Transcript Psychiatric Inpatient Places for the under 18s

Jane Morris
 Literature
 Psychology
 Medicine
 Motherhood
 Cullen
 Glasgow
 Edinburgh
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Child and Adolescent Psychiatry are
surprisingly different from Adult Psychiatry
Some of this is about different responses and
traditions rather than different problems –
CAMHS accept referrals where there is social
dysfunction even in the absence of ‘diagnosis’
Child psychiatry is genuinely different from
Adolescent Psychiatry...
...but fun and playfulness are essential in both
The practice of Adolescent psychiatry could
teach adult psychiatrists a great deal - it
taught me, anyway – about formulation and
systemic awareness and daily use of
psychotherapeutic approaches....
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...and about the evolution of mental illnesses
and dysfunctional defences.
The role of sleep, activity, rest & nutrition in
mental as well as physical development
The very existence of Asperger’s and the
autistic spectrum was an eye-opener
- Sula Wolff’s ‘Loners’
That transitions need to be handled well – so
that the loss and progression are meaningful
and educational rather than destructive
Above all, that a well-integrated team is
wisdom incarnate!
 Sue Palmer
 Harry Burns ‘The Biology of Poverty’ 2008
 My daughter’s school
 Suicides at school
 Streetwise young people
 www-wise young people
 Body image conscious & ashamed – obesity & anorexia
 Alcohol and other substances (caffeine in Buckfast!)
 Child protection, health & safety and other defensive
approaches
PERSONALITY = TEMPERAMENT + CHARACTER
If temperament is relatively fixed (New
York Longitudinal Study on Infant
Temperament, Thomas & Chess 1984)
can we at least find interventions that
are ‘character-forming’?
....and where do traits, constructs,
schemata, defences,
factors etc etc fit in to
all this?
Are they learned?
If so, when?
Can they be un-learned or re-learned?
When and how?
 SSRIs and neuroleptics eg olanzapine
 Undoubtedly swing the balance in some cases,
allowing learning to occur
 How do they work?
 No coincidence that at high dose SSRIs or low dose
neuroleptics are anxiolytic
 Reducing the amount of anxiety and arousal the
individual has to experience to within a
manageable amount
 Scott recommends a ‘picture fitting’ approach to
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diagnosis for treatment purposes, though a ‘menu-driven’
approach may be necessary in research
Conduct disorder certainly associated with discord in the
family home but what is cause and what is effect?
Scott even considers that disordered attachment may be a
consequence as well as a cause of disorder
.. 1982 Patterson found more, unclear and inconsistent
commands issued in families of CD children
Virginia Twin study interviewed fathers, mothers and
young people for evidence of heritability of CD – based
on Dads’ accounts it is 27% herrtable, according to child
36%, according to Mum’s accounts it is 69% heritable!
 D4DR gene : 1996 2 independent teams reported
association of novelty-seeking/risk taking/impulsivity
with polymorphism in a gene on short arm of
chromosome 11 – associated with dopamine receptor
expression
 SLC6A4 gene on chromosome 17 associated with
reduce serotonin uptake and associated with greater
fearfulness/neuroticism – on of at least a dozen genes
found to be associated with ‘neuroticism’
 As well as dopamine and serotonin, oxytocin,
vasopressin and prolactin involved in social bonding,
and hypophyseal-adrenal axis response to social
challenge mediates early brain development
Transplanting a gene from the monogamous
prairie vole transforms the behaviour of
promiscuous mice
 1994 Brunner, Nelson et al – MAO gene
mutation in Dutch family associated with
extreme aggression in males who possessed
the gene
 2002 Caspi et al In a large sample of abused
children, only those with gene for low MAO
activity went on to be antisocial in adult life
 Animal evidence also suggests wellpreserved serotonin function helps to
attenuate aggressive impulses
The power of the
environment to affect
genes - their
transmission and
expression!
 The biology of stress hormones, acute and chronic
 Their effects on mood, arousal, aggression and learning
 Applications to abused and traumatised children and
their parents and the interactions between the two
 Deblinger and Heflin’s Trauma-focussed CBT for
sexually abused children – healing by imaginal exposure
and relearning
 Parent interventions often shown to benefit the child –
do they also benefit the personality of the parents?
