b p. 542). Assessment: key areas \200 \200 \200 Involve family where possible. Substance \200\224types, routes, quantity, cost, context. Co nsequences of use \200\224family, friends, development, education, employment, physical and mental health, criminal activity. Attitude to referral \200\224Prochaska \200\231s theory of change. Link with other agencies, e.g. social services, education, youth justice. Risk \200\224to self, others, child protection. \200 \200 Management \200 Brief interventions may be suf \201 cient for young people with less severe substance misu se problems. Developmental stage and shorter history means rapid changes can be made. More severe problems are addressed by co-ordination of multiple agencies, e.g. mainstream CAMHS, social and education services. Structured treatment by specialist young people \200\231s s ubstance misuse treatment services is recommended for under-18s who have signi \201 cant s ubstance misuse problems (normally polydrug and alcohol misuse). This could include harm re duction interventions, psychosocial treatments (motivational therapies, cognitive behaviora l treatments, family-based supports and treatment) and occasionally pharmacological interve ntions. Again this occurs in the context of interventions to address all of the young perso n \200\231s health, social, family, and educational needs, and therefore involves multiple agencies. The involvement of a young person \200\231s family or those with parental respons ibility is considered good practice and may be required with regard to consent. 16_Semple_Chap16.indd 660 12/7/2012 3:49:05 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 662 Child abuse 1: general issues1 In recent decades there has been growing awareness that the abuse of children can take many forms. All forms of child abuse involve the ele- ments of p ower imbalance, exploitation, and the absence of true consent. They may concern acts of com mission or acts of omission. Over recent times, domestic violence and parental substance mi suse have been rec- ognized as situations which should prompt concern for the protection of children from abuse. Categories of abuse Physical abuse includes hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. (Includes Munchausen syndrome by proxy \200\224see Box 16.3.) Neglect is the persistent failure to meet a child \200\231s basic physical/psychologi- cal needs, likely to result in serious impairment of the child \200\231s health and development . Includes failure to provide adequate: food, clothing, shelter and supervision; protection from harm or danger; and access to appropri- ate medical care. Also includes substance mis use during pregnancy. Emotional abuse persistent emotional maltreatment resulting in severe and persistent effect s on the child \200\231s emotional development. Includes denigration or rejection, emotiona l neglect, developmentally inappropri- ate expectations, repeated separations and mis-socia lization of the child. Other types of abuse are likely to result in emotional abuse. Sexual abuse involves forcing or enticing a child into sexual activity. This may include pe netrative and non-penetrative physical acts, and non- contact activities such as involving children in looking at or produc- ing sexual images, watching sexual activities or encourag ing children to behave in sexually inappropriate ways. Box 16.3 Munchausen \200\231s syndrome by proxy: factitious or induced illness syndrome (FI IS) \200 Part of a factitious syndrome that is manifest by a person feigning or inducing illness in a child (or others) in order to obtain medical attention. A form of child abuse in that it subjects the child to emotional abuse, unnecessary medical procedures, hospitalization or o ther treatments that are harmful to the child. Can be very dif \201 cult to detect as the perpetrating (and colluding) adult/s often deny and disguise their behavior. It is essentia l for professionals to be alert to it, especially where a child repetitively presents for m edical attention. Undetected, this form of abuse can result in very serious consequences (including fatality) for the child. 