Psychiatric Disorders of Childhood - Dr Jo Godfrey (2024-25) PDF

Psychiatric Disorders and Neurodevelopmental Conditions in Childhood Dr Jo Godfrey Plymouth CAMHS [email protected]  Overview – Learning Outcomes Definition of mental health problems Detection of mental health problems Neurodevelopmental condition...

Psychiatric Disorders and Neurodevelopmental Conditions in Childhood Dr Jo Godfrey Plymouth CAMHS [email protected]  Overview – Learning Outcomes Definition of mental health problems Detection of mental health problems Neurodevelopmental conditions: autism spectrum condition (ASC) and attention deficit hyperactivity disorder (ADHD) Relevance to dental practice  Overview - Plan Childhood Mental Health Mental Health of Children and Young People in England Survey How mental health problems present Common psychiatric disorders affecting children and adolescents Assessment Process (history, mental state examination, formulation) Adverse childhood experiences Neurodevelopmental conditions Relevance to dental practice  Mental Health of Children and Young People in England, 2023 Follow up report to the Mental Health in Children and Young People survey undertaken in 2017 Survey series providing high quality data on trends in child mental health in England Fourth wave follow up survey, 2370 children and young people Strengths and Difficulties Questionnaire (SDQ) Key Point 1 In 2023, about 1 in 5 children and young people aged 8 – 25 had a probable mental disorder Key Point 2 In 8 – 16 year olds, rates of probable mental disorder were similar for boys and girls In 17 – 25 year old, rates were twice as high for young women than young men Key Point 3 Rates of probable mental disorder rose between 2017 and 2022 but have remained stable since then Key Point 4 Self-harm in those with a probable mental disorder in the past four weeks 8 – 16 year olds: 5.9% 17 – 25 year olds: 10.6% Key Point 5 11 to 16 year olds with a probable mental disorder were more likely to have been bullied in the past year than those who were unlikely to have one Key Point 6 Amongst the 8-16 year olds, those with a probable mental disorder were more likely to have a parent who was worried about money, or be worried about money themselves Key Point 7 54.8% of 17 – 25 year olds reported being worried about the impact of climate change Key Point 8 Eating disorders were identified in 2.6% of 11-16 year olds 12.5% of 17 – 19 year olds 5.9% of 20 – 25 year olds How do mental health problems present? Emotional Symptoms Behavioural Relationship Problems Difficulties Developmental Delays  Emotional Symptoms Anxiety and fears Avoidance, somatic symptoms Low mood Hopelessness, worthlessness Anhedonia Sleep disturbance Altered appetite Lack of energy Self harm, suicidal thoughts  Behavioural Problems Defiance Not following rules, not following instructions Aggression Fighting, harming people or animals, damaging property Antisocial behaviour Stealing, fire setting  Developmental Delays Attention Speech and language Play Motor skills Bladder and bowel control Educational attainment  Normal Developmental Milestones Attention (2- Fleeting Rigid attention Single channelled Focussing attention 3-4y Sustained and integrated 3mins per year attention 0- 1-2y attention 2-3y Two channeled attention attention 5 y + of age) 1y 4-5y Speech and Babbles 6m Joins 2 to 3 Sentences 2.5-3y Lots of questions 3-4y Fluent speech 6y Language Words 10m words 12-24m Play Peek-a-boo Symbolic 18- Parallel play 2y Associate play 3-4y 10-12m 24m Takes turns 2.5- Cooperative play 4y+ 3y Motor Walks steadily Runs and jumps Tripod grip 4-6y Uses scissors 15m 2.5y Dresses / undresses Dresses alone with assistance 4y Hops 5-6y Bladder/Bowel Control 3-4y Educational Count 1-10 2-3y Count back from 5 or 10 Reading, writing, addition, Count 1-30 3-4y 4-5y subtraction 7-8y Draws person with 6 body parts 5y  Relationship Difficulties Variable and wide ranging May be in most relationships or specific ones Attachment relationships  When does a problem become a disorder? Nearly all children will experience symptoms at various times A disorder is only diagnosed if symptoms are having a significant impact on the child Impact Social Impairment (family life, classroom learning, friendships, activities) Distress Disruption to others Diagnostic classification systems (DSMV and ICD-11) Psychiatric Disorders Mood disorders (depression, bipolar affective disorder) Anxiety disorders (generalised anxiety, social anxiety, selective mutism, panic disorder, specific phobias) Obsessive-compulsive disorders Stress disorders (post traumatic stress disorder, complex post traumatic stress disorder) Psychotic disorders (schizophrenia, delusional disorders, drug induced psychosis) Eating disorders (anorexia, bulimia, binge-eating disorder, avoidant restrictive food intake disorder) Conduct disorder, oppositional defiant disorder Tic