Child and Adolescent Psychiatry Module Week 1 Dr Sarah Huline-Dickens Consultant in Child...
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Transcript of Child and Adolescent Psychiatry Module Week 1 Dr Sarah Huline-Dickens Consultant in Child...
Child and Adolescent Psychiatry Module
Week 1Dr Sarah Huline-Dickens
Consultant in Child Psychiatry,
Mount Gould Hospital, Plymouth
Introductions
• To group
• To module
• To ground rules
• To reading list
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…
• 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
• 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?
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
• 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 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
• 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?
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
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 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
• 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
• Many disorders co morbid
• Most untreated
• Many persistent, especially conduct problems
• Marked gender differences
Classification
• ICD 10• DSM IV• Both have multi-axial schemes:1. Psychiatric disorder2. Specific delay in development3. Intellectual level4. Medical condition5. Psychosocial adversity6. Adaptive functioning
Classification 2
• 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
• 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…….
• 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:
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 5
• Consider whether child, family, environmental factors are:
– PREDISPOSING– PRECIPITATING– PERPETUATING
• What is protective and aiding resilience?
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:
1) leading directly to psychopathology e.g. autism;
2) confering greater susceptibility to less favourable environments;
3) causing individual to seek out risk situations/ behaviours
Lunch!
Resume of this morning
• What did you learn?
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
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
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
• In groups summarise in 20 words what you understand by attachment theory
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
• 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
• 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
• 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 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)
• 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• 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) 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) 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) 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• 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• 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) 4
• Aetiology: genetic (twin heritability 90%)
• Psychological deficit: ?theory of mind (Sally Anne test) ?executive function
• Treatment: educational interventions. Some role for psychotropic medication
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
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
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
• 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
• 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
• 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
• 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