1. Child and Adolescent Mental Health

2. Child and Adolescent Mental Health
Dr. Patsy Chapman
Consultant, Child and Adolescent Psychiatry
and
Mark Swindells
Senior Primary Mental Health Worker
Calderdale CAMHS

3. Child and Adolescent Mental Health
Common presentations to General Practice
NICE Guidance/Evidence-based practice
Discussions from practice
Service issues and making a referral to specialist CAMHS

4. A note about evidence-based practice.
Considered to be the
‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients…
integrating individual clinical expertise with the best available external clinical evidence from systematic research’.
Sackett et al (1996) BMJ

5. Common presentations to GPs
Attention Deficit Hyperactivity Disorder
(ADHD)
Autistic Spectrum Disorders
Conduct disorders
Depression
Anxiety
Obsessional-Compulsive Disorder (OCD)
Eating Disorders
Tic Disorders (inc Tourettes’s syndrome)

6. Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is a pervasive, heterogeneous behavioural syndrome characterised by the core symptoms of inattention, hyperactivity and impulsivity.

7. ADHD
Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
Parents of pre-school children with ADHD should be offered a referral to a parent-training/education programme as the first-line treatment.
If the child or young person with ADHD has moderate levels of impairment, the parents should be offered referral to a group parent-training/education programme.
In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered group-based parent-training.

8. ADHD
Methylphenidate, atomoxetine and dexamfetamine are recommended, within their licensed indications, as options for the management of ADHD.
In Calderdale and Kirklees only schools can refer to the specialist CAMH service for an assessment of ADHD. This is part of the clinical pathway for the management of ADHD.
Following assessment and diagnosis by specialist CAMHS, “shared care” arrangements are usually made with the child’s GP.
Children with an ADHD diagnosis and on medication are routinely followed up every 4 – 6 months by the specialist CAMH service.

9. Autistic Spectrum Disorder
An intrinsic condition, ASD manifests core features which are pervasive and include deficits in:
- Social communication
- Social interaction
- Social imagination
Current prevalence of all ASD diagnoses: 1.6%
Children with an ASD have a higher risk than peers of developing other mental health problems.
NICE have recently released a draft proposal for clinical guidelines which will cover recognition, referral and diagnosis of ASD in children.

10. ASD In Calderdale, diagnosis is a two stage process:
Screening in the community for core features at
home and school using standardised measures. Only those children who demonstrate significant and pervasive core features of ASD are referred on to the specialist CAMH service.
The CAMH service coordinates a multi-disciplinary
assessment of the child by a clinical psychologist,
psychiatrist, paediatrician, educational psychologist and speech and language therapist.

11. CONDUCT DISORDERS
Conduct disorders are the most common reason for referral of children to mental health services
They have a significant impact on quality of life for those involved, and, in the case of early onset (aggression at three years of age) outcomes for children are poor
Many children do not receive support because of limited resources, high prevalence and difficulty engaging some families
Early effective intervention is particularly important: recent research has established a neuro-developmental basis for this finding
Refer to the full guidance, page 4
Quality of life
Conduct disorders have a significant and detrimental impact on both the child and their family or carer(s). Children with conduct disorders are at high risk of experiencing future disadvantage through social exclusion, poor school achievement, long-term unemployment, juvenile delinquency and crime. They are also at high risk of having poor interpersonal relationships, leading to family break-up in adulthood, divorce and abuse of their own children
Early effective treatment
More than 60% of 3-year-olds with conduct disorders still exhibit problems at the age of 8 years if left untreated, and many problems will persist into adolescence and adulthood. Approximately half of the children diagnosed with conduct disorders receive a diagnosis of antisocial personality disorders as adults, with others being diagnosed with psychiatric disturbances, including substance misuse, mania, schizophrenia, obsessive-compulsive disorder, major depressive disorder, and panic disorder. This reinforces the importance of early treatment.

12. Conduct disorder and ODD
Conduct disorder: repetitive and persistent pattern of antisocial, aggressive or defiant conduct and violation of social norms
Oppositional defiant disorder: persistently hostile or defiant behaviour without aggressive or antisocial behaviour
Oppositional defiant disorder, may be a precursor of conduct disorder. A child is diagnosed with oppositional defiant disorder when he or she shows signs of being hostile and defiant for at least 6 months. Oppositional defiant disorder may start as early as the preschool years, while conduct disorder generally appears when children are older. Oppositional defiant disorder and conduct disorder are not co-occurring conditions.

