CAMHS Flashcards
Mild depression in children can be managed with watchful waiting and advise about healthy habits. (Follow up within 2 weeks is advised) Referral to CAMS should be considered for children with moderate to severe depression.
Treatment options include what?
• Full assessment
• Psychological therapy (first line)
• Fluoxetine starting at 10mg max 20mg (first line antidepressant in children; followed by Sertraline and Citalopram)
When they do not respond to medical treatment they may require intensive psychological therapy
Where there is follow up monitoring in secondary care, the mood and feelings questionnaire (MFQ) may be used to assess progress.
Admission may be required where there is high risk of self harm, suicide or self-neglect or where they may be an immediate safeguarding issue.
What are potential psychosocial contributors to depression in children and adolescents
Potential triggers (e.g. loss of a family member)
Home environment
Family relationships
Relationship with friends
Sexual relationships
School situations and pressures
Bullying
Drugs and alcohol
History of self harm
Thoughts of self harm or suicide
Family history
Parental depression
Parental drug and alcohol use
History of abuse or neglect
What can be used to assess progress in children and adolescents being seen by secondary care for depression
mood and feelings questionnaire (MFQ)
How might depression present in children
Low mood
Anhedonia, a lack of pleasure in activities
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding social situations (e.g. school)
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms such as abdominal pain
What is tourettes?
Tourette’s syndrome is characterised by the development of tics that are persistent for over a year.
What is a tic?
Tics are involuntary movements or sounds that the child performs repetitively throughout the day.
These tics become more prominent when the person is under pressure or excited. The person may describe an overwhelming urge to perform the tic.
This urge increases the more they suppress it.
They feel they need to complete the tic, often several times, to get relief from that urge.
These feelings are called premonitory sensations.
When do tics tend to develop
Around or after 5 years of age
What conditions are tics associated with?
Tourette’s
OCD
ADHD
Examples of simple tics
Clearing throat
Blinking
Head jerking
Sniffing
Grunting
Eye rolling
Examples of complex tics
Performing physical movements, such as twirling on the spot or touching objects
Copropraxia involves making obscene gestures
Coprolalia involves saying obscene words
Echolalia involves repeating other people’s words
Managements of tics/tourettes?
Usually tics will improve over time. Mild cases with no signs of underlying disease may only require reassurance and monitoring. Taking measures to reduce stress, anxiety and triggers can be helpful.
More severe or troublesome tics should be referred to a specialist. They may benefit from:
Habit reversal training
Exposure with response prevention
Medications may be tried in very severe cases, usually with antipsychotic medications
Co-morbid conditions such as OCD and ADHD may benefit from treatment.
What distinguishes child from adult psychiatry?
That nowhere is development more marked than in childhood and adolescence.
Children have to be viewed in the context of their families on whom they are generally dependent and definitions and compositions of the families are changing all the time.
The cultural context of the child is even more significant as both the first two features are related to this aspect.
Most often the nominated patient does not present themselves but is presented (brought to services)
Cultural mismatches between young people and their carers which may affect presentations to mental health services and how they are managed.
What factors may affect when a child presents to secondary care?
Age
Frequency
Severity
Individual characteristics or temperament
Impact on others
Social or family circumstances
How are mental disorders in children generally categorised?
Neurodevlopmental
Behavioural
Emotrional
Influences which affect
interaction with children
ENVIRONMENT
- Privacy
- Suitability
- Noisy/overstimulating
- Access to toys/materials
- Age appropriate
- Intimidating
- Correct for what is being assessed
CHILD ADOLESCENCE
- Feeling safe/secure
- Willingness to engage
- Family or carers present/not present
- Cognitive ability: IQ/processing problems
- Communication/language problems
- Emotional development
CLINICIAN FACTORS
- Setting enough time
- Appropriate use of language
- Appropriate non-verbal communication
- Using the right method for the situation
- Avoid being patronising/condescending
- Try not to sound rehearsed
- (It is easier if you like children)
CAMHS - considering the parents/carers
- Not the referred person but may need to be
- Multiple informants
- Expectations
- Parental mental health
- Family dynamics i.e divorce
- Engagement
- Ability to leave the child
CAMHs history
- Certain elements have greater relevance
- Present/Hx presenting complaint
- Development Hx
- Family Hx
- Social Hx
- School
- Observation of the child/child and carers
- Consider these when watching videos
What different types of assessment are different in CAMHS
- Psychometric
- Sensory assessments
- School observations
Emotional disorders common in children
Generalised Anxiety Disorders
Separation Anxiety Disorders
Phobic Disorders
Obsessive-Compulsive Disorders
Post-Traumatic Stress Disorders
Depression
How might children present with GAD
Free floating anxiety
Fears of death, loss (of child or parents)
Somatic manifestations (nausea, abdominal pain, sickness,
headaches, sweating, palpitations, tension)-more common in
children
Panic attacks (sudden onset, extreme fear, physical symptoms,
faintness
How might separation anxiety present in children?
Anxiety manifest upon separation (or threat of separation) from
attachment figures (usually parent, particularly mother)
Somatic manifestations
Nightmares with separation themes
School refusal
What are the two main features of OCD
OBSESSIONAL THOUGHTS – intrusive persisting, awareness of
their illogicality, resistance to them (e.g. counting, urge to wash
hands or touch wood a certain number of times)
COMPULSIVE ACTIONS – related to the thoughts
General principals behind PTSD
Persistently re-experiencing trauma
Avoidance of associated stimuli or numbing of
responsiveness
Increased arousal (sleep disturbance, irritability,
poor concentration)
How might anxiety disorders be managed in children?
Behaviour therapy (systemic desensitisation, flooding,
response prevention)
Psychotherapies (brief psychodynamic, family and
cognitive therapy)
Anxiolytics-most common fluoxetine (SSRI)
How might mood disorders be masked in young boys?
