Transcript emotional disorders - Primary and Integrated Mental Health Care

ELFT Training Packages
for Primary Care
‘MIDDLE CHILDHOOD’
- Emotional and Behavioural
problems CAMHS ELFT
Graeme Lamb
Clinical Director
Learning objectives: by the end of
this lecture students should
• Know the presentation, aetiology, epidemiology of
common behavioural problems (ADHD, conduct and
oppositional defiant disorder) presenting to child and
adolescent psychiatry.
• Know the presentation, aetiology, epidemiology of
common emotional problems (anxiety, depression,
school refusal) presenting to child and adolescent
psychiatry.
• Consider the multidisciplinary management of these
presentations in middle childhood.
Overview
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Review of developmental stages
Emotional disorders - overview
ADHD
Conduct problems
Developmental issues
• Physical Development
• Cognitive Development
• Emotional Development
• Affective Development
Developmental tasks
continue through middle
childhood in the same
domains as in early
childhood
Developmental issues
• Physical Development
• height, motor skills
• Cognitive Development
• Academic, logic,
reasoning
• Emotional Development
• Friendships (Same –
sex), teamwork, morality
• Affective Development
• Motivation, self esteem,
sense of self
Disorders of Middle Childhood
• Emotional disorders
• School Refusal
• Hyperkinetic disorder
(ADHD)
• Conduct disorder
Includes:
•Anxiety
•Depressive
•Mixed emotional disorders
•Is it Common ?
•Prevalence rate of 4% in 5-15-year-olds
EMOTIONAL DISORDERS:
How do emotional disorders present
in children?
Is it different to adult anxiety
and depression?
• Symptoms (more commonly
mixed symptoms)
• Anxiety and Misery
• Somatic complaints
• Irritability/oppositional
• Features
• Less pervasive
• Less clear cut biological symptoms
• Associated presentations
• Developmental regression
• Academic decline, school refusal
• Simple suicidal ideas
Emotional disorders:
Aetiology
• Child:
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genetic
temperamentally anxious
behavioural inhibition
physical health problems
PRACTICE POINT:
• Family:
• emotional over-involvement
• over-protection
• Environment:
• social adversity
• stressful experiences
Remember the aetiological
grid (predisposing,
precipitating and perpetuating)
in each of these three domains
when assessing cases
Emotional disorders:
Management
Psycho-education
Support parents in
 comforting the child
 encouraging facing of difficult situations
 ensuring there is not excess avoidance
 family therapy
Individual work with the child on
 anxiety management including relaxation techniques
 behaviour therapy
 cognitive –behavior therapy
Work with other agencies
 Liaison with school to establish graded return and provide
emotional support (especially in school refusal)
Medication
 Used much less regularly
 Less clear evidence base in middle childhood
Emotional disorders: Outcome
• The majority of children with emotional disorders
improve
• But remain anxiety prone and vulnerable to depression
• Risk of recurrence of increased if
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Family history of depression
Lack of complete recovery
Pre-existing social dysfunction
History of sexual abuse
Family discord
• Life time rates of recurrence are as high as 70%
Birmaher et al 2002 Course and outcome of child and adolescent major depressive disorder. Child and Adolescent
Psychiatric clinics of North American 11, 619-637
Comorbidity
•At least a third meet the criteria for 2 or
more anxiety disorders.
•Other co-morbidities
• Conduct disorder
• ADHD
• Depression
• Autistic Spectrum Disorders ( Muris et al 84%)
Muris P, Steerneman P, et al (1988) Comorbid anxiety symptoms in children with pervasive developmental disorders.
Journal of Anxiety Disorders 12 387-93
Hyperkinetic disorder (ADHD)
Conduct disorder
BEHAVIOURAL DISORDERS
OF MIDDLE CHILDHOOD
Learning Outcomes: By the end of
this lecture students should
• Know the presentation, aetiology,
epidemiology of common behavioural
problems (ADHD, conduct and
oppositional defiant disorder) presenting to
child and adolescent psychiatry.
• Consider the multidisciplinary
management of these presentations.
Attention
Deficit
Hyperactivity
Disorder
ADHD or Hyperkinetic
Disorder
Characteristic Features
ADHD
Prevalence
0.5%- 1% of children
Hyperactivity
More common in boys
4:1 M:F
Inattention
Impulsivity
ADHD
Discussion
Why might it be seen more
commonly in boys?
Characteristic Features
Hyperactivity &
Restlessness:
ADHD
Hyperactivity
Inattention
Impulsivity
• Can’t sit still
• Squirms in seat
• Fidgety
• Unable to wait (queues,
games, conversations)
Characteristic Features
ADHD
Impulsivity
Hyperactivity
Inattention
Impulsivity
• Impulsive acts – runs into
road
• Acts without thinking
• Answers before question is
completed
• Trouble waiting for turn
Characteristic Features
ADHD
Innattention
Hyperactivity
Inattention
Impulsivity
•Jumps from task to task
•Can’t focus at school, makes
careless mistake, forgets things
•Not listening properly to
rules/instructions
Making a diagnosis
• Symptoms
– Core features of ADHD must be present in more than
one setting (eg school and home)
– Present early in development
• Assessment
– Requires history from parents and school and direct
observation in clinic
– Assessment can be supplemented by structured
questionnaires such as the Conner’s Questionnaire.
