Child and Adolescent Psychiatry Module

1. Child and Adolescent Psychiatry Module Week 1 Dr Sarah Huline-Dickens Consultant in Child Psychiatry, Mount Gould Hospital, Plymouth sarah.huline-dickens@plymouth.nhs.uk

2. Introductions • To group • To module • To ground rules • To reading list

3. Learning Objectives for Todaythis morning… • Describe a typical CAMHS • Describe the continuities of childhood disorders into adult life • Describe the classification systems used and the aetiology and epidemiology of the major psychiatric disorders of childhood and adolescence

4. Learning Objectives for Today this afternoon… • Recall the principles of attachment theory • Describe the features of the disorders of development (ASD and ADHD) and their treatment including indications for drug treatment

5. Session content • Introduction to child psychiatry and CAMHS • Continuities into adult life (group work) • Classification, epidemiology and aetiology • Lunch • Attachment theory (group work) • Break • Developmental disorders: ADHD and ASD (mock CASC and video) • Finish at 4pm

6. What’s it like for a new boy?

7. CAMHS 1 • Based in Mount Gould Hospital • Erme House is for out-patients • The Terraces is a day unit for under 13s with severe problems (4 week assessment) • Out-patient clinics • COT, a crisis intervention team • Cotehele, the regional adolescent unit, opened January 2007

8. CAMHS 2 • Multidisciplinary team • Single point of entry with primary mental health workers (tier 2) • Choice and partnership system • Some specialist clinics

9. ABNORMAL in relation to: child’s age and gender developmental stage culture persistence extent of disturbance severity and frequency IMPAIRMENT causes suffering to child/distress to family social restriction impedes the child’s development effects on others What is a psychiatric disorder?An impairing abnormality of behaviour, emotions and relationships

10. What kinds of disorders? • Emotional disorders (internalizing) • anxiety disorders • phobias • depression • OCD • Some somatisation • Disruptive behavioural disorders (externalizing) • hyperkinetic disorder/ADHD • conduct disorder

11. What kinds of disorders?cont’d • Developmental disorders -speech/language delay -reading delay -autistic disorders -generalised learning disabilities -enuresis and encopresis • Adult onset disorders -psychosis -eating disorders -mood disorders, DSH

12. How common are they? Prevalence of some psychiatric disorders: • Conduct disorder 5-10% • Hyperkinetic disorder 1-5% • Anorexia nervosa 0.1-0.7% of adolescent girls • Autism 2 per 1000 • See Ford T (2008) JCPP 49:9 p900-914

13. Continuity into adult life Tasks: • Group 1 prepare for a radio interview • Group 2 think about how you would devise a teaching session based on this information for paediatricians • Group 3 consider how you would make a poster with the key messages

14. National or local cohort studies e.g. Dunedin (NZ) study for 1972-3 births Melzer (2000) Child Mental Health Survey used child benefit records. 10% of children up to 16 had an ICD 10 diagnosis. Strong association with social class. Follow-up showed only 20% in contact with specialist services Local population surveys e.g. Isle of Wight, Ontario, Waltham Forest, Puerto Rico Epidemiology 1

15. Epidemiology 2 • Pre-school: Richman (1982) Waltham Forest 3- year- olds. Overall rate 22%. Severe behavioural and emotional problems 7%. • Middle Childhood: Rutter (1979) Isle of Wight 10-11- year- olds. Overall rate 7% (double in London). Important associations with parental psychiatric disorder, learning disability and physical health (especially epilepsy). Boys exceed girls. Problems tend to persist. Mainly conduct and emotional disorders.

