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Child and Adolescent Mental Health


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									Child and Adolescent Mental Health
      Child and Adolescent Mental Health

Dr. Patsy Chapman
Consultant, Child and Adolescent Psychiatry


Mark Swindells
Senior Primary Mental Health Worker

Calderdale CAMHS
      Child and Adolescent Mental Health

   Common presentations to General Practice

   NICE Guidance/Evidence-based practice

   Discussions from practice

   Service issues and making a referral to
    specialist CAMHS
A note about evidence-based practice.

 Considered to be the

 ‘conscientious, explicit and judicious use of
 current best evidence in making decisions
 about the care of individual patients…
 integrating individual clinical expertise with
 the best available external clinical evidence
 from systematic research’.
                               Sackett et al (1996) BMJ
    Common presentations to GPs
    Attention Deficit Hyperactivity Disorder
   Autistic Spectrum Disorders
   Conduct disorders
   Depression
   Anxiety
   Obsessional-Compulsive Disorder (OCD)
   Eating Disorders
   Tic Disorders (inc Tourettes’s syndrome)
 Attention Deficit Hyperactivity
        Disorder (ADHD)

ADHD is a pervasive, heterogeneous behavioural
syndrome characterised by the core symptoms of
inattention, hyperactivity and impulsivity.
   Drug treatment for children and young people with ADHD should
    always form part of a comprehensive treatment plan that includes
    psychological, behavioural and educational advice and
   Parents of pre-school children with ADHD should be offered a
    referral to a parent-training/education programme as the first-line
   If the child or young person with ADHD has moderate levels of
    impairment, the parents should be offered referral to a group
    parent-training/education programme.
   In school-age children and young people with severe ADHD,
    drug treatment should be offered as the first-line treatment.
    Parents should also be offered group-based parent-training.
   Methylphenidate, atomoxetine and dexamfetamine are
    recommended, within their licensed indications, as
    options for the management of ADHD.

   In Calderdale and Kirklees only schools can refer to the
    specialist CAMH service for an assessment of ADHD.
    This is part of the clinical pathway for the management
    of ADHD.

   Following assessment and diagnosis by specialist
    CAMHS, “shared care” arrangements are usually made
    with the child’s GP.

   Children with an ADHD diagnosis and on medication are
    routinely followed up every 4 – 6 months by the
    specialist CAMH service.
             Autistic Spectrum Disorder
    An intrinsic condition, ASD manifests core features
     which are pervasive and include deficits in:
    - Social communication
    - Social interaction
    - Social imagination

    Current prevalence of all ASD diagnoses: 1.6%

    Children with an ASD have a higher risk than peers of
     developing other mental health problems.

    NICE have recently released a draft proposal for
     clinical guidelines which will cover recognition, referral
     and diagnosis of ASD in children.
    In Calderdale, diagnosis is a two stage process:

•      Screening in the community for core features at
       home and school using standardised measures.
       Only those children who demonstrate significant
       and pervasive core features of ASD are referred on
       to the specialist CAMH service.

•      The CAMH service coordinates a multi-disciplinary
       assessment of the child by a clinical psychologist,
       psychiatrist, paediatrician, educational
       psychologist and speech and language therapist.
                 CONDUCT DISORDERS

   Conduct disorders are the most common reason for
    referral of children to mental health services
   They have a significant impact on quality of life for those
    involved, and, in the case of early onset (aggression at
    three years of age) outcomes for children are poor
   Many children do not receive support because of limited
    resources, high prevalence and difficulty engaging some
   Early effective intervention is particularly important:
    recent research has established a neuro-developmental
    basis for this finding
Conduct disorder and ODD

    Conduct disorder: repetitive and
     persistent pattern of antisocial,
     aggressive or defiant conduct and
     violation of social norms

    Oppositional defiant disorder:
     persistently hostile or defiant behaviour
     without aggressive or antisocial behaviour
Estimated UK prevalence

  Conduct disorder (including
Age        Males      Females
(years)    (%)         (%)
5 - 10      6.9           2.8
11 - 15     8.1           5.1
       Associated conditions

