Transcript Slide 1

MRCPsych Phase 11
CAMHS Module
Dr Femi Akerele
ST5 CAMHS
Plymouth
Session outline
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Taking history in CAMHS
Communicating with children
Conducting a family interview
Treatments in CAMHS
Resilience
How?
• Lecture slides
• Group work
• Role play / mock
• Quiz
History Taking
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Essentially same components as adult but:
Involve parents/family
Greater emphasis on family relationships
Collateral information
Importance of observation
Importance of developmental history
History Taking… 5 key components
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Symptoms
Impact
Risks
Strengths
Explanatory model
Developmental History
Task:
Present the important and relevant aspects
of a developmental history
Communicating with children and
Families
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
Why is good communication with
children important?
• It helps the doctor to understand the
child’s 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
Communication difficulties
• Language development
Child may not have adequate speech to
describe language and feelings
• Cognitive devt
Child may not have reached the necessary level
of understanding
• Emotional devt
Child may be wholly or partially dependant on
parental support.
Aids to communication
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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 and sym
Appropriate vocabulary
Vocabulary with children
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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
The parent
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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
2 patients!
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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
Don’t take sides or compete
Negotiate to interview each separately if they wish
Keep the boundaries safe
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
Interviewing the child
• 1° objective is establishing rapport and
gaining confidence
• Invite the child to play, paint or draw
• Begin away from the problem….hobbies,
interests, school, friends, etc
• Enquire about child’s view of the problem
• Be flexible in approach
The interview
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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.
Establishing rapport
• The 1st few minutes are very important…
• Greet the child by his 1st name
• Preferably introduce yourself by 1st name (Dr
with adolescents)
• Start with questions the child can answer…”how
old are you?”,“who’s your best friend?”.
• Have a working knowledge of types of toys and
activities for his age
• Engage them in activities…play, drawing, roles
play (e.g as a doctor)
Role play
Volunteer?
Role play
• You have been asked to see Sarah, a 15yr old
girl whose father is concerned about her weight
loss. She had a really bad flu 3 months ago, but
since, hasn’t 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.
Treatments
• Prevention
• Psychological interventions
• Medications
Prevention
• “Prevention is better than cure”
• Needs to be effective, feasible and costeffective
• Primary vs Secondary prevention
Types of prevention
• Universal
• Targeted
• Indicated
Prevention … continued
Conduct disorder illustrates what can be
achieved in preventive child psychiatry:
• Easy to screen for risk
• Effective intervention
• Expensive and serious consequences of the
disorder
• Lack of treatments.
Treatments…continued
• 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)
Psychological
• CBT… depression, anxiety, OCD
• Behaviour therapy… star charts, graded
exposure
• Parent training… behavioural & conduct
problems
• Family therapy… e.g eating disorders
• Group therapy …social skills problem,
sexually abused children
Psychological
• Occupational therapy …???
• Individual therapy… counselling,
psychodynamic, play therapy
• Art therapy
• Drama therapy
Medications…principles
• Medication is just part of comprehensive
management plan
• Meds usually not 1st line
• Children are not small adults
• More susceptible to side effects
• Education of child + family important
Medications…principles
• START LOW
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GO SLOW
Target symptoms, not diagnoses
Dosage calculated in mg/kg
Monitor response in more than 1 setting
Avoid poly-pharmacy as much as possible
ADHD
Stimulants
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Methylphenidate
Dexamphetamine
Mixed amphetamine salts
Pemoline …hepatotoxic
Non Stimulants
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NARI …….Atomoxetine
TCA…..Imipramine, Desipramine
α2 agonists………clonidine
Bupropion
Antidepressants
Depression
• Fluoxetine 1st line (8yrs >). 2nd Sertraline
OCD
• Sertraline 1st line (6yrs >)
• Fluvoxamine(8yrs>), clomipramine, Fluoxetine
Anxiety
• Fluoxetine, other SSRIs
NB..Paroxetine & Venlafaxine unsuitable
Antidepressants…tricyclics
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.
Atypical Antipsychotics …uses
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Psychosis
Disorganized behavior
Bipolar disorder
Tics
More controversial but increasing:
– ADHD
– Conduct disorder
– Pretty much any behavior we don’t like
Atypical Antipsychotics
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Similar action and effect as in adults
Most commonly used ..Risperidone(0.5-3mg)
Olanzapine, Aripiprazole,
Clozapine ..for treatment resistant Schz
Haloperidol…tics, not common anymore
Risperidone indicated Rx of aggression in
autism and conduct disorder.
Melatonin
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Recent increase in use in CAMHS
Used in treatment of Insomnia
Hormone produced by pineal gland
Licensed in >55, ‘off license’ use in children
Usual dose between 2-4mg
Side effects ..headaches,nausea,
confusion, tachycardia.
• Long term side effects not yet evaluated
Mood Stabilizers
• Lithium, Carbamazepine, Na Valproate
• Often used in Rx of Bipolar disorder and
aggression
• Lithium can be used to augment
antidepressants
• More recent use of atypical antipsychotics
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
QUIZ
1. In child psychiatric assessments:
a) There’s low level agreement btw parental reports
and self-reports of children’s emotional symptoms
b) Families and professionals’ explanation of
symptoms often differ widely
c) If symptoms cause distress but no social
impairment, a disorder shd not be diagnosed
d) It is usually possible to identify the cause of
disorders
2. When eliciting information from parents:
a) Fully-structured interviews give more detailed
picture than semi-structured
b) Questionnaires are useful for screening
c) With semi-structured, the presence of symptoms
is typically rated according to the interviewer’s
criteria and not the respondent
d) It is usual to see the father separately to elicit his
concerns and view of the problem
e) The early childhood history is not relevant for
disorders of adolescence
3. In child assessments:
a) Children rarely volunteer information on
obsessions or compulsions unless asked directly
b) All children shd have a full physical exam
including hgt, wgt and cardiac auscultation
c) Most dysmorphic syndromes will be missed
unless the child is seen undressed
d) Teachers may miscontrue learning problems as
hyperactivity
4. The following are more common in boys than girls:
a) Animal phobia
b) Delayed speech
c) School refusal
d) Teenage overdose
e) Completed suicide
f) Conduct disorder
g) Diurnal enuresis
h) ADHD
i) Selective mutism
ANSWERS
Answers
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a) T ..parent and children report of emotional
problems often differ.
b) T
c) F
d) F
Answers
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a) F …fully structured are “respondent based” with
predetermined wordings and closed questioning.
b) T
c) T ..semi-structured are “interviewer-based" and
allows exploration of views
d) F
e) F
Answers
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a) T …they are often ashamed of such symptoms
b) F ..cardiac auscultation is rarely necessary unless
indicated
c) F ..most features appear in the head, face and hands
that can be seen without undressing the child.
d) T
Answers
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a)
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F …specific phobias commoner in girls
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F ..equal prevalence
F …commoner in girls, also post-pubertal depression
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F …equal prevalence