Introduction to Child Psychiatry for Medical Students

1. Introduction to Child Psychiatry for Medical Students Dr Rachel Elvins MRCPsych SpR / Clinical Tutor in Child and Adolescent Psychiatry

2. Format of Presentation • General Introduction • Psychiatric illness and disorder in children • Structure of services in CMFT • Learning Opportunities • Psychiatric History Taking and MSE • The OSCE

3. General Introduction • Child and Adolescent Psychiatrists – after foundation jobs, train in general psychiatry (CT1-3) gaining MRCPsych, then specialise in child psychiatry (ST4-6) • Many have training in paediatrics or general practice as well • Usually work within CAMHS (Child and Adolescent Mental Health Services) in multidisciplinary teams including clinical psychologists, nurse specialists and psychiatric social workers. • Some child psychiatrists work in superspecialist services (e.g. learning disability, forensic services) • Often work with multiple agencies including schools, youth offending services and child and family social services

4. Child Psychiatry – General Introduction • Relatively small specialty numerically BUT has a large reach. • Between general psychiatry and paediatrics • 7-20% children have mental health problems • 10% of these see specialist child mental health services

5. Child Psychiatry • 40% of consultations in GP are family ones • > 25% of these relate to mental health • Therefore 10% of total GP consultations may be children’s mental health related • Paediatric OPD 30% mental health related • Paediatric inpatients nearer 60%. • An appreciation of child mental health is important whatever specialty you go into.

6. Child Psychiatry • Reach of child mental health – • Most not seen by child psychiatrists: teachers, GPs, youth workers etc • Specialists have an important role in disseminating information, training etc • Recent “hot topics” include ADHD, anti – social behaviour etc

7. Distribution of Disorders • Diagnostic groupings: • Disruptive behaviour disorders – Conduct disorder (prevalence 5.3%), Oppositional defiant disorder • Hyperkinetic disorders (ADHD) (up to 5%). • Tic Disorders e.g. Tourettes’ (up to 2%) • Affective disorders – Depression (2%), BPAD.

8. Distribution of Disorders • Anxiety disorders (3.8%), GAD, phobias, separation anxiety, panic, PTSD. • Obsessive Compulsive disorder (3%) • Dissociative and somatoform disorders (rare)

9. Distribution of Disorders • Psychosis e.g. drug induced, schizophrenia (v. rare in childhood, peak incidence late teens to early twenties). • Developmental disorders – general (2.4%) or specific learning disability, autistic spectrum disorders (0.06 to 1.5%) and other PDD • Social functioning disorders e.g. elective mutism, attachment disorders • Eating disorders (3%) e.g. Anorexia, Bulimia, Binge eating

10. Distribution of Disorders • Sleep disorders e.g. night terrors, narcolepsy • Psychological factors affecting physical disease (e.g. liaison psychiatry in cystic fibrosis clinic) • Mental and behavioural disorders due to substance misuse • Other disorders such as non organic enuresis and encopresis, pica • “looked – after” (i.e. those in social services care) children have 5x higher rates of psychiatric disorder.

11. Assessing Children • What makes child mental health thinking distinctive? • Developmental approach (relates to the way paediatricians also think) • All assessments, management etc must be related to child development. E.g. what is the normal attention span at different ages? How well should a 5 year old read? • You need to become familiar with normal developmental milestones (motor, verbal, and social) and developmental assessments (e.g. in community paeds)

12. Assessing Children • Systemic thinking – The “Biopsychosocial” approach. • This means thinking about how the child functions and the impact of their illness on families and educational achievement, as well as individual symptoms. • Synthesising information from different sources into a “formulation” or problem list e.g. school report, genetic tests, clinical assessment etc. • Take time to develop assessment skills of both younger children and adolescents.

13. Introduction to CMFT • District out patient CAMHS teams (North Manchester, Salford, South Manchester, Central Manchester) • Day Hospital in Salford • 16-18 yrs services in Central Manchester and Salford • RMCH – Harrington Building: • Paediatric Liaison Service • Chronic Fatigue Service • Specialist outpatient service (Social Development Clinic) to North West England • Specialist Inpatient service (Galaxy House – Ward 87) to North West • Hospital school.

