Child and Adolescent Psychiatry Module Week 1 Dr Sarah Huline-Dickens Consultant in Child Psychiatry, Mount Gould Hospital, Plymouth [email protected]

Child and Adolescent Psychiatry Module

Week 1Dr Sarah Huline-Dickens

Consultant in Child Psychiatry,

Mount Gould Hospital, Plymouth

[email protected]

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)



• Associated features:• Mental retardation

(verbal IQ lower than non-verbal IQ)

• Seizures in a third of mentally retarded

• Hyperactivity common• Self-injury



• 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!



• 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)



• 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

Documents

Child and Adolescent Psychiatry Module Week 1 Dr Sarah Huline-Dickens Consultant in Child Psychiatry, Mount Gould Hospital, Plymouth [email protected]