CAMHS Flashcards
How common is childhood mental health problems?
High on government and media agenda
Increased incidence and severity of referrals
Evolving speciality - lots of neuroscience underpinning child mental health
Children cannot get dementia
Cannot decrease likelihood of recurrent illness
Increased incidence of self-harm
What are the differences between CAMHS and AMH?
Both deal with severe mental illnesses
Both deal with developmental disorders
CAMHS works on a systemic framework
AMH medication is main treatment whereas CAMHS breadth of treatment options
CAMHS works mainly on preventative measures - primary and secondary, whereas AMH works with secondary and tertiary prevents
What is the developmental approach in CAMHS?
Some conditions treated are developmental disorders - ADHD, ASD
Need to take into account the developmental stage when assessing young people - use play, assessment of suicidal ideas needs to take into account concept of death at different ages
What is the systemic approach of CAMHS?
Central to CAMHS
Holistic approach
Emphasises effect of systems around child on presentation and potential treatment
Interview patient and parents before treatment
Family/systemic therapy treatment used
System around young person - family, friends, school, neighbourhood
What is the prevention used in CAMHS?
Provides opportunity for early prevention in mental illness eg treatment of attachment disorder to prevent development of personality disorder
Chronic illness CBT decreases chance of recurrence of depression
What kind of treatment do CAMHS use?
Family
Friends
School
Neighbourhood
How does ASD present in children?
Rituals
Unusual/delayed language
Social difficulty - lack of theory of mind, can’t read others
How does PTSD present in children?
Intrusive sensations/memories - flashbacks
Avoidance
Anxiety
How long might children have ASD?
Lifelong
May present with different severity at different times in life
What is the diagnostic criteria of anorexia in the ICD-10?
Deliberately keeping weight below 85% of expected
- Restricted dietary choice
- Excessive exercise
- Induced vomiting, use of appetite suppressants and diuretics
Dread of fatness - intrusive overvalued ideas
What are the endocrine effects of anorexia?
Menstruation stops or puberty is delayed if menarche not yet achieved
In men - loss of sexual interest/potency
How common is anorexia?
1 in 250 females 1 in 2000 males 1 15 year old girl in every 150 1 15 year old boy in every 1000 Mean age of onset 16-17
What can cause/increase the risk of anorexia?
Social pressure Perfectionist characteristics Reversing or halting effects of puberty Family - Attitudes to food in family to food and body shape - Refusing food as a way of being heard Some genetic links Depression Low self-esteem Occupation and interest eg ballet dancers Anxiety disorders Past or present events - Life difficulties - Sexual abuse - Physical illness - Upsetting events - death/break-up of a relationship - Important events - marriage or leaving home
How is anorexia diagnosed?
Screening for eating problems SCOFF
History
What is the SCOFF questionnaire?
Do you make yourself Sick because you’re uncomfortably full?
Do you worry that you’ve lost Control over how much you eat?
Have you recently lost more than 6kg (about One stone) in 3 months?
Do you believe you’re Fat when others say you’re thin?
Would you say that Food dominates you r life?
What questions should you ask in an anorexia history?
Ask about over-valued ideation of body shape and weight - intense fear of becoming fat
Active maintenance of low body weight < 85% expected weight
Amenorrhoea in post-pubertal females
What clinical signs might suggest anorexia?
Dry skin Lanugo hair Orange skin and palms Cold hands and feet Bradycardia Drop in BP on standing Oedema Weak proximal muscles - squat test
Who assesses an anorexia patient in CAMHS?
Psychiatrist Psychologist Family therapist Paediatrician Dietician
What decisions need to be made by the MDT?
Whether to treat in community or as an inpatient
How common is ADHD?
Common condition in people of all ages
Associated with impaired QoL
- Reduced educational attainment, higher unemployment
- Increased risk of poor peer relationships and relationship breakdown
- Association with substance misuse and mental health problems
- Increased offending behaviours
- Increased mortality
Early diagnosis and treatment reduces morbidity
3-4% of all school-aged children
5.3% under-18s worldwide and 3.4% adults
Male to female 4:1 in childhood
Equally common in adulthood
Girls tend to present in masked way
Occurs in all cultures, higher prevalence in Western cultures
Often have co-existing conditions eg ASD, attachment disorders
What are the main symptoms of ADHD?
Inattention
Hyperactivity
Impulsivity
What are the symptoms of inattention?
Decreased concentration, lack of persistent focus/attention, easily distractible, forgetful, disorganised, not following instruction, careless mistakes
What are the symptoms of hyperactivity?
Not able to sit still, constantly on the go, fidgety, not able to queue, loud/noisy play
What are the symptoms of impulsivity?
Poor sense of danger, blurts out answers, interrupts or intrudes into others - when someone is talking, during activities, games
How is ADHD diagnosed?
