Child and adolescent psychiatry accounts for approximately 8% of Paper B marks — roughly 12 of 150 questions. The topics tested are distinct from adult psychiatry and cover neurodevelopmental disorders, attachment theory, safeguarding, and the legal framework for minors.
Most candidates find child psychiatry questions challenging because they assume that knowledge from adult practice transfers directly. It does not. The presentations, assessment frameworks, and management strategies are fundamentally different.
Neurodevelopmental Disorders
Attention Deficit Hyperactivity Disorder (ADHD)
Core features (ICD-11): Persistent pattern (at least 6 months) of inattention, hyperactivity, and impulsivity that is developmentally inappropriate, present across multiple settings, and causes functional impairment. Onset before age 12. Three presentations: predominantly inattentive, predominantly hyperactive-impulsive, and combined.
Prevalence: Approximately 5% of children worldwide. Male:female ratio of 2:1 in childhood (narrowing in adulthood to 1:1). Comorbid with oppositional defiant disorder (ODD), conduct disorder, anxiety, depression, and autism spectrum disorder.
Management (NICE guidance):
- Under 5 years: Parent training programmes as first-line. Medication is not recommended.
- School-aged children (5–18 years): Methylphenidate as first-line pharmacological intervention. If ineffective or not tolerated, switch to lisdexamfetamine or dexamfetamine. Guanfacine and atomoxetine are second-line options.
- Environmental modifications: Behavioural interventions in the classroom, structured routines, organisational support, and psychoeducation for parents and teachers.
Key drug comparisons for the exam: Methylphenidate blocks dopamine and noradrenaline reuptake. Lisdexamfetamine increases dopamine and noradrenaline release. Both are Schedule 2 controlled drugs. Atomoxetine is a selective noradrenaline reuptake inhibitor, not a controlled drug, but takes 4–8 weeks to reach full effect. Guanfacine is an alpha-2 agonist, also not controlled.
Autism Spectrum Disorder (ASD)
Core features (ICD-11): Persistent deficits in social communication and social interaction (across multiple contexts) AND restricted, repetitive patterns of behaviour, interests, or activities. Symptoms must be present in the developmental period (though may not fully manifest until social demands exceed capacity). ICD-11 removed the subcategories (Asperger syndrome, childhood autism) and replaced them with a single spectrum diagnosis.
Prevalence: Approximately 1–2% of children. Male:female ratio of 4:1 (though this may reflect underdiagnosis in females, who tend to present with less obvious restricted interests and better surface social skills).
Red flags in early development: Reduced joint attention (not pointing to share interest), delayed speech or unusual language development (echolalia, pronoun reversal), lack of pretend play, unusual sensory responses (hypersensitivity to sounds/textures/foods), rigid routines, and repetitive movements (hand flapping, rocking).
Management: There is no pharmacological treatment for the core symptoms. Management focuses on behavioural and educational interventions (Early Intensive Behavioural Intervention, TEACCH, social skills training, speech and language therapy, occupational therapy for sensory integration). Medication is used only for comorbid conditions (irritability, aggression, anxiety, ADHD symptoms) and should be prescribed cautiously as children with ASD are more sensitive to side effects.
Intellectual Disability (Learning Disability)
Definition: Significant impairment of intellectual functioning (IQ below 70) AND significant impairment of adaptive functioning, with onset during the developmental period. Severity: mild (IQ 50–69), moderate (IQ 35–49), severe (IQ 20–34), profound (IQ below 20).
Common causes (exam-favourite): Down syndrome (trisomy 21), Fragile X syndrome (triplet repeat on X chromosome, most common inherited cause), Fetal alcohol spectrum disorder, Rett syndrome (MECP2 mutation, almost exclusively in females), Angelman syndrome (maternal 15q11 deletion — happy puppet, seizures, ataxia), Prader-Willi syndrome (paternal 15q11 deletion — hyperphagia, obesity, hypotonia).
