Psychiatric Inpatient Places for the under 18s

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Scottish Personality Disorder Network Conference
Thursday 4th March 2010
Queen Mother Conference Centre
Royal College of Physicians of Edinburgh
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The Roots of Personality and its disorders

• Jane Morris

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The evolution of my own personality.......

• Literature
• Psychology
• Medicine
• Motherhood
• Cullen
• Glasgow
• Edinburgh

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2002 - 2010 A 7 year adventure into the
realms of Child Adolescent Psychiatry........
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What did I discover?

• 1 Child and Adolescent Psychiatry are
  surprisingly different from Adult Psychiatry
• 2 Some of this is about different responses
  and traditions rather than different problems
  CAMHS accept referrals where there is social
  dysfunction even in the absence of diagnosis
• 3 Child psychiatry is genuinely different
  from Adolescent Psychiatry...
• 4 ...but fun and playfulness are essential
  in both
• 5 The practice of Adolescent psychiatry
  could teach adult psychiatrists a great deal -
  it taught me, anyway about formulation and
  systemic awareness and daily use of
  psychotherapeutic approaches....

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• 6 ...and about the evolution of mental
  illnesses and dysfunctional defences.
• 7 The role of sleep, activity, rest
  nutrition in mental as well as physical
  development
• The very existence of Aspergers and the autistic
  spectrum was an eye-opener
• - Sula Wolffs Loners
• 9 That transitions need to be handled well
  so that the loss and progression are
  meaningful and educational rather than
  destructive
• 10 Above all, that a well-integrated team is
  wisdom incarnate!

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3 good books (and lots of teen lit)
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TOXIC CHILDHOOD?

• Sue Palmer
• Harry Burns The Biology of Poverty 2008
• My daughters school
• Suicides at school
• Streetwise young people
• www-wise young people
• Body image conscious ashamed obesity
  anorexia
• Alcohol and other substances (caffeine in
  Buckfast!)
• Child protection, health safety and other
  defensive approaches

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What is personality?

• PERSONALITY TEMPERAMENT CHARACTER
• If temperament is relatively fixed (New York
  Longitudinal Study on Infant Temperament, Thomas
  Chess 1984) can we at least find interventions
  that are character-forming?

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What is personality?

• ....and where do traits, constructs, schemata,
  defences,
• factors etc etc fit in to
• all this?
• Are they learned?
• If so, when?
• Can they be un-learned or re-learned?
• When and how?

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Pharmacological interventions?

• SSRIs and neuroleptics eg olanzapine
• Undoubtedly swing the balance in some cases,
  allowing learning to occur
• How do they work?
• No coincidence that at high dose SSRIs or low
  dose neuroleptics are anxiolytic
• Reducing the amount of anxiety and arousal the
  individual has to experience to within a
  manageable amount

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What causes conduct/ personality disorder?

• Scott recommends a picture fitting approach to
  diagnosis for treatment purposes, though a
  menu-driven approach may be necessary in
  research
• Conduct disorder certainly associated with
  discord in the family home but what is cause and
  what is effect?
• Scott even considers that disordered attachment
  may be a consequence as well as a cause of
  disorder
• .. 1982 Patterson found more, unclear and
  inconsistent commands issued in families of CD
  children
• Virginia Twin study interviewed fathers, mothers
  and young people for evidence of heritability
  of CD based on Dads accounts it is 27
  herrtable, according to child 36, according to
  Mums accounts it is 69 heritable!

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Genetics environment of aggression

• D4DR gene 1996 2 independent teams reported
  association of novelty-seeking/risk
  taking/impulsivity with polymorphism in a gene on
  short arm of chromosome 11 associated with
  dopamine receptor expression
• SLC6A4 gene on chromosome 17 associated with
  reduce serotonin uptake and associated with
  greater fearfulness/neuroticism on of at least
  a dozen genes found to be associated with
  neuroticism
• As well as dopamine and serotonin, oxytocin,
  vasopressin and prolactin involved in social
  bonding, and hypophyseal-adrenal axis response to
  social challenge mediates early brain development

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Genes can have spectacular consequences

• Transplanting a gene from the monogamous prairie
  vole transforms the behaviour of promiscuous mice

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• 1994 Brunner, Nelson et al MAO gene mutation in
  Dutch family associated with extreme aggression
  in males who possessed the gene
• 2002 Caspi et al In a large sample of abused
  children, only those with gene for low MAO
  activity went on to be antisocial in adult life
• Animal evidence also suggests well-preserved
  serotonin function helps to attenuate aggressive
  impulses

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The new science of epigenetics

• The power of the environment to affect genes -
  their transmission and expression!

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Cullen-Rivers Centre 1999-2001,Rillbank Terrace
Child Sexual Abuse Service The study of trauma
and of families

• The biology of stress hormones, acute and chronic
  
• Their effects on mood, arousal, aggression and
  learning
• Applications to abused and traumatised children
  and their parents and the interactions between
  the two
• Deblinger and Heflins Trauma-focussed CBT for
  sexually abused children healing by imaginal
  exposure and relearning
• Parent interventions often shown to benefit the
  child do they also benefit the personality of
  the parents?