MDT clinical assessment Good clinical history - interview with child, parents, teachers - Presenting issues/difficulties - Birth and developmental history - Social history - Our observations in different settings - School observations - Feedback from school - Degree of impairment - Behaviour rating scales by parents and teacher Physical examination Scales - Connors Tests - Ob test, TEACH, cognitive assessment
What is the DSM-V criteria for ADHD?
Under age 17
6 or more hyperactivity or impulsivity symptoms OR 6 or more inattention symptoms
Symptoms for more than 6 months before the age of 12
Interferes with functioning or development - interferes/reduces quality of social/academic/occupational function
Must not be due to another mental illness
Developmentally inappropriate
Several symptoms in 2/more settings
What could be differential diagnoses for ADHD?
ASD Anxiety disorder Attachment difficulties Learning difficulties or learning disability Sensory issues Epilepsy Drug S/E
What causes ADHD?
Not known
Suggestions - reduced/abnormal frontal lobe function, reduced dopamine levels in brain
Genetic component - twin studies suggest 76% heritability
Environment acting through gene-environment interactions
Dietary factors idiosyncratic
What can increase the risk of ADHD?
Maternal smoking Foetal O2 deprivation Low birth weight Prematurity Heroin use during pregnancy
How is ADHD managed?
Parent training first line for most cases unless severe
Support offered to school
CBT - supports emotional regulation, problem-solving, social skills
Medication not advocated for pre-school children
Stimulants
Non-stimulant
Combined
What advice is offered to parents with a child with ADHD?
Regular routine Set clear boundaries Positive reinforcement Brief and specific instructions Incentive schemes Regular exercise and healthy diet Bedtime routine Short and sweet social interactions
Give an example of a stimulant medication used to treat ADHD
Methylphenidate
Amphetamines
- Long-acting - lisdexamphetamine
- Short-acting - dexamphetamine
Give an example of a non-stimulant medication used to treat ADHD
Atomoxetine (SNRI)
Guanfacine
What are the S/E of stimulants?
Hypertension
Loss of appetite
Psychiatric symptoms
Diversion
Which of stimulants/non-stimulants is better for ADHD treatment?
Stimulants - good if only require at certain times, more effective
Non-stimulants - need to take all the time, different S/E
How do stimulants work?
Increased amount of dopamine released by brain
What is the prognosis of ADHD?
30% exhibit full remission of symptoms by adolescence
15% meet full ADHD criteria aged 25 (but many still meet some)
School drop-out rate high
Chronic pattern of symptoms throughout adulthood may lead to broken marriages and friendships, incomplete college degrees, unsteady jobs
Prognosis in adulthood dependant on severity of symptoms, efficacy of treatment, and presence of comorbidity
What is self harm?
Act with intent to hurt self
Includes cutting, burning with ice, hitting self, and overdose
No intention to kill slef
Why do people self harm?
May want to release tension, make feel self, others to see distress (cry for help)
What are the most common methods of self harm?
Cutting, swallowing small amounts of toxic substances
What are some other methods of self harm?
Burning, scalding, hitting, scratching, hair pulling
What is a suicidal act?
Act with intent to kill self
Includes overdose, attempted hanging
Intention includes desire to be dead
Important to assess severity and whether ongoing
How common is self harm?
1 in 10 young people will self-harm at some point, it can occur at any age
More common in young women than men 4:1
Rates highest in those groups with highest level of poverty
Gay and bisexual people more likely to self harm
Sometimes do it in groups - having a friend who self-harms may increase your chances of doing it too
More common in some sub-cultures eg goths
More likely to have experienced physical, emotional, or sexual abuse during childhood
Rates have increased over the past decade and in UK amongst highest in Europe
In subsequent 12 months following an episode of self-harm - 20% will repeat and approx 1% will die of suicide
Around half patients with DSH consulted GP in 4 weeks following episode
What risk factors can increase the risk for self harm?
Depression Bullying Sexual abuse Family/friend conflict Subculture Drugs and alcohol Family history
How do you assess self harm?
Check for associated suicidal attempt/ideas
Social factors eg family, school, abuse, drugs, and alcohol
Frequency, severity, measures
Reason - eg relief of distress
How is suicide assessed?
Circumstances eg alone, did they tell anyone Planned or impulsive Left letter Continuing ideas What would stop a further episode Future
What questions should you ask about family in suicide and self harm assessment?
Family history of mental illness/self-harm
Family stress, bereavement ect
What questions should you ask about school and social in suicide and self harm assessment?
Social support
Educational difficulties
What factors can increase risk of suicide?
Presence of psychiatric disorder
Previous suicide attempt
Alcohol or substance misuse
How is self harm treated?
Alternative strategies eg talk with friend, distractions, soothing eg music
Manage/treat underlying cause eg family therapy for family conflict, bullying
How is suicide treated?
Manage immediate risk
Tell parents - plan for young people to tell parents if have further thoughts
Manage any underlying mental health condition eg depression
If too severe - hospital/intensive home treatment
If parents unable - consider social care
How common is depression?