1 Adapted from HM Government (2006) What to do if you \200\231re worried a child is being a bused. London: HMSO. 16_Semple_Chap16.indd 662 12/7/2012 3:49:05 PM CHILD ABUSE 2: THE DUTY OF CARE 663 Child abuse 2: the duty of care All practitioners have a duty to safeguard and promote the welfare of children. It is important to remain alert to the possibility of abuse or neglect . The assessment of risk, and interventions to protect children, require a multidisciplinar y and multi-agency approach. In general, the duty to patients, including that of con \201 dentiality, is overridden by the duty to protect children. Referrals regarding possible abuse will usually be made to social services or the police. Making a child protection referral \200 Know how to access your local multi-agency Child Protection Procedures and follow them. It is good practice to discuss the referral with the child, as appropriate to their age and un derstanding, and with their parents, to seek agreement to the referral unless such discussi on would place the child at risk of signi \201 cant harm. It is not necessary to have agre ement to make the referral. Ensure that you carefully document all concerns, discussions, d ecisions made and reasons for these decisions. Discuss the situation with a senior colleagu e. Follow up oral communications in writing. Have as much information regarding the child a nd your concerns available as possible. Do not do anything which may jeopardize a police in vestigation, e.g. asking a child leading questions, or attempting to investigate the allega tions of abuse. \200 \200 Child abuse \200\224where does CAMHS \201 t in? \200 Being alert to abuse, responding to concerns expressed by individuals and families, and mak ing a child protection referral. Involvement in multi-agency discussion and planning for th e child. Post-abuse work with children and families (abusing and non-abusing). \200 Psychiatric outcome of chronic abuse Children who are abused have an extremely high rate of psychiatric disor- ders, both during the abuse and later on. Some of the most common disorders associated with previous abuse: PTSD Dissociative disorde rs Conversion disorders Borderline personality disorder Depression Paraphilias Substance ab use. \200 \200 \200 \200 \200 \200 16_Semple_Chap16.indd 663 12/7/2012 3:49:06 PM CHAPTER 16 Child and adolescent psychiatry 664 The looked-after-child (LAC) \200\230Looked after \200\231 is the term used to describe al l children in public care, including those in foster or residential homes, and those still with their own parents but subject to care orders. The majority have become \200\230looked after \200\231 because of abuse or neglect. Outcomes for LAC On leaving care, young people have signi \201 cantly poorer outcomes in t erms of education, employment, and physical and mental health. Teenage pregnancy, homelessn ess, and involvement in crime as both victim and perpetrator are increased. Mental health of LAC These children have often experienced many risk factors for developmen t of mental disorder: abuse or neglect, family dysfunction, parental ill-health or substanc e misuse, changes of carer, high socio-economic disadvantage, discrimination and trauma. At tachment is likely to have been disrupted. Common presentations include conduct disorder, depression, anxiety disorders, substance misuse, ADHD, and ASD-like dif \201 culties. Working with LAC This requires multi-agency co-operation as multiple needs must be met. \200 A stable and secure environment for the child where his physical, emotional, and soci al developmental needs are met is fundamentally important. Even if a change of environment is unavoidable, continuity in the form of attending the same school, retaining the same wor kers is desirable. Support to the child \200\231s carers \200\224social services, CAMHS, an d other agencies may all play a role. Individual CAMHS work with the child can be helpful i n the context of these needs being met. It is very unlikely to be of bene \201 t while the child remains in an insecure or harmful environment. \200\230The test of the morality of a society is what it does for its children. \200\231 Dietrich Bonhoeffer (1906 \200\2231945) German Protestant theologian and anti-Nazi activist 16_Semple_Chap16.indd 664 12/7/2012 3:49:06 PM PRESCRIBING IN CHILDREN AND ADOLESCENTS 665 Prescribing in children and adolescents1,2 Principles \200 They are not small adults! This is particularly important in regard to the dynamics and kin etics of drugs. Some drugs are metabolized faster while others more readily cross the blood \200\223brain barrier. Susceptibility to side-effects also varies with age (e.g. children are more likely to develop dystonias and less likely to develop akathisia with neuroleptic treatment). Medication should be considered as just one component of treatment \200\224it s hould be accompanied by psychological, social, and educational interventions. Drugs are oft en prescribed for symptoms rather than syndromes (e.g. stimulants for hyperactivity symptom s in a variety of disorders). Drug trials in children are problematic both ethically and pr actically, so there is inadequate data regarding safety and ef \201 cacy for many psychotr opics. Thus clinicians are often faced with ethical decisions regarding the use of drugs no t licensed for use in these age groups. The decision to prescribe needs to take into accoun t both the young person \200\231s and parents \200\231 attitudes to medication, and to cons ider issues of consent and capacity. 