MRCPsych Course CAMHS Module Dr Nazma Portch ST5 CAMHS DPT

MRCPsych Course

CAMHS ModuleDr Nazma Portch

ST5 CAMHSDPT

• Taking a history in CAMHS• Communicating with children• Conducting a family interview• Resilience• Treatments in CAMHS

Essentially same components as adult but:•Involve parents/family•Greater emphasis on family relationships•Collateral information•Importance of observation•Importance of developmental history

• Symptoms• Impact• Risks• Strengths• Explanatory model

-Why is it important?

-What are the important and relevant aspects of a developmental history?

• Detailed description at key stages• Various sources• Look at age of milestones- use anchor points• Any loss of skills• Current abilities-as expected for age?• Age appropriate behaviour eg. Tantrums at 2

vs. at 10?

• What age do children?– Walk– Talk– Ride a tricycle– Draw person– Play fantasy games

• Walking- 12months• Talking:

– 12months using 2-3 words– By 2 using 2-3 word phrases. Starts to use pronouns– By 5 fluent speech with articulation

• Ride a tricycle- 3 years• Draw person with 6 parts- 5 years• Fantasy games – 2yrs• Remember there is range of ‘normal’

Exercise

• Get in pairs/groups• Pick an age from 5-18• Imagine you are going to see a psychiatrist

because you are unhappy at school

• What are your worries and concerns?

• Do the same but imagine you are a parent

• 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

• 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

• Language development Child may not have adequate speech to describe

language and feelings

• Cognitive development Child may not have reached the necessary level of

understanding

• Emotional development Child may be wholly or partially dependant on

parental support

• 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• Appropriate vocabulary

• 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

• 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

• 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

• 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.

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

adolescents)• Start with questions the child can answer…

– Who has come along?– 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)

• Why do they think they are here?• Why do you think they are here?• Enquire about child’s view of the problem• Be flexible in approach• Less formal and less structured• Expect short answers and help develop them• Ask same question to different people• Do not persist if topic difficult for child• Show empathy and normalize difficulties• Active listening, avoid judgments, be patient,

engage

• 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

• Think of family as a system• The family will have homeostatic mechanisms

to resist change eg grandparent usage if absent parent

• Family myths eg anger is destructive• Roles within families both good and bad eg

scapegoat, academic aspirations• When families’ behaviour hard to understand

think of this

• Child – behaviours, symptoms, responses, play etc• Interactions

– Child- parent– Child – interviewer– Parent - parent– Child – child

Who is spokesperson?Who is most worried?What is family hierarchy?How do they deal with conflict?How well do they communicate?

• You have been asked to see Sarah, a 15yr old girl whose father is concerned about her weight loss. She had 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.

Resilience

• Individual differences in response to stress- why are some children more vulnerable to adverse effects of negative environments?

• Resilience is a dynamic process that involves adaptations prior to, during and after stress exposure

• Not the type of childhood but the ability to reflect on it that is important

• Emotional well being/high self esteem• Empathy• Positive social relationships• Secure attachment

• May be endogenous eg genetic or environmental affecting developing brain eg poor nutrition, smoking

• Diathesis- stress model• One form of MAOA Gene found in males +

exposure to childhood maltreatment high risk conduct disorder. Neither alone increased risk. (Caspi et al 2002)

Probability of depression

No of life events

0 1 2 3 4+

40%

30%

20%

10%

HOMOZYGOUS LONG

HETEROZYGOUS L/S

HOMOZYGOUS SHORT

31%

51%

17%18%

• IQ protective for developing CD if exposed to sig life events. Weaker predictor if no events

• Way in which appraise or give meaning to events important

• Negative appraisals of self or world events increase vulnerability to adverse environment

• Sense of personal agency• Self reflective style• Commitment to relationships• Social support• Sibling relationships• Positive mood

• Reflective self function is key to resilience

Temperament- behavioural predisposition inherent but subject to environmental influence

• Described by Thomas and Chase (86) as broadly 3 types:– Easy– Difficult– Slow to warm

• Bass and Plomin (84)as genetically grounded and able to predict adult personality– Emotionality– Activity– sociability

Treatments

• Prevention

• Psychological interventions

• Medications

• “Prevention is better than cure”• Needs to be effective, feasible and cost-

effective

• Primary vs Secondary prevention

• Universal- whole population

• Targeted- those at higher risk

• Indicated- those showing early signs

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

• Easy to screen for risk• Effective intervention-parent training• Expensive and serious consequences of the disorder• Lack of treatments

• 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)

• 1st line approach either alone or in conjunction with meds

• CBT-depression, anxiety, OCD• Behaviour therapy-School refusal, selective mutism• Parent training-Behavioural & conduct problems• Family therapy- Eating disorders• Group therapy -Social skills problem, sexually

abused children

• Occupational therapy

• Individual therapy… Exposure and response prevention (ERP), counselling, psychodynamic, play therapy

