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Childhood Mental Health Disorders

Dr Durre Shahwar
Attending physician
Child and Adolescents Psychiatry
Sidra Medicine

10/15/2019
What does a child/adolescent psychiatrist do ?

• Works with children, adolescents, and


families who have problems with their:

• Emotions

• Behavior

• Cognition/thinking
Why study mental health in children & adolescents?

• 10% are affected by mental health disorders

• Essential to detect disorders in primary &


secondary care

• Many adult disorders originate in childhood &


adolescence (approx 75%)

• Useful not only for those interested in


psychiatry, but also primary care, pediatrics,
general medicine etc.

• You can refer to clinical/research work going on


in Wales throughout.

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Why study Child & Adolescent Psychiatry?

• High prevalence of mental health problems among adolescents and young adults; estimated at
20% by Surgeon General’s Report of 1999.

• Is this due to better diagnosis, an actual increase in prevalence, or both?

• Half of all lifetime cases of mental illness are now recognized to begin by age 14 and the rest
by age 24 (Kessler et al, 2005).

• The median number of years from the time a child first experiences psychiatric disturbance
and receives treatment is 9 years (2 years for psychotic illnesses); Kessler et al, 2005

• Despite effective treatments, however, there are typically long delays, sometimes decades,
between when individuals first experience clinically significant symptoms and when they first
seek and receive treatment.
Video AACAP

https://www.youtube.com/watch?v=r8ed-9NEt7Y&feature=youtu.be
Statistics of mental Health in Children in England 2018

This survey series provides England’s best source of data on trends


in child mental health

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What's the situation in Qatar

• About 550,000 Children and Adolescents in


Qatar

• Currently few child & adolescent


psychiatrists

• Limited Child and Adolescent Psychiatric


Services

• No Inpatient Child & Adolescent Beds

• No Training Programs

• Limited Research
What's the situation in Qatar

• A 2013 study by the then-Supreme Council of Health found that mental health issues
in Qatar are “common” and are expected to affect one in five adults in the country.

• 20 percent of people seeking help are diagnosed with generalized anxiety disorder,
19 percent with major depressive disorder and 13 percent with other psychiatric
disorders. About 10 percent of mental disorders are classified as severe.

• Children appear to be particularly at risk. A separate study in 2013 found that nearly
one in four teens here appear to be suffering from depression.

• However, experts said that social stigmas and a perceived need to keep the illnesses

secret have hampered the effectiveness of treatment.

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What's the situation in Qatar

• At the time of its launch three years’ ago, the mental health strategy laid out a 10-point
plan for change.

• This included raising public awareness about mental health and reducing the stigma
and educating healthcare professionals so that they can pick up on problems at an early
stage.

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Aims of Pediatric Psychiatry Interview & Assessment

1. Create a good therapeutic relationship

2. Understand the exact reason for referral (“Whose problem is it?” “Why now?”

3. Identify the child’s and parent’s implicit and explicit expectations and concerns about the

evaluation

4. Identify the main complaint of the child and the family

5. Evaluate the child in the context of his or her current functioning in the family, the school,

and with peers, with sensitivity to cultural or community influences and the extent this has

been impaired
Aims of Pediatric Psychiatry Interview & Assessment

6. Obtain an accurate picture of the child’s developmental functioning from birth to now

7. Obtain a picture of the parents and family functioning, and family history both medical
and psychiatric

8. Clinical formulation

9. Communicate this clinical formulation and recommendations to the parents and the child
in an understandable and constructive way

10. Establish target symptom priorities and clarify the focus of treatment

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Assessment

Identifying Information / Chief History of Present Illness


Complaint
1. Depression
1. Name
2. Anxiety
2. Age
3. Mania
3. School Grade
4. Psychosis
4. Parent/Guardian
5. PTSD
5. Living Situation
6. ADHD
6. Main Reason for Referral
7. Street Drugs
7. Who Referred
8. Current Medications

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Assessment

Impact of Illness Past Psychiatric History


1. School 1. Previous Treatments
2. Family 2. Past Medications
3. Peer Relationships 3. Past Hospitalizations
4. Daily Routine 4. Previous Suicide Attempts
5. History of Violence
Risk Assessment Medical History
1. Suicide 1. Seizures
2. Homicide 2. Head Injuries
3. Medical Issues
4. Pediatric Medications
5. Surgeries