13. Estimated UK prevalence
Conduct disorder (including ODD)
Age (years)
Males
(%)
Females
5 - 10
6.9
2.8
8.1
5.1
Prevalence may in fact be higher where children and young people are managed through social care services, voluntary organisations and the youth justice system and do not come into contact with the health service

14. Associated conditions
Conduct disorders are often seen in association with:
attention deficit hyperactivity disorder (ADHD)
depression
learning disabilities (particularly dyslexia)
substance misuse
less frequently, psychosis and autism

15. Predisposing risk factors
Family factors including
marital discord
substance misuse
criminal activities
abusive or injurious parenting practices
Individual factors including
‘difficult’ temperament
brain damage
epilepsy
chronic illness
cognitive deficits
Environmental factors including
social disadvantage
homelessness
low socioeconomic status
poverty
overcrowding
social isolation
There are a number of risk factors that can predispose children to conduct disorders. These factors can be associated with the family, the children themselves or be environmental.

16. Recommendations for children < 12 years
Group-based parent-training/education programmes are recommended in the management of younger children with conduct disorders. Not routinely provided by specialist CAMHS.
Individual-based parent-training/education programmes are recommended in the management of children with conduct disorders only in situations where there are particular difficulties in engaging with the parents or a family’s needs are too complex to be met by group based parent-training/education programmes.
Local family support teams and children centres operate to support with family relationships and parenting.
This guidance only applies to the management of children aged 12 years or younger or with a developmental age of 12 years or younger.

17. Recommendations for children > 12 years
There is limited evidence only for effective interventions with older children/young people.
Those programmes which show early promise are currently being evaluated, for example:
- Multi-systemic therapy
- Functional family therapy
These approaches tend to be intensive and expensive. They are not currently available locally, though specialist CAMHS do offer other forms of therapeutic support to some families (family therapy, for example).
This guidance only applies to the management of children aged 12 years or younger or with a developmental age of 12 years or younger.

18. Depression
At any one time, the estimated number of children and young people suffering from depression:
1 in 100 children
1 in 33 young people
Prevalence figures exceed treatment numbers:
about 25% of children and young people with depression detected and treated
Suicide is the:
3rd leading cause of death in 15–24-year-olds
6th leading cause of death in 5–14-year-olds
Transition to Adult services, where appropriate, requires careful planning

19. Depression KEY SYMPTOMS ASSOCIATED SYMPTOMS
persistent sadness, or low or irritable mood:
AND/OR
loss of interests and/or pleasure
fatigue or low energy
poor or increased sleep
poor concentration or indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
Mild
Up to 4 symptoms
Moderate
5-6 symptoms
Severe
7-10 symptoms

20. Depression When to refer to the specialist CAMH service:
Depression with multiple-risk histories in another family member
Mild depression and no response to interventions in tier 1 after 2–3 months (Low level intervention and “watchful waiting”)
Moderate or severe depression (including psychotic depression)
Recurrence after recovery from previous moderate or severe depression
Unexplained self-neglect of at least 1 month’s duration that could be harmful to physical health
Active suicidal ideas or plans
Young person or parent/carer requests referral

21. Depression
Anti-depressants should only be prescribed following assessment by a psychiatrist and only be offered in combination with psychological treatments
First-line pharmacological treatment is fluoxetine*
Do NOT use: tricyclic antidepressants, paroxetine, venlafaxine, St John’s wort
Monitor for agitation, hostility, suicidal ideation and self-harm and advise urgent contact with prescribing doctor if detected
Sertraline or citalopram* as second-line treatment
Consider adding atypical antipsychotic if psychotic depression
Continue for 6 months following remission, then phase out over 6–12 weeks

22. Anxiety
No specific NICE guidance for children and young people for Anxiety, though guidance is available for children with Post Traumatic Stress Disorder and Obsessional Compulsive Disorder
Type of anxiety experienced by the child (social, generalised, panic, separation, specific phobia) and degree of impairment to functioning is important to detail in referral
Cognitive Behavioural Therapy (CBT) and other behavioural approaches indicated for most anxiety disorders.

