MRCPsych Course CAMHS Module

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MRCPsych CourseCAMHS Module

• Dr Nazma Portch
• ST5 CAMHS
• DPT

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Session outline

• Taking a history in CAMHS
• Communicating with children
• Conducting a family interview
• Resilience
• Treatments in CAMHS

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History Taking

• Essentially same components as adult but
• Involve parents/family
• Greater emphasis on family relationships
• Collateral information
• Importance of observation
• Importance of developmental history

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History Taking 5 key components

• Symptoms
• Impact
• Risks
• Strengths
• Explanatory model

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Developmental History

• -Why is it important?
• -What are the important and relevant aspects of a
  developmental history?

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Developmental history

• Detailed description at key stages
• Various sources
• Look at age of milestones- use anchor points
• Any loss of skills
• Current abilities-as expected for age?
• Age appropriate behaviour eg. Tantrums at 2 vs.
  at 10?

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What is normal?- Test yourself!

• What age do children?
• Walk
• Talk
• Ride a tricycle
• Draw person
• Play fantasy games

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Ages..

• Walking- 12months
• Talking
• 12months using 2-3 words
• By 2 using 2-3 word phrases. Starts to use
  pronouns
• By 5 fluent speech with articulation
• Ride a tricycle- 3 years
• Draw person with 6 parts- 5 years
• Fantasy games 2yrs
• Remember there is range of normal

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Communicating with children and Families
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Exercise

• Get in pairs/groups
• Pick an age from 5-18
• Imagine you are going to see a psychiatrist
  because you are unhappy at school
• What are your worries and concerns?
• Do the same but imagine you are a parent

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Special factors to consider

• Children and adolescents require different
  communication skills to adults
• The consultation involves at least 2 patients
• Illness is particularly frightening to both
• Communication with both is crucial
• It is important to consider interpersonal issues
  between them

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Why is good communication with children important?

• It helps the doctor to understand the childs
  condition better
• It helps the child to understand about the
  illness and treatment better, and be
• Less frightened
• More able to participate in decisions
• More willing to accept treatment

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Communication difficulties

• Language development
• Child may not have adequate speech to describe
  language and feelings
• Cognitive development
• Child may not have reached the necessary level
  of understanding
• Emotional development
• Child may be wholly or partially dependant on
  parental support

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Aids to communication

• Find out where the child is most comfortable
• Put yourself at the same level
• Use of toys and play
• Use humour and fun
• Drawings and models
• Specially designed scales for pain
• Appropriate vocabulary

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Vocabulary with children

• Avoid jargon / medical terms
• Avoid ambiguous words
• Check understanding regularly
• Beware of frightening words
• Use clear and appropriate language
• Use words the child uses in their description

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Adolescents a special case

• Often have difficulties communicating with
  adults, including doctors and parents
• Are discovering the boundaries of acceptable
  behaviour may need your help in this
• Rarely consult but have specific health issues
• You may need to state that you are their advocate
  and not to be seen to be siding with parents
• You may need to confront at the same time as
  showing care

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The parent

• May feel more anxious
• May feel guilty or inadequate
• May be helpful when examining the child
• May be part of the problem
• May interfere in communication between the doctor
  and the child

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The interview

• Be well prepared in advance
• Know the age, gender reason for referral
• Prepare the room
• Prepare to have the whole family
• Clothing?
• Prepare age appropriate play materials toys,
  paper, colour pencils, Lego, animals.

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Establishing rapport

• The 1st few minutes are very important
• Greet the child by 1st name
• Preferably introduce yourself by 1st name (Dr
  with adolescents)
• Start with questions the child can answer
• Who has come along?
• How old are you?
• Whos your best friend?
• Have a working knowledge of types of toys and
  activities for his age
• Engage them in activitiesplay, drawing, roles
  play (e.g as a doctor)

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• Why do they think they are here?
• Why do you think they are here?
• Enquire about childs view of the problem
• Be flexible in approach
• Less formal and less structured
• Expect short answers and help develop them
• Ask same question to different people
• Do not persist if topic difficult for child
• Show empathy and normalize difficulties
• Active listening, avoid judgments, be patient,
  engage

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2 patients!