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School History Family Psychiatric History
1. Elementary School 1. Mood Disorders, Psychotic Disorders, Anxiety
Disorders, etc
2. High School
2. Substance use
3. Special Classes
3. Suicide
4. Learning Disabilities
4. Developmental Disorders: ASD, Intellectual
5. School Issues
Disabilities
Developmental History Social History / Personal History
1. Pregnancy 1. Parents (Education, Marriage, Occupation)
2. Delivery 2. Siblings
3. Speech Milestones 3. Housing Situation
4. Motor Milestones 4. Interests / Strengths
5. Any Issues in First Few Years of Life 5. Relationships / Friends

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Mental Status Examination Formulation
1. Appearance and Behavior 1. Biological
2. Speech 2. Psychological
3. Mood Affect 3. Social
4. Thought Process, Content
5. Thought Perception  Differential Diagnosis
6. Orientation DSM 5
7. Wishes / Future Goals
8. Insight / Judgment

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Treatment and Management

• Collateral Information

• Safety Plan & Level of Care

• Laboratory Tests

• Psycho education

• Psychological: Testing, Individual Therapy, Family Therapy

• Social Interventions: School, Family, etc

• Medications

• Prognosis

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Kirsty
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https://youtu.be/A_zaMu6g5n4

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Case 1

Dear CAMHS Team,

Kindly review this 9 years old. Parents are 1. What further information
concerned that he is struggling at school , would you want, &
doesn’t listen, can’t concentrate and is from whom?
often fidgety. The parents are very worried
about him. 2. Which differential diagnoses
are you considering & why?
Yours sincerely
Group discussion
Dr Ahmed(GP)
Hyperkinetic disorder – ICD-10

Multi-disciplinary assessment – including


Pervasive (>1 setting), >6 months, Onset clinic, parent & school reports
before 7 years, Difficulty in following areas: Screening questionnaires e.g. Connors

Inattention Hyperactivity
Fidgets / squirms
Attention to details / careless errors
Leaves seat
Sustaining attention
Unduly noisy
Listening to others Excessive motor activity
Following through on instructions
Organizing tasks Impulsivity
Avoiding tasks requiring sustained effort
Losing things Blurts out answers
Distracted by external stimuli Fails to wait in line
Forgetful Interrupts/intrudes
Talks excessively

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Hyperkinetic disorder / ADHD

• Around 3.4% of children; More common in males


• Highly heritable
• Environmental risks e.g. perinatal factors (unclear)
Management
Education & support (for family/school), support groups; Behavioural treatment, delivered
by parent
First line medication: Methylphenidate
• Rapid, short acting (tds dosing usually)
• Possible side effects: poor appetite & growth, insomnia, tics, cardiovascular, headache
• Also: Dexamfetamine, atomoxetine
Assess/treat comorbid difficulties (eg autism, mood disorder, dyslexia)

(NICE clinical guideline, updated 2013)

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Case 2

• Group discussion

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Autism - ICD-10

Reciprocal social interaction, difficulty with Restricted, repetitive, stereotyped patterns


the following: of interest
Eye-to-eye gaze, facial expression, body Non-functional routines / rituals
posture & gesture
Motor mannerisms eg hand flapping
Development of peer relationships
Part-objects
Socio-emotional reciprocity
Spontaneous seeking to share
enjoyment/interests/achievements Onset before 3 years old, Pervasive
MDT assessment: CAMHS, Child Health,
Communication: S&L Therapy, Educational Psychology etc
Delay/ total lack of spoken language
Difficulty initiating/sustaining conversation
Repetitive use of language
Lack of spontaneous make-believe/social
imitative play

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Autism - ICD-10

Epidemiology
• ASD up to 1% in school-children
• More common in males than females

Aetiology
• Strongly genetic
• Genetic syndromes eg Fragile X, Tuberous Sclerosis
• Early antenatal/perinatal factors (unclear)

Management
• Family support / Specialised educational provision
• Manage possible behavioural problems & comorbidities
• Speech & language therapy

NICE clinical guidelines - assessment (2011) & management (2013)

