Transcript Mental Health

Child and Adolescent Mental Health
Services:
Psychiatric disorders in Learning
disability
Dr Latha Hackett
Consultant in Child and Adolescent Psychiatry
Dr Jo Bromley.
Consultant Child and Adolescent Clinical Psychologist.
Child & Adolescent Mental Health
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Mental Health.
Mental Health Problem.
Mental Disorder/ illness.
Psychiatric disorders in Children and
Adolescent with Learning disability.
 CAMH services in Manchester.
Mental Health
 The ability to develop psychologically, emotionally,
intellectually and spiritually.
 The ability to develop and sustain emotionally
satisfying personal relationships.
 The ability to become aware of others and to
empathise with them.
 The ability to use psychological distress as a
developmental process, so that it does not hinder
or impair further development.
Indicator of Good Mental Health
 A capacity to enter and sustain mutually satisfying
personal relationship.
 Continuing
progression
of
psychological
development.
 An ability to play and to learn so that attainments
are appropriate for age and intellectual level.
 A developing moral sense of right and wrong.
 The degree of psychological distress and
maladaptive behaviour within normal limits for the
child’s age and context (Hill, 1995).
Mental Health Problems
Are difficulties/disabilities may arise due to  Congenital Factors.
 Constitutional Factors
 Environmental Factors
 Family Factors.
 Illness factors.
Child/Family/Environment.
Mental Health Problem
Presenting features are outside the  The normal range for the child’s age,
intellectual level & culture
&
 This causes suffering to the child or others
in contact as a consequence.
Mental Health Problem
There is  Change in the child’s usual behaviour,
emotions or thoughts.
 Persistence of the problem – for at least 2
weeks.
 Severe enough to interfere with the child’s
everyday life
 A disability to the child and or the carers.
Mental Health Problem
Can cause concern & distress e.g.
 Developmental difficulty – Speech and
language disorder.
 Educational Difficulties – Specific reading
retardation or other LD.
 Social difficulties –Parental Violence, sexual
abuse or illness.
Mental Health problem Vs
Disorder
 Symptoms of Mental health Problem &
Mental disorder/illness are similar.
 Behaviour problems – common pathway for
variety of underlying problems.
 Mental Disorder is not an exact term.
Mental disorder/Illness.
 Existence of a clinically recognisable set of
symptoms
Or
 Behaviour associated with distress and
interference with personal function
(impairment).
Mental Health Problem Vs
Disorder
 When does a problem become a disorder?
 When does a fever a URTI or a Meningitis?
 When is a headache a symptom of stress or a
brain tumour?
 Behaviour a symptom of ASD?
 When does a cold become a pneumonia?
 Low mood to a depressive illness?
 Normal dieting to a eating disorder – AN?
 Sensitive to others comments – delusion – to a
psychotic illness.?
Mental disorder.
What leads to a mental Disorder?
 Predisposing factors.
 Precipitating factors.
 Perpetuating factors.
 Protective factors.
These are all associated factors not causal
factors.
Predisposing factors – Child
Factors
Genetic influences – Boys > Girls.
Low IQ & LD
Specific Developmental delay.
Communication difficulty.
Difficult temperament.
Physical illness esp. – chronic illness & or
Neurological
 Academic failure
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Predisposing -Family Risk factors
 Parental conflicts, family breakdown.
 Inconsistent or unclear discipline.
Hostile or rejecting relationship
 Failure to adapt to child’s changing dev
needs.
 Abuse – physical/sexual &/ or emotional
 Parental psychiatric illness, criminality,
alcoholism & personality disorder.
Predisposing -Environmental
factors
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Socio-economic disadvantage.
Homelessness.
Disaster
Discrimination.
School – bullying and other factors.
Precipitating Factors.
Any reason that leads to the presentation of
symptoms e.g.
 DSH following an argument with loved one.
 Change from Primary to secondary school in
a child with SCD.
 A physical illness leading to school refusal.
Protective factors
 Self esteem, sociability & autonomy.
Average or above average IQ.
 Family compassion. Warmth & absence of
parental discord.
 Social support systems that encourage
personal effort and coping.
CAMHS.
0.075 % children will need Tier 4
1.85% Tier 3
7% Tier 2
15% Tier 1
Psychiatric disorders and Learning
disability
 1-3 % of the population have LD - Mild to
profound LD (MR for ICD X and DSM IV).
 Of these 80% are Mild (50-70), 12% Moderate (35-49 ). 7% - Severe (20-34),
1% - profound - <20)
 Educational terms – 50-70% moderate
Learning Difficulty. < 50 Severe LD
 Medical term – ICD X Mental retardation.
RCPsych – learning disability.
Psychiatric Symptoms and Disorders
Mild MR ( (IQ 50-69):
 Psychiatric disorder has the same
distribution as in children of normal IQ.
