Paediatric dilemmas in the 10 minute consultation

1. Paediatric dilemmas in the 10 minute consultation January 2014

2. Dilemmas to be considered • What do I need to know to deal with the depressed and suicidal young person in the 10 minute consultation? • Constipation in children. • The Crying baby. • The bed wetting child.

3. Depression & Suicidal behaviour in children and adolescents

4. RCGP Curriculum Statement 13: Care of people with mental health problems:Learning Objectives: • Manage people experiencing mental health problems. • Knowledge of difficulties in the psychological well-being of children and young people, including depression, appropriate treatments and mental health promotion. • Know how to access and obtain advice from child and adolescent mental health services (CAMHS) • Have skills in assessing the mental state and suicide risk.

5. Young people Mental Health stats • 1 in 10 children and young people aged 5 - 16 suffer from a diagnosable mental health disorder - that is around three children in every class. • Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm. • There has been a big increase in the number of young people being admitted to hospital because of self harm. Over the last ten years this figure has increased by 68%. • More than half of all adults with mental health problems were diagnosed in childhood. Less than half were treated appropriately at the time. • Over 8,000 children aged under 10 years old suffer from severe depression. • 72% of children in care have behavioural or emotional problems - these are some of the most vulnerable people in our society. • 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder. • The number of young people aged 15-16 with depression nearly doubled between the 1980s and the 2000s. • The proportion of young people aged 15-16 with a conduct disorder more than doubled between 1974 and 1999.

6. Risk Factors ALCOHOL • In 2010 21% of men aged 16-24 drank more than the recommended 21 units and 18% of women aged 16-24 drank more than the recommended 14 units. CRIME • In December 2012 there were 7,672 15-20-year-olds being held in prisons in England and Wales. •  7,423 were young men and 249 were young women. • 989  were aged between 15-17years and 6,683 were aged between 18-20 years. STATISTICS ABOUT YOUNG PEOPLE AND DRUGS • Young people aged between 16-24 reported the highest levels of drug use in 2009/10. • It is estimated that about 2.7 million young people in England and Wales have used an illicit drug at some point in their lives. 1.3 million used drugs in the previous year. • It is estimated that 16.4% of 16-24 year olds had used a Class A drug at least once in their lifetime. • It is estimated that 40.7% of 16-24 year olds have used one or more illicit drugs in their lifetime and 11.6% in the last month. • In 2009/10 22.3% of 16-19 year olds reported illicit drug use. LEARNING DISABILITIES • 36% of children and young people with a learning disability have a mental disorder. EDUCATION AND EMPLOYMENT • It was estimated that in July-September 2012, the youth unemployment rate (age 16-24) was 20.7%. HOMELESSNESS • Provisional data for 2009/10 indicated that in England there were 15,510 homeless young people aged between 16-24. This data is based on local authorities’ decisions on homeless applications so the actual figure could be higher. LEAVING CARE • 10,000 young people aged 16 and over ceased to be looked after in 2012. TEENAGE PREGNANCY • Teenage mothers have three times the rate of post-natal depression of older mothers and a higher risk of poor mental health for three years after the birth. • Children of teenage mothers have a 63% increased risk of being born into poverty compared to babies born to mothers in their twenties, have higher mortality rates under 8 and are more likely to have accidents and behavioural problems. • In 2006 there were 103,120 conceptions for women aged under 20. 42% ended in abortion.

7. GP Awareness: • Presentation of depression. • Be on the look out for DSH. • Family and social situation. • Risk Factors.

8. Depressive Disorder in adolescents Aetiology: Diagnosis: • What differentiates between fluctuating teenage mood & depression? • Diagnostic (ICD-10) criteria the same as adults but often low mood not the main issue. • Females > males • Physical symptoms in primary care. • Prevalence of depression • Family History of depressive disorder • Family conflict • Abuse and social poverty • Precipitating causes: life events

9. How do we assess? • Read notes. • See alone. • Shift from physical to psychological assessment. • Behaviour assessment. • Use parental contributions. • Irritability. • Social withdrawal/functioning. • DSH.

10. Case: Charlotte, aged 15 years comes to see you about her acne. You give her a repeat script for her acne but she seems hesitant to leave. “Anything else Charlotte?” You say. Her mother has depression and her sister had a miscarriage. Charlotte explains that she feels sad, not sleeping well and tired and not enjoying school. She blames herself for the sister’s miscarriage as they were arguing before it happened.Charlotte is normally very sociable and a high achiever.What further questions would you ask in your assessment?What management options would you consider?

11. How do we manage these cases? • Review • Information sheets/ websites • School nurse • Time to talk • Substance misuse services • Local CMHS services • Child and adolescent Social services • Local admission

12. Suicide behaviour in childhood and adolescents. • Uncommon in childhood and early adolescent. • Increase in mid-adolescence. • Females > males • 7% of adolescents report DSH in the previous year. • > 50% of young people who DSH have consulted their GP in the previous months.

13. Aetiologicalfactors • Individual:psychiatric/ anxiety/ substance misuse/self blame/abuse/poor problem solving. • Family:Communication difficultiesFH mental illness/ chronic disease / divorce. • Wider environment:School problems / Bullying/ Relationship problems / Exposure to suicide. • Precipitating problems:Interpersonal conflicts/arguments/rejection

14. Assessing suicide risk and intent: • General and become specific in history. • Quantify frequency and intensity of thoughts. • Specific behaviours: Alone/ timing/avoidance of discovery/anticipations of death/advance planning/note/failure to alert others after failed attempt.

15. Assessment in primary care • Ascertain risk & consider if self harm has taken place. • The dilemma of age. • MH assessment:Assess current risk.Understand the person’s and family’s difficulties & how this led to self harm.Determine if the person is suffering from a psychiatric disorder, D&A misuse.Assess child and family’s resources.

16. Management • Keep the person safe. • Appropriate emotional support:- Family intervention/Family system orientated therapy.- Dialectical behaviourtherapy- self acceptance, increase assertiveness, reduce interpersonal conflicts & avoid trigger situations.- CBT- D&A services

17. Useful resources http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo.aspx www.youngminds.org.uk/my-head-hurts http://www.time-to-change.org.uk/youngpeople http://www.bdct.nhs.uk/our-mental-health-services/child-adolescent-mental-health-services/children-and-young-people/