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Conduct disorder antisocial personality

• CD the commonest reason for referral to child
  psychiatry 5 10 all children and adolescents
• Often co-exists with ADHD but not interchangeable
  disorders
• Commoner in boys
• Seen where lower SES and larger families
• Has the 2nd highest continuity into adult life of
  all traits

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Conduct disorder

• About half of childhood onset CD persist into
  adult life but only 15 adolescent onset cases
  persist
• Remember to differentiate and treat if co-morbid
  
• - ADHD,
• - PTSD,
• - ASD,
• - Specific general LDs,
• - mood disorders
• - Substance abuse
• Differentiate subcultural deviance

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Dunedin Study1037 people born 1972, continue to
be followedDemonstrated crucial brain
development in first 3 years of life
importance of warm secure attachments in this
timeFurther Christchurch cohort 1977
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Forteviot House, Hope Terrace

• Brenda Renz
• Day service for children under 14
• Only one referral to Glasgow IPU
• in 5 years
• Very close adherence to Webster-Stratton
  Incredible Years programme
• Both parenting groups and Dinosaur School
  elements, but in fact parenting intervention
  known to be almost as effective alone
• Warmth, energy, nurturing, play!

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• 6 randomized control group evaluations of the
  parenting Intervention by the program developer
  colleagues
• and 5 independent replications indicated -
• increases in parent positive affect such as
  praise and reduced use of criticism and negative
  commands.
• Increases in parent use of effective
  limit-setting by replacing spanking and harsh
  discipline with non-violent discipline.
• Reduced parental depression, increased parental
  self-confidence. 
• Increased positive family communication
  problem-solving.
• Reduced conduct problems in childrens
  interactions with parents and increases in their
  positive affect and compliance to parental
  commands.
• ALSO
• Maintenence of benefits in 75 cases 5-6 years
  later

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BUT.......

• How do we select families for the intervention?
• When should the child as well as parents be
  involved?
• Are the boundaries between social control and
  child psychiatric care too blurred?
• When the child is creeping like snail unwillingly
  to school, is this a psychiatric disorder?
• How much is enough? - Rutter on Surestart

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Adolescence what is normal, what is not? DSH
emerging Borderline disorder

• Adolescence as a second phase of amazing brain
  development scans of Jay Giedd

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EDINBURGH CONNECTGita Ingram Fiona Mactaggart

• After puberty many more cases of conduct
  disorder, but in general those already present in
  childhood likely to endure, whereas those of
  adolescent onset likely to burn out by mid
  twenties
• Edinburgh Connect uses a tiny staff team to
  consult with carers of looked after children,
  including those in Social Work homes and those in
  foster care, rather than taking on large direct
  caseloads.
• Emergence of Borderline Disorder now
  recognised

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YPU Day Programme

• Psychiatric clerking and psychology assessment
• Developmental assessment from parents
• Home visits
• School reports assessment in our schoolroom
• Observation of patient with peers both in formal
  groups and informal space
• Physical and growth records
• Team formulation meeting and review with young
  person and family
• Development (after 6 weeks) of tailormade care
  plan

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Day Programme management

• Individual work with psychologist and key worker
• Dynamic risk management
• IPT, DBT, CBT, CAT
• Groups Psychodynamic, DBT, art therapy,
  practical, out and about, social skills etc
• Attention to nutrition, sleep, diurnal rhythms
• Medication or its withdrawal!
• Lunches, snacks, games, sitting room, garden
  social
• Family work, formal family therapy, sometimes BFT
• Education own school or schoolroom
• 6 weekly reviews
• Careful discharge planning and transition care

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Dialectical behaviour therapy

• Works with DSH risk avoid rewarding risk taking
  and instead use attachment to reward healthy
  responses
• Teaches skills of mindfulness, emotion
  regulation, distress tolerance and interpersonal
  skills to replace unhealthy acting out
• Stresses need for regular team communication and
  supervision approach is by team, not by
  individual therapist
• Playful and irreverent

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Why be pessimistic?

• Large scale, cheap versions dont work!
• Not all are helped
• The most resistant cases are least likely to
  benefit but use up the resource
• The environment is increasingly toxic and we are
  not keeping up with its risks (eg new
  technologies, where most teenagers are savvy but
  older porfessionals often naive)
• Nutrition is getting worse, activity and sleep
  are reduced, substance abuse is ever more
  available
• It is not inevitable that interventions can help
  but they CAN harm!

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Why be optimistic?

• Environmental manipulations can even affect genes
• There are known effective parenting treatments to
  address substantial numbers of cases of
  prepubertal CD and ODD, which are the enduring
  problems
• BPD increasingly appears to be a disorder of
  immaturity which can mellow out, particularly
  with therapy, not a life sentence
• Medication can help though it may not cure and is
  not limited to the treatment of comorbid
  conditions
• The study of stress and trauma responses is
  increasingly open to multidisciplinary
  exploration
• A new generation of clinicians is passionate
• about personality and psychotherapy!

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Man is born broken and lives by mending
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Scottish Personality Disorder Network Conference
Thursday 4th March 2010
Queen Mother Conference Centre
Royal College of Physicians of Edinburgh