1 psychiatric perspectives in children psychiatric perspectives in children with special educational...

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Psychiatric Perspectives in Children Psychiatric Perspectives in Children

with Special Educational Needswith Special Educational Needs

Prof Maurice PlaceProf Maurice Place

Copy of Presentation @ Copy of Presentation @ www.tinyurl.com/www.tinyurl.com/yzp2axyyzp2axy

[email protected]@northumbria.ac.uk

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James 14 yrs

Presentation - A good student until 18 months ago,

now poor work and frequently not handing in homework

violent outbursts at school for last few months

- excluded from school following an assault on teacher.

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Becky 14 yrs

Presentation -Always a rather quiet girl, but not prompted concern until now

- recently more withdrawn – at break times either alone

or with “smoking group”

- says being bullied at school

- frequent arguments with mother about friends she’s out with,

time in etc.

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What do you think is going on?

Do either of these cases require referral to a professional?

What would you expect the professional to achieve?

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Issues of Diagnosis in Mental HealthIssues of Diagnosis in Mental Health

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What Constitutes a Problem?

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Who’s Problem is it?

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Who’s Problem is it?

The Child

The Parent

The Teacher

“Society”

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How to define it?

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How to define it?

Unit 1 the child is frightened of going to school Unit 2 an unwritten contract between two people. The child is frightened to separate from mother Unit 3 triangular relationships - coalitions & alliances. The child is in close alliance with mother and her "problem" of school attendance takes precedence over marital difficulties

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How to define it?

Unit 1 the child is frightened of going to school Unit 2 an unwritten contract between two people. The child is frightened to separate from mother Unit 3 triangular relationships - coalitions & alliances. The child is in close alliance with mother and her "problem" of school attendance takes precedence over marital difficulties

Probably two elements - school issues & family themes conspiring to produce non-attendance (Perugi et al 1988; Last & Strauss 1990)

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• memory

• thought

• mood

• hallucinations - visual - tactile - auditory

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• delusions

• behaviour

• vegetative

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Let us consider:Let us consider:

A white english man who is referred because he is telling

his GP that he has had a message from God and been told to

give away all his possessions and preach on street corners.

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He is - a heavy drinker

- the managing director of an engineering firm.

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He is - an anglican vicar

- his wife has recently died

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Disorder is characterised by:Disorder is characterised by:

atypical behaviour and/or distressatypical behaviour and/or distress

AND

dysfunction dysfunction

which is - persistent & severe

(Lask 2003)

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How do these “adult concepts” apply to children?

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Disorder is characterised by:Disorder is characterised by:

atypical behaviour and/or distressatypical behaviour and/or distress

AND

dysfunction dysfunction

which is - persistent & severe

(Lask 2003)

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• Parenting Quality

• Family Dynamics

• Developmental Themes

• Friendships & Their Influences

• School Performance

Elements considered in assessment

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So what of our two initial cases?

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James 14 yrs

Presentation - A good student until 18 months ago, now poor work and frequently not handing in homework violent outbursts at school for last few months - excluded from school following an assault on teacher.

violent outbursts at home over same period. - frequent arguments with mother - “walking on egg-shells all the time”. 2 episodes where threatened to cut own throat with knife.

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Presentation

Family & History - Only child. Parents separated 3 yrs ago. Marriage acrimonious & violent, sometimes towards James. Developmental milestones average. As junior - good peers, school attendance & performance. Weekend contact to dad - James tries to avoid going.

James 14 yrs

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Presentation

Family & History.

Examination - Truculent, quick to angry responses. Never out with friends, only goes out with mother since exclusion. Spends most of day watching TV. Eating - not eating for 2 days then binges. Sleep - bed after midnight, to sleep in early hours, wakes at lunchtime. Says he is “sick of my life” & gets weepy when thinks of it.

James 14 yrs

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Becky 14 yrs

Presentation -Always a rather quiet girl, but not prompted concern until now

- recently more withdrawn – at break times either alone

or with “smoking group”

- says being bullied at school

- frequent arguments with mother about friends she’s out with,

time in etc. - constant conflict with mother for 18 mths, most recent about hiding stolen mobile phone.

- mother feels losing control of daughter.

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Presentation

Family & History - Older sister allies with mother - fights with Becky. Father works away during week; mother works and seen by everyone as manager of family. Developmental milestones early. As junior - good peers, school attendance fine & seen as high flyer. Helpful round the house. Favourite aunt died in car accident 2 yrs ago.

Becky 14 yrs

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Examination Quietly spoken, minimising issues, but is worried by loss of temper. Feels parents are constantly “on her back”. Sees dead aunt “covered in blood” who tells her life will get worse. Eating - episodes of over-eating - has sometimes been sick afterwards because of amount. Sleep - awake until 3 am, grumpy in mornings. Weeps quite frequently but she always ascribes to life events. School performance poor in recent months - “can’t be bothered… ...don’t see the point”. Interests - used to horse ride; friendships reduced to 2 – both frequently excluded from school for disruptive behaviour.