• Establish and maintain rapport with both
• Seek to learn both perspective of the problem
• Seek to understand address both set of agendas
• Tailor explanations to both
• Involve both in the decision making process
• Check the understanding of both
• Dont take sides or compete
• Negotiate to interview each separately if they
  wish
• Keep the boundaries safe

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Interviewing families

• Think of family as a system
• The family will have homeostatic mechanisms to
  resist change eg grandparent usage if absent
  parent
• Family myths eg anger is destructive
• Roles within families both good and bad eg
  scapegoat, academic aspirations
• When families behaviour hard to understand think
  of this

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Observe

• Child behaviours, symptoms, responses, play etc
• Interactions
• Child- parent
• Child interviewer
• Parent - parent
• Child child
• Who is spokesperson?
• Who is most worried?
• What is family hierarchy?
• How do they deal with conflict?
• How well do they communicate?

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Role play

• You have been asked to see Sarah, a 15yr old girl
  whose father is concerned about her weight loss.
  She had really bad flu 3 months ago, but since,
  hasnt been eating well. She is however pleased
  by her weight loss.
• Spend the next 10minutes conducting an interview
  for an assessment while addressing all concerns.

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Resilience
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Resilience

• Individual differences in response to stress- why
  are some children more vulnerable to adverse
  effects of negative environments?
• Resilience is a dynamic process that involves
  adaptations prior to, during and after stress
  exposure
• Not the type of childhood but the ability to
  reflect on it that is important

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What contributes to resilience?

• Emotional well being/high self esteem
• Empathy
• Positive social relationships
• Secure attachment

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Biological moderators

• May be endogenous eg genetic or environmental
  affecting developing brain eg poor nutrition,
  smoking
• Diathesis- stress model
• One form of MAOA Gene found in males exposure
  to childhood maltreatment ? high risk conduct
  disorder. Neither alone increased risk. (Caspi et
  al 2002)

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Caspi et al., Science August 2003Serotonin
transporter gene 5-HTT
Probability of depression
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HOMOZYGOUS SHORT
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HETEROZYGOUS L/S
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HOMOZYGOUS LONG
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17
10
No of life events
0 1 2 3 4
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Cognitive moderators

• IQ protective for developing CD if exposed to sig
  life events. Weaker predictor if no events
• Way in which appraise or give meaning to events
  important
• Negative appraisals of self or world events
  increase vulnerability to adverse environment

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Coping, temperament and relationship moderators

• Sense of personal agency
• Self reflective style
• Commitment to relationships
• Social support
• Sibling relationships
• Positive mood
• Reflective self function is key to resilience

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Temperament- behavioural predisposition inherent
but subject to environmental influence

• Described by Thomas and Chase (86) as broadly 3
  types
• Easy
• Difficult
• Slow to warm
• Bass and Plomin (84)as genetically grounded and
  able to predict adult personality
• Emotionality
• Activity
• sociability

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Treatments
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Treatments

• Prevention
• Psychological interventions
• Medications

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Prevention

• Prevention is better than cure
• Needs to be effective, feasible and
  cost-effective
• Primary vs Secondary prevention

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Types of prevention

• Universal- whole population
• Targeted- those at higher risk
• Indicated- those showing early signs

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Prevention continued

• Conduct disorder illustrates what can be achieved
  in preventive child psychiatry
• Easy to screen for risk
• Effective intervention-parent training
• Expensive and serious consequences of the
  disorder
• Lack of treatments

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Treatment

• Preference for psychological methods rather than
  medication
• Multi-disciplinary approach
• Emphasis on family involvement
• Out-patient rather than in-patient (only very few
  specialist centres)

