Transcript Dr N Portch 26th October 2012

Dr Nazma Portch
ST5 CAMHS
Plymouth
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Taking history in CAMHS
Communicating with children
Conducting a family interview
Treatments in CAMHS
Resilience
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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
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Symptoms
Impact
Risks
Strengths
Explanatory model
-Why is it important?
-What are the important and relevant
aspects of a 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?
• What age do children?
– Walk
– Talk
– Ride a tricycle
– Draw person
– Play fantasy games
• 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
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Ride a tricycle- 3 years
Draw person with 6 parts- 5 years
Fantasy games – 2yrs
remember there is range of ‘normal’
• 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
• 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
• 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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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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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
• 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
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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
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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.
• 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…
– Who has come along?
– 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,
• Why do they think they are here?
• Why do you think they are here?
• Enquire about child’s 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
• 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
• 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
• Child – behaviours, symptoms, responses,
play etc
• Interactions
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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?
• 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.
• 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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Emotional well being/high self esteem
Empathy
Positive social relationships
Secure attachment
• May be endogenous eg genetic or
environmental affecting developing brain
eg poor nutrition, smoking
• Diatheses- 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)
Probability of depression
31%
40%
HOMOZYGOUS SHORT
30%
51%
HETEROZYGOUS L/S
20%
HOMOZYGOUS LONG
18%
17%
10%
No of life events
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4+
• 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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Sense of personal agency
Self reflective style
Commitment to relationships
Social support
Sibling relationships
Positive mood
• Reflective self function is key to resilience
• Prevention
• Psychological interventions
• Medications
• “Prevention is better than cure”
• Needs to be effective, feasible and costeffective
• Primary vs Secondary prevention
• Universal
• Targeted
• Indicated
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.
• 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)
• 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
• Occupational therapy …???
• Individual therapy… counselling,
psychodynamic, play therapy
• Art therapy
• Drama therapy
• 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
• 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
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
Depression
• Fluoxetine 1st line (8yrs >). 2nd Sertraline
OCD
• Sertraline 1st line (6yrs >)
• Fluvoxamine(8yrs>), clomipramine, Fluoxetine
Anxiety
• Fluoxetine, other SSRIs
NB..Paroxetine & Venlafaxine unsuitable
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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Psychosis
Disorganized behavior
Bipolar disorder
Tics
More controversial but increasing:
– ADHD
– Conduct disorder
– Pretty much any behaviour we don’t like
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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.
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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
• 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
• 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
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
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
a) Methylphenidate and dexamphetamine
are equally effective in terms of ADHD
symptoms
b) Atomoxetine can exacerbate tic disorders
by altering dopamine levels in the
striatum
c) Parent training programmes are
ineffective at reducing hyperkinetic
symptoms
d) Non response rate to stimulants are
a) Provocative victims are popular with
peers
b) Children engaging in bullying are prone to
anxiety and poor self-esteem
c) Boys who bully are at increased risk of
alcohol misuse in adult life
d) Girls who bully characteristically use
physical aggression
e) there is a slight excess of female victims
ANSWERS
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a) T ..parent and children report of emotional
problems often differ.
b) T
c) F
d) F
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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
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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
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a)
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F …specific phobias commoner in girls
T
F ..equal prevalence
F …commoner in girls, also post-pubertal
depression
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g)
h)
i)
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T
T
F …equal prevalence
• 5.
• B is false. It does not impact on dopamine
levels
• 6. c is true