16. Epidemiology 3 • Adolescents: rates of depression rise dramatically in girls and deliberate self-harm emerges • Rate probably 15-20% but studies vary in criteria used • Adolescent turmoil is not universal

17. Epidemiology 4 • Many disorders co morbid • Most untreated • Many persistent, especially conduct problems • Marked gender differences

18. Classification • ICD 10 • DSM IV • Both have multi-axial schemes: • Psychiatric disorder • Specific delay in development • Intellectual level • Medical condition • Psychosocial adversity • Adaptive functioning

19. Classification2 • But… • Ever increasing complexity • High rates of comorbidity • High use of NEC by clinicians mean this may be revised • So instead of 16 DSM and 10 ICD 10 chapters likely to be 5 large groups in the future (neurocognitive, neurodevelopmental, psychoses, emotional and externalising disorders) • See Goldberg D (2010) BJPsych 196 p 255-256

20. Aetiology 1 • the genetics of common mental disorders • gene – environment interactions • environmental factors that modify HPA sensitivity • the biology of good and bad attachment experiences • the later effects of childhood abuse • (these 3 slides courtesy of Goldberg 2009)

21. Aetiology 2Genes control……. • Hormones, neurotransmitters and immune responses • The tendency to experience anxious symptoms; and conversely general resilience to life stress – but there is an important G x E interaction here • About half – sometimes more - of the variance of major personality types; but environmental factors also play a part

22. Aetiology 3 Factors in life increasing the incidence rates for CMD by increasing HPA sensitivity: Severe early deprivation [orphanage reared children] ∙ Maternal deprivation ∙ Maternal depression ∙ Sexual and physical abuse during childhood (not only depression & anxiety, also eating disorders and poor sexual adjustment) see Glaser, D. (2000) JCPP, 41, 1, p 97-116

23. Child boys low intelligence difficult temperament physical illness developmental delay genetic factors Family traumatic stress ineffectual parenting style overprotective parenting marital disharmony maternal ill-health paternal psychiatric disturbance abuse Environment peer relationship problems social deprivation school factors stresses resulting from accidents Aetiology 4

24. Aetiology 5 • Consider whether child, family, environmental factors are: • PREDISPOSING • PRECIPITATING • PERPETUATING • What is protective and aiding resilience?

25. Aetiology 6Nature vs. nurture becomes nature and nurture • Genetic factors are important in autism, bipolar affective disorders, schizophrenia, tic disorders, and probably hyperactivity • Genetic liability may translate into poorer outcomes through: • leading directly to psychopathology e.g. autism; • confering greater susceptibility to less favourable environments; • causing individual to seek out risk situations/ behaviours

26. Lunch!

27. Resume of this morning • What did you learn?

28. Quiz Q1 • The following statements concerning conduct disorder are true: • A it is the most prevalent child psychiatric disorder • B antisocial behaviour associated with personality abnormalities is more likely to be solitary than socialised • C delinquency is a synonymous term • D reading retardation is significantly associated • E prognosis is good

29. Q2 • In the Isle of White child psychiatry study: • A the prevalence of psychiatric disorder in boys was twice that in girls • B the prevalence of psychiatric disorder increased as intelligence decreased • C uncomplicated epilepsy was not a significant risk factor • D 4 years later over half were still handicapped by their problems • E the subsequent inner London survey showed broadly similar rates

30. Q3 • Epidemiological studies of children and adolescents have generally shown that: • A 25-40% have a psychiatric disorder • B autistic disorders are one of the commonest child psychiatric disorders • C children with conduct problems only rarely have emotional problems too • D most children with psychiatric disorders are in contact with mental health professionals • E psychosocial disorders have become less common over recent decades

31. Attachment theory • In groups summarise in 20 words what you understand by attachment theory

32. Attachment • Bowlby (1907-1990) • Ethology (the biological study of behavioural processes) • Need to be attached as important as other needs (see Harlow 1965) • Internal working models generated which influence relationships and attitudes throughout life

33. Attachment 2 • Mary Ainsworth’s Strange Situation Procedure in 12-18 month children • 7 phase experiment to assess attachment status with carer and stranger present involving two brief separations and reunions • A= avoidant • B=secure • C=resistant/ambivalent • D=disorganised/disorientated

34. Attachment 3 • Importance throughout life • Mary Main’s Adult Attachment Interview draws upon discourse analysis to rate state of mind concerning attachments • Parent and infant attachment styles correspond highly (2/3 match) • Secure infants tend to be happy infants • In adult clinical samples likelihood of secure attachment is 10%

35. Attachment 4 • Interesting work on mentalising (ability to work out people’s mental states) and attachment (Fonagy) i.e. insecure infants are less likely to be able to think in situations of anger or arousal and fall apart • Secure attachment is maintaining the balance between inhibiting thought about others and feeling strongly for them