Behavioural phenotypes: Down syndrome = friendly disposition, relative strength in social skills. Fragile X = social anxiety, gaze aversion, ADHD features. Prader-Willi = food-seeking, skin picking, temper outbursts. Angelman = frequent laughter, happy demeanour, hand-flapping.
Attachment Theory
Attachment theory appears consistently in child psychiatry questions. The key concepts are John Bowlby’s attachment theory and Mary Ainsworth’s Strange Situation Procedure.
Bowlby’s key ideas: Attachment is an innate biological system that keeps the infant close to the caregiver for protection. The internal working model (mental representation of the self in relation to others) formed in infancy influences relationships throughout life.
Ainsworth’s attachment styles (Strange Situation):
- Secure attachment: Distressed when caregiver leaves, easily soothed on return, uses caregiver as secure base for exploration. Approximately 60–65% of children in low-risk samples.
- Insecure-avoidant attachment: Little distress when caregiver leaves, avoids or ignores caregiver on return. Caregiver is typically rejecting or unresponsive. Approximately 15–20%.
- Insecure-ambivalent (resistant) attachment: Intense distress when caregiver leaves, difficult to soothe on return, both seeks and resists contact. Caregiver is inconsistent. Approximately 10–15%.
- Disorganised attachment: Contradictory behaviours (freezing, stereotypies, approaching then turning away). Often associated with maltreatment or caregiver unresolved trauma. Approximately 5–10% in low-risk samples, higher in high-risk groups.
Clinical relevance: Insecure attachment patterns are risk factors for later psychopathology. Disorganised attachment is most strongly associated with subsequent mental health problems and is considered the attachment pattern of maltreated children.
Safeguarding and Child Protection
Safeguarding questions are mandatory content in Paper B. The key legal and procedural knowledge:
- Types of maltreatment: Physical abuse, emotional abuse, sexual abuse, neglect, fabricated or induced illness (previously called Munchausen syndrome by proxy). The highest mortality is associated with neglect.
- Children Act 1989: The welfare of the child is paramount. Section 17 (duty to provide services to children in need), Section 47 (duty to investigate if significant harm is suspected). Emergency Protection Order (EPO) lasts 8 days with a possible extension of 7 days. Care order lasts until the child turns 18.
- Gillick competence and Fraser guidelines: A child under 16 can consent to treatment if they have sufficient understanding and intelligence to comprehend what is proposed. Fraser guidelines specifically apply to contraceptive advice. In Scotland, age of legal capacity is 12.
- Mental Capacity Act 2005 and children: MCA does not apply to under-16s. For 16-17 year olds, MCA applies but is modified by the Children Act. If a 16-17 year old lacks capacity, the decision is made by someone with parental responsibility or the court, applying the best interests standard.
- When to refer: Any concern about significant harm must be referred to the local authority children’s social care. You do not need parental consent to make a safeguarding referral. If a child discloses abuse, you should listen, record verbatim, do not promise secrecy, explain what you will do, and refer.
Common Exam Question Patterns
- Differential diagnosis of developmental regression: Regressive autism (regression in language and social skills around 18–24 months), Rett syndrome (regression around 6–18 months in females with hand-wringing), Landau-Kleffner syndrome (acquired epileptic aphasia), and neurodegenerative disorders (rare).
- ADHD vs ASD overlap: Both present with inattention and social difficulties. Key distinction: ADHD inattention is modulated by interest (can focus on preferred activities), ASD social deficits are more pervasive and accompanied by restricted interests and sensory differences.
- Tourette syndrome: Multiple motor tics and at least one vocal tic, present for more than 1 year, onset before age 18. Comorbid with ADHD and OCD in most cases.
- School refusal vs truancy: School refusal is driven by anxiety (child remains at home with parental knowledge). Truancy involves concealment from parents and antisocial behaviour. Management differs: school refusal requires anxiety-focused intervention; truancy requires behavioural and social support.
PsychStar’s Paper B bank covers child and adolescent psychiatry with questions that reflect real exam difficulty and style. Start with 5 free questions at psychstar.io/try.