   Conduct disorders are often seen in
    association with:
      attention deficit hyperactivity disorder
      depression

      learning disabilities (particularly
      substance misuse

      less frequently, psychosis and autism
      Predisposing risk factors

                        Family factors including
                               marital discord
                            substance misuse
                             criminal activities
                  abusive or injurious parenting practices

Individual factors including       Environmental factors including
    ‘difficult’ temperament               social disadvantage
          brain damage                      homelessness
             epilepsy                  low socioeconomic status
          chronic illness                        poverty
        cognitive deficits                   overcrowding
                                            social isolation
      Recommendations for children < 12 years

   Group-based parent-training/education programmes are
    recommended in the management of younger children with
    conduct disorders. Not routinely provided by specialist CAMHS.
   Individual-based parent-training/education programmes are
    recommended in the management of children with conduct
    disorders only in situations where there are particular difficulties
    in engaging with the parents or a family’s needs are too
    complex to be met by group based parent-training/education
   Local family support teams and children centres operate to
    support with family relationships and parenting.
     Recommendations for children > 12 years

   There is limited evidence only for effective interventions with
    older children/young people.

   Those programmes which show early promise are currently
    being evaluated, for example:
     - Multi-systemic therapy
     - Functional family therapy

   These approaches tend to be intensive and expensive. They
    are not currently available locally, though specialist CAMHS
    do offer other forms of therapeutic support to some families
    (family therapy, for example).
   At any one time, the estimated number of children and young
    people suffering from depression:
      1 in 100 children
      1 in 33 young people

   Prevalence figures exceed treatment numbers:
      about 25% of children and young people with depression
       detected and treated

   Suicide is the:
      3rd leading cause of death in 15–24-year-olds
      6th leading cause of death in 5–14-year-olds

   Transition to Adult services, where appropriate, requires
    careful planning

persistent          poor   or increased           Mild
                                             Up to 4 symptoms
sadness, or low or   sleep
irritable mood:      poor concentration
AND/OR               or indecisiveness
loss of interests   low self-confidence       Moderate
and/or pleasure      poor or increased       5-6 symptoms
fatigue or low      appetite
energy               suicidal thoughts or
                     acts                         Severe
                     agitation or slowing    7-10 symptoms
                     of movements
                     guilt or self-blame
When to refer to the specialist CAMH service:
   Depression with multiple-risk histories in another family
   Mild depression and no response to interventions in tier 1 after
    2–3 months (Low level intervention and “watchful waiting”)
   Moderate or severe depression (including psychotic
   Recurrence after recovery from previous moderate or severe
   Unexplained self-neglect of at least 1 month’s duration that
    could be harmful to physical health
   Active suicidal ideas or plans
   Young person or parent/carer requests referral
   Anti-depressants should only be prescribed following
    assessment by a psychiatrist and only be offered in
    combination with psychological treatments
   First-line pharmacological treatment is fluoxetine*
   Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine,
    St John’s wort
   Monitor for agitation, hostility, suicidal ideation and self-harm
    and advise urgent contact with prescribing doctor if detected
   Sertraline or citalopram* as second-line treatment
   Consider adding atypical antipsychotic if psychotic depression
   Continue for 6 months following remission, then phase out over
    6–12 weeks
   No specific NICE guidance for children and young
    people for Anxiety, though guidance is available for
    children with Post Traumatic Stress Disorder and
    Obsessional Compulsive Disorder

   Type of anxiety experienced by the child (social,
    generalised, panic, separation, specific phobia) and
    degree of impairment to functioning is important to
    detail in referral

   Cognitive Behavioural Therapy (CBT) and other
    behavioural approaches indicated for most anxiety
     Obsessional-Compulsive disorder
   Obsessive-compulsive disorder (OCD): characterised
    by the presence of either obsessions (repetitive,
    distressing, unwanted thoughts) or compulsions
    (repetitive, distressing, unproductive behaviours) –
    commonly both. Symptoms cause significant functional

   1% of young people are affected – adults often report
    experiencing first symptoms in childhood

   Onset can be at any age. Mean age is late adolescence
    for men, early twenties for women
     Obsessional-Compulsive disorder

