Adolescent mental health Dr Mike Basher Consultant Peterborough CAMHS

Aims A warm up exercise A little about assessment in adolescence Why adolescent mental health might be important The kinds of disorders we see

Eating disorder scenario 15 year old girl presenting at A+E with her dance teacher following a dizzy spell in class. BMI 13. (Major organic cause excluded). What are the things that need to be considered in your assessment and management?

Eating disorders Around 1% for anorexia Bulimic symptoms common but bulimia rarely presents Anorexia tends to present late Can be severe and chronic with significant mortality Physical risks – MARSIPAN, Kings College Guide ‘Recovery model’ approach – learning to live with the illness more successfully

Assessment - Confidentiality Information is for sharing Confidentiality is about privacy not secrecy “If a young person does not wish their parents to be involved in decisions about their care every effort should be made to fully understand the reasons for this and to ascertain whether any steps could be taken to address the young person’s reasons for not wishing information to be shared” – NIMHE guidance

Assessment - talking to adolescents Talk to them! Be clear and avoid jargon Be yourself and don’t try to be trendy Be honest and open See the parents Explore ambivalence but use your authority if needed – be clear about consequences At an operational level relationship with paediatrics critical

Assessment - Legal framework Mental Capacity Act Capacity assumed over 16 Young people may be unable to decide if they lack capacity OR due to ‘immaturity’ Parental responsibility – ‘Zone of Parental Control’ Under 18 you cannot make an advanced directive Complicated for those aged 16 or 17 Mental Health Act

Why adolescent mental health might be important The nature of adolescence and our beliefs about it ‘Chronic diseases of the young’ Service organisation

Typical adolescents?

Same as it ever was.. “I would there was no age between ten & three and twenty…for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing and fighting”

Same as it ever was.. “I would there was no age between ten & three and twenty…for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing and fighting” Shakespeare – The Winter’s Tale

And more bad press… “The children now love luxury; they have bad manners , contempt for authority; they show disrespect for elders and love chatter in the place of exercise. Children are now tyrants……”

And more bad press… “The children now love luxury; they have bad manners , contempt for authority; they show disrespect for elders and love chatter in the place of exercise. Children are now tyrants……” Socrates

What changes in Adolescence? Physical – puberty, sex hormones, brain maturation; synaptic pruning (specialisation, ‘use it or lose it’), frontal lobe activation (developing executive function, incl. impulse control). Effects on the Detection, Affective and Cognitive-regulatory nodes (functional arrangements.) Cognitive – Formal operational thought (abstract concepts like justice…), Understanding the mental states of others (ToM/mentalising), Academic attainment,… Emotional – Affect regulation, deferred gratification, Depressive position, mentalising function. Self-identity and individuation/separation – Gender identity, Differentiating from family, achieving mature Sexuality… Social – Adopting Adult roles, from Gangs to Groups, Pro-social Vs. Anti-Social peer-groups.

Academic qualifications Social Skills Living Skills Available Support

- schools, health, social Adult services Children services - schools, health, social Mind the gap Academic qualifications Social Skills Living Skills

Chronic diseases of the young World health organisation defined as such on the basis of Kessler – “roughly half of all lifetime mental disorders in most studies start by the mid teens and three quarters by the mid 20s” Single biggest cause of morbidity at this age Delays to treatment in the order of 10 years for most disorders

Some more of the evidence Rutter (1980) – large longitudinal study in America showing 20% adolescents have significant difficulties Rutter – continuities have been mapped through prospective studies for many disorders

To summarise Adolescent mental health matters because it as at this age (or perhaps more specifically 14-25) that a major proportion of severe mental illness emerges …..“the chronic diseases of the young” Services have not been well designed to meet the needs of this age group BUT remember (especially if you are a parent and perhaps contrary to popular belief) the majority of adolescents are not mad

Types of psychiatric disorder Mood disorders Anxiety disorders and OCD Psychosis Eating disorders Deliberate self harm Personality disorder Conduct disorder Substance misuse disorders

Neurodevelopmental disorders ADHD Autistic spectrum disorders Learning disability Chronic disabilities associated with high levels of mental health difficulties Face their own particular transition challenges in adolescence

Deliberate self harm Is a communication Assess risk AND needs Manage risk

What are the suicide risk factors to consider in a young person who self harms?

What are the suicide risk factors to consider in a young person who self harms? How – planned, note left Who – male, past history, substance misuse, LAC What – violent methods Where – attempts to avoid discovery When – post discharge, after argument

Don’t forget other risks and the ‘needs assessment’ Medical Mental health Educational Family – social care – occasionally safeguarding

College guidelines on role of ED team Physical assessment Support engagement Identify safeguarding issues and refer to CSC if needed To gather psychosocial risk related history To ensure every YP under 16 is routinely admitted

Personality disorder “I hate you…..don’t leave me” NICE recommends avoiding terms like ‘emergent’ Associated with the ‘child in care’ population What do mental health services have to offer? MST – multi systemic therapy pre-care placement an offending focus intensive & expensive…..spend to save Planning and communication between services

Conduct and behaviour disorders A challenge to all services High rates of mental health problems in the youth offending population MST has a limited evidence base Too late for parent training?

Scenario 14 year old girl brought into A+E from local care home where staff say they cannot cope with her behaviour – running off, aggressive, threats to kill herself …They tell you she needs to be sectioned. What are the issues to consider here?

Psychosis Rare before 17 Concept of ARMS – At Risk Mental States Family history, cannabis use Close working with the Early intervention services (CAMEO)

Early intervention in psychosis Early detection and treatment Cover the ‘gap’ – a transition service (14-35) Active youth engagement – ‘out there’ Now good evidence for early intervention At Risk Mental States and phase specific interventions

Sedation of disturbed adolescents What to use?

Sedation of disturbed adolescents Promethazine Lorazepam Haloperidol at a push….and if good evidence of psychosis

Mood disorders Up to 10% Duration, persistence and impact of symptoms Feelings (including irritability) Thoughts Behaviour and biology (sleep etc) Assess and manage suicidality Look for comorbidity especially anxiety Medication not first line

Anxiety disorders and OCD Can be very impairing Relatively common Can be easily missed or ignored as they keep quiet and pose little ‘risk’ Respond well to CBT and in more severe cases SSRIs

Neurodevelopmental disorders in adolescence ADHD around 5%, ASD 1%, LD 2-5% For ADHD consider the secondary deficits - peers, drugs, conduct problems ASD we see a second peak of epilepsy LD high rates (x5) of all mental health problems

To summarise Adolescent mental health matters because it as at this age (or perhaps more specifically 14-25) that a major proportion of severe mental illness emerges …..“the chronic diseases of the young” Services are not necessarily well suited to meet the needs of this group

- schools, health, social Adult services Children services - schools, health, social Mind the gap Academic qualifications Social Skills Living Skills