Child and Adolescent Psychiatry Module

1
Child and Adolescent Psychiatry Module

• Week 1
• Dr Sarah Huline-Dickens
• Consultant in Child Psychiatry,
• Mount Gould Hospital, Plymouth
• sarah.huline-dickens_at_plymouth.nhs.uk

2
Introductions

• To group
• To module
• To ground rules
• To reading list

3
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
•  
•  

4
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  
•  

5
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

6
Whats it like for a new boy?
7
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

8
CAMHS 2

• Multidisciplinary team
• Single point of entry with primary mental health
  workers (tier 2)
• Choice and partnership system
• Some specialist clinics

9
What is a psychiatric disorder?An impairing
abnormality of behaviour, emotions and
relationships

• ABNORMAL in relation to
• childs 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 childs development
• effects on others

10
What kinds of disorders?

• Emotional disorders (internalizing)
• anxiety disorders
• phobias
• depression
• OCD
• Some somatisation
• Disruptive behavioural disorders (externalizing)
• hyperkinetic disorder/ADHD
• conduct disorder

11
What kinds of disorders?contd

• Developmental disorders
• -speech/language delay
• -reading delay
• -autistic disorders
• -generalised learning disabilities
• -enuresis and encopresis
• Adult onset disorders
• -psychosis
• -eating disorders
• -mood disorders, DSH

12
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 499 p900-914

13
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

14
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

15
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.

16
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

17
Epidemiology 4

• Many disorders co morbid
• Most untreated
• Many persistent, especially conduct problems
• Marked gender differences

18
Classification

• ICD 10
• DSM IV
• Both have multi-axial schemes
• Psychiatric disorder
• Specific delay in development
• Intellectual level
• Medical condition
• Psychosocial adversity
• Adaptive functioning

19
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

20
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)

21
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

22
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

23
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

24
Aetiology 5

• Consider whether child, family, environmental
  factors are
• PREDISPOSING
• PRECIPITATING
• PERPETUATING
• What is protective and aiding resilience?

25
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
• leading directly to psychopathology e.g. autism
• confering greater susceptibility to less
  favourable environments
• causing individual to seek out risk situations/
  behaviours

26
Lunch!
27
Resume of this morning

• What did you learn?

28
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

29

• 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

30

• 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

31
Attachment theory

• In groups summarise in 20 words what you
  understand by attachment theory

32
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

33
Attachment 2

• Mary Ainsworths 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
• Bsecure
• Cresistant/ambivalent
• Ddisorganised/disorientated

34
Attachment 3

• Importance throughout life
• Mary Mains 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

35
Attachment 4

• Interesting work on mentalising (ability to work
  out peoples 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

36
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

37
ADHD 1 (hyperkinetic disorder, hyperactivity)

• Core features triad of restlessness, impulsivity
  and inattentiveness
• Pervasive
• Early onset by 7 years
• Prevalence 3-5. Male female 31
• 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.

38
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

39
Pervasive developmental disorders (communication
disorders, autistic spectrum disorders) 1

• Prevalence 2 per 1000 have PDD
• For autism 0.5 per 1000
• Male female ratio 31
• No clear association with socio-economic status

• Triad of social impairment, communication
  problems and restrictive/ repetitive interests
  and behaviours
• Early onset (before 36 months)

40
Pervasive developmental disorders (communication
disorders, autistic spectrum disorders) 2

• Associated features
• Mental retardation (verbal IQ lower than
  non-verbal IQ)
• Seizures in a third of mentally retarded
• Hyperactivity common
• Self-injury

41
Pervasive developmental disorders (communication
disorders, autistic spectrum disorders) 3

• Differentiate from
• Language disorders
• Aspergers syndrome
• Mental retardation
• Retts syndrome (girls, regression at 12 months,
  hand-washing stereotypies and overbreathing,
  death often before 30)

• Neurodegenerative disorders
• Extreme early deprivation
• Deafness!

42
Pervasive developmental disorders (communication
disorders, autistic spectrum disorders) 4

• Aetiology genetic (twin heritability 90)
• Psychological deficit ?theory of mind (Sally
  Anne test) ?executive function
• Treatment educational interventions. Some role
  for psychotropic medication

43
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

44
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 3341069-70 for review (Morgan
  Taylor)

45
Pervasive developmental disorders (communication
disorders, autistic spectrum disorders) 4

• Aetiology genetic (twin heritability 90)
• Psychological deficit ?theory of mind (Sally
  Anne test) ?executive function
• Treatment educational interventions. Some role
  for psychotropic medication

46
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 persons
  distress

47

• 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

48

• 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

49
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)

50
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

51
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
•  

52
Learning Objectives for today contd

• 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  

53
The End