Psychiatric Perspectives in Children with Special Educational Needs

1. Psychiatric Perspectives in Children with Special Educational Needs Prof Maurice Place Copy of Presentation @ www.tinyurl.com/yzp2axy maurice.place@northumbria.ac.uk

2. James 14 yrs • Presentation - A good student until 18 months ago, • now poor work and frequently not handing in homework • violent outbursts at school for last few months • - excluded from school following an assault on teacher.

3. Becky 14 yrs • Presentation -Always a rather quiet girl, but not prompted concern until now • - recently more withdrawn – at break times either alone • or with “smoking group” • - says being bullied at school • - frequent arguments with mother about friends she’s out with, • time in etc.

4. What do you think is going on? Do either of these cases require referral to a professional? What would you expect the professional to achieve?

5. Issues of Diagnosis in Mental Health

6. What Constitutes a Problem?

7. What Constitutes a Problem? Who’s Problem is it?

8. What Constitutes a Problem? Who’s Problem is it? The Child The Parent The Teacher “Society”

9. How to define it?

10. How to define it? Unit 1 the child is frightened of going to school Unit 2 an unwritten contract between two people. The child is frightened to separate from mother Unit 3 triangular relationships - coalitions & alliances. The child is in close alliance with mother and her "problem" of school attendance takes precedence over marital difficulties

11. How to define it? Unit 1 the child is frightened of going to school Unit 2 an unwritten contract between two people. The child is frightened to separate from mother Unit 3 triangular relationships - coalitions & alliances. The child is in close alliance with mother and her "problem" of school attendance takes precedence over marital difficulties Probably two elements - school issues & family themes conspiring to produce non-attendance (Perugi et al 1988; Last & Strauss 1990)

12. What Constitutes a Problem?

13. memory • thought • mood • hallucinations - visual • - tactile • - auditory

14. delusions • behaviour • vegetative

15. Let us consider: A white english man who is referred because he is telling his GP that he has had a message from God and been told to give away all his possessions and preach on street corners.

16. Let us consider: A white english man who is referred because he is telling his GP that he has had a message from God and been told to give away all his possessions and preach on street corners. He is - a heavy drinker - the managing director of an engineering firm.

17. Let us consider: A white english man who is referred because he is telling his GP that he has had a message from God and been told to give away all his possessions and preach on street corners. He is - an anglican vicar - his wife has recently died

18. Disorder is characterised by: atypical behaviour and/or distress AND dysfunction which is - persistent & severe (Lask 2003)

19. How do these “adult concepts” apply to children?

20. Disorder is characterised by: atypical behaviour and/or distress AND dysfunction which is - persistent & severe (Lask 2003)

21. Elements considered in assessment • Parenting Quality • Family Dynamics • Developmental Themes • Friendships & Their Influences • School Performance

22. So what of our two initial cases?

23. James 14 yrs • Presentation - A good student until 18 months ago, • now poor work and frequently not handing in homework • violent outbursts at school for last few months • - excluded from school following an assault on teacher. • violent outbursts at home over same period. • - frequent arguments with mother • - “walking on egg-shells all the time”. • 2 episodes where threatened to cut own throat with knife.

24. James 14 yrs Presentation Family & History - Only child. Parents separated 3 yrs ago. Marriage acrimonious & violent, sometimes towards James. Developmental milestones average. As junior - good peers, school attendance & performance. Weekend contact to dad - James tries to avoid going.

25. James 14 yrs • Presentation • Family & History. • Examination - Truculent, quick to angry responses. • Never out with friends, • only goes out with mother since exclusion. • Spends most of day watching TV. • Eating - not eating for 2 days then binges. • Sleep - bed after midnight, to sleep in early hours, • wakes at lunchtime. • Says he is “sick of my life” & gets weepy when thinks of it.

26. Becky 14 yrs Presentation -Always a rather quiet girl, but not prompted concern until now - recently more withdrawn – at break times either alone or with “smoking group” - says being bullied at school - frequent arguments with mother about friends she’s out with, time in etc. - constant conflict with mother for 18 mths, most recent about hiding stolen mobile phone. - mother feels losing control of daughter.

27. Becky 14 yrs Presentation Family & History - Older sister allies with mother - fights with Becky. Father works away during week; mother works and seen by everyone as manager of family. Developmental milestones early. As junior - good peers, school attendance fine & seen as high flyer. Helpful round the house. Favourite aunt died in car accident 2 yrs ago.

28. Becky 14 yrs Examination Quietly spoken, minimising issues, but is worried by loss of temper. Feels parents are constantly “on her back”. Sees dead aunt “covered in blood” who tells her life will get worse. Eating - episodes of over-eating - has sometimes been sick afterwards because of amount. Sleep - awake until 3 am, grumpy in mornings. Weeps quite frequently but she always ascribes to life events. School performance poor in recent months - “can’t be bothered… ...don’t see the point”. Interests - used to horse ride; friendships reduced to 2 – both frequently excluded from school for disruptive behaviour.