Hyperkinesis/ADHD.
Conduct Disorder.
Emotional disorders.
Depression.
Asperger’s syndrome.
Psychiatric Symptoms and Disorders
Severe MR (IQ <50).
 Psychiatric disorder predominantly
PDD/Autism.
Severe Social Impairment.
Self-injurious behaviour.
Psychiatric Symptoms and Disorders
Other disorders.
 Mood disorders.
 Schizophrenia and other disorders
 Obsessive Compulsive disorder
 Eating difficulties.
 Mental Illness secondary to a medical disorder –
Seizure disorder, anaemia, malnutrition, pain due
to any physical cause, brain tumour, degenerative
disorder, endocrine problem, accidental poisoning,
side effects of drugs
Presentation of Psychiatric disorders
 ADHD – Present <7, Inattention, poor concentration,
Hyperactivity.
 ASD – Present before the age of 3. The triad.
 OCD – Obsessions, rituals with compulsion
 Tourette’s disorder – motor and vocal tics.
 Anxiety disorder – Common problem -10%. panic dis,
specific ph, social ph, PTSD, gen anx dis, acute stress dis.
Fragile X – social anxiety & shyness , William Syndrome –
anxiety and fearfulness. Adole – hyperactivity.
Prader-Willi – anxiety, low self esteem and OC preoccupation – cleanliness and food.
ASD – anxiety common.
Presentation of Psychiatric disorders
 Mood disorder – Change in beh – regressive,
pica, rocking, tearfulness, diurnal var mood, loss
of energy, interest, social isolation, disturbed
sleep, appetite, SIB, weight loss, screaming,
aggression. Down’s syn & ASD – adole dep
common – mistaken for oppositional beh.
 Psychotic illness – Schizophrenia and Bipolar
disorder – change in beh., irritability, disorganised
beh, poverty of thought, social and intell funct
worsening, striking out or shouting at empty space
- clues to hallucinations.
Assessment.
1. Developmental/Cognitive assessment is crucial
 Expectation may be wildly inappropriate.
 Need to evaluate symptoms in developmental
context.
2. Communication difficulties – usefulness of art
3. Organic factors
 Epilepsy & medication.
 Behavioural phenotypes.
 Physical examination.
4. Reliance on observation.
 Changes, deterioration in intellectual functioning.
 Emergence of new behaviour.
 Behavioural analysis.
5. Family issues.
Coming to terms/anger/denial/chronic sorrow.
Life cycle – eg leaving home.
Dependence/independence.
Parental and sibling emotional disturbance and family
disharmony.
Vulnerability to abuse/ scape goating -?MR may as act as
protective(severe) or vulnerability factor (mild)
6. MR may affect vulnerability to environmental
adversities.
7. Social factors – loss of earning, restricted
opportunities and social isolation.
Educational effects – to get the right educational
input is difficult. Variation between school and
authorities do not help. Lack of resources.
Treatments
 Psychological – Behavioural, CBT, Family,
social skills, individual psychodynamic.
 Environmental – respite, educational etc.
 Medical – Commonest – Methylphenidate,
Melatonin, Risperidone, antidepressants
and other psychotropics as appropariate.
Referral Pathway.
 Direct referrals – General Practitioners,
Community Paediatricians, Hospital
Paediatricians, School doctors.
 Other referrals from education psychologists,
EWO’s - Referrer has discussed with the GP/
School doctors/Com Paed. Copied to the GP
 HV, SN – referral discussed with the GP or Com
Paed, referral copied to the GP.
 SS & YOT – Liaison meetings
CAMHS in Manchester – Tier 2 3
&4
CAMHS directorate - Tier 2 & 3
 North – Psychology, Psychiatry (BHH) CPN.
 Central – Psychology & Psychiatry – Winnicott Centre.
 South – Psychology & Psychiatry – Carol Kendrick unit.
 Youth Access Team, special projects – CAPS, CAPS TIP,
CP-LAC, CP-LD, Manchester Link etc.
Tier 4 – Booth hall, McGuiness unit & CAFTU at the Winnicott
Centre.
All services are made of small number of clinicians.
Treatments offered.
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Psychotherapy.
Behaviour therapy.
Cognitive behaviour therapy.
Parent training
Family Therapy.
Group therapy.
Medication.
Where do we work from
The assessments are undertaken where ever
it is appropriate in the unit, school or home
situation.
Treatments offered will depend on the clinical
situation.
Professionals.
 Child and adolescent psychiatrists
 Clinical Psychologists.
 Nurses in Child Psychiatry – Practitioners,
Therapists and CPN.
 Child & Adolescent Mental Health
Practitioners/Therapists.
 Specialist Speech and Language therapists
Assessments & Interventions
 Complex.
 Lengthy.
 Partnership between child/family, other
agencies.