   All people with OCD should have access to evidence-
    based treatments: CBT including exposure and response
    prevention (ERP) and/or pharmacology
   If CBT ineffective or refused - review and consider adding
    an SSRI
   Sertraline and fluvoxamine are the only SSRIs licensed
    for use in children and young people with OCD*
   Monitor carefully and frequently
   If successful, continue for 6 months post remission
   Withdraw slowly with monitoring
     Obsessional-Compulsive disorder
Considerations for work with children:

   Symptoms are similar in children, young people and
    adults and they respond to the same treatments
   Stressful life events may worsen symptoms or relapse
    may occur:
    - school transitions and examination times
    - relationship difficulties
    - transition from adolescence to adult life
    (careful planning of transition to adult services needed)
   Parents may feel guilty and anxious
   Tendency to increase in severity if left untreated
                   Anorexia nervosa
   Severe dietary restriction despite very low weight (BMI <17.5
   Morbid fear of fatness
   Distorted body image (that is, an unreasonable belief that one
    is overweight)
   Amenorrhoea
   A proportion of patients binge and purge
   In assessing whether a person has anorexia nervosa, attention
    should be paid not just to one off weight and BMI but also to
    the overall clinical assessment (repeated over time), including
    rate of weight loss, growth rates in children, objective physical
    signs and appropriate laboratory tests. Include all information
    in referral.
                   Anorexia nervosa
   On referral to specialist CAMHS patients are usually offered a
    range of individual therapies (often CBT) and family therapy.
   Close working alliance with a dietary specialist is assumed.
   No evidence or justification for sole treatment of AN via
    Co-morbid mood disorders may respond to treatment with
    SSRI (NB. Cardiac function)
   Inpatient treatment should be considered for people with
    anorexia nervosa where:
    - The disorder has not improved with appropriate outpatient
    - There is a significant risk of suicide or severe self-harm.
    - There is a high or moderate physical risk.
                     Bulimia nervosa
   Characterised by an irresistible urge to overeat, followed by
    self-induced vomiting or purging and accompanied by a morbid
    fear of becoming fat.

   Patients with bulimia nervosa who are vomiting frequently or
    taking large quantities of laxatives (especially if they are also
    underweight) should have their fluid and electrolyte balance
o   Selective serotonin reuptake inhibitors (SSRIs) and specifically
    fluoxetine, are the drugs of first choice for the treatment of
    bulimia nervosa.The effective dose of fluoxetine is higher than
    for depression (60 mg daily).
    No drugs, other than antidepressants, are recommended for
    the treatment of bulimia nervosa.
                       Tic Disorders
             (including Tourettes’s Syndrome)

   Tics are involuntary, rapid, recurrent, non-rhythmic
    motor movements.
   Transient tic problems are very common in childhood,
    more common in boys, and a family history of tics is
   Chronic and complex tic disorders require careful
    management and referral to specialist CAMHS.
   Tourette’s syndrome is a constellation of multiple motor
    and vocal tics originating in childhood/adolescence and
    often persisting into adulthood.
                      Tic Disorders
            (including Tourettes’s Syndrome)


   Psycho-social approaches

   Pharmocological approaches:
      - Haloperidol
      - Risperidone
      - Pimozide
      - Clonidine
   Making a referral to the specialist
           CAMH service

Referrals are allocated as follows:

- Urgent (seen within one working day)

- Priority (seen within six weeks)

- Routine (placed on our waiting list)
      Making a referral to the specialist
              CAMH service
   Referrals are screened daily

   Not all referrals to the service are accepted. Often
    referrals are signposted to other appropriate services.
    (“Children’s mental health is everybody’s business”)

   In future it is likely that other pathways will be developed
    to manage particular clinical presentations.

   If in doubt, contact the primary mental health worker on
    duty to discuss possible referrals to the service or for
    advice on any issue relating to CAMH
       Primary mental health work
   The primary mental health work (PMHW) team
    serves to link community based services with the
    specialist CAMH service.

   Alongside responsibilities for screening of all
    referrals they also undertake:
     - training
     - advice
     - consultation
     - liaison

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