Child and Adolescent Mental Health

Child and Adolescent Mental Health

Dr. Patsy ChapmanConsultant, Child and Adolescent Psychiatry

and

Mark SwindellsSenior Primary Mental Health Worker

Calderdale CAMHS

Child and Adolescent Mental Health

Common presentations to General Practice

NICE Guidance/Evidence-based practice

Discussions from practice

Service issues and making a referral to specialist CAMHS

A note about evidence-based practice.

Considered to be the

‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients…

integrating individual clinical expertise with the best available external clinical evidence from systematic research’.

Sackett et al (1996) BMJ

Common presentations to GPs

Attention Deficit Hyperactivity Disorder (ADHD)

Autistic Spectrum Disorders

Conduct disorders

Depression

Anxiety

Obsessional-Compulsive Disorder (OCD)

Eating Disorders

Tic Disorders (inc Tourettes’s syndrome)

Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is a pervasive, heterogeneous behavioural syndrome characterised by the core symptoms of inattention, hyperactivity and impulsivity.

ADHD

Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.

Parents of pre-school children with ADHD should be offered a referral to a parent-training/education programme as the first-line treatment.

If the child or young person with ADHD has moderate levels of impairment, the parents should be offered referral to a group parent-training/education programme.

In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered group-based parent-training.

ADHD

Methylphenidate, atomoxetine and dexamfetamine are recommended, within their licensed indications, as options for the management of ADHD.

In Calderdale and Kirklees only schools can refer to the specialist CAMH service for an assessment of ADHD. This is part of the clinical pathway for the management of ADHD.

Following assessment and diagnosis by specialist CAMHS, “shared care” arrangements are usually made with the child’s GP.

Children with an ADHD diagnosis and on medication are routinely followed up every 4 – 6 months by the specialist CAMH service.

Autistic Spectrum Disorder An intrinsic condition, ASD manifests core features

which are pervasive and include deficits in: - Social communication - Social interaction - Social imagination

Current prevalence of all ASD diagnoses: 1.6%

Children with an ASD have a higher risk than peers of developing other mental health problems.

NICE have recently released a draft proposal for clinical guidelines which will cover recognition, referral and diagnosis of ASD in children.

ASD

In Calderdale, diagnosis is a two stage process:

• Screening in the community for core features at home and school using standardised measures.

Only those children who demonstrate significant and pervasive core features of ASD are referred

on to the specialist CAMH service.

• The CAMH service coordinates a multi-disciplinary

assessment of the child by a clinical psychologist,

psychiatrist, paediatrician, educational psychologist and speech and language therapist.

CONDUCT DISORDERS

Conduct disorders are the most common reason for referral of children to mental health services

They have a significant impact on quality of life for those involved, and, in the case of early onset (aggression at three years of age) outcomes for children are poor

Many children do not receive support because of limited resources, high prevalence and difficulty engaging some families

Early effective intervention is particularly important: recent research has established a neuro-developmental basis for this finding

Conduct disorder and ODD

Conduct disorder: repetitive and persistent pattern of antisocial, aggressive or defiant conduct and violation of social norms

Oppositional defiant disorder: persistently hostile or defiant behaviour without aggressive or antisocial behaviour

Estimated UK prevalence

Conduct disorder (including ODD)

Age (years)

Males (%)

Females (%)

5 - 10 6.9 2.8

11 - 15 8.1 5.1

Associated conditions

Conduct disorders are often seen in association with: attention deficit hyperactivity disorder

(ADHD) depression learning disabilities (particularly dyslexia) substance misuse less frequently, psychosis and autism

Predisposing risk factors

Family factors includingmarital discord

substance misusecriminal activities

abusive or injurious parenting practices

Environmental factors including social disadvantage

homelessnesslow socioeconomic status

povertyovercrowding

social isolation

Individual factors including‘difficult’ temperament

brain damageepilepsy

chronic illnesscognitive deficits

Recommendations for children < 12 years

Group-based parent-training/education programmes are recommended in the management of younger children with conduct disorders. Not routinely provided by specialist CAMHS.

Individual-based parent-training/education programmes are recommended in the management of children with conduct disorders only in situations where there are particular difficulties in engaging with the parents or a family’s needs are too complex to be met by group based parent-training/education programmes.

Local family support teams and children centres operate to support with family relationships and parenting.

Recommendations for children > 12 years

There is limited evidence only for effective interventions with older children/young people.

Those programmes which show early promise are currently being evaluated, for example:

- Multi-systemic therapy

- Functional family therapy

These approaches tend to be intensive and expensive. They are not currently available locally, though specialist CAMHS do offer other forms of therapeutic support to some families (family therapy, for example).