Becky 14 yrs

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Differential Diagnoses

• depression

• conduct disorder/ opposition defiance

• adolescent challenge/ rebellion

• PTSD (James)

• abnormal bereavement reaction (Becky)

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5 or more of:-5 or more of:-

1) Depressed mood Depressed mood as indicated by either subjective report (e.g. as indicated by either subjective report (e.g.

feels sad or empty) or observation made by others (e.g. tearful). feels sad or empty) or observation made by others (e.g. tearful).

In young people can be irritable mood.In young people can be irritable mood.

2) Markedly diminished Markedly diminished interest in activities.interest in activities.

3) Significant change in weight or appetite.Significant change in weight or appetite.

4) InsomniaInsomnia..

5) Psychomotor agitation or retardationPsychomotor agitation or retardation as observed by others. as observed by others.

6) Fatigue or loss of energyFatigue or loss of energy..

7) Feelings of worthlessness or guilt Feelings of worthlessness or guilt (which may be delusional).(which may be delusional).

8) Diminished ability to think or concentrate.Diminished ability to think or concentrate.

9) Recurrent thoughts of death.Recurrent thoughts of death.

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James

1) Depressed mood/irritability Depressed mood/irritability x

2) Markedly diminished interest in activities.Markedly diminished interest in activities. x

3) Significant change in weight or appetite. Significant change in weight or appetite. x

4) InsomniaInsomnia. . x

5) Psychomotor agitation/retardation. Psychomotor agitation/retardation. -

6) Fatigue or loss of energyFatigue or loss of energy. . x

7) Feelings of worthlessness or guiltFeelings of worthlessness or guilt. . -

8) Diminished ability to think or concentrate. Diminished ability to think or concentrate. x

9) Recurrent thoughts of death. Recurrent thoughts of death. ?

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James Becky

1) Depressed mood/irritability Depressed mood/irritability x x x

2) Markedly diminished interest in activities.Markedly diminished interest in activities. x x x

3) Significant change in weight or appetite. x Significant change in weight or appetite. x x

4) InsomniaInsomnia. x . x x

5) Psychomotor agitation/retardation. - Psychomotor agitation/retardation. - -

6) Fatigue or loss of energyFatigue or loss of energy. x . x ?

7) Feelings of worthlessness or guiltFeelings of worthlessness or guilt. - . - x

8) Diminished ability to think or concentrate. x Diminished ability to think or concentrate. x x

9) Recurrent thoughts of death. ? Recurrent thoughts of death. ? x

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Causes of Disturbance and Distress

Intrinsic - - e.g. birth trauma, epilepsy, ADHD, Pervasive

Developmental Disorder

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Intrinsic

Parenting problems - failed system - - abusive, neglectful

- flawed system - - parental disagreement

- flawed delivery - - inconsistent


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Intrinsic

Parenting problems

Aggressive maritals exaggerated emotions, poor self esteem,

aggressive with peers


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Intrinsic

Parenting problems

Aggressive maritals

Alcohol / drug abuse in parents aggressive, poor emotional

control, moodiness, depression


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Intrinsic

Parenting problems

Aggressive maritals

Alcohol / drug abuse in parents

Other adverse life events - bereavement


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Intrinsic

Parenting problems

Aggressive maritals


Other adverse life events – bereavement

divorce


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Intrinsic

Parenting problems

Aggressive maritals



divorce

significant bullying


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Intrinsic

Parenting problems

Aggressive maritals



divorce

significant bullying

abuse/trauma


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Prevalence of Disorders

Overall prevalence

12% in the pre-adolescent age group (Kolvin et al., 1981)

25% in the adolescent population (Macmillan et al., 1980; Place et al., 1985)

Most not involved with mental health services (Offord et al., 1987; Rutter, Tizard, & Whitmore, 1970)

but a significant proportion do attend social services and primary care settings

(Kurtz, Thornes, & Wolkind, 1994).

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Prevalence of Specific Disorders

Anxiety disorders - 12%

Disruptive conduct disorders-10%

Depression 6% (increasing in adolescence)

Attention deficit hyperactivity disorder (ADHD) - 3%

Pervasive developmental disorders 1%

Psychoses are rare, affecting less than 1 %

Prevalence of Disorders

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Issues of Diagnosis in Our Issues of Diagnosis in Our Two CasesTwo Cases

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Oppositional Defiance

• losing one's temper

• arguing with adults

• actively defying or refusing to comply with rules

• deliberately doing things that will annoy others

• blaming others for his misbehaviour

• being touchy or easily annoyed by others

• being angry and resentful

• being spiteful or vindictive

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Oppositional Defiance

Child’s Temperament difficult, unadaptive (Bates et al. 1991).

Parents conflict destructive, rather than divorce per se (O'Leary and Emery 1982)

unemployment, divorce & poverty more prevalent (Webster–Stratton 1993)

fewer positive behaviours towards their children

more likely to threaten, criticise, and humiliate their children

less likely to monitor their children's behaviours

don't give enough time to comply with commands (Delfini et al. 1976; Forehand et al. 1975; Webster–Stratton and Spitzer 1991).

