23/06/2015. Absolutely none!!

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1 Absolutely none!! Child and adolescent Mental Health can we help? Dr Tina Nicholson CCFP Family Practitioner and Medical Lead, Cochrane Clinical Lecturer Dept Family Med. U of C. Member of CanReach Faculty 1. Raise awareness of the current available provision for child and adolescent mental health our region 2. Suggest an approach to managing such cases in the Primary Care setting 3. Introduce assessment tools applicable to primary care management 4. Brief Description of CanReach course Total Percentage of Children in Calgary with a mental disorder over the first 18 years of life 34% Percentage Family Physician or General Practitioner Pediatrician Psychiatrist Other 1

2 21% Total numbers of Children 18 years old in 2013 in Calgary ^ 300,000 Number of Children with Mental Disorders diagnosed by 81,000 Physicians in Calgary Numbers of Children served by the entire Publically Funded Child and Adolescent Mental Health System in Calgary (present capacity) 300,000 81,000 20,285 Number of Child and Adolescent Psychiatrists in Calgary 25 Number of Child and Adolescent Psychiatrists in Canada 400 Raise our own awareness of potential psychiatric disorders in our young population Become more familiar with interviewing and managing child and adolescent psychiatric cases Increase levels of comfort with assessing and treating common childhood psychiatric disorders Increase awareness and develop networks with support services in our localities 9yr old boy brought in after concerns raised by school teacher in grade 4 -Excessive fatigue- - falling asleep at desk --lack of interest in schoolwork -Unable to complete tasks --difficult to engage --high level anxiety separation issues --never enjoys things -- no longer playing with friends -Seems very sad despite their best efforts to help him he remains closed off - Noticed change in his behavior since parents split a year before - Separation issues- will not travel without mum, sleeps in her bed, constantly texts or rings her whilst he is at school - Has said he needs to be with her as if she died he would want to die too - Initial insomnia (2am) - Disinterested and inactive - Weight gain -Always struggles with organization worse in last 12m Aware that he worries a lot wants to be with Mom all the time and constantly thinks about her when at school Tends to like routine and does not like change Finds some things interesting but hates math Prefers to be alone and feels he is different to his peers Has a friend with Aspergers finds him easier to understand as he is straightforward 2

3 ?Depression?Separation Anxiety?Anxiety Disorder?Learning Disability?ADD?Abuse?Bullying ASD Additional History Developmental history - Normal School Records Grade level, struggles in math and with organization Past psychiatric history- none Past medical history - none Family history and social history extensive FH of anxiety and depression. Only child, parents separated 18m ago lives with Mom. Do not forget physical exam - Normal Mental Health assessment - Chad feels sad, cannot recall the last time he felt happy or looked forward to anything Aware he is scared all the time- especially of losing his Mom does think about her dying Dislikes school and his peers Prefers talking to adults or being alone No thought disorder, delusions or hallucinations noted No suicidal ideation Lab? none Screening tools Why should we use them? Can improve identification and assessment of mental health problems and easy to use in practice. -May increase reliability of diagnosis - Useful as a tracking tool when reviewing patient 1. C-GAS Children's Global Assessment Scale - A rating scale measuring psychological, social and school functioning for children aged 6-17yrs 2. SCARED- Screen for Child Anxiety Related Disorders parent and child versions 3. Vanderbilt ADHD diagnostic rating scale parent and teacher versions 4. Pediatric Symptom Checklist- PSC-17 Psychosocial screen designed for busy office use, takes 5mins parent and youth versions Looks at attention/internalizing and externalizing subscales 3