• Art therapy

• Drama therapy

• Medication is just part of comprehensive management plan

• Meds usually not 1st line• Education of child + family important• Unlicenced/off label use• Prescription writing – age legal requirement in

prescription-only medicines if <12

• START LOW GO SLOW• Target symptoms, not diagnoses• Dosage calculated in mg/kg• Children are not small adults• More susceptible to side effects • Monitor response in more than 1 setting• Avoid poly-pharmacy as much as possible

Depression • Fluoxetine 1st line (8yrs >)- start 10mg• 2nd Sertraline• NICE-SSRIs along with psychological input but

this is debated• Adolescent response better than <12yrs• Inform parents and child of side effects- monitor

closely• Study found that only 10% difference between

placebo and drug response rates-Est only 1 in 6 will benefit

• Long half life may help if poor compliance

Depression • Treatment of Adolescents with Depression

Study(TADS)-fluoxetine only patients more suicide related events. However for most part they help.

• Duration treatment – 6-12 months then tapered over 6-12 weeks

• Note that due to more extensive metabolism young people require higher mg/kg doses.

• Be aware 20-40% presenting with depression develop BAD-– if Sx severe/+psychosis/rapid mood shift or worsens

with Rx suspect BAD. Younger child greater risk.

Anxiety disorders

OCD- CBT+/-:• Sertraline 1st line (6yrs >)• Fluvoxamine(8yrs>), Fluoxetine, clomipramine • ERPGAD –CBT+/-• Fluoxetine, other SSRIs• ?venlafaxine- unsuitable for depressionSpecific PhobiasCBT

Can be used in the treatment of • Nocturnal enuresis• OCD• Hyperactivity …if stimulants fail• Panic disorderSide effects of dry mouth, sedation, malaise,

cardiac arrhythmias and sudden death.

• Similar action and effect as in adults• Most commonly used-Risperidone(0.5-3mg),

Olanzapine, Aripiprazole• Haloperidol-small doses in LD, not common

anymore

• Psychosis- – 1st-aripiprazole/olanzapine/risperidone– 2nd–other from above group– 3rd–clozapine (olanzapine prior to this- Agid et al 2011)

• Disorganized behaviour• More controversial but increasing:

– ADHD– Conduct disorder- risperidone– Pretty much any behaviour we don’t like

• Tic Disorders– Clonidine – adrenergic alpha2 agonist– Risperidone

• ASD– Aggression-risperidone (licensed), ?aripiprazole– Restrictive repetitive behaviours and interests -

RRBIs- SSRIs (lower dose)

• Lithium, Carbamazepine, Na Valproate• Can be used in aggression• Lithium can be used to augment antidepressants• Bipolar Affective Disorder

– Quetiapine/olanzapine/aripiprazole/risperidone

– SGAs greater short term efficacy than mood stabilisers but more wt gain and drowsiness

– 2nd choice- Li– 3rd -Carbamazapine/valproate

Stimulants • Methylphenidate• Dexamphetamine• Mixed amphetamine salts• Pemoline …hepatotoxicNon Stimulants• NARI …….Atomoxetine(4-6wks)• TCA…..Imipramine, Desipramine• α2 agonists………clonidine• Bupropion

• Methylphenidate- central nervous stimulant • s/e -insomnia, anorexia, raised BP, growth

deceleration• Consider-

– Comorbid conditions– Convenience of dosing– Diversion– Duration – Tolerability– Monitoring– Cost

• 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

• 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 between 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 should 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

a) Methylphenidate and dexamphetamine are equally effective in terms of ADHD symptoms

b) Atomoxetine can exacerbate tic disorders by altering dopamine levels in the striatum

c) Parent training programmes are ineffective at reducing hyperkinetic symptoms

d) Non response rate to stimulants are greater in adolescents(37%) than in younger children (20-25%)

a) Provocative victims are popular with peersb) Children engaging in bullying are prone to

anxiety and poor self-esteemc) Boys who bully are at increased risk of

alcohol misuse in adult lifed) Girls who bully characteristically use physical

aggressione) there is a slight excess of female victims

ANSWERS

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

problems often differ.b) Tc) Fd) F

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

predetermined wordings and closed questioning.

b) Tc) T ..semi-structured are “interviewer-based" and

allows exploration of views

d) Fe) F

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

4a) F …specific phobias commoner in girls

b) Tc) F ..equal prevalence

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

e) Tf) Tg) F- nocturnal enuresis common in boys h) Ti) F …equal prevalence

• 5.• B is false. It does not impact on dopamine

levels

• 6. c is true