Middle Childhood Emotional and Behavioral Problems Training Package

1. ELFT Training Packagesfor Primary Care ‘MIDDLE CHILDHOOD’- Emotional and Behavioural problems - CAMHS ELFT Graeme Lamb Clinical Director

2. Learning objectives: by the end of this lecture students should • Know the presentation, aetiology, epidemiology of common behavioural problems (ADHD, conduct and oppositional defiant disorder) presenting to child and adolescent psychiatry. • Know the presentation, aetiology, epidemiology of common emotional problems (anxiety, depression, school refusal) presenting to child and adolescent psychiatry. • Consider the multidisciplinary management of these presentations in middle childhood.

3. Overview • Review of developmental stages • Emotional disorders - overview • ADHD • Conduct problems

4. Developmental issues • Physical Development • Cognitive Development • Emotional Development • Affective Development Developmental tasks continue through middle childhood in the same domains as in early childhood

5. Developmental issues • Physical Development • height, motor skills • Cognitive Development • Academic, logic, reasoning • Emotional Development • Friendships (Same –sex), teamwork, morality • Affective Development • Motivation, self esteem, sense of self

6. Disorders of Middle Childhood • Emotional disorders • School Refusal • Hyperkinetic disorder (ADHD) • Conduct disorder

7. Includes: Anxiety Depressive Mixed emotional disorders Is it Common ? Prevalence rate of 4% in 5-15-year-olds Emotional disorders:

8. How do emotional disorders present in children? Is it different to adult anxiety and depression? • Symptoms (more commonly mixed symptoms) • Anxiety and Misery • Somatic complaints • Irritability/oppositional • Features • Less pervasive • Less clear cut biological symptoms • Associated presentations • Developmental regression • Academic decline, school refusal • Simple suicidal ideas

9. Emotional disorders:Aetiology • Child: • genetic • temperamentally anxious • behavioural inhibition • physical health problems • Family: • emotional over-involvement • over-protection • Environment: • social adversity • stressful experiences PRACTICE POINT: Remember the aetiological grid (predisposing, precipitating and perpetuating) in each of these three domains when assessing cases

10. Emotional disorders:Management • Psycho-education • Support parents in • comforting the child • encouraging facing of difficult situations • ensuring there is not excess avoidance • family therapy • Individual work with the child on • anxiety management including relaxation techniques • behaviour therapy • cognitive –behavior therapy • Work with other agencies • Liaison with school to establish graded return and provide emotional support (especially in school refusal) • Medication • Used much less regularly • Less clear evidence base in middle childhood

11. Emotional disorders: Outcome • The majority of children with emotional disorders improve • But remain anxiety prone and vulnerable to depression • Risk of recurrence of increased if • Family history of depression • Lack of complete recovery • Pre-existing social dysfunction • History of sexual abuse • Family discord • Life time rates of recurrence are as high as 70% Birmaher et al 2002 Course and outcome of child and adolescent major depressive disorder. Child and Adolescent Psychiatric clinics of North American 11, 619-637

12. Comorbidity • At least a third meet the criteria for 2 or more anxiety disorders. • Other co-morbidities • Conduct disorder • ADHD • Depression • Autistic Spectrum Disorders ( Muriset al 84%) Muris P, Steerneman P, et al (1988) Comorbid anxiety symptoms in children with pervasive developmental disorders. Journal of Anxiety Disorders 12 387-93

13. Hyperkinetic disorder (ADHD) Conduct disorder Behavioural Disorders of Middle Childhood

14. Learning Outcomes: By the end of this lecture students should • Know the presentation, aetiology, epidemiology of common behavioural problems (ADHD, conduct and oppositional defiant disorder) presenting to child and adolescent psychiatry. • Consider the multidisciplinary management of these presentations.

15. Attention Deficit HyperactivityDisorder ADHD or Hyperkinetic Disorder

16. Characteristic Features ADHD Prevalence 0.5%- 1% of children More common in boys 4:1 M:F Discussion Why might it be seen more commonly in boys? ADHD

17. Characteristic Features ADHD Hyperactivity & Restlessness: Can’t sit still Squirms in seat Fidgety Unable to wait (queues, games, conversations)

18. Characteristic Features ADHD Impulsivity Impulsive acts – runs into road Acts without thinking Answers before question is completed Trouble waiting for turn

19. Characteristic Features ADHD Innattention • Jumps from task to task • Can’t focus at school, makes careless mistake, forgets things • Not listening properly to rules/instructions

20. Making a diagnosis • Symptoms • Core features of ADHD must be present in more than one setting (eg school and home) • Present early in development • Assessment • Requires history from parents and school and direct observation in clinic • Assessment can be supplemented by structured questionnaires such as the Conner’s Questionnaire.