Anger
How might low mood in depressive illness differ in children to adults?
In children with depressive illness the low mood is persistent BUT may not be pervasive
The biological symptoms are not
consistent-appetite/sleep may not be affected.
Concentration/motivation are generally worse
Managing depressive illness in children
Cognitive-behavioural therapy
Antidepressants (SSRIs)
Managing the underlying or comorbid problems
What are the characteristics of oppositional disorder?
Uncooperative, unwilling to comply with requests, frequent temper tantrums
Wilful, defiant, may also be aggressive
Unless managed, tends to escalate
Features of children with conduct disorder
Socialised and unsocialised types
Socialised conduct disorder is usually viewed as less serious and
tends to be phasic in nature
Unsocialised conduct disorder is more serious, and potentially
leads to criminality and a later diagnosis of antisocial personality
disorder
Lying, stealing, truanting, violence to people
and animals
Behavioural problems - risk factor
Lack of clear boundaries, inconsistent parenting
Rejection Rejection
Family conflict, especially witnessing violence and aggression
Child abuse
Child temperament
Comorbid learning or developmental difficulties
Treatment of behavioural issues
Consistent care and parenting
Behavioural therapy Behavioural therapy
School-based interventions School-based interventions
Community interventions
How often does ADHD persist beyond childhood
Symptoms persist into adulthood in approximately 2/3 of
cases
Features of ADHD
Poor attention and concentration
Physical overactivity
Impulsivity
Needs to occur in more than one environment
Diagnosis after 6 years, but symptoms
present before
What is attachment?
lasting psychological connectedness between human beings
(Childs attachment TO the parent)
Management of ADHD
- Mild and moderate: consider parenting and school interventions first
- Severe: medication first line
– Methylphenidate: short or long-acting stimulant
– Lisdexamphetamine
– Atomoxetine
– Guanfacine - Treat co-morbidity-anxiety, behavioural problems, substance use.
Autism co-morbidities
Associated with a number of co-morbid conditions eg.
– Anxiety
– ADHD
– Sleep problems
– OCD
– Learning difficulties
Symptoms of autism
Socio/communication difficulties-verbal/non verbal
difficulties
Effects on thinking-lack of flexibility, social imagination, theory of mind, generalisation
Needs to occur in more than one environment
Symptoms must be present before 3 years of age
Approaches to managing autism
– Psycho-education
– Stress reduction
– Environmental changes
– Treat co-morbidities
When are eating disorders rare?
Rare in the pre-adolescent period
Increasingly prevalence in adolescence - similar symptoms to adult presentation
Delayed puberty and growth are significant issues
Prognosis worse if younger or male
Key significant issue in children with eating disorders
Delayed puberty and growth are significant issues
Poor prognostic factors in ED
Prognosis worse if younger or male
Children with psychosis - features
Hallucinations
Delusions
Thought disorder
Need to consider substance misuse
Rare before pubertY
How might depression present in children?
Low mood
Anhedonia, a lack of pleasure in activities
Low energy
Anxiety and worry
Clinginess
Irritability
Avoiding social situations (e.g. school)
Hopelessness about the future
Poor sleep, particularly early morning waking
Poor appetite or over eating
Poor concentration
Physical symptoms such as abdominal pain
Initiation of SSRIs in under 18s
May be initiated in primary care but must be referred to secondary care for follow up and monitoring
CAMHS risk management
Personal factors increasing risk:
Cognative impairment, physical or mental health issues, sleep problems, ND conditions, ACRs, criminal judgement system risk, non-engaement, gender issues, nutritional issues, protective factors
Social factors increasing risk:
LAC/adopted child, NEET, academic or work pressures, victim of bullyinh, bullying others, isolation, negative impact of social media, bereavement, concerns about saftey of medication management
Risk of harm to self, others, from others, (past present)
any other risks, driving
Social/enviromental stressors in children?
Trauma
Accident
Illness
Death
Biggest adverse factors that put children at risk developing mental disorders
Poverty
Parental mental illness
Examples of cihronic adversity
Socio-economic
Parental mental illness
Parental loss
Family conflict - violence
Parenting
Abuse (physical secual neglect emotional)
Exposure to community violence
Biological factors influencing child mental health?
- Temperament
- Genetic
- Neurodevelopmental
- Biochemical
- Appearance
Developmental/psychological influencing child mental health?
- Attachment-important
- Learning
- Cognitive
- Emotional
Significant environmental influences on child mental health?
- Parents and family
– Type of parenting
– What constitutes good parenting?
– Family structure - School
– Academic success/failure
– Friendships
– Bullying - Culture
Protective factors against mental illness in children?
Temperament
Coping strategies
Problem-solving
Self-esteem
Stability
Secure relationships
Friendships
Achievement
What is Coprolalia
Coprolalia refers to uncontrollable outbursts of obscenities or swear words in socially inappropriate settings. This has also been liked to left frontal seizures or strokes, but is most commonly associated with Tourette’s syndrome.
What questionaries might be used in ADHD screening?
Conners Questionnaire
Dundee Difficult Times of the Day Scale (D- DTODS)
SNAP – IV
Strengths and Difficulties questionnaire
What is the GARS questionaries used to screen for?
The GARS questionnaire is used to screen for Autism.
If a patient had a family history sudden death in a first-degree relative under 40 years of
age suggesting a cardiac disease, what are some important interventions prior to starting
possible ADHD medication?
This patient would be referred to the Paediatric Cardiologist for assessment. They would take
a history and perform a clinical examination. They would usually do a blood pressure, EGG,
and echocardiogram. With that family history it would also be useful to do a 24-hour ECG
tape recording