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Other Disorders: Mood Disorders/Behavioral/Psychosis
Conduct disorders
Anxiety disorders
• Common reason for referral to CAMHS
• Social Anxiety
• Repeated & persistent pattern of angry mood
• Similar categories to adult anxiety & aggressive/antisocial behaviours
disorders with addition of separation • ADHD is an important differential diagnosis -
anxiety conduct disorders often co-morbid with ADHD,
but conduct difficulties alone not a core
• Treatments include psychoeducation,
feature of ADHD
psychological therapies (CBT).
• Management includes group-based parent
Medication (SSRI) only for severe
training, individual approaches with child,
anxiety
treatment of co-morbidity, & liaison with other
• Obsessive compulsive Disorder agencies

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• Psychotic Disorders • Eating Disorders
• ICD 10 F20-29 Anorexia nervosa
• The schizophrenic disorders are • Body weight at least 15% below expected/ BMI
characterized in general by fundamental 17.5 or less/ failure to make expected weight
and characteristic distortions of thinking gain.
and perception, and affects that are
• Self induced: avoidance/ vomiting/ purging/
inappropriate or blunted.
excess exercise/ use of pills or medicines
• Clear consciousness and intellectual
• Body image distortion- dread of fatness/
capacity are usually maintained although
impose low weight threshold
certain cognitive deficits may evolve in the
course of time. • Overvalued Idea
• The most important psychopathological • Endocrine changes- amenorrhoea in females
phenomena include thought echo; thought
• Pubertal delay if onset is pre-pubertal
insertion or withdrawal; thought
broadcasting; delusional perception and
delusions of control; influence or passivity;
hallucinatory voices commenting or
discussing the patient in the third person;
thought disorders and negative symptoms.
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Case 3

Dear CAMHS Team ,

I would be grateful for your opinion on this 1. What further information


14 year-old girl. Her mother is concerned would you want, & from
that for the past 2 months, Noor has whom?
become increasingly withdrawn and has
lost weight. Noor remained quiet during 2. Which differential diagnoses
the consultation. She appeared withdrawn
and unkempt. I think she needs to be are you considering, & why?
assessed urgently.
Group discussion

Yours sincerely
Dr Ahmed (GP)
Depressive episode

ICD-10
• Core features: Low mood, anhedonia, low energy
• Also: Low self-esteem, guilt, suicidal thoughts/behaviour,
concentration difficulties, psychomotor retardation/agitation,
sleep disturbance, change in appetite & weight
• Other: early morning wakening, worse in morning, loss of libido
• Impairing & persistent over at least 2 weeks

• Irritability also a core feature in adolescents (DSM)


• May present as non-specific difficulties
• Might not be primary problem
• Always assess risk of self-harm

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Treatment and Management

• Psychoeducation
• Reduce environmental stresses
• Individual psychotherapy: cognitive therapy, inter-personal therapy
• Family work
• Anti-depressant medication (SSRIs – fluoxetine)
(NICE clinical guideline, updated 2015)

Management of self-harm
• Medical treatment/monitoring & mental health assessment
• Lower threshold for hospital admission compared to adults
• Follow-up & individual/family work as indicated
• Consider social services

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Differential Diagnosis

• Anxiety disorders

• Eating Disorders
Anorexia Nervosa, Bulimia Nervosa

• Bipolar Affective Disorder

• Psychosis
Schizophrenia (e.g. prodromal phase),
Mood disorders, Drug use

• Autistic Spectrum Disorders

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• What are the 3 core features of
• Quiz 1 ADHD?

• What are the main management


approaches?

• What is the first line medication for


ADHD?

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• How might depression present
Quiz 2 differently in adolescence, compared
to adulthood?

• What is the differential diagnosis?

• What are the main treatment


approaches?

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• Quiz 3 • What are the 3 core features of
autism?

• How is this assessed?

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SUMMARY

• Thorough Assessment

• Developmental Approach

• Impact on Life of a Child & Family

• Risk Assessment

• Biopsychosocial Formulation

• Differential Diagnosis

• Comprehensive Child & Family Centered Treatment

• Evidence Based Treatment


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Resources and Content Contribution

• Child & Adolescent Psychiatry’(3rd ed) Goodman & Scott

• ‘Rutter’s Child & Adolescent Psychiatry’ (6th ed)

• Child & Adolescent Psychiatry Section, Institute of Psychological Medicine


& Clinical Neurosciences, Cardiff University

• NICE Guidelines, UK

• Mental Health Strategy, Qatar

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