Therese and Cameron bring 4yo Samantha in. The childcare centre she attends told them that they felt unable to manage her any longer. They come in with Samantha and her 1yo brother, Liam. You previously saw Liam at 7 months because he was unsettled in the day and not sleeping well at night although thriving, no physical disease and normal developmental milestones.
Therese struggled to soothe Liam when he was upset and looked frustrated and distressed when her efforts to distract him didn’t work. When Liam was not distressed, Therese was able to play with him and he smiled in response as she passed him a toy.
Before Liam’s birth, Therese and Cameron had a “wonderful” relationship but now all they talked about was how to settle Liam. Cameron was spending longer and longer at work and kept telling her not to worry so much.

1. TRUE/FALSE - these diagnoses need to be considered for Liam’s parents.
a) Postnatal depression

1. TRUE/FALSE - these diagnoses need to be considered for Liam’s parents.
b) Postnatal anxiety

1. TRUE/FALSE - these diagnoses need to be considered for Liam’s parents.
c) Domestic violence

1. TRUE/FALSE - these diagnoses need to be considered for Liam’s parents.
d) Substance abuse

1. TRUE/FALSE - these diagnoses need to be considered for Liam’s parents.
e) Marital problem

Therese was unable to sleep even after Liam settled. She kept worrying about whether he was healthy, what she had to do that day and her husband kept telling her she worried too much.
She still enjoyed going out with her girlfriends. She had one glass of wine with dinner after feeding Liam but no other substances and was not psychotic nor suicidal and had no wish or plans to harm anyone else. While Cameron thought Therese was worrying too much, and less available, there were no other problems between them.
What is going on?
a. Marital problem
b. Post-natal depression and/or anxiety disorder
c. No diagnosis – normal post-natal course
d. Parent-infant relationship difficulties
e. Physical neglect

3. TRUE/FALSE - management options:
a) No treatment because this will resolve

3. TRUE/FALSE - management options:
b) CBT for anxiety +/- depression for Therese

3. TRUE/FALSE - management options:
c) Referral for home visiting program or Family Care Centre to improve parent-infant relationship

3. TRUE/FALSE - management options:
d) Circle of Security parenting program (with review and follow-up by GP)

4. Why address the parent’s health and relationship/s?
a) Parents whose own emotional and/or physical health is not attended to are less able to meet babies and children’s emotional (and physical) needs
b) Parental distress - unresolved marital problems, maternal depression or social isolation are major risk factors for child mental health problems
c) Anxiety in either parent perinatally predicts somatic complaints and anxiety for the child later

5. Which diagnosis best explains the presenting problems?
a. Autistic Spectrum Disorder
b. Separation Anxiety Disorder
c. No diagnosis – this is normal behaviour under the circumstances
d. Parental mental health Disorder
e. Oppositional Defiant Disorder
f. Attention Deficit Hyperactivity Disorder

6. Which comorbid diagnoses are important to consider?
a. Hearing or speech problem in Samantha
b. Marital problem
c. Attention Deficit Hyperactivity Disorder
d. Child abuse or neglect of either child
e. Parental mental health or substance abuse problem

7. Prognosis for the oppositional defiant disorder?
a. Good
b. Depends on intervention
c. Poor

8. Management:
a. Explanation (psychoeducation) alone
b. Marital Therapy (eg Relationships Australia)
c. Explanation (psychoeducation), liaison with preschool and Parent Management Training (eg. Triple P) –even if only one parent attends
d. Address parental mental health or relationship problems
e. Consider notification of government agency regarding possible child abuse - alongside with parents as cry for help (not blame)

Things improve substantially in the family after marital therapy and Circle of Security Parenting
program. Liam is now 14, his mother is waiting in the waiting room. In Year 9 at local selective High School. 2 months of irritable and sad mood. Falling marks over last term. Good rapport – seems able to talk freely with you.
Has transient thoughts about suicide but never a specific plan or act. He is able to talk with you about his thoughts of wanting to die and is willing to come for follow up. He is reluctant for you to speak with his mother, with whom he lives and who has brought him for the assessment.

9. TRUE/FALSE - management of Liam’s depression:
a. Selective Serotonin Reuptake Inhibitors (eg sertraline, brand name Zoloft) are contraindicated because Liam has suicidal thoughts

9. TRUE/FALSE - management of Liam’s depression:
b. Cognitive Behavioural Therapy (CBT) and/or SSRI (eg fluoxetine 1st line, sertraline 2nd line)

9. TRUE/FALSE - management of Liam’s depression:
c. Attachment Based Family Therapy

9. TRUE/FALSE - management of Liam’s depression:
d. Do not speak with his mother unless Liam consents

9. TRUE/FALSE - management of Liam’s depression:
e. Cognitive Behavioural Therapy

9. TRUE/FALSE - management of Liam’s depression:
f. Discuss the need to involve his parent/s in helping him to stay safe and monitor his thoughts of self harm and then speak with his mother