CAMHS Overview Dr Mahesh Kulkarni Consultant Child and Adolescent Psychiatrist Dr Nefeli Karakitsou CAMHS Speciality doctor MRCPsych Dr Jenny Doe Consultant Clinical Psychologist Luton & Dunstable hospital 25.04.2017

Outline Distinction between mental health problems and disorders Prevalence of mental health problems seen in CAMHS Risk and protective factors Specific factors related to CAMHS assessments Anxiety disorders, Depression

Experiment 3 + 5 = 8 9 + 3 = 12 4 + 7 = 10 6 + 3 = 9

Prevalence of Mental Health Problems Distinction needs to be made between mental health problems and disorders

Problems: are seen to encompass a very broad range of emotional and behavioural difficulties which may cause concern or distress. They are relatively common and encompass mental disorders Disorders: are more severe and persistent and usually defined using fairly clear diagnostic criteria

World Health Organization Worldwide 10-20% of children and adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14 and three-quarters by mid-20s. Neuropsychiatric conditions are the leading cause of disability in young people in all regions. http://www.who.int/mental_health/maternal-child/child_adolescent/en/

Common CAMHS Disorders Mood disorders Anxiety disorders and OCD Eating disorders e.g. pre-school or later anorexia / bulimia Deliberate self-harm Conduct disorder Attachment disorders Hyperactivity & attention problems Developmental disorders, e.g. delay in acquiring speech, social or other skills or more pervasive developmental disorders, like autism Habit disorders, e.g. tics, sleeping problems, soiling Post-traumatic stress syndromes Psychotic disorders, e.g. schizophrenia, mania, delusional depression, drug-induced states Kessler et al 2005

Risk factors having a long-term physical illness having a parent who has had mental health problems, problems with alcohol or has been in trouble with the law experiencing the death of someone close to them having parents who separate or divorce having been severely bullied or physically or sexually abused living in poverty or being homeless experiencing discrimination acting as a carer for a relative, taking on adult responsibilities having long-standing educational difficulties having learning disabilities Public Health England, 2016 Physical illness, especially if chronic and/or neurological – having an on-going illness makes a child different to peers. Spells in hospital mean being away from the family, and episodes of illness usually mean falling behind on school work and friends moving on. Genetic influences – often, when doing assessments, it is discovered that someone else in the family has had a mental health problem. This suggests a genetic link, but again, it is not a predictive factor. Scientists have been trying for decades to identify genetic links and have not been able to prove a predictive gene. Death and loss – including loss of friendships – grieving is normal when there has been a loss, it becomes a problem if a child or young person is not able to move through the grieving process. If grief is still acute after a year, for example, then this would be considered a problem. That is not to say that the child won’t still miss that person after a year. When children move home or school, they often lose friends, their grief at this loss needs to be acknowledged. Overt parental conflict – rules may be unclear if parents are saying different things. Living with conflict can be anxiety inducing. Children learn by imitating the behaviours they see around them. Family breakdown – not always a problem, it’s how it is handled that makes the difference. Low IQ and learning difficulties – this may be about not being able to express needs, so can’t get them met, leading to frustration and problems. Kessler et al 2005

Resilience factors- child secure early relationships being female higher intelligence easy temperament when an infant positive attitude, problem-solving approach religious faith capacity to reflect Kessler et al 2005

Resilience factors- family at least one good parent-child relationship affection clear, firm and consistent discipline support for education supportive long-term relationship/absence of severe discord Kessler et al 2005

Assessment of mental health problems Consider: Age, gender Type of Symptoms Severity and frequency of symptoms Persistence of difficulties Extent of Disturbance Change in behaviour Situation specificity Life circumstances Kessler et al 2005

Any factors in any of these supra-systems which impinge on the child Child and the Supra-systems MGPs PGPs F M Child Neighbours Teachers Sib Sib Society Law Friends Any factors in any of these supra-systems which impinge on the child

Anxiety disorders & mean age of onset Selective mutism 3-4 years Separation anxiety 6-10 years Specific phobia 5-12 years Social anxiety 8-15 years Agoraphobia 13-33 years Panic disorder 16-40 years Generalized anxiety disorder 20-47 years The onset of particular types of anxiety disorders often mirrors the normative development of these sort of fears and worries Kessler et al. 2005 Kessler et al 2005

New classification DSM 5 – OCD – now falls under OC and related disorders , PTSD – trauma and stress related disorders Kessler et al. 2005

