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Child and Adolescent Mental Health Services: Psychiatric disorders in Learning disability Dr Latha Hackett Consultant in Child and Adolescent Psychiatry Dr Jo Bromley. Consultant Child and Adolescent Clinical Psychologist. Child & Adolescent Mental Health Mental Health. Mental Health Problem. Mental Disorder/ illness. Psychiatric disorders in Children and Adolescent with Learning disability. CAMH services in Manchester. Mental Health The ability to develop psychologically, emotionally, intellectually and spiritually. The ability to develop and sustain emotionally satisfying personal relationships. The ability to become aware of others and to empathise with them. The ability to use psychological distress as a developmental process, so that it does not hinder or impair further development. Indicator of Good Mental Health A capacity to enter and sustain mutually satisfying personal relationship. Continuing progression of psychological development. An ability to play and to learn so that attainments are appropriate for age and intellectual level. A developing moral sense of right and wrong. The degree of psychological distress and maladaptive behaviour within normal limits for the child’s age and context (Hill, 1995). Mental Health Problems Are difficulties/disabilities may arise due to Congenital Factors. Constitutional Factors Environmental Factors Family Factors. Illness factors. Child/Family/Environment. Mental Health Problem Presenting features are outside the The normal range for the child’s age, intellectual level & culture & This causes suffering to the child or others in contact as a consequence. Mental Health Problem There is Change in the child’s usual behaviour, emotions or thoughts. Persistence of the problem – for at least 2 weeks. Severe enough to interfere with the child’s everyday life A disability to the child and or the carers. Mental Health Problem Can cause concern & distress e.g. Developmental difficulty – Speech and language disorder. Educational Difficulties – Specific reading retardation or other LD. Social difficulties –Parental Violence, sexual abuse or illness. Mental Health problem Vs Disorder Symptoms of Mental health Problem & Mental disorder/illness are similar. Behaviour problems – common pathway for variety of underlying problems. Mental Disorder is not an exact term. Mental disorder/Illness. Existence of a clinically recognisable set of symptoms Or Behaviour associated with distress and interference with personal function (impairment). Mental Health Problem Vs Disorder When does a problem become a disorder? When does a fever a URTI or a Meningitis? When is a headache a symptom of stress or a brain tumour? Behaviour a symptom of ASD? When does a cold become a pneumonia? Low mood to a depressive illness? Normal dieting to a eating disorder – AN? Sensitive to others comments – delusion – to a psychotic illness.? Mental disorder. What leads to a mental Disorder? Predisposing factors. Precipitating factors. Perpetuating factors. Protective factors. These are all associated factors not causal factors. Predisposing factors – Child Factors Genetic influences – Boys > Girls. Low IQ & LD Specific Developmental delay. Communication difficulty. Difficult temperament. Physical illness esp. – chronic illness & or Neurological Academic failure Predisposing -Family Risk factors Parental conflicts, family breakdown. Inconsistent or unclear discipline. Hostile or rejecting relationship Failure to adapt to child’s changing dev needs. Abuse – physical/sexual &/ or emotional Parental psychiatric illness, criminality, alcoholism & personality disorder. Predisposing -Environmental factors Socio-economic disadvantage. Homelessness. Disaster Discrimination. School – bullying and other factors. Precipitating Factors. Any reason that leads to the presentation of symptoms e.g. DSH following an argument with loved one. Change from Primary to secondary school in a child with SCD. A physical illness leading to school refusal. Protective factors Self esteem, sociability & autonomy. Average or above average IQ. Family compassion. Warmth & absence of parental discord. Social support systems that encourage personal effort and coping. CAMHS. 0.075 % children will need Tier 4 1.85% Tier 3 7% Tier 2 15% Tier 1 Psychiatric disorders and Learning disability 1-3 % of the population have LD - Mild to profound LD (MR for ICD X and DSM IV). Of these 80% are Mild (50-70), 12% Moderate (35-49 ). 