1. Adolescent mental health
Dr Mike Basher
Consultant
Peterborough CAMHS

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

3. 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?

4. 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

5. 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

6. 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

7. 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

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

9. Typical adolescents?

10. 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”

11. 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

12. 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……”

13. 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

14. 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.

15. Academic qualifications
Social Skills
Living Skills
Available Support

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

17. 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

18. 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

19. 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

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

21. 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

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

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

24. 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

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

26. 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

27. 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

28. 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?

29. 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?

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

31. 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

32. Sedation of disturbed adolescents
What to use?

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

34. 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

35. 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

36. 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

37. 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

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