2.7% 11-16 year olds
0.3% 5-10 year olds
25% detected and treated
What can cause depression?
School - bullying, learning difficulties, family history, thyroid disorder, steroids, chronic physical illness
Psychological - low self esteem
Previous history of depression
Family - abuse/neglect, domestic violence
Drugs and alcohol - alcohol is depressant, speed
What protective factors are there for depression?
Friendships
Close family
What are the key symptoms of depression?
Persistent sadness or low mood
Loss of interest or enjoyment
Fatigue or low energy
What are the associated symptoms of depression?
Poor or increased sleep Poor or increased appetite Poor concentration or indecisiveness Low self-confidence Agitation or slowing of movements Guilt or self blame
What are the types of depression?
Mild up to 4 symptoms
Moderate 5-6 symptoms
Severe 7-8 symptoms
How is depression treated?
Information Community CBT therapists Specialist CBT IPT - interpersonal therapy Family therapy Antidepressants - fluoxetine, sertraline, citalopram
What might children with ADHD have difficulty with before school?
Waking up
Getting ready for school
Struggling excessively with parents
What might children with ADHD have difficulty with at school?
Lower grades
Lack of focus
Disruptive
Difficulty with friendships
What might children with ADHD have difficulty with after school?
Sports/clubs
Completing homework
Risky behaviour and injuries
Sitting through dinner
What might children with ADHD have difficulty with at bedtime?
Homework
Sibling interactions
Bedtime prep
Settling down and falling asleep
How might a 6-12 year old present with ADHD?
Distractibility Motor restlessness Impulsive and disruptive behaviour Associated problems and implications - Specific learning disorders - Aggressive behaviour - Low self-esteem - Repetition of classes/grades - Rejection by peers - Impaired family relationships
How might a 13-17 year old with ADHD present?
Difficulty in planning and organisation Persistent inattention Reduction of motor restlessness Associated problems - Aggressive, antisocial, and delinquent behaviour - Alcohol and drug problems - Emotional problems - Accidents
How might an adult with ADHD present?
Residual symptoms in around 70% Associated problems - Other mental disorders - Antisocial behaviour/delinquency - Lack of achievement in academic and professional career
How far behind can people with ADHD be in terms of socially and emotionally?
1/3 behind those of their age
Catches up in adulthood
How is ADHD investigated?
Clinical interview
ADHD nurse classroom observation
QB test - performance test to control impulsivity
Questionnaires
What can cause ADHD?
Neuroanatomic/neurochemical
Genetics
CNS insults
Environmental factors
How is ADHD treated?
Education ADHD parenting programme School support and liaison Medication Stress importance of balanced diet and exercise Mental health
What should you check before prescribing stimulants for ADHD?
Cardiac assessment
What should you check for in a pre-treatment cardiac assessment in ADHD?
Hx of cardiac disease FHx of sudden death Symptoms of cardiac death - Effort intolerance - Palpitations - Syncope (exercise, frequent) Other medications Dysmorphic features Pulse BP HS Femoral pulses
How common is ASD?
1:100
1/2 million in UK
Boys 4x than girls
What is the cause of ASD?
Exact cause unknown
Genetics important
What are the symptoms of ASD?
Social communication and repetitive behaviour and sensory interests
Sleeping difficulties
Eating difficulties
Obsessions
Rituals
Fears and phobias
Overlap with other developmental disorders
What symptoms of communication difficulties might you get in ASD?
Lack of desire to communicate
Communicating needs only
Disordered or delayed language
Repeats speech/echolalia
Poor non-verbal communication, gesture, body language
Good language
No social awareness
Unable to start up or keep a conversation
Pedantic language, very literal, poor or no understanding of idioms or jokes
What symptoms of social interaction problems might ASD present with?
No desire to interact with others
Being interested in others to have needs met
Lack of motivation to please others
Affectionate on own terms
Friendly but with odd interactions
No understanding of unspoken social rules
Limited interaction with unfamiliar people in unfamiliar circumstances
What behaviour, imagination, or rigidity problems might someone with ASD present with?
Using toys as objects Inability to play or write imaginatively Resisting change Playing same game over and over Obsessions/rituals - helps with anxiety, relaxation - really enjoy these Learning by rote, no understanding Inability to see others point of view or wider picture Follows rules exactly Asks same question even when answered
What other developmental disorders might someone with ASD present with?
ADHD Dyspraxia Tics Anxiety Depression Epilepsy Learning disability/difficulty Dyslexia
How is ASD managed?
Education and information ASD parenting workshops School liaison/support Manage comorbidity Communication temptations - play based techniques Picture exchange communication system Written instructions/visual cues Timetables/schedules Visual behaviour support Pull out talents
How is ASD diagnosed?
Questionnaires
Play with them - multiple specialists involved