29. Differential Diagnoses • depression • conduct disorder/ opposition defiance • adolescent challenge/ rebellion • PTSD (James) • abnormal bereavement reaction (Becky)

31. 5 or more of:- 1) Depressed mood as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. tearful). In young people can be irritable mood. 2) Markedly diminished interest in activities. 3) Significant change in weight or appetite. 4) Insomnia. 5) Psychomotor agitation or retardation as observed by others. 6) Fatigue or loss of energy. 7) Feelings of worthlessness or guilt (which may be delusional). 8) Diminished ability to think or concentrate. 9) Recurrent thoughts of death.

32. James 1) Depressed mood/irritability x 2) Markedly diminished interest in activities.x 3) Significant change in weight or appetite. x 4) Insomnia. x 5) Psychomotor agitation/retardation. - 6) Fatigue or loss of energy. x 7) Feelings of worthlessness or guilt. - 8) Diminished ability to think or concentrate. x 9) Recurrent thoughts of death. ?

33. James Becky 1) Depressed mood/irritability x x 2) Markedly diminished interest in activities. x x 3) Significant change in weight or appetite. x x 4) Insomnia. x x 5) Psychomotor agitation/retardation. - - 6) Fatigue or loss of energy. x ? 7) Feelings of worthlessness or guilt. - x 8) Diminished ability to think or concentrate. x x 9) Recurrent thoughts of death. ? x

34. Causes of Disturbance and Distress Intrinsic - e.g. birth trauma, epilepsy, ADHD, Pervasive Developmental Disorder

35. Causes of Disturbance and Distress Intrinsic Parenting problems- failed system - abusive, neglectful - flawed system- parental disagreement - flawed delivery- inconsistent

36. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritalsexaggerated emotions, poor self esteem, aggressive with peers

37. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritals Alcohol / drug abuse in parentsaggressive, poor emotional control, moodiness, depression

38. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritals Alcohol / drug abuse in parents Other adverse life events - bereavement

39. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritals Alcohol / drug abuse in parents Other adverse life events – bereavement divorce

40. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritals Alcohol / drug abuse in parents Other adverse life events – bereavement divorce significant bullying

41. Causes of Disturbance and Distress Intrinsic Parenting problems Aggressive maritals Alcohol / drug abuse in parents Other adverse life events – bereavement divorce significant bullying abuse/trauma

42. Prevalence of Disorders Overall prevalence 12% in the pre-adolescent age group (Kolvin et al., 1981) 25% in the adolescent population (Macmillan et al., 1980; Place et al., 1985) Most not involved with mental health services(Offord et al., 1987; Rutter, Tizard, & Whitmore, 1970) but a significant proportion do attend social services and primary care settings (Kurtz, Thornes, & Wolkind, 1994).

43. Prevalence of Disorders Prevalence of Specific Disorders Anxiety disorders - 12% Disruptive conduct disorders-10% Depression 6% (increasing in adolescence) Attention deficit hyperactivity disorder (ADHD) - 3% Pervasive developmental disorders 1% Psychoses are rare, affecting less than 1 %

44. Issues of Diagnosis in Our Two Cases

45. Oppositional Defiance • losing one's temper • arguing with adults • actively defying or refusing to comply with rules • deliberately doing things that will annoy others • blaming others for his misbehaviour • being touchy or easily annoyed by others • being angry and resentful • being spiteful or vindictive

46. Oppositional Defiance Child’s Temperamentdifficult, unadaptive(Bates et al. 1991). Parents conflict destructive, rather than divorce per se (O'Leary and Emery 1982) unemployment, divorce & poverty more prevalent (Webster–Stratton 1993)   fewer positive behaviours towards their children more likely to threaten, criticise, and humiliate their children less likely to monitor their children's behaviours don't give enough time to comply with commands (Delfini et al. 1976; Forehand et al. 1975; Webster–Stratton and Spitzer 1991).

47. Conduct Disorder Oppositional Defiance elements with - aggression towards others destruction of property theft and deceit If emerge in early years then a distinctly different group from those where emerges in adolescence.

48. Conduct Disorder Severe conduct disorder associated with drug misuse, criminality, affective illness and youth suicide (Loeber et al., 2000) If emerge in early years then a strong link with development of antisocial personality disorder (Frick, 1998). Rates of conduct disorder (adolescent emergence) are increasing quite dramatically (Loeber & Farrington, 1998; Smith, 1995).

49. conduct disorder should be viewed as the most important area for mental health services to concentrate their efforts in order to find effective interventions (Werry 2000)

50. Child -focussed TreatmentsTask orientated - social skills, self esteem Individual psychotherapy Behaviour management Drug therapy