disorders Substance abuse  Overview - Plan Mental health problems in childhood Mental Health of Children and Young People in England Survey How mental health problems present Common psychiatric disorders affecting children and adolescents Assessment Process (history, mental state examination, formulation) Adverse childhood experience Neurodevelopmental conditions Relevance to dental practice  Psychiatric Assessment Take a history from the child or young person and their parents / carers Presenting problem, current functioning, family history, developmental history, education, physical health, social situation See the child alone Mental state examination Physical examination Observe the family as a whole Obtain collateral information (school, college, social care)  Mental State Examination Appearance Behaviour How they relate to the clinician and parents (ease of separation, eye contact, rapport, facial expressions) Activity level (psychomotor slowing or agitation, hyperactivity) Tics, stereotypies, odd mannerisms Speech and Language Fluency, spontaneity Rate, volume and tone Any delays or abnormalities  Mental State Examination Mood and Affect Subjective, parent / carers opinion and objective assessment Thoughts Obsessions, abnormalities in form or content (delusions) Perceptions Presence of abnormalities (hallucinations)  Mental State Examination Cognition Orientation to time, place and person Developmental delay Attention and memory Insight What do they think about the reasons for their difficulties and the things that could be done to help Risk To self / to others / from others  Formulation Presenting problem Predisposing factors Precipitating factors Perpetuating factors Protective factors Adverse Childhood Experiences Household Challenges Neglect Emotional Domestic violence Physical Substance abuse Mental Illness Abuse Emotional Parental separation / divorce Physical Incarcerated parent Sexual Adverse Childhood Experiences Why are they important? They are common They can have an impact across the lifespan They can contribute to the development of physical and mental ill health There is the potential for intervention  Overview - Plan Mental health problems in childhood Mental Health of Children and Young People in England Survey How mental health problems present Common psychiatric disorders affecting children and adolescents Assessment Communication Process (history, mental state examination, formulation) Adverse childhood experience Neurodevelopmental conditions Relevance to dental practice  Autism Spectrum Condition ICD-11 Diagnostic Criteria Persistent deficits in initiating and maintaining social communication and reciprocal social interaction that are outside that expected Persistent restricted, repetitive and inflexible patterns of behaviour / activities / interests that are clearly atypical or excessive for age and sociocultural context Early onset, though may present later when social demands exceed capacity Features of autism result in significant impairment in functioning 1 in 100 children in the UK have a diagnosis  Persistent deficits in initiating and maintaining social communication and reciprocal social interaction that are outside that expected Understanding of, interest in, or inappropriate responses to the verbal or non-verbal social communications of others Integration of spoken language with typical complimentary non-verbal cues (eye contact, gestures, facial expressions and body language) which may be reduced in frequency or intensity Understanding and use of language in social contexts and ability to initiate and sustain reciprocal social conversations Social awareness Ability to imagine and respond to the feelings, emotional states, and attitudes of others Mutual sharing of interests Ability to make and sustain typical peer relationships  Persistent restricted, repetitive and inflexible patterns of behaviour / activities / interests that are clearly atypical or excessive for age and sociocultural context Lack of adaptability to new experiences and circumstances, with associated distress, that can be evoked by trivial changes to a familiar environment or in response to unanticipated events Inflexible adherence to particular routines eg following familiar routes, precise timings Excessive adherence to rules (eg when playing games) Excessive and persistent ritualised patterns of behaviour Repetitive and stereotyped motor movements Persistent preoccupation with one or more special interests, parts of objects, or specific types of stimuli or an unusually strong attachment to particular objects Lifelong, excessive and persistent hypersensitivity or hyposensitivity to sensory stimuli or unusual interest in a sensory stimulus  Autism Spectrum Condition: Support Psychoeducation Parenting work Assessment and treatment of co-morbidities Reasonable adjustments  Attention Deficit Hyperactivity Disorder 2017 mental health