MRCPsych Phase 11

CAMHS ModuleDr Femi Akerele

ST5 CAMHS

Plymouth

Session outline

• Taking history in CAMHS

• Communicating with children

• Conducting a family interview

• Treatments in CAMHS

• Resilience

How?

• Lecture slides

• Group work

• Role play / mock

• Quiz

History Taking

• Essentially same components as adult but:

• Involve parents/family

• Greater emphasis on family relationships

• Collateral information

• Importance of observation

• Importance of developmental history

History Taking… 5 key components

• Symptoms

• Impact

• Risks

• Strengths

• Explanatory model

Developmental History

Task:

Present the important and relevant aspects of a developmental history

Communicating with children and Families

Special factors to consider

• Children and adolescents require different communication skills to adults

• The consultation involves at least 2 patients

• Illness is particularly frightening to both

• Communication with both is crucial

• It is important to consider interpersonal issues between them

Why is good communication with children important?

• It helps the doctor to understand the child’s condition better

• It helps the child to understand about the illness and treatment better, and be:

Less frightened

More able to participate in decisions

More willing to accept treatment

Communication difficulties

• Language development

Child may not have adequate speech to describe language and feelings

• Cognitive devt

Child may not have reached the necessary level of understanding

• Emotional devt

Child may be wholly or partially dependant on parental support.

Aids to communication

• Find out where the child is most comfortable

• Put yourself at the same level

• Use of toys and play

• Use humour and fun

• Drawings and models

• Specially designed scales for pain and sym

• Appropriate vocabulary

Vocabulary with children

• Avoid jargon / medical terms

• Avoid ambiguous words

• Check understanding regularly

• Beware of frightening words

• Use clear and appropriate language

• Use words the child uses in their description

The parent

• May feel more anxious

• May feel guilty or inadequate

• May be helpful when examining the child

• May be part of the problem

• May interfere in communication between the doctor and the child

2 patients!

• Establish and maintain rapport with both• Seek to learn both perspective of the problem• Seek to understand & address both set of agendas• Tailor explanations to both• Involve both in the decision making process• Check the understanding of both• Don’t take sides or compete• Negotiate to interview each separately if they wish• Keep the boundaries safe

Adolescents – a special case

• Often have difficulties communicating with adults, including doctors and parents

• Are discovering the boundaries of acceptable behaviour & may need your help in this

• Rarely consult but have specific health issues• You may need to state that you are their

advocate and not to be seen to be siding with parents

• You may need to confront at the same time as showing care

Interviewing the child

• 1° objective is establishing rapport and gaining confidence

• Invite the child to play, paint or draw

• Begin away from the problem….hobbies, interests, school, friends, etc

• Enquire about child’s view of the problem

• Be flexible in approach

The interview

• Be well prepared in advance

• Know the age, gender & reason for referral

• Prepare the room

• Prepare to have the whole family

• Clothing?

• Prepare age appropriate play materials …toys, paper, colour pencils, Lego, animals.

Establishing rapport

• The 1st few minutes are very important…• Greet the child by his 1st name• Preferably introduce yourself by 1st name (Dr

with adolescents)• Start with questions the child can answer…”how

old are you?”,“who’s your best friend?”.• Have a working knowledge of types of toys and

activities for his age• Engage them in activities…play, drawing, roles

play (e.g as a doctor)

Role play

Volunteer?

Role play

• You have been asked to see Sarah, a 15yr old girl whose father is concerned about her weight loss. She had a really bad flu 3 months ago, but since, hasn’t been eating well. She is however pleased by her weight loss.

• Spend the next 10minutes conducting an interview for an assessment while addressing all concerns.

Treatments

• Prevention

• Psychological interventions

• Medications

Prevention

• “Prevention is better than cure”

• Needs to be effective, feasible and cost-effective

• Primary vs Secondary prevention

Types of prevention

• Universal

• Targeted

• Indicated

Prevention … continued

Conduct disorder illustrates what can be achieved in preventive child psychiatry:

• Easy to screen for risk• Effective intervention• Expensive and serious consequences of the

disorder• Lack of treatments.

Treatments…continued

• Preference for psychological methods rather than medication

• Multi-disciplinary approach

• Emphasis on family involvement

• Out-patient rather than in-patient (only very few specialist centres)

Psychological

• CBT… depression, anxiety, OCD

• Behaviour therapy… star charts, graded exposure

• Parent training… behavioural & conduct problems

• Family therapy… e.g eating disorders

• Group therapy …social skills problem, sexually abused children

Psychological

• Occupational therapy …???