7% - Severe (20-34), 1% - profound - <20) Educational terms – 50-70% moderate Learning Difficulty. < 50 Severe LD Medical term – ICD X Mental retardation. RCPsych – learning disability. Psychiatric Symptoms and Disorders Mild MR ( (IQ 50-69): Psychiatric disorder has the same distribution as in children of normal IQ. Hyperkinesis/ADHD. Conduct Disorder. Emotional disorders. Depression. Asperger’s syndrome. Psychiatric Symptoms and Disorders Severe MR (IQ <50). Psychiatric disorder predominantly PDD/Autism. Severe Social Impairment. Self-injurious behaviour. Psychiatric Symptoms and Disorders Other disorders. Mood disorders. Schizophrenia and other disorders Obsessive Compulsive disorder Eating difficulties. Mental Illness secondary to a medical disorder – Seizure disorder, anaemia, malnutrition, pain due to any physical cause, brain tumour, degenerative disorder, endocrine problem, accidental poisoning, side effects of drugs Presentation of Psychiatric disorders ADHD – Present <7, Inattention, poor concentration, Hyperactivity. ASD – Present before the age of 3. The triad. OCD – Obsessions, rituals with compulsion Tourette’s disorder – motor and vocal tics. Anxiety disorder – Common problem -10%. panic dis, specific ph, social ph, PTSD, gen anx dis, acute stress dis. Fragile X – social anxiety & shyness , William Syndrome – anxiety and fearfulness. Adole – hyperactivity. Prader-Willi – anxiety, low self esteem and OC preoccupation – cleanliness and food. ASD – anxiety common. Presentation of Psychiatric disorders Mood disorder – Change in beh – regressive, pica, rocking, tearfulness, diurnal var mood, loss of energy, interest, social isolation, disturbed sleep, appetite, SIB, weight loss, screaming, aggression. Down’s syn & ASD – adole dep common – mistaken for oppositional beh. Psychotic illness – Schizophrenia and Bipolar disorder – change in beh., irritability, disorganised beh, poverty of thought, social and intell funct worsening, striking out or shouting at empty space - clues to hallucinations. Assessment. 1. Developmental/Cognitive assessment is crucial Expectation may be wildly inappropriate. Need to evaluate symptoms in developmental context. 2. Communication difficulties – usefulness of art 3. Organic factors Epilepsy & medication. Behavioural phenotypes. Physical examination. 4. Reliance on observation. Changes, deterioration in intellectual functioning. Emergence of new behaviour. Behavioural analysis. 5. Family issues. Coming to terms/anger/denial/chronic sorrow. Life cycle – eg leaving home. Dependence/independence. Parental and sibling emotional disturbance and family disharmony. Vulnerability to abuse/ scape goating -?MR may as act as protective(severe) or vulnerability factor (mild) 6. MR may affect vulnerability to environmental adversities. 7. Social factors – loss of earning, restricted opportunities and social isolation. Educational effects – to get the right educational input is difficult. Variation between school and authorities do not help. Lack of resources. Treatments Psychological – Behavioural, CBT, Family, social skills, individual psychodynamic. Environmental – respite, educational etc. Medical – Commonest – Methylphenidate, Melatonin, Risperidone, antidepressants and other psychotropics as appropariate. Referral Pathway. Direct referrals – General Practitioners, Community Paediatricians, Hospital Paediatricians, School doctors. Other referrals from education psychologists, EWO’s - Referrer has discussed with the GP/ School doctors/Com Paed. Copied to the GP HV, SN – referral discussed with the GP or Com Paed, referral copied to the GP. SS & YOT – Liaison meetings CAMHS in Manchester – Tier 2 3 &4 CAMHS directorate - Tier 2 & 3 North – Psychology, Psychiatry (BHH) CPN. Central – Psychology & Psychiatry – Winnicott Centre. South – Psychology & Psychiatry – Carol Kendrick unit. Youth Access Team, special projects – CAPS, CAPS TIP, CP-LAC, CP-LD, Manchester Link etc. Tier 4 – Booth hall, McGuiness unit & CAFTU at the Winnicott Centre. All services are made of small number of clinicians. Treatments offered. Psychotherapy. Behaviour therapy. Cognitive behaviour therapy. Parent training Family Therapy. Group therapy. Medication. Where do we work from The assessments are undertaken where ever it is appropriate in the unit, school or home situation. Treatments offered will depend on the clinical situation. Professionals. Child and adolescent psychiatrists Clinical Psychologists. Nurses in Child Psychiatry – Practitioners, Therapists and CPN. Child & Adolescent Mental Health Practitioners/Therapists. Specialist Speech and Language therapists Assessments & Interventions Complex. Lengthy. Partnership between child/family, other agencies.