23. Obsessional-Compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD): characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress
1% of young people are affected – adults often report experiencing first symptoms in childhood
Onset can be at any age. Mean age is late adolescence for men, early twenties for women

24. Obsessional-Compulsive disorder (OCD)
All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology
If CBT ineffective or refused - review and consider adding an SSRI
Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD*
Monitor carefully and frequently
If successful, continue for 6 months post remission
Withdraw slowly with monitoring

25. Obsessional-Compulsive disorder (OCD)
Considerations for work with children:
Symptoms are similar in children, young people and adults and they respond to the same treatments
Stressful life events may worsen symptoms or relapse may occur:
- school transitions and examination times
- relationship difficulties
- transition from adolescence to adult life
(careful planning of transition to adult services needed)
Parents may feel guilty and anxious
Tendency to increase in severity if left untreated

26. Anorexia nervosa
Severe dietary restriction despite very low weight (BMI <17.5 kg/m2)
Morbid fear of fatness
Distorted body image (that is, an unreasonable belief that one is overweight)
Amenorrhoea
A proportion of patients binge and purge
In assessing whether a person has anorexia nervosa, attention should be paid not just to one off weight and BMI but also to the overall clinical assessment (repeated over time), including rate of weight loss, growth rates in children, objective physical signs and appropriate laboratory tests. Include all information in referral.

27. Anorexia nervosa
On referral to specialist CAMHS patients are usually offered a range of individual therapies (often CBT) and family therapy.
Close working alliance with a dietary specialist is assumed.
No evidence or justification for sole treatment of AN via medication.
Co-morbid mood disorders may respond to treatment with SSRI (NB. Cardiac function)
Inpatient treatment should be considered for people with anorexia nervosa where:
- The disorder has not improved with appropriate outpatient
treatment.
- There is a significant risk of suicide or severe self-harm.
- There is a high or moderate physical risk.

28. Bulimia nervosa
Characterised by an irresistible urge to overeat, followed by self-induced vomiting or purging and accompanied by a morbid fear of becoming fat.
Patients with bulimia nervosa who are vomiting frequently or
taking large quantities of laxatives (especially if they are also
underweight) should have their fluid and electrolyte balance
assessed.
Selective serotonin reuptake inhibitors (SSRIs) and specifically
fluoxetine, are the drugs of first choice for the treatment of
bulimia nervosa.The effective dose of fluoxetine is higher than for depression (60 mg daily).
No drugs, other than antidepressants, are recommended for
the treatment of bulimia nervosa.

29. Tic Disorders (including Tourettes’s Syndrome)
Presentation:
Tics are involuntary, rapid, recurrent, non-rhythmic motor movements.
Transient tic problems are very common in childhood, more common in boys, and a family history of tics is common.
Chronic and complex tic disorders require careful management and referral to specialist CAMHS.
Tourette’s syndrome is a constellation of multiple motor and vocal tics originating in childhood/adolescence and often persisting into adulthood.

30. Tic Disorders (including Tourettes’s Syndrome)
Management:
Psycho-social approaches
Pharmocological approaches:
- Haloperidol
- Risperidone
- Pimozide
- Clonidine

31. Making a referral to the specialist CAMH service
Referrals are allocated as follows:
- Urgent (seen within one working day)
- Priority (seen within six weeks)
- Routine (placed on our waiting list)

32. Making a referral to the specialist CAMH service
Referrals are screened daily
Not all referrals to the service are accepted. Often referrals are signposted to other appropriate services. (“Children’s mental health is everybody’s business”)
In future it is likely that other pathways will be developed to manage particular clinical presentations.
If in doubt, contact the primary mental health worker on duty to discuss possible referrals to the service or for advice on any issue relating to CAMH

33. Primary mental health work
The primary mental health work (PMHW) team serves to link community based services with the specialist CAMH service.
Alongside responsibilities for screening of all referrals they also undertake:
- training
- advice
- consultation
- liaison

34. ANY FURTHER
QUESTIONS?