Hyperkinetic disorder: Aetiology
•Child:
• neuro-developmental abnormalities
• temperamental factors
• genetic factors
•Family:
• maternal depression and smoking in
pregnancy
Asherton et al (2005) Unravelling the complexity of attention-deficit hyperactivity disorder. British Journal of Psychiatry,
187, 103-105
Why is it important to recognise
ADHD?
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Under performance at school
Getting into trouble at school
Relationship/Peer problems
Employment
Crime, drugs and alcohol
ADHD
TREATMENTS
Interventions
• Behavioural
interventions
• School interventions
• Social skills work
• Diet
• Parenting support
• Medications
Examples
Treatments for ADHD
TREATMENTS
Interventions
• Behavioural
interventions
• School interventions
• Social skills work
• Diet
• Parenting support
• Medications
Examples
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Positive reinforcement - lots
of praise immediately after
good behaviour
Reward system: Star charts,
a treat (not sweets)
Clear boundaries and
instructions (just before,
check they’ve understood)
Consistent consequences for
bad behaviour.
Structure and routine.
Treatments for ADHD
TREATMENTS
Interventions
Examples
• Behavioural
interventions and
parenting programmes
• School interventions
• Social skills work
• Diet
• Medications
• Sit near front, away from
distractions, Time out
• Use timetables, highlight
reminders, extra pens/kit
• Break large tasks into
smaller tasks.
• Ensure appropriate
support for co-morbid
specific learning problems
Treatments for ADHD
TREATMENTS
Interventions
• Behavioural
interventions and
parenting programmes
• School interventions
• Social skills work
• Diet
• Medications
Examples
• Work through common
problem areas:
– Supermarkets
– Parties
– Playing with others e.g
turn taking
Treatments for ADHD
TREATMENTS
Interventions
Examples
• Behavioural
interventions and
parenting programmes
• School interventions
• Social skills work
• Diet
• Medications
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Caffeine
Cordials
Colouring
Sugar
• NB: There is insufficient
evidence to link food
additives to ADHD, but worth
taking detailed food and
activity diary
Treatments for ADHD
Interventions
Examples
• Behavioural
interventions and
parenting programmes
• School interventions
• Social skills work
• Diet
• Medications
• Methylphenidate /
Ritalin/Concerta
– “stimulant”
– Allows child to focus,
calmer, think before
acting
Medication for ADHD
• Medication has common side
effects
• Headache, stomach ache
• Appetite suppression
• Growth suppression
• Medication has less common
but important side effects
• Increased pulse and blood
pressure
• Medication has rare and serious
side effects
• Sudden cardiac death if
underlying conduction problems
• Others to consider
• Tics (but this is a common
comorbidity)
• Regular Medical monitoring
• Pulse and blood pressure
• Height and weight
• All plotted and growth centile
charts
Childhood and Adolescence
CONDUCT DISORDER
Conduct Disorder
ICD -10 Diagnosis
Epidemiology
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• 5-10 years
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Repetitive and persistent pattern
of dissocial, aggressive, or
defiant conduct
• 7% boys
• 35 girls
• 11-16 years
More severe than ordinary
childish mischief or adolescent
rebelliousness. (5% of 10 year
olds)
Present >6 months
• 8% boys
• 5% girls
• Looked after children (those
experiencing abuse or on child
pr0tection registers)
• Up to 40% conduct disorders
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Note ODD in younger children
Source. Office National Statistics
2005
Conduct Disorder
Examples
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Excessive fighting or bullying;
Cruelty to animals
Destruction to property
Firesetting
Stealing
Repeated lying
Truancy from school
Running away
Severe temper tantrums
Defiant provocative behaviour
Persistent severe disobedience
Conduct disorder: Outcome
• Varies considerably with the
nature and extent of the
antisocial behaviour
• Risk factor for wide range of
negative outcomes
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Antisocial personality disorders
Criminal and violent offending
Drug use
Poor physical healthy
Sexually transmitted infections
Other psychiatric disorders
(mania, schizophrenia, suicidal
behaviour)
Moffitt et al (2002) Males on the life-course persistent and adolescence-limited antisocial
pathways: follow-up at age 26. Development and Psychopathology, 14, 179–206.
Kim-Cohen et al (2003) Prior juvenile diagnoses in adults with mental disorder: developmental
follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 60, 709–717.
Finally…
• Full of challenges for children and parents
and schools
• Assessment and treatment has to
therefore include child, family and
education
• Look for change in behaviour, school
performance, physical health