaptive change in behavior related to the attacks. A panic attack is defined as an abrupt surge of intense fear or discomfort that reaches a peak within minutes that occurs in conjunction with several other associated symptoms such as palpitations, sweating, trembling, shortness of breath, and chest pain. Features of panic disorder that are more common in adolescents than in adults include less worry about additional panic attacks and decreased willingness to openly discuss their symptoms. All patients with suspected panic disorder should undergo a medical history, physical examination, and laboratory workup to exclude medical causes of panic attacks. Cognitive behavioral therapy (CBT) including interoceptive exposures is the gold standard therapy intervention. Medications including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) can also help reduce symptoms.

An adolescent requesting to pause puberty

Gender dysphoria occurs when a patient has distress associated with incongruence between a person’s experienced gender and the gender traditionally associated with their sex assigned at birth. This must occur for at least six months. The psychiatric assessment of a patient with gender dysphoria should include exploration of the child’s developmental history of gender-expansive identification and expression; sources of distress relating to familial, community, and social stigma; and ways to help families adopt an accepting and nurturing response. Gender affirmation can include psychological, social, legal, and biological interventions. The goal of psychotherapy is to help a person explore, discover, and affirm their gender identity. Social affirmation may include changing names, pronouns, and gender expression. Legal gender affirmation may take place through a name or gender marker change on official documents. Biological affirmation may include pubertal suppression for younger adolescents, gender-affirming hormone therapy, and/or gender-affirming surgery.

An adolescent with binge drinking

Alcohol use disorder (AUD) occurs in approximately 5% of adolescents. The diagnosis of AUD requires the presence of at least two signs or symptoms of problematic alcohol use. Adolescent AUD differs from adult AUD in several ways. Adolescents are more likely to engage in binge drinking rather than daily drinking. They are also less likely to experience tolerance or withdrawal and are more likely to engage in risk-taking behaviors related to substance use. All adolescents should be screened for alcohol and other substance use. A motivational interviewing approach should be used. Treatment includes individual and family therapy; parent involvement is an essential component of treatment. Medication options include naltrexone, acamprosate, and disulfiram.

Young boy with social impairment and repetitive behaviors

Autism spectrum disorder (ASD) is a lifelong, highly heterogeneous neurodevelopmental disorder characterized by deficits in social communication and interaction as well as restricted, repetitive patterns of behavior, interests, or activities. The symptoms begin early in development but may not become apparent until social demands exceed abilities. The diagnostic assessment should include a medical assessment; evaluation by a clinician familiar with the signs/symptoms of ASD such as a developmental pediatrician, child psychiatrist, or child neurologist; neuropsychological testing to assess for comorbid intellectual disability; a speech and language evaluation; and an occupational therapy evaluation. There is no cure for ASD, but early diagnosis and intervention are associated with better functional outcomes. The treatment approach should be multidisciplinary and may include behavioral therapy, speech therapy, occupational therapy, and educational interventions. Pharmacologic treatment may be used to manage psychiatric comorbidities and maladaptive behaviors.

Persistent reading difficulty despite improved focus on a stimulant medication

Specific learning disorder is a developmental disorder characterized by difficulties learning a specific academic skill (reading, written expression, or mathematics), leading to substantially reduced achievement compared to same-age peers. Attention-deficit/hyperactivity disorder is a common comorbidity. Low academic performance must not be attributable to a more general condition such as intellectual disability, lack of educational opportunity, or low language proficiency. The learning difficulties are present from the early school years. The diagnostic assessment includes standardized academic achievement testing, review of academic records, and cognitive testing to rule out intellectual disability. Treatment includes specialized multimodal educational interventions in conjunction with academic accommodations. Pharmacologic treatment of comorbid psychiatric disorders may provide indirect benefit by helping the child better access educational interventions.