A GP quizzes an expert to take a medical issue beyond the textbook
GP Dr Stefan Cembrowicz talks to adolescent psychiatrist Dr Ian Skeldon about getting specialist help for teenagers with mental health problems
Practical points · Child and adolescent psychiatry has rediscovered its biological roots · Accessing specialist help takes local knowledge · Diagnosing ADHD can be tricky but treatment is straightforward · Obsessive compulsive disorder affects 1 per cent of the school population · Abuse may not surface for many years
· Child and adolescent psychiatry has rediscovered its biological roots
· Accessing specialist help
takes local knowledge
· Diagnosing ADHD can be tricky but treatment is straightforward
· Obsessive compulsive disorder affects 1 per cent of the school population
· Abuse may not surface for many years
Understanding the spectrum of adolescent psychiatric illness
What range of conditions does adolescent psychiatry deal with?
Fifteen years ago there was huge interest in family and individual therapy and we favoured a strong psychosocial and therapeutic approach. Now child and adolescent psychiatry has re-discovered its biological roots.
We increasingly deal with young people with severe psychiatric disorders including psychoses. We've re-focussed towards more formal psychiatric disorders. From mid-childhood to adolescence we see emergence of the psychiatric disorders recognised in adults. We increasingly see psychotic illnesses: obsessive-compulsive disorder, attention deficit hyperactivity disorder, depression and eating disorders.
How common is psychological disturbance among adolescents?
Five to 10 per cent of adolescents will have a recognisable disorder, although the majority don't have a formal diagnosis. Those who present to GPs usually have behavioural and emotional problems. The challenge in this age group is to understand their problems in the context of their incomplete cognitive and emotional development and often troubled backgrounds.
How mental health services work for adolescents
How are child and adolescent mental health service teams structured and what are the usual referral routes?
These teams should have specialists from psychiatry, psychology, nursing and therapies. Because of the huge demand and lack of resources, there is a move to prioritise cases at the severe end of the spectrum. Most people come via their GP. Increasingly, specialised workers support people on the coalface and most work is done outside specialist clinics. There are services for children with more complex, enduring difficulties, needing higher levels of expertise and often more than one team member (such as in anorexia nervosa).
Child and adolescent mental health teams are hard pressed, and waiting times for referrals can be long. What is your advice for GPs concerned about a young person?
Get to know your local team. Telephone advice can go a long way. Develop knowledge of the resources in your patch. There are a huge number of initiatives for young people.
What happens when young people graduate from your service?
Most have a cut-off at 17 to 18. Adult community mental health teams work with the severely ill and are overstretched. I'm very concerned about the number of 17 and 18-year-olds with enduring and complex difficulties who slip through the net. Hopefully most services have good transfer protocols for a 17-year-old with bipolar disorder or schizophrenia: but with the less severe conditions it's hard to know how a young person can continue to get help.
Treating attention deficit hyperactivity disorder
What is the best source of help for young people graduating from child and adolescent services with attention deficit hyperactivity disorder (ADHD)?
Many services are overwhelmed with requests for assessment and management of ADHD. Adult services don't feel knowledgeable or have the resources or time to see them. A few adult psychiatrists prescribe, and some are interested in the concept of adult ADHD.
Stimulant medications might be effective in this group. There are a few model services for 17 to 22-year-olds. However, I can't see these being high priority for most commissioners at the moment. Shared care ADHD management protocols with GPs are being developed.
Ongoing management of ADHD is not rocket science. It is a tricky and complicated diagnosis but treatment is straightforward. The NICE guidelines are very reassuring about the safety and efficacy of stimulant drugs. Recent good large-scale trials have confirmed stimulant drugs are very effective, certainly when we're confident of the diagnosis.
What is current best practice for ADHD diagnosis and management and what is your experience of the duration of treatment?
Diagnosis is really only made by observation and parents are the best witnesses. Observations need to be made in a variety of settings. It is easy to be fooled in the clinic; young people with quite severe ADHD can be quiet and reasonably attentive and only start to play up at the end of an assessment.
After discussing stimulant medicine with parents, I point them to the NICE guidelines. I ask them to chart their child's general behaviour and concentration after a small dose of methylphenidate. If it looks promising, I extend charting to school perhaps prescribing a lot of medication on alternate days for comparison. It's pretty obvious if stimulant medication is working. This is how we establish the child's correct and appropriate treatment. Medication is less effective in later adolescence but it can still have a beneficial effect especially in on-task behaviour around attention and concentration. There is still major controversy about the efficacy of these medicines in late adolescence and adult life.
Patterns of presenting psychiatric illnesses
Use of the term Asperger's syndrome seems increasingly common. How is your service involved with young people at this end of the autistic spectrum?
These young people often present with a rather confusing pattern of problems. They'll have been a worry at school because of their social difficulties and may have been seen by paediatricians at developmental clinics. They present with associated behavioural problems such as obsessionality. Information and contact with experienced professionals who can guide families through the maze of resources and help ensure the right educational placement is crucial. We pick up many more of these young people now due to growing awareness in the community about autistic spectrum disorders. People are more aware these aren't just unusually shy or quirky kids. Asperger's kids are highly obsessional and often have extremely challenging and difficult behaviours. In the past they have been dismissed as having conduct disorder, or just being difficult.
How many children with obsessive-compulsive disorder (OCD) present?
It affects about 1 per cent of the school population. Few present with specific complaints of obsessions and compulsions; families exasperated by the behaviour present them to GPs, and there is often conflict. When you look at what might be going on in the child's inner world and suspect OCD you often discover what lies behind the behaviour. Children with OCD are reluctant to talk about their symptoms. Unless you ask them specific questions you can easily miss the condition. OCD is increasingly regarded as a neuropsychiatric disorder. The most effective treatment is drugs SSRIs are well established as anti-obsessional plus general family, psycho-education approaches and cognitive behaviour therapy. A synthesis of the biological and psychosocial, treating the serotonergic disturbance but also social and psychological factors is needed.
Even with support, abuse may be concealed
How common is abuse in the background of children with adolescent psychological disturbances and what can turn the corner for them?
Sadly it's very common. Young people who show patterns of repeated severe disturbance of behaviour and emotions and patterns of repeated self-harm often present in ways that make it difficult to offer a helpful response, so they often fail to engage with follow up.
We need a very high index of suspicion that somewhere in their background there may have been physical, emotional or sexual abuse. These kids give a strong message that something's going on but are very ambivalent about talking frightened of their dilemma, fearful of the responses of those they might tell or of how talking might affect their family. They often only tell their stories later in life.
Recently we had a boy who attended our unit for seven months as a day patient. We were unable to make progress with him and it was another two years before he could come back and tell us he had been severely abused by his father for many years.
They can sometimes be helped if someone is prepared to listen, who isn't put off by their distress or story. It's about being prepared to risk an emotional connection and being able to reassure the young person that however awful things have been, something can be done.
Stefan Cembrowicz is a GP in Bristol
Ian Skeldon is a consultant child and adolescent psychiatrist at the Riverside Adolescent Unit, Bristol