Symptoms description Separation anxiety: Developmentally inappropriate and excessive fear/anxiety concerning separation from those to whom the child is attached, which has been present for at least 4 weeks Specific phobia: Marked fear/anxiety about a specific object or situation that is out of proportion to the actual danger posed and the sociocultural context and is persistent, typically lasting 6 months or more. The object or situation almost always provokes immediate fear/anxiety and is actively avoided or endured with intense fear/anxiety Selective mutism: Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations, for at least 1 month (not limited to the first month of school) Social anxiety: Marked fear/anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others, occurring in peer settings and not just in interactions with adults. Situations are avoided or endured with intense fear/anxiety, which is out of proportion to the actual threat posed and sociocultural context, typically lasting for 6 months or more Kessler et al, 2005

What Works for Whom, Peter Fonagy et al 2015 Comorbidities Other anxiety disorders Depression ADHD What Works for Whom, Peter Fonagy et al 2015

Treatment of anxiety disorders Consider developmental state and particular disorder First line psychological interventions CBT (self-help, individual, groups, parent led) Second line medication SSRIs; Sertraline best evidence Combination of CBT and Sertraline better than monotherapy Cathy Creswell, Polly Waite Evi Based Mental Health August 2016

What works for whom, Peter Fonagy et al. 2015 No evidence Benzodiazepines Limited research Small (N=15) placebo-controlled study on the use of Clonazepam produced negative results and reported considerably difficulty with side effects Double-blind placebo-controlled trial of Alprazolam found no significance difference with placebo. What works for whom, Peter Fonagy et al. 2015

What works for whom, Peter Fonagy et al. 2015 No evidence TCA Limited and conflicting evidence with the exemption of Clomipramine in OCD What works for whom, Peter Fonagy et al. 2015

What Works for Whom, Peter Fonagy et al. 2015 Prognosis Only some children with AD go on to have AD/Depression in adulthood However, most adults with AD/Depression are likely to have a childhood h/o anxiety What Works for Whom, Peter Fonagy et al. 2015

Depression- Diagnostic criteria Key symptoms (at least one of these, most days, most of the time for at least 2 weeks) persistent sadness or low mood, and/or loss of interests or pleasure fatigue or low energy Associated symptoms: disturbed sleep – decreased or increased poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame ICD-10 Kessler et al 2005

Beck’s cognitive triad Negative view of self Negative view of life Negative view of future

Treatment of mild, moderate and severe depression Mild – watchful waiting, psycho-education Moderate and severe - Specific psychological therapy (for at least 3 months) individual CBT interpersonal therapy family therapy psychodynamic psychotherapy Offer Fluoxetine if moderate to severe depression is unresponsive to a specific psychological therapy after 4 to 6 sessions. If treatment with Fluoxetine is unsuccessful or is not tolerated because of side effects, Sertraline or Citalopram are the recommended second‑line NICE guidelines Kessler et al 2005

Treatment of moderate and severe depression Unresponsive to combined treatment MDT needs and risk assessment Review of diagnosis/ comorbidities Individual, family and social causes of depression Assessment for further psychological therapy for the patient and additional help for the family Adjunctive medication Inpatient admission NICE guidelines Kessler et al 2005

When prescribing SSRIs Monitor for the appearance of suicidal behaviour, self‑harm or hostility particularly at the beginning of treatment NICE guidelines Kessler et al 2005

Resources Link up with pastoral support at school Mind Mind provide advice and support to anyone experiencing a mental health problem. 0300 123 3393 (information) www.mind.org.uk Samaritans Talk to us anythime you like, in your own way and off the record – about whatever’s getting to you. 08457 90 90 90 (talk anytime) www.samaritans.org Get Connected Get Connected is the UK’s free, confidential helpline service for young people under 25 who need help, but don’t know where to turn. 0808 808 4994 (counselling) www.getconnected.org.uk Childline 0800 1111 (information, counselling) www.childline.org.uk Mindfull Are you feeling down, depressed or worried? Is your mind full of negative thoughts or questions? Do you want to talk about your mental health? If so, MindFull is the place for you! (telephone counselling) www.mindfull.org Young Minds YoungMinds is the UK’s leading charity committed to improving the emotional wellbeing and mental health of children and young people. (parent helpline) www.youngminds.org.uk And for anxiety – why not try any of the above or also Anxiety Care UK 07552 877 219 www.anxietycare.org AnxietyUK 08444 775 774 www.anxietyuk.org.uk Nopanic 0800 138 8889 www.nopanic.org.uk

Resources http://www.stem4.org.uk/ Lots of useful and user-friendly information An app for dealing with self-harm

Thank you Kessler et al 2005