Child and Adolescent Mental Health

Child and Adolescent Mental Health

Child and Adolescent Mental Health Dr. Patsy Chapman Consultant, Child and Adolescent Psychiatry and 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 (ADHD) • 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.

ADHD • 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 interventions. • Parents of pre-school children with ADHD should be offered a referral to a parent-training/education programme as the first-line treatment. • 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.

ADHD • 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.

ASD 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 families • 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

Associated conditions • Conduct disorders are often seen in association with: • attention deficit hyperactivity disorder (ADHD) • depression • learning disabilities (particularly dyslexia) • 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 ‘difficult’ temperament brain damage epilepsy chronic illness cognitive deficits Environmental factors including social disadvantage homelessness low socioeconomic status poverty 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 programmes. • 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).

Depression • 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

Depression Mild Up to 4 symptoms Moderate 5-6 symptoms Severe 7-10 symptoms

Depression When to refer to the specialist CAMH service: • Depression with multiple-risk histories in another family member • 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 depression) • Recurrence after recovery from previous moderate or severe depression • 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

Depression • 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

Anxiety • 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 disorders.

Obsessional-Compulsive disorder (OCD) • 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 impairment/distress • 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 (OCD) • 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 (OCD) 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 kg/m2) • 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 medication. 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 treatment. - 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 assessed. • 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) Presentation: • 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 common. • 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) Management: • 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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Child and Adolescent Mental Health