1. ELFT Training Packages for Primary Care ‘Common Childhood Mental Health Problems’ Dr Justin Wakefield Consultant Child & Adolescent Psychiatrist East London NHS Foundation Trust 12.02.2015

2. Definition of a “problem” Impairing abnormalities of behaviour, emotions and relationships ABNORMAL in relation to –child’s age and gender –developmental stage –culture –persistence –extent of disturbance –severity and frequency IMPAIRMENT –causes suffering to child/distress to family –social restriction –impedes the child’s development –effects on others

3. Which of these may be a problem? A 3-year-old soiling during the day A 7-year-old soiling during the day Frequent temper tantrums aged 2 Frequent temper tantrums aged 10 Severe anxiety at leaving mother at nursery gate aged 3 Severe anxiety at leaving mother at secondary school gate aged 11

4. Importance of Child and Adolescent Mental Health ½ of mental illness in adults has started before the age of 15

5. Aetiology Child –boys –low intelligence –difficult temperament –physical illness –developmental delay –genetic factors Family –traumatic stress –parenting issues –marital disharmony –maternal ill-health –parental psychiatric disturbance/substance misuse issues –abuse Environment –peer relationship problems –social deprivation –school factors –stresses resulting from accidents

6. Aetiology Consider whether child, family, environmental factors are: –PREDISPOSING –PRECIPITATING –PERPETUATING WHAT IS PROTECTIVE AND AIDING RESILIENCE?

7. Common Childhood Mental Health Problems Pre-school behavior problems Conduct disorders Emotional disorders Adjustment disorders Disorders of activity and attention Failures of normal development Attachment disorders and abuse Adult-type disorders

8. Epidemiology Overall rates of problems -pre-school behaviour problems22% -signif behav or emotional problems aged 1015% -signif psychological problems in adolescence20% Prevalence of some psychiatric disorders -Conduct disorder5% -Hyperkinetic disorder1% -Anorexia nervosa 0.1-0.2% of adolescent girls -Autism 0.66%

9. 1. Pre-school behaviour problems Feeding and eating sleeping temper tantrums oppositional behaviour

10. 2. Conduct disorder Disorder of behaviour characterised by repetitive and persistent pattern of dissocial, aggressive or defiant conduct. Not just delinquency Problem behaviours vary with development New NICE guidelines

11. Conduct disorder - under 5s aggression - physical and verbal destructiveness poor attention and concentration frequent, severe tantrums

12. Conduct disorder - 5-12 years lying stealing defiance disruption in school cruelty to animals fire setting solvent abuse

13. Conduct disorder - adolescence truancy delinquency violence sex offences drug/alcohol/substance abuse

14. Conduct disorder – risk factors boys >> girls inner cities > rural areas socio-economic disadvantage family conflict and poor communication in the family “difficult” temperament Specific reading disability

15. 3. Emotional disorders Disturbances of mood, persistent and not in response to a single identified stressor. Disabling Anxiety and fearfulness Depression

16. Emotional disorders - symptoms Fears - separation anxiety; social anxiety; specific phobias Lack of pleasure; loss of interest; hopelessness; despair; sadness; tearfulness; lack of energy Physical symptoms - abdominal pain, headaches Fall off in school performance

17. Emotional disorders – risk factors boys = girls no association with socio-economic status family factors - overprotection; parental anxiety quiet, compliant temperament no specific educational problems

18. School non-attendance Truancy School refusal (separation anxiety) Child kept at home by parent Fear of school (eg bullying)

19. 4. Adjustment disorders Distress and emotional disturbance arising in a period of adaptation to a significant life change or to the consequence of a stressful life event bereavement divorce physical illness

20. 5. Attention Deficit / Hyperactivity Disorder (ADHD) overactivity inattention impulsivity early onset pervasive and persistent boys >>> girls

21. 6. Failures of normal development : specific speech and language ( receptive and expressive) reading (dyslexia) spelling arithmetical skills motor function (dyspraxia) enuresis / encopresis

22. 6. Failures of normal development : pervasive Autistic spectrum disorders - impaired quality of reciprocal social interaction - impaired communication - restricted, repetitive interests Asperger’s Syndrome

23. 7. Attachment disorders Marked distress and social impairment as a result of an extremely abnormal pattern of attachment, typically repeated changes of care-giver in early childhood Reactive attachment disorder Disinhibited attachment disorder

24. Abuse physical (non-accidental injury) emotional sexual neglect Munchaussen Syndrome by Proxy??/ Factitious Induced Illness (FII)

25. 8. Adult type disorders psychoses - schizophrenia; bipolar disorder depression post traumatic stress disorder obsessive compulsive disorder eating disorders deliberate self harm

26. Assessment Main areas to cover in assessment. i)Description and history of main problems ii)Child’s peri-natal, developmental, medical, educational and social history iii)Family history including any psychological health problems and information regarding parents own experience of being parented iv)Mental state of the child v)Family communication and relationships An assessment also offers the opportunity to engage therapeutically with a family.

27. Formulation Following an assessment it is important to formulate the case. A formulation is a compact summary of relevant aspects of : i) presenting features ii) aetiological factors iii) diagnosis iv) management plan v) prognosis.

28. Diagnosis There are two major diagnostic systems: –ICD- 10 Classification of Mental and Behavioural Disorders –DSM-5 Diagnostic and Statistical Manual of Mental Disorders Both systems multi-axial. In ICD 10: –Axis IClinical Syndrome –Axis IIDisorders of Psychological Development –Axis IIIMental Retardation –Axis IVMedical Illness –Axis VAbnormalities of psychosocial environment –Axis VILevel of disability

29. Treatment approaches in child psychiatry Parental counselling Psycho-education Behaviour therapy Cognitive-behavioural therapy Family therapy Pharmacotherapy Individual psychotherapy Group therapy Liaison with other agencies –(education, social services, Paediatrics) Usually out-patient –Also day hospital or in-patient

30. Prognosis This depends on –nature and severity of the disorder –family and environmental context –treatment offered Symptoms tend to be stubborn without treatment Treatment effectiveness include –Behavioural work for behavioural problems –Methylphenidate in hyperkinetic disorder –Family work in anorexia nervosa