4 C-GAS 45 Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area, such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor to inappropriate social skills, frequent episodes of aggressive or other antisocial behavior with some preservation of meaningful social relationships. 2. SCARED - Parental Total Score 30 ( > 25 indicates Anxiety Disorder) Child Total Score Vanderbilt Parental score - Positive score for inattentive subtype ADD Positive score for Anxiety/Depression Borderline score for ODD 4. PSCY-17 Parent score - 18 ( >15 is positive) for internalizing i.e. anxiety/depression but negative for ADD - Child score - 11 Separation Anxiety, panic disorder and generalized anxiety are likely to be causing moderate impairment in functioning at school, at home and when separated from Mom Oppositional behavior is borderline probably as result of anxiety ADD borderline? Affected by anxiety chicken and egg -Address the most prominent impairment - ANXIETY -Team approach:- Child Parents and carers School teachers and psychologist Behavioral health nurse in clinic Healthy minds /Healthy child SW physician - Remember - It takes a village to raise a child 4

5 Educate and counsel families and child about the diagnosis and possible treatments What are they actually getting? Support only? OR Evidence based psychotherapy such as -CBT -Interpersonal Psychotherapy -Anxiety Management strategies for both child and parents Prescribe homework:- Anxiety management techniques Breathing and relaxation Strategies for avoiding catastrophising thoughts Dipping into the AnxietyBC.com website both parents and child Review progress and consider adding in medication Chad took melatonin to aid sleep prior to presentation. For Chad the decision to add medication was made 4months after initial visit as progress had been slow and Mom was getting burnt out trying to manage his anxiety SSRI s Health Canada states no indication for their use under aged 17, but there are FDA approvals for some medications and evidence based support in their use in conjunction with therapy in this age group for anxiety and depression 5

6 Fluoxetine Sertraline Escitalopram START LOW, GO SLOW, MONITOR WEEKLY Rx given Escitalopram 5mg daily Carefully monitored for side effects, suicidality. No effects after 2 weeks dose increased to 7.5 mg and then 10mg this caused disinhibition so dose reduced back to 7.5mg with good effect Nausea and Dry Mouth Somnolence or insomnia Tremor Ejaculatory dysfunction Decreased libido Serious- Serotonin Syndrome, increased Suicidality Worsening Depression or mania Chad continued to feel tired but showed some disinhibition as dose increased adjusted accordingly Despite SSRI, academic performance was not improving 2months post Rx C-GAS now 55 variable functioning in some social areas Vanderbilt scoring also improved in social functioning but worse in academic function Decision taken to treat his inattentive ADD Addition of Methylphenidate again start low and go slow Monitor mood, weight and height, BP and pulse Stimulants :- Methylphenidate Amphetamines Advantages can have immediate onset - ability to alter dose drug holiday - multiple options for delivery, peak actions and duration of actions Disadvantages tolerance or psychological dependence - worsen tics - may suppress growth - cardiac effects? Atomoxetine SNRI - weight based dose - less chance of abuse potential - no apparent effect on growth or tics Disadvantages delayed onset of action (1-2 weeks) - not as effective for some - side effects irritability and insomnia Also Wellbutrin Clonidine Guanfacine Anxiety symptoms much improved -Marked reduction in texting and phoning Mom - Coped with weekends at Dads house better - No more panic attacks --sleep improved -ADD meds made him feel jittery but marked difference noted by Mom and teachers in school performance -Despite this he does not like the taste or how he feels so has asked to switch to alternative - just initiated -He will remain under close observation until stable 6

7 YES! Chad commented on laughing spontaneously at school with friends without pretending! His anxiety is minimal now His attention is improving His Mom is very happy with his progress so far and feels much better equipped to support him. SCARED Parent score now 20 ( previously 30) Child Score now 5 ( previously 41) C-GAS 68 generally functioning well Vanderbilt- no longer positive for inattentive ADD both parent and teacher scorings A 6 month mini-fellowship in Child and Adolescent psychopharmacology Aim : train primary care providers in effective and evidence based mental health assessment and intervention to help them transform their practices, increase productivity, and improve work satisfaction Structure: 3 day (15 hour) course that uses a combination of intensive face-to-face teaching and hands-on practice followed by 6 months of ongoing case-based coaching using distance learning You will never be alone in managing these cases again!! THANK YOU! 7