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Conduct Disorder

Oppositional Defiance elements with -

aggression towards othersdestruction of property theft and deceit

If emerge in early years then a distinctly different group from those where emerges in adolescence.

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Conduct Disorder

Severe conduct disorder associated with drug misuse, criminality, affective illness and youth suicide (Loeber et al., 2000)

If emerge in early years then a strong link with development of antisocial personality disorder (Frick, 1998). Rates of conduct disorder (adolescent emergence) are increasing quite dramatically (Loeber & Farrington, 1998; Smith, 1995).

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conduct disorder should be viewed as the most

important area for mental health services to

concentrate their efforts in order to find effective

interventions (Werry 2000)

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Child -focussed Treatments Task orientated - social skills, self esteem

Individual psychotherapy

Behaviour management

Drug therapy

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Drug therapy

– do medicines have a role?

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? When would meds be appropriate to

change classroom behaviour

and when would it not

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Why treat these children?Why treat these children?• Presents a persistent and severe impairment of

psychological development

• The negative impact of a high level of inattentiveness, restless and impulsive behaviour upon functioning

• Increased risk (x4) of substance misuse later in life

(Biederman et al 1999)

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Heritability from twin studies 65 – 90% (Thapar et al 2001)

Parents and siblings x4 more likely to have ADHD also (Faraone et al 2000)

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MTA Study Results (n = 579 Children)

Meds had strongest effect on the core symptoms of ADHD - adding psychosocial treatment did not improve effects

- in non-ADHD areas combining behavioural and medicine showed a modest advantage over medication alone

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Methylphenidate has a therapeutic to toxic ratio of 100:1

making it one of the safest paediatric drugs on the market

(Greenhill 1992)

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Monotherapy- methylphenidate – Concerta, Equasym, Medikinet or dexamfetamine - Vyvanse

Antidepressant – Bupropion (McCellan & Werry 2003)

Alpha agonists – clonidine (Riddle et al 1999) guanfacine (Posey & McDougle 2007)

maintenancemaintenance

Texas Treatment Algorithm

NSRI - Atomoxetine (Kratochvil et al 2002)

Antidepressant (2) – imipramine (Geller et al 1999)

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OutcomesOutcomes

Stimulants improve 70% of children (Miller 2002)

Reduce overactivity & impulsivity; increase academic productivity & cognitive functioning (O’Toole et al 1997)

Improves social interaction and sensitivity in perceiving communications (Wilens et al 2007)

85% reduction in drug misuse if treated (Biederman et al 2007)

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(NICE) Guidance on ADHD Treatments

ADHD affects children and adolescents in different ways and degrees but the consequences of severe ADHD can be serious both for the individual and family

Children with severe ADHD often have low self esteem, develop emotional and social problems, and frequently underachieve at school

ADHD may persist into adolescence and adulthood and is often associated with continuing emotional and social problems, substance misuse, unemployment and involvement in crime

www.nice.org.uk

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Onset in early childhood,

but up to 70% of children may have

difficulties into adulthood

(Searight et al 2000; Clarke et al 2005; Kooij et al 2005)

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Drug therapy

– Risperidone increasingly recognised as an effective

intervention for Conduct Disorder

(Pappadopulos et al., 2003;European Consensus 2007)

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treatment ___ control

improvement improvement

Effect size = ------------------------------------------Effect size = ------------------------------------------

((dd) pooled standard) pooled standard

deviationdeviation

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Effect Size

less than 0.5 = small effect

0.5 – 0.80.5 – 0.8 = medium effect= medium effect

greater than 0.8greater than 0.8 = large effect= large effect

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Effect Size




Risperidone’s reduction of Risperidone’s reduction of

conduct problems = 0.79 conduct problems = 0.79

(Aman et al 2004)

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Child -focussed Treatments

Parent -focussed Treatments parent training courses

marital therapy (Relate)

problem focussed - e.g. alcoholism

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Child -focussed Treatments

Parent -focussed Treatments

Family-focussed Treatments Solution focussed therapy

Family therapy

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Do they work?Do they work?

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Effect Size




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Depression - Adults

Psychotherapy – minor 0.83 major 0.02

(Pinquart et al 2006)

Cognitive Behaviour Therapy 0.82 (Cuijpers 1997)

Medication (SSRI) 0.55 (Otto et al 2001)

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Depression – Child & Adolescent

Psychotherapy – 0.34 (Weisz et al 2006)

Cognitive Behaviour Therapy 0.32

Medication (SSRI) 0.68

-- combined 0.98 (March et al 2006)

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Can these children be managed

in mainstream classrooms?

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Questions?Questions?

1 psychiatric perspectives in children psychiatric perspectives in children with special educational...

Documents

mental health slide

school unit

tactile auditory slide

problem of school attendance

mother unit

whos problem

school frequent arguments

yrs presentation