survey gave an estimated prevalence of 1.6% Rates were 2.6% for boys and 0.9% for girls Prevalence varied between ethnic groups  Attention Deficit Hyperactivity Disorder: ICD-11 Diagnostic Criteria Persistent pattern (more than 6 months) of inattention and / or hyperactivity / impulsivity that has a direct impact on academic, occupational or social functioning Evidence of significant symptoms by the age of 12, typically occurring in early to mid childhood Relative balance and specific manifestations of characteristics varies between individuals and over the course of development Manifestations must be present across multiple situations or settings, but vary Attention Deficit Hyperactivity Disorder: ICD-11 Diagnostic Criteria Inattention Difficulty sustaining attention on tasks that are not stimulating, provide reward or require sustained mental effort Easily distracted Loses things Hyperactivity / Impulsivity Excess motor activity Difficulty with quiet activity or talks too much Blurts things out, difficulty waiting in turn May act without thinking  Attention Deficit Hyperactivity Disorder: Support Psychoeducation Parenting work Assessment and treatment of co-morbidities Medication Stimulants (methylphenidate, long acting methylphenidate, lisdexamfetamine), non-stimulants (atomoxetine, guanfacine), sleep medication  Attention Deficit Hyperactivity Disorder: Prognosis Children and young people with a hyperactivity disorder are at increased risk of developing dysfunctional personality traits Estimated 15% will retain the diagnosis of the age of 25 Estimated 50% will be in partial remission by the age of 25 Persistence of impairing symptoms  Overview - Plan Mental health problems in childhood Mental Health of Children and Young People in England Survey How mental health problems present Common psychiatric disorders affecting children and adolescents Assessment Communication Process (history, mental state examination, formulation) Adverse childhood experience Neurodevelopmental conditions Relevance to dental practice Before the appointment: Good Practise Website with photos of staff and video of layout of building Communication Passport including: Strengths Challenges (including topics to avoid) Interests / topics I like Sensory needs (eg lights on/off) Pain perception Communication On the day During the appointment: Good Practice Approach Slow things down, a ‘less is more’ approach may lead to long term success Communication Engagement with use of pleasant / neutral topics Is there a mental health or neurodevelopmental condition that requires adjustment of your usual communication Use of a pre-agreed stop signal Risks Behaviours of distress During the appointment: Good Practice Visual board eg: now and next Visual timers Squidgee / squeeze items Soft blankets / fleecy blankets / weighted items Ear defenders Screens on ceiling – youtube / films / animation Mirrors / soft lighting Unflavoured mouth washes / trial different ones / own water bottle The Sensory Homunculus  Pain – under reporting of pain History from parent / carer / young person important May have other sensory sensitivities not related to pain Dental staff may need to use more clinical observations / assessment and less subjective for true assessment Education to parents for after care (eg after numbing / surgery really important)  Some General Tips Generally deeper touch is often easier than light touch (not always – check) Consider positioning of dental staff (may need increased visual input) Positioning of young person: Seating (vestibular dysregulation if tipped back) Standard chair and then move to dental chair gradually Familiarising with tools before put in mouth (eg mime / or on toy) Temperatures: check preferences Breaks in between  Overview - Plan Mental health problems in childhood Mental Health of Children and Young People in England Survey How mental health problems present Common psychiatric disorders affecting children and adolescents Assessment Communication Process (history, mental state examination, formulation) Adverse childhood experiences Neurodevelopmental conditions Relevance to dental practice Feedback Your Voice App: https://telmed.uk/yourvoice/  Support Student Services Hub (Nancy Astor) - [email protected] / 01752 (5)87676 Student Services Website Tutors, Year Leads References and Resources  Goodman R, Scott S. Child and Adolescent Psychiatry. 3rd ed. Chichester: Wiley-Blackwell; 2012.  Mental Health of Children and Young People in England 2023 - wave 4 follow up to the 2017 survey. NHS Digital.2023. Available from: Mental Health of Children and Young People in England, 2023 - wave 4 follow up to the 2017 survey - NHS England Digital [Accessed 2nd November 2024].  Adverse Childhood Experience’s  The Wave Trust  Centers for Disease Control and Preventions  The Attachment Theory: How childhood affects life  Royal College of Psychiatrists website