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Psychological

• 1st line approach either alone or in conjunction
  with meds
• CBT-depression, anxiety, OCD
• Behaviour therapy-School refusal, selective
  mutism
• Parent training-Behavioural conduct problems
• Family therapy- Eating disorders
• Group therapy -Social skills problem, sexually
  abused children

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Psychological

• Occupational therapy
• Individual therapy Exposure and response
  prevention (ERP), counselling, psychodynamic,
  play therapy
• Art therapy
• Drama therapy

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Medicationsprinciples

• Medication is just part of comprehensive
  management plan
• Meds usually not 1st line
• Education of child family important
• Unlicenced/off label use
• Prescription writing age legal requirement in
  prescription-only medicines if lt12

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Medicationsprinciples

• START LOW GO SLOW
• Target symptoms, not diagnoses
• Dosage calculated in mg/kg
• Children are not small adults
• More susceptible to side effects
• Monitor response in more than 1 setting
• Avoid poly-pharmacy as much as possible

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Depression

• Fluoxetine 1st line (8yrs gt)- start 10mg
• 2nd Sertraline
• NICE-SSRIs along with psychological input but
  this is debated
• Adolescent response better than lt12yrs
• Inform parents and child of side effects- monitor
  closely
• Study found that only 10 difference between
  placebo and drug response rates-Est only 1 in 6
  will benefit
• Long half life may help if poor compliance

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Depression

• Treatment of Adolescents with Depression
  Study(TADS)-fluoxetine only patients more suicide
  related events. However for most part they help.
• Duration treatment 6-12 months then tapered
  over 6-12 weeks
• Note that due to more extensive metabolism young
  people require higher mg/kg doses.
• Be aware 20-40 presenting with depression
  develop BAD-
• if Sx severe/psychosis/rapid mood shift or
  worsens with Rx suspect BAD. Younger child
  greater risk.

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Anxiety disorders

• OCD- CBT/-
• Sertraline 1st line (6yrs gt)
• Fluvoxamine(8yrsgt), Fluoxetine, clomipramine
• ERP
• GAD CBT/-
• Fluoxetine, other SSRIs
• ?venlafaxine- unsuitable for depression
• Specific Phobias
• CBT

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Antidepressantstricyclics

• Can be used in the treatment of
• Nocturnal enuresis
• OCD
• Hyperactivity if stimulants fail
• Panic disorder
• Side effects of dry mouth, sedation, malaise,
  cardiac arrhythmias and sudden death.

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Atypical Antipsychotics

• Similar action and effect as in adults
• Most commonly used-Risperidone(0.5-3mg),
  Olanzapine, Aripiprazole
• Haloperidol-small doses in LD, not common anymore

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Atypical Antipsychotics uses

• Psychosis-
• 1st-aripiprazole/olanzapine/risperidone
• 2ndother from above group
• 3rdclozapine (olanzapine prior to this- Agid et
  al 2011)
• Disorganized behaviour
• More controversial but increasing
• ADHD
• Conduct disorder- risperidone
• Pretty much any behaviour we dont like

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• Tic Disorders
• Clonidine adrenergic alpha2 agonist
• Risperidone
• ASD
• Aggression-risperidone (licensed), ?aripiprazole
• Restrictive repetitive behaviours and interests
  -RRBIs- SSRIs (lower dose)

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Mood Stabilizers

• Lithium, Carbamazepine, Na Valproate
• Can be used in aggression
• Lithium can be used to augment antidepressants
• Bipolar Affective Disorder
• Quetiapine/olanzapine/aripiprazole/risperidone
• SGAs greater short term efficacy than mood
  stabilisers but more wt gain and drowsiness
• 2nd choice- Li
• 3rd -Carbamazapine/valproate