 CD the commonest reason for referral to
child psychiatry – 5 – 10% all children and
adolescents
 Often co-exists with ADHD but not
interchangeable disorders
 Commoner in boys
 Seen where lower SES and larger families
 Has the 2nd highest continuity into adult life
of all traits
 About half of childhood onset CD persist into adult
life but only 15% adolescent onset cases persist
 Remember to differentiate and treat if co-morbid –
- ADHD,
- PTSD,
- ASD,
- Specific & general LDs,
- mood disorders
- Substance abuse
 Differentiate ‘subcultural deviance’
Brenda Renz
 Day service for children under 14
 Only one referral to Glasgow IPU
in 5 years
 Very close adherence to Webster-Stratton Incredible
Years programme
 Both parenting groups and ‘Dinosaur School’
elements, but in fact parenting intervention known to
be almost as effective alone
 Warmth, energy, nurturing, play!
6 randomized control group evaluations of the parenting
Intervention by the program developer & colleagues
and 5 independent replications indicated  increases in parent positive affect such as praise and reduced
use of criticism and negative commands.
 Increases in parent use of effective limit-setting by replacing
spanking and harsh discipline with non-violent discipline.
 Reduced parental depression, increased parental selfconfidence.
 Increased positive family communication & problem-solving.
 Reduced conduct problems in children’s interactions with
parents and increases in their positive affect and compliance
to parental commands.
ALSO
 Maintenence of benefits in 75% cases 5-6 years later
 How do we select families for the
intervention?
 When should the child as well as parents be
involved?
 Are the boundaries between social control
and child psychiatric care too blurred?
 When the child is creeping like snail
unwillingly to school, is this a psychiatric
disorder?
 How much is enough? - Rutter on Surestart
 Adolescence as a second phase of amazing
brain development – scans of Jay Giedd
After puberty many more cases of conduct disorder,
but in general those already present in childhood likely
to endure, whereas those of adolescent onset likely to
‘burn out’ by mid twenties
Edinburgh Connect uses a tiny staff team to consult
with carers of looked after children, including those in
Social Work homes and those in foster care, rather
than taking on large direct caseloads.
Emergence of ‘Borderline Disorder’ now recognised
•Psychiatric clerking and psychology assessment
•Developmental assessment from parents
•Home visits
•School reports & assessment in our schoolroom
•Observation of patient with peers both in formal
groups and informal space
•Physical and growth records
•Team formulation meeting and review with young
person and family
•Development (after 6 weeks) of tailormade care plan
 Individual work with psychologist and key worker
 Dynamic risk management
 IPT, DBT, CBT, CAT
 Groups – Psychodynamic, DBT, art therapy, practical,
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out and about, social skills etc
Attention to nutrition, sleep, diurnal rhythms
Medication – or its withdrawal!
Lunches, snacks, games, sitting room, garden – social
Family work, formal family therapy, sometimes BFT
Education – own school or schoolroom
6 weekly reviews
Careful discharge planning and transition care
 Works with DSH risk – avoid rewarding risk taking
and instead use attachment to reward healthy
responses
 Teaches skills of mindfulness, emotion regulation,
distress tolerance and interpersonal skills to
replace unhealthy acting out
 Stresses need for regular team communication
and supervision – approach is by team, not by
individual therapist
 Playful and irreverent
 Large scale, cheap versions don’t work!
 Not all are helped
 The most resistant cases are least likely to benefit but
use up the resource
 The environment is increasingly toxic and we are not
keeping up with its risks (eg new technologies, where
most teenagers are savvy but older porfessionals often
naive)
 Nutrition is getting worse, activity and sleep are
reduced, substance abuse is ever more available
 It is not inevitable that interventions can help but they
CAN harm!
 Environmental manipulations can even affect genes
 There are known effective parenting treatments to
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address substantial numbers of cases of prepubertal CD
and ODD, which are the enduring problems
BPD increasingly appears to be a disorder of immaturity
which can mellow out, particularly with therapy, not a
life sentence
Medication can help though it may not cure and is not
limited to the treatment of comorbid conditions
The study of stress and trauma responses is increasingly
open to multidisciplinary exploration
A new generation of clinicians is passionate
about personality and psychotherapy!