Jane Morris

LiteraturePsychologyMedicineMotherhoodCullenGlasgowEdinburgh

1 Child and Adolescent Psychiatry are surprisingly different from Adult Psychiatry

2 Some of this is about different responses and traditions rather than different problems – CAMHS accept referrals where there is social dysfunction even in the absence of ‘diagnosis’

3 Child psychiatry is genuinely different from Adolescent Psychiatry...

4 ...but fun and playfulness are essential in both

5 The practice of Adolescent psychiatry could teach adult psychiatrists a great deal - it taught me, anyway – about formulation and systemic awareness and daily use of psychotherapeutic approaches....

6 ...and about the evolution of mental illnesses and dysfunctional defences.

7 The role of sleep, activity, rest & nutrition in mental as well as physical development

8 The very existence of Asperger’s and the autistic spectrum was an eye-opener

- Sula Wolff’s ‘Loners’9 That transitions need to be handled well – so

that the loss and progression are meaningful and educational rather than destructive

10 Above all, that a well-integrated team is wisdom incarnate!

Sue PalmerHarry Burns ‘The Biology of Poverty’ 2008My daughter’s schoolSuicides at schoolStreetwise young peoplewww-wise young peopleBody image conscious & ashamed – obesity &

anorexiaAlcohol and other substances (caffeine in

Buckfast!)Child protection, health & safety and other

defensive approaches

PERSONALITY = TEMPERAMENT + CHARACTER

If temperament is relatively fixed (New York Longitudinal Study on Infant Temperament, Thomas & Chess 1984) can we at least find interventions that are ‘character-forming’?

....and where do traits, constructs, schemata, defences,

factors etc etc fit in to all this?Are they learned?If so, when?Can they be un-learned or re-learned?When and how?

SSRIs and neuroleptics eg olanzapineUndoubtedly swing the balance in some

cases, allowing learning to occurHow do they work?No coincidence that at high dose SSRIs or

low dose neuroleptics are anxiolyticReducing the amount of anxiety and

arousal the individual has to experience to within a manageable amount

Scott recommends a ‘picture fitting’ approach to diagnosis for treatment purposes, though a ‘menu-driven’ approach may be necessary in research

Conduct disorder certainly associated with discord in the family home but what is cause and what is effect?

Scott even considers that disordered attachment may be a consequence as well as a cause of disorder

.. 1982 Patterson found more, unclear and inconsistent commands issued in families of CD children

Virginia Twin study interviewed fathers, mothers and young people for evidence of heritability of CD – based on Dads’ accounts it is 27% herrtable, according to child 36%, according to Mum’s accounts it is 69% heritable!

D4DR gene : 1996 2 independent teams reported association of novelty-seeking/risk taking/impulsivity with polymorphism in a gene on short arm of chromosome 11 – associated with dopamine receptor expression

SLC6A4 gene on chromosome 17 associated with reduce serotonin uptake and associated with greater fearfulness/neuroticism – on of at least a dozen genes found to be associated with ‘neuroticism’

As well as dopamine and serotonin, oxytocin, vasopressin and prolactin involved in social bonding, and hypophyseal-adrenal axis response to social challenge mediates early brain development

Transplanting a gene from the monogamous prairie vole transforms the behaviour of promiscuous mice

1994 Brunner, Nelson et al – MAO gene mutation in Dutch family associated with extreme aggression in males who possessed the gene

2002 Caspi et al In a large sample of abused children, only those with gene for low MAO activity went on to be antisocial in adult life

Animal evidence also suggests well-preserved serotonin function helps to attenuate aggressive impulses

The power of the environment to affect genes - their transmission and expression!

The biology of stress hormones, acute and chronic Their effects on mood, arousal, aggression and

learningApplications to abused and traumatised children

and their parents and the interactions between the two

Deblinger and Heflin’s Trauma-focussed CBT for sexually abused children – healing by imaginal exposure and relearning

Parent interventions often shown to benefit the child – do they also benefit the personality of the parents?