21. Hyperkinetic disorder: Aetiology • Child: • neuro-developmental abnormalities • temperamental factors • genetic factors • Family: • maternal depression and smoking in pregnancy Asherton et al (2005) Unravelling the complexity of attention-deficit hyperactivity disorder. British Journal of Psychiatry, 187, 103-105

22. Why is it important to recognise ADHD? • Under performance at school • Getting into trouble at school • Relationship/Peer problems • Employment • Crime, drugs and alcohol

23. ADHD TREATMENTS Interventions Examples • Behavioural interventions • School interventions • Social skills work • Diet • Parenting support • Medications

24. Treatments for ADHD TREATMENTS Interventions Examples Positive reinforcement - lots of praise immediately after good behaviour Reward system: Star charts, a treat (not sweets) Clear boundaries and instructions (just before, check they’ve understood) Consistent consequences for bad behaviour. Structure and routine. • Behavioural interventions • School interventions • Social skills work • Diet • Parenting support • Medications

25. Treatments for ADHD TREATMENTS Interventions Examples Sit near front, away from distractions, Time out Use timetables, highlight reminders, extra pens/kit Break large tasks into smaller tasks. Ensure appropriate support for co-morbid specific learning problems • Behavioural interventions and parenting programmes • School interventions • Social skills work • Diet • Medications

26. Treatments for ADHD TREATMENTS Interventions Examples Work through common problem areas: Supermarkets Parties Playing with others e.g turn taking • Behavioural interventions and parenting programmes • School interventions • Social skills work • Diet • Medications

27. Treatments for ADHD TREATMENTS Interventions Examples Caffeine Cordials Colouring Sugar NB: There is insufficient evidence to link food additives to ADHD, but worth taking detailed food and activity diary • Behavioural interventions and parenting programmes • School interventions • Social skills work • Diet • Medications

28. Treatments for ADHD Interventions Examples Methylphenidate / Ritalin/Concerta “stimulant” Allows child to focus, calmer, think before acting • Behavioural interventions and parenting programmes • School interventions • Social skills work • Diet • Medications

29. Medication for ADHD • Medication has common side effects • Headache, stomach ache • Appetite suppression • Growth suppression • Medication has less common but important side effects • Increased pulse and blood pressure • Medication has rare and serious side effects • Sudden cardiac death if underlying conduction problems • Others to consider • Tics (but this is a common comorbidity) • Regular Medical monitoring • Pulse and blood pressure • Height and weight • All plotted and growth centile charts

30. Childhood and Adolescence CONDUCT DISORDER

31. Conduct Disorder ICD -10 Diagnosis Epidemiology 5-10 years 7% boys 35 girls 11-16 years 8% boys 5% girls Looked after children (those experiencing abuse or on child pr0tection registers) Up to 40% conduct disorders Source. Office National Statistics 2005 • Repetitive and persistent pattern of dissocial, aggressive, or defiant conduct • More severe than ordinary childish mischief or adolescent rebelliousness. (5% of 10 year olds) • Present >6 months • Note ODD in younger children

32. Conduct Disorder Examples Excessive fighting or bullying; Cruelty to animals Destruction to property Firesetting Stealing Repeated lying Truancy from school Running away Severe temper tantrums Defiant provocative behaviour Persistent severe disobedience

33. Conduct disorder: Outcome • Varies considerably with the nature and extent of the antisocial behaviour • Risk factor for wide range of negative outcomes • Antisocial personality disorders • Criminal and violent offending • Drug use • Poor physical healthy • Sexually transmitted infections • Other psychiatric disorders (mania, schizophrenia, suicidal behaviour) Moffitt et al (2002) Males on the life-course persistent and adolescence-limited antisocial pathways: follow-up at age 26. Development and Psychopathology, 14, 179–206. Kim-Cohen et al (2003) Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 60, 709–717.

34. Finally… • Full of challenges for children and parents and schools • Assessment and treatment has to therefore include child, family and education • Look for change in behaviour, school performance, physical health