14. Learning Objectives for your placement • F&C module - placement on paediatric ward. Good opportunity to look for cases that combine paeds and child psychiatry. • Goals - our goal is to support your learning of the biopsychosocial model within the context of mental health • Objectives: • 1. Hands on experience in assessing young people on wards or OPD • 2. Thinking about diagnoses or formulations and management options. OPD, seminars and wider reading.

15. Organisation of your time • We like you to attend 2 clinics during your placement. Takes a whole morning or afternoon. Preferably only 2 students per clinic. • Seminar series. Use these as valuable time to discuss your cases from the wards / clinics as well as didactic learning. • Opportunities will be organised by Dr Latha Hackett (Central Manchester CAMHS, Winnicott Centre) via Wendy Linney. Will not necessarily be in central Manchester

16. Your time • PBL • We can act as “expert resources” for your mental health related PBL scenarios. You can always contact us if you need information or further experiences. We are very keen to teach and encourage you in learning about mental health! • You can arrange SSCs with us, attend the Inpatient Unit (you must have prior permission to do this from Dr Jane Whittaker) • Possibility of Project Options over the summer.

17. Resources • Medical Student Child Psychiatry Handbook – available on MedLea • Contains basic theoretical knowledge needed • Contact addresses and numbers for Consultant led services in Manchester

18. Psychiatric Assessment • Introduce yourself • Obtain consent from parent(s). • Interview both child and parents, separately and together.

19. Psychiatric Assessment • Full History from parents and child. • Mental State Examination of child. • Physical examination – should include neurological exam and full examination of any systems related to suspected psychiatric diagnosis e.g thyroid and cardiovascular in depression. • Differential Diagnosis. Risk Assessment. Management plan.

20. History Taking • Presenting complaint • History of presenting complaint. • Assessment of symptoms’ duration, severity and effect on functioning. • Systematic enquiry about presence or absence of mood, anxiety and psychotic symptoms • Past psychiatric history. Contact with services previously? Self harm? Diagnosis? Treatment?

21. History Taking • Past Medical / Surgical History • Medications (prescribed and OTC) • Family History (medical, psychiatric and developmental disorders). Genogram. • Substance Misuse History (drugs and alcohol). • Forensic History

22. History Taking • Developmental History • Pregnancy. Maternal illness, medications, drugs and alcohol. Birth. Developmental milestones. Social functioning in early childhood. Problems with separation from mother. Academic, social and behavioural progress at school. Activities of Daily Living. Relationships. Social circumstances of family. • Premorbid personality. • What was the child like before the current problem?

23. Mental State Examination • Signs / Symptoms and Behaviour at the time of the interview. Equivalent of the physical examination. • Appearance and Behaviour. • General appearance, facial appearance, social behaviour, retardation or agitation, quality of rapport established. • Speech. • Rate and quantity. Content. Flow e.g. rapid shifts or sudden interruptions.

24. Mental State Examination • Mood and Affect. • Low mood, anxiety, elation. How mood varies. Subjective and Objective. • Thoughts and Perceptions • delusions, illusions and hallucinations, obsessional thoughts. Thoughts of harm to self or others. • Cognition. • Orientation, attention and memory e.g MMSE

25. Mental State Examination • Insight. Does the patient think they are ill? What kind of illness? Do they think they need treatment and if so, what kind.

26. Your Exams!! • The OSCE • 2-3 stations in the Paediatric OSCE are child mental health related • A) case management scenario with questions from the examiner. You must identify the relevant issues and must appear SAFE practitioners at all costs! • B) short answer /MCQs / ISQs around clinical topics • C) Communication skills station. Usually rated by paediatrician and psychiatrist.

27. OSCE techniques • Read the Medical Student handbook – all the factual info you need is in here. • Attend clinical opportunities – you must get practical experience of seeing children and learning about clinical assessment. You must also practice talking to parents about their child in a sensitive and accurate manner (this is specifically tested in the comm. skills station) • PRACTICE likely stations with each other.

28. Other Resources • Recommended text books are: • 1. Illustrated Textbook of Paediatrics by Lissauer and Clayden (esp. chapter on history and examination). • 2. Child Psychiatry by Goodman and Scott. • 3. Seminars in Child Psychiatry by Simon Gowers (more of a postgraduate text but still useful). • 4. Lecture Notes in Psychiatry or Short Oxford Textbook of Psychiatry (single vol. not the 3 vol. one!) or the Oxford Handbook of Psychiatry. • ANY QUESTIONS?