• Individual therapy… counselling, psychodynamic, play therapy

• Art therapy

• Drama therapy

Medications…principles

• Medication is just part of comprehensive management plan

• Meds usually not 1st line

• Children are not small adults

• More susceptible to side effects

• Education of child + family important

Medications…principles

• START LOW GO SLOW• Target symptoms, not diagnoses

• Dosage calculated in mg/kg

• Monitor response in more than 1 setting

• Avoid poly-pharmacy as much as possible

ADHD

Stimulants • Methylphenidate• Dexamphetamine• Mixed amphetamine salts• Pemoline …hepatotoxic

Non Stimulants• NARI …….Atomoxetine• TCA…..Imipramine, Desipramine• α2 agonists………clonidine• Bupropion

Antidepressants

Depression• Fluoxetine 1st line (8yrs >). 2nd SertralineOCD• Sertraline 1st line (6yrs >)• Fluvoxamine(8yrs>), clomipramine, FluoxetineAnxiety• Fluoxetine, other SSRIsNB..Paroxetine & Venlafaxine unsuitable

Antidepressants…tricyclics

Can be used in the treatment of

• Nocturnal enuresis

• OCD

• Hyperactivity …if stimulants fail

• Panic disorder

Side effects of dry mouth, sedation, malaise, cardiac arrhythmias and sudden death.

Atypical Antipsychotics …uses

• Psychosis

• Disorganized behavior

• Bipolar disorder

• Tics

• More controversial but increasing:– ADHD– Conduct disorder– Pretty much any behavior we don’t like

Atypical Antipsychotics

• Similar action and effect as in adults

• Most commonly used ..Risperidone(0.5-3mg)

• Olanzapine, Aripiprazole,

• Clozapine ..for treatment resistant Schz

• Haloperidol…tics, not common anymore

• Risperidone indicated Rx of aggression in autism and conduct disorder.

Melatonin

• Recent increase in use in CAMHS

• Used in treatment of Insomnia

• Hormone produced by pineal gland

• Licensed in >55, ‘off license’ use in children

• Usual dose between 2-4mg

• Side effects ..headaches,nausea, confusion, tachycardia.

• Long term side effects not yet evaluated

Mood Stabilizers

• Lithium, Carbamazepine, Na Valproate

• Often used in Rx of Bipolar disorder and aggression

• Lithium can be used to augment antidepressants

• More recent use of atypical antipsychotics

Psych Meds in Kids - summary

• Very little supportive evidence for efficacy (except stimulants in ADHD)

• Many known side-effects• Unknown effects – long term effects on

the developing brain and body• Overused? – recent study of child

psychiatrists show that 9/10 of their patients are on meds

• Need much more than meds to help kids

QUIZ

1. In child psychiatric assessments:

a) There’s low level agreement btw parental reports and self-reports of children’s emotional symptoms

b) Families and professionals’ explanation of symptoms often differ widely

c) If symptoms cause distress but no social impairment, a disorder shd not be diagnosed

d) It is usually possible to identify the cause of disorders

2. When eliciting information from parents:

a) Fully-structured interviews give more detailed picture than semi-structured

b) Questionnaires are useful for screeningc) With semi-structured, the presence of symptoms

is typically rated according to the interviewer’s criteria and not the respondent

d) It is usual to see the father separately to elicit his concerns and view of the problem

e) The early childhood history is not relevant for disorders of adolescence

3. In child assessments:

a) Children rarely volunteer information on obsessions or compulsions unless asked directly

b) All children shd have a full physical exam including hgt, wgt and cardiac auscultation

c) Most dysmorphic syndromes will be missed unless the child is seen undressed

d) Teachers may miscontrue learning problems as hyperactivity

4. The following are more common in boys than girls:a) Animal phobiab) Delayed speechc) School refusald) Teenage overdosee) Completed suicidef) Conduct disorderg) Diurnal enuresish) ADHDi) Selective mutism

ANSWERS

Answers

1a) T ..parent and children report of emotional

problems often differ.

b) T

c) F

d) F

Answers

2a) F …fully structured are “respondent based” with

predetermined wordings and closed questioning.

b) T

c) T ..semi-structured are “interviewer-based" and allows exploration of views

d) F

e) F

Answers

3a) T …they are often ashamed of such symptoms

b) F ..cardiac auscultation is rarely necessary unless indicated

c) F ..most features appear in the head, face and hands that can be seen without undressing the child.

d) T

Answers

4a) F …specific phobias commoner in girls

b) Tc) F ..equal prevalence

d) F …commoner in girls, also post-pubertal depression

e) Tf) Tg) Th) Ti) F …equal prevalence