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ADHD

• Stimulants
• Methylphenidate
• Dexamphetamine
• Mixed amphetamine salts
• Pemoline hepatotoxic
• Non Stimulants
• NARI .Atomoxetine(4-6wks)
• TCA..Imipramine, Desipramine
• a2 agonistsclonidine
• Bupropion

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• Methylphenidate- central nervous stimulant
• s/e -insomnia, anorexia, raised BP, growth
  deceleration
• Consider-
• Comorbid conditions
• Convenience of dosing
• Diversion
• Duration
• Tolerability
• Monitoring
• Cost

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Melatonin

• Recent increase in use in CAMHS
• Used in treatment of Insomnia
• Hormone produced by pineal gland
• Licensed in gt55, off license use in children
• Usual dose between 2-4mg
• Side effects ..headaches,nausea, confusion,
  tachycardia.
• Long term side effects not yet evaluated

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Psych Meds in Kids - summary

• Very little supportive evidence for efficacy
  (except stimulants in ADHD)
• Many known side-effects
• Unknown effects long term effects on the
  developing brain and body
• Overused? recent study of child psychiatrists
  show that 9/10 of their patients are on meds
• Need much more than meds to help kids

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• QUIZ

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• 1. In child psychiatric assessments
• Theres low level agreement between parental
  reports and self-reports of childrens emotional
  symptoms
• Families and professionals explanation of
  symptoms often differ widely
• If symptoms cause distress but no social
  impairment, a disorder should not be diagnosed
• It is usually possible to identify the cause of
  disorders

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• 2. When eliciting information from parents
• Fully-structured interviews give more detailed
  picture than semi-structured
• Questionnaires are useful for screening
• With semi-structured, the presence of symptoms is
  typically rated according to the interviewers
  criteria and not the respondent
• It is usual to see the father separately to
  elicit his concerns and view of the problem
• The early childhood history is not relevant for
  disorders of adolescence

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• 3. In child assessments
• Children rarely volunteer information on
  obsessions or compulsions unless asked directly
• All children shd have a full physical exam
  including hgt, wgt and cardiac auscultation
• Most dysmorphic syndromes will be missed unless
  the child is seen undressed
• Teachers may miscontrue learning problems as
  hyperactivity

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• 4. The following are more common in boys than
  girls
• Animal phobia
• Delayed speech
• School refusal
• Teenage overdose
• Completed suicide
• Conduct disorder
• Diurnal enuresis
• ADHD
• Selective mutism

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5. Which of the following are false?

• Methylphenidate and dexamphetamine are equally
  effective in terms of ADHD symptoms
• Atomoxetine can exacerbate tic disorders by
  altering dopamine levels in the striatum
• Parent training programmes are ineffective at
  reducing hyperkinetic symptoms
• Non response rate to stimulants are greater in
  adolescents(37) than in younger children
  (20-25)

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6. Which is true?

• Provocative victims are popular with peers
• Children engaging in bullying are prone to
  anxiety and poor self-esteem
• Boys who bully are at increased risk of alcohol
  misuse in adult life
• Girls who bully characteristically use physical
  aggression
• there is a slight excess of female victims

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• ANSWERS

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Answers

• 1
• T ..parent and children report of emotional
  problems often differ.
• T
• F
• F

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Answers

• 2
• F fully structured are respondent based with
  predetermined wordings and closed questioning.
• T
• T ..semi-structured are interviewer-based" and
  allows exploration of views
• F
• F

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Answers

• 3
• T they are often ashamed of such symptoms
• F ..cardiac auscultation is rarely necessary
  unless indicated
• F ..most features appear in the head, face and
  hands that can be seen without undressing the
  child.
• T

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Answers

• 4
• F specific phobias commoner in girls
• T
• F ..equal prevalence
• F commoner in girls, also post-pubertal
  depression
• T
• T
• F- nocturnal enuresis common in boys
• T
• F equal prevalence

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Answers

• 5.
• B is false. It does not impact on dopamine levels

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Answers

• 6. c is true

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