Child and adolescent psychiatry module
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Child and Adolescent Psychiatry Module. Week 1 Dr Sarah Huline-Dickens Consultant in Child Psychiatry, Mount Gould Hospital, Plymouth [email protected] Introductions. To group To module To ground rules To reading list. Learning Objectives for Today this morning….

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Child and Adolescent Psychiatry Module

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Child and adolescent psychiatry module

Child and Adolescent Psychiatry Module

Week 1

Dr Sarah Huline-Dickens

Consultant in Child Psychiatry,

Mount Gould Hospital, Plymouth

[email protected]


Introductions

Introductions

  • To group

  • To module

  • To ground rules

  • To reading list


Learning objectives for today this morning

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


Learning objectives for today this afternoon

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


Session content

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


What s it like for a new boy

What’s it like for a new boy?


Camhs 1

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


Camhs 2

CAMHS 2

  • Multidisciplinary team

  • Single point of entry with primary mental health workers (tier 2)

  • Choice and partnership system

  • Some specialist clinics


What is a psychiatric disorder an impairing abnormality of behaviour emotions and relationships

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


What kinds of disorders

What kinds of disorders?

  • Emotional disorders (internalizing)

    • anxiety disorders

    • phobias

    • depression

    • OCD

    • Some somatisation

  • Disruptive behavioural disorders (externalizing)

    • hyperkinetic disorder/ADHD

    • conduct disorder


What kinds of disorders cont d

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


How common are they

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


Continuity into adult life

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


Epidemiology 1

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


Epidemiology 2

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.


Epidemiology 3

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


Epidemiology 4

Epidemiology 4

  • Many disorders co morbid

  • Most untreated

  • Many persistent, especially conduct problems

  • Marked gender differences


Classification

Classification

  • ICD 10

  • DSM IV

  • Both have multi-axial schemes:

  • Psychiatric disorder

  • Specific delay in development

  • Intellectual level

  • Medical condition

  • Psychosocial adversity

  • Adaptive functioning


Classification 2

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


Aetiology 1

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)


Aetiology 2 genes control

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


Aetiology 3 factors in life increasing the incidence rates for cmd by increasing hpa sensitivity

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


Aetiology 4

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


Aetiology 5

Aetiology 5

  • Consider whether child, family, environmental factors are:

    • PREDISPOSING

    • PRECIPITATING

    • PERPETUATING

  • What is protective and aiding resilience?


Aetiology 6 nature vs nurture becomes nature and nurture

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


Lunch

Lunch!


Resume of this morning

Resume of this morning

  • What did you learn?


Child and adolescent psychiatry module

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


Child and adolescent psychiatry module

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


Child and adolescent psychiatry module

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


Attachment theory

Attachment theory

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


Attachment

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


Attachment 2

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


Attachment 3

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%


Attachment 4

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


Attachment 41

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


Adhd 1 hyperkinetic disorder hyperactivity

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.


Adhd 2

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 1

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 2

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 3

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 4

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 5

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


Pervasive developmental disorders communication disorders autistic spectrum disorders 6

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)


Pervasive developmental disorders communication disorders autistic spectrum disorders 41

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


Child and adolescent psychiatry module

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


Child and adolescent psychiatry module

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


Child and adolescent psychiatry module

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


Management 1

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)


Management 2

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


Learning objectives for today

Learning Objectives for today

  • 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


Learning objectives for today cont d

Learning Objectives for today cont’d

  • 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


The end

The End


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