CD the commonest reason for referral to child psychiatry – 5 – 10% all children and adolescents

Often co-exists with ADHD but not interchangeable disorders

Commoner in boysSeen where lower SES and larger

familiesHas the 2nd highest continuity into adult

life of all traits

About half of childhood onset CD persist into adult life but only 15% adolescent onset cases persist

Remember to differentiate and treat if co-morbid – - ADHD, - PTSD,- ASD,- Specific & general LDs,- mood disorders- Substance abuseDifferentiate ‘subcultural deviance’

Brenda RenzDay service for children under 14Only one referral to Glasgow IPU in 5 yearsVery close adherence to Webster-Stratton

Incredible Years programmeBoth parenting groups and ‘Dinosaur School’

elements, but in fact parenting intervention known to be almost as effective alone

Warmth, energy, nurturing, play!

6 randomized control group evaluations of the parenting Intervention by the program developer & colleagues

and 5 independent replications indicated - increases in parent positive affect such as praise and reduced use

of criticism and negative commands.Increases in parent use of effective limit-setting by replacing

spanking and harsh discipline with non-violent discipline.Reduced parental depression, increased parental self-confidence. Increased positive family communication & problem-solving.Reduced conduct problems in children’s interactions with parents

and increases in their positive affect and compliance to parental commands.

ALSOMaintenence of benefits in 75% cases 5-6 years later

How do we select families for the intervention?

When should the child as well as parents be involved?

Are the boundaries between social control and child psychiatric care too blurred?

When the child is creeping like snail unwillingly to school, is this a psychiatric disorder?

How much is enough? - Rutter on Surestart

Adolescence as a second phase of amazing brain development – scans of Jay Giedd

After puberty many more cases of conduct disorder, but in general those already present in childhood likely to endure, whereas those of adolescent onset likely to ‘burn out’ by mid twenties

Edinburgh Connect uses a tiny staff team to consult with carers of looked after children, including those in Social Work homes and those in foster care, rather than taking on large direct caseloads.

Emergence of ‘Borderline Disorder’ now recognised

•Psychiatric clerking and psychology assessment•Developmental assessment from parents•Home visits•School reports & assessment in our schoolroom•Observation of patient with peers both in formal groups and informal space•Physical and growth records•Team formulation meeting and review with young person and family•Development (after 6 weeks) of tailormade care plan

Individual work with psychologist and key workerDynamic risk managementIPT, DBT, CBT, CATGroups – Psychodynamic, DBT, art therapy, practical, out

and about, social skills etcAttention to nutrition, sleep, diurnal rhythmsMedication – or its withdrawal! Lunches, snacks, games, sitting room, garden – social Family work, formal family therapy, sometimes BFTEducation – own school or schoolroom 6 weekly reviewsCareful discharge planning and transition care

Works with DSH risk – avoid rewarding risk taking and instead use attachment to reward healthy responses

Teaches skills of mindfulness, emotion regulation, distress tolerance and interpersonal skills to replace unhealthy acting out

Stresses need for regular team communication and supervision – approach is by team, not by individual therapist

Playful and irreverent

Large scale, cheap versions don’t work!Not all are helpedThe most resistant cases are least likely to benefit

but use up the resourceThe environment is increasingly toxic and we are

not keeping up with its risks (eg new technologies, where most teenagers are savvy but older porfessionals often naive)

Nutrition is getting worse, activity and sleep are reduced, substance abuse is ever more available

It is not inevitable that interventions can help but they CAN harm!

Environmental manipulations can even affect genesThere are known effective parenting treatments to address

substantial numbers of cases of prepubertal CD and ODD, which are the enduring problems

BPD increasingly appears to be a disorder of immaturity which can mellow out, particularly with therapy, not a life sentence

Medication can help though it may not cure and is not limited to the treatment of comorbid conditions

The study of stress and trauma responses is increasingly open to multidisciplinary exploration

A new generation of clinicians is passionate about personality and psychotherapy!