1. ELFT Training Packages for Primary Care ‘Paediatric Liaison’ CAMHS ELFT Graeme Lamb Clinical Director

2. Paediatric Liaison Learning Objectives Medically Unexplained (physical) Symptoms in the Paediatric setting Delirium, acute confusional states and psychiatric symptoms in Paediatric illness Mental health presentations of children with chronic physical illness

3. Medically Unexplained (Physical) Symptoms Medically unexplained physical symptoms (MUPS) are when someone suffers from physical symptoms for which no underlying physical cause can be found. 1 About one in 10 children and adolescents suffer from this condition. 1 1. Royal College of Psychiatrists

4. MUPS symptoms Common symptoms: headaches, stomach aches, joint pains and tiredness. Less commonly: muscle weakness, collapses, ‘fit-like’ episodes, and severe and chronic pain.

5. Why are the symptoms unexplained 1.Symptoms are of psychogenic origin – somatoform disorders, anxiety disorder, and depression 2.Symptoms are fabricated or induced by the parent – proxy factitious disorder 3.Symptoms are fabricated by the adolescent – factitious disorder and malingering 4.Symptoms are due to a yet undetected medical condition

6. Treatment Key principle in understanding such conditions and working with children and families with MUPS is good liaison between Paediatric and Child mental health (as well as other key agencies like school and social care). Treatment: Assess and manage underlying disorder (anxiety/depression) Multi-disciplinary treatment: Often involves mental health liaising with OT/Pysios

7. Delirium DEFINITIONS A temporary disturbance in consciousness, with reduced ability to focus attention and solve problems. Occasionally sleeplessness and severe agitation and irritability are part of "delirium." Hallucination, drowsiness, and disorientation may be present. OR A sudden state of severe confusion and rapid changes in brain function, sometimes associated with hallucinations and hyperactivity, during which the patient is inaccessible to normal contact

8. Common causes of delirium in childhood -In decreasing order of frequency 1 : –Infection –Drug-induced –Auto-immune –Post-transplant –Post-operative –Trauma –Neoplasm –Organ failure 1 - S Turkel, J Tavare. Delirium in Children and Adolescents. The Journal of Neuropsychiatry and Clinical Neurosciences 2003;15:431-435.

9. Psychiatric presentation of a physical illness “The presence of mental symptoms that are judged to be the direct physiological consequences of a general medical condition” DSM-IV-TR Failure to identify the medical cause of psychiatric symptoms can be potentially dangerous because serious, and frequently reversible, diseases can be overlooked.

10. Features suggestive of a physical illness Known underlying medical condition Atypical presentation of a specific psychiatric diagnosis Absence of personal and family history of psychiatric illnesses Illicit substance use Medication use Treatment resistance or unusual response to treatment Sudden onset of mental symptoms Abnormal vital signs Waxing and waning mental status

11. Medical Disorders That Can Induce Psychiatric Symptoms* Medical and Toxic Effects Central Nervous System InfectiousMetabolic/EndocrineCardiopulmonaryOther  Alcohol  Cocaine  Marijuana  Phencyclidine (PCP)  Lysergic acid diethylamide (LSD)  Heroin  Amphetamines  Jimson weed  Gamma-hydroxybutyrate (GHB)  Benzodiazepines  Prescription drugs Subdural hematoma Aneurysm Severe hypertension Meningitis Encephalitis Normal- pressure hydrocephalus Seizure disorder Multiple sclerosis Tumours Pneumonia Urinary tract infection Sepsis Malaria Legionnaire disease Syphilis Typhoid Diphtheria HIV Rheumatic fever Herpes Thyroid disorder Adrenal disorder Renal disorder Hepatic disorder Wilson disease Hyperglycemia Hypoglycemia Vitamin deficiency Electrolyte imbalances Porphyria Myocardial infarction Congestive heart failure Hypoxia Hypercarbia Systemic lupus erythematosu s Anemia Vasculitis Auto- immune Encepahlopa thies: NMDAR VGKC *Adapted from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am. May 2000;18(2):185-98. (For reference only)

12. Interaction between physical illness on mental health of children Children with a long-lasting physical illness are twice as likely to suffer from emotional problems or disturbed behaviour. This is especially true of physical illnesses that involve the brain, such as epilepsy and cerebral palsy.1 Diabetes Depression increases risk of retinopathy in childhood-onset insulin dependent diabetes mellitus.(Kovac, Mukerji, Drash et al 1995). 1. Royal College of Psychiatrists