36. Attachment 4 • Contrast with attachment disorder (much rarer) which is pervasive and severe and results in distress • Recognised in ICD 10 and DSM IV as disinhibited or inhibited type • Differentiate from: ADHD, mania, frontal lobe conditions, ASD • Can result in problems with relationships, behavioural problems and cognitive development

37. ADHD 1 (hyperkinetic disorder, hyperactivity) • Core features: triad of restlessness, impulsivity and inattentiveness • Pervasive • Early onset by 7 years • Prevalence 3-5%. Male: female 3:1 • Linked with deprivation • Comorbidity very common (conduct, poor peer relationships, learning problems, clumsiness and developmental disorders but no demonstrable brain damage) • Aetiology unclear: seems to be heritable. Idea of a dopamine transfer deficit.

38. ADHD 2 • Management: must exclude other reasons for hyperactive behaviour • MTA study (1999) confirmed use of stimulants more effective than other treatments • Educational measures • Diet: unclear benefit • Stimulants, most commonly methylphenidate acting as indirect sympathomimetic agents ↑DA (side effects: appetite suppression, tics, sleep disturbance, need to monitor growth, but not addictive) • Prognosis: most will improve in symptoms in adolescence, but a minority will still be restless and inattentive adults

39. Prevalence 2 per 1000 have PDD For autism 0.5 per 1000 Male: female ratio 3:1 No clear association with socio-economic status Triad of: social impairment, communication problems and restrictive/ repetitive interests and behaviours Early onset (before 36 months) Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 1

40. Associated features: Mental retardation (verbal IQ lower than non-verbal IQ) Seizures in a third of mentally retarded Hyperactivity common Self-injury Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 2

41. Differentiate from: Language disorders Asperger’s syndrome Mental retardation Rett’s syndrome (girls, regression at 12 months, ‘hand-washing stereotypies and overbreathing, death often before 30) Neurodegenerative disorders Extreme early deprivation Deafness! Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 3

42. Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 4 • Aetiology: genetic (twin heritability 90%) • Psychological deficit: ?theory of mind (Sally Anne test) ?executive function • Treatment: educational interventions. Some role for psychotropic medication

43. Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 5 • Indications for drug treatment: • Mainly aggression (more common in marked intellectual retardation and impaired communication and poor living skills) • If specialised education, behaviour therapy and environmental change fail • Treat comorbidity e.g. ADHD or depression

44. Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 6 • Recent studies have shown benefit of risperidone in autism* in aggression • Adverse events: somnolence, EPS, weight gain, raised prolactin • Not licensed for irritability in UK (although is in US) • Monitoring needed (see review: growth, BP, behaviour, EPS) • * see BMJ 2007; 334:1069-70 for review (Morgan & Taylor)

45. Pervasive developmental disorders (communication disorders, autistic spectrum disorders) 4 • Aetiology: genetic (twin heritability 90%) • Psychological deficit: ?theory of mind (Sally Anne test) ?executive function • Treatment: educational interventions. Some role for psychotropic medication

46. Quiz Q4 • Children with a disinhibited attachment disorder commonly show: • A attention-seeking behaviour • B hypervigilance • C reduced need for sleep • D indiscriminate friendliness • E aggression in response to another person’s distress

47. Q5 • Hyperactivity is: • A usually associated with a history of parental neglect • B commonly associated with demonstrable brain damage • C more frequent in those with epilepsy • D associated with other developmental disorders • E commoner in children reared in institutions from infancy

48. Q6 • The following are characteristic of infantile autism: • A poor understanding of speech • B echolalia • C hallucinations • D poor eye-to-eye gaze • E pronominal reversal

49. Management 1 • The importance of the biopsychosocial approach • Indications for out-patient, day patient and inpatient care • Think about risk assessments • Mention NICE guidelines (ADHD, eating disorders, depression in young people, atypical anti-psychotics, DSH) or strategic documents (e.g. national autism plan for children)

50. Management 2 • Investigations: information (old notes, GP, informants), psychological, medical, social • Short, medium and long-term • Prognosis: the condition in general and this particular patient