Depression

At any one time, the estimated number of children and young people suffering from depression: 1 in 100 children 1 in 33 young people

Prevalence figures exceed treatment numbers: about 25% of children and young people with depression

detected and treated

Suicide is the: 3rd leading cause of death in 15–24-year-olds 6th leading cause of death in 5–14-year-olds

Transition to Adult services, where appropriate, requires careful planning

Depression

KEY SYMPTOMS ASSOCIATED SYMPTOMS

persistent sadness, or low or irritable mood:AND/ORloss of interests and/or pleasurefatigue or low energy

poor or increased sleeppoor concentration or indecisivenesslow self-confidencepoor or increased appetitesuicidal thoughts or actsagitation or slowing of movementsguilt or self-blame

Mild Up to 4 symptoms

Moderate5-6 symptoms

Severe7-10 symptoms

Depression

When to refer to the specialist CAMH service:

Depression with multiple-risk histories in another family member

Mild depression and no response to interventions in tier 1 after 2–3 months (Low level intervention and “watchful waiting”)

Moderate or severe depression (including psychotic depression)

Recurrence after recovery from previous moderate or severe depression

Unexplained self-neglect of at least 1 month’s duration that could be harmful to physical health

Active suicidal ideas or plans

Young person or parent/carer requests referral

Depression

Anti-depressants should only be prescribed following assessment by a psychiatrist and only be offered in combination with psychological treatments

First-line pharmacological treatment is fluoxetine*

Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, St John’s wort

Monitor for agitation, hostility, suicidal ideation and self-harm and advise urgent contact with prescribing doctor if detected

Sertraline or citalopram* as second-line treatment

Consider adding atypical antipsychotic if psychotic depression

Continue for 6 months following remission, then phase out over 6–12 weeks

Anxiety

No specific NICE guidance for children and young people for Anxiety, though guidance is available for children with Post Traumatic Stress Disorder and Obsessional Compulsive Disorder

Type of anxiety experienced by the child (social, generalised, panic, separation, specific phobia) and degree of impairment to functioning is important to detail in referral

Cognitive Behavioural Therapy (CBT) and other behavioural approaches indicated for most anxiety disorders.

Obsessional-Compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD): characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress

1% of young people are affected – adults often report experiencing first symptoms in childhood

Onset can be at any age. Mean age is late adolescence for men, early twenties for women

Obsessional-Compulsive disorder (OCD)

All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology

If CBT ineffective or refused - review and consider adding an SSRI

Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD*

Monitor carefully and frequently If successful, continue for 6 months post remission Withdraw slowly with monitoring

Obsessional-Compulsive disorder (OCD)

Considerations for work with children:

Symptoms are similar in children, young people and adults and they respond to the same treatments

Stressful life events may worsen symptoms or relapse may occur:- school transitions and examination times- relationship difficulties- transition from adolescence to adult life

(careful planning of transition to adult services needed) Parents may feel guilty and anxious Tendency to increase in severity if left untreated

Anorexia nervosa

Severe dietary restriction despite very low weight (BMI <17.5 kg/m2)

Morbid fear of fatness

Distorted body image (that is, an unreasonable belief that one is overweight)

Amenorrhoea

A proportion of patients binge and purge

In assessing whether a person has anorexia nervosa, attention should be paid not just to one off weight and BMI but also to the overall clinical assessment (repeated over time), including rate of weight loss, growth rates in children, objective physical signs and appropriate laboratory tests. Include all information in referral.

Anorexia nervosa

On referral to specialist CAMHS patients are usually offered a range of individual therapies (often CBT) and family therapy.

Close working alliance with a dietary specialist is assumed. No evidence or justification for sole treatment of AN via

medication.

Co-morbid mood disorders may respond to treatment with SSRI (NB. Cardiac function)

Inpatient treatment should be considered for people with anorexia nervosa where:

- The disorder has not improved with appropriate outpatient

treatment.

- There is a significant risk of suicide or severe self-harm.

- There is a high or moderate physical risk.

Bulimia nervosa

Characterised by an irresistible urge to overeat, followed by self-induced vomiting or purging and accompanied by a morbid fear of becoming fat.

Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed.

o Selective serotonin reuptake inhibitors (SSRIs) and specifically fluoxetine, are the drugs of first choice for the treatment of bulimia nervosa.The effective dose of fluoxetine is higher than

for depression (60 mg daily).

No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa.

Tic Disorders(including Tourettes’s Syndrome)

Presentation: Tics are involuntary, rapid, recurrent, non-rhythmic

motor movements. Transient tic problems are very common in childhood,

more common in boys, and a family history of tics is common.

Chronic and complex tic disorders require careful management and referral to specialist CAMHS.

Tourette’s syndrome is a constellation of multiple motor and vocal tics originating in childhood/adolescence and often persisting into adulthood.

Tic Disorders(including Tourettes’s Syndrome)

Management:

Psycho-social approaches

Pharmocological approaches: - Haloperidol - Risperidone - Pimozide - Clonidine

Making a referral to the specialist CAMH service

Referrals are allocated as follows:

- Urgent (seen within one working day)

- Priority (seen within six weeks)

- Routine (placed on our waiting list)

Making a referral to the specialist CAMH service

Referrals are screened daily

Not all referrals to the service are accepted. Often referrals are signposted to other appropriate services. (“Children’s mental health is everybody’s business”)

In future it is likely that other pathways will be developed to manage particular clinical presentations.

If in doubt, contact the primary mental health worker on duty to discuss possible referrals to the service or for advice on any issue relating to CAMH

Primary mental health work

The primary mental health work (PMHW) team serves to link community based services with the specialist CAMH service.

Alongside responsibilities for screening of all referrals they also undertake:

- training - advice - consultation - liaison

ANY FURTHER

QUESTIONS?