1 For an interesting historical review see Zito JM, Derivan AT, Kratochvil CJ, et al. (2008 ) Off- label psychopharmacologic prescribing for children: history supports close monitorin g. Child and Adolescent Psychiatry and Mental Health 2: 24. Available online: M http://www. capmh.com/ content/2/1/24 2 Riddle MA, Kastelic EA, and Frosch E (2001) Pediatric psychopha rmacology. J Child Psychol Psychiat 42: 73 \200\22390. 16_Semple_Chap16.indd 665 12/7/2012 3:49:06 PM CHAPTER 16 Child and adolescent psychiatry 666 Family therapy (FT) Family therapy (FT) originated in the 1950s and has been in \202 uence d by many schools of thought since then, including psychodynamic theory, gen- eral systems theory, social constructionism, and feminist approaches. FT approaches differ in many ways, but all recognize the interrelatedness of the person with the problem and their family mem bers, and the role of the family in problem resolution. Indications FT can be useful wherever there are dif \201 culties in family relationships w hich are impacting on a family member \200\231s mental health. This may be as the main trea tment, or concurrently with other treatment modalities, e.g. individual therapies, medicati on. Key elements of some FT models Structural FT Clear rules govern family organization \200 \224hierarchies, subsys- tems, boundaries. Distortion of these produces symptoms. Therapist takes directive stance to change family behaviors, and thereby their beliefs. Strategic FT Family transactions are key. The problem is serving an inter- personal functio n for some members, so family is ambivalent about change. Therapist takes strategic stance and gives family tasks. Milan Systemic FT Emphasis on family beliefs and meanings, no objective truth. Several tech niques \200\224reframing, hypothesizing, neutrality, curiosity. Team behind screen. Therapi st takes \200\230not-knowing \200\231, non-expert stance. Brief Solution Focused FT Collaborative; focus on exceptions, solutions, and competence of family. Use of goals and scales. Narrative FT Problems relate to unhelpful, dominant, inaccurate narra- tive about life. Uni que outcomes, differing from dominant narrative, are explored allowing a new, more helpful narrative to emerge. Therapist non-expert. Many FT practitioners will use eclectic approaches, often incorporating teams. Re \202 ect ing teams put family in observer position of hearing their conversation with the therapist discussed, allowing new perspectives to emerge. Duration Extremely varied. Treatment can be as short as 1 or 2 sessions or take 12 \200\223 24-weekly sessions or more. It is usually shorter than forms of long- term psychotherapy li ke psychodynamic psychotherapy. Recommended further reading Carr A (2006) Family therapy: concepts, process and practice. C hichester: John Wiley and Sons. 16_Semple_Chap16.indd 666 12/7/2012 3:49:06 PM PARENT MANAGEMENT TRAINING 667 Parent management training Parent management training (PMT) has until very recently been de scribed as a group of treatment procedures in which parents are trained to modify their chi ld \200\231s behavior. More recent de \201 nitions of PMT encompass its broader power in i mproving the communication within families. PMT is not simply about generically changing a child \200\231s behavior, which is achieved mostly by improving the quality of communicatio n within the family. More importantly, PMT helps foster meaningful mutual understanding wit hin the families, and helps create an environment that fosters healthier psycho- logical de velopment for children. The treatment is conducted primarily with the parents (both parents when possible, but it c an be conducted only with one parent or caregiver). PMT can be offered as its own therapeut ic intervention, as one component of family therapy, or can be combined with pharmacologica l treatments (as in the case of children with ADHD). Signi \201 cantly, the therapist work s only with the parents, and therefore all the changes in a child \200\231s behaviors are m ediated by the changes in the ways that parents/caregivers communicate with their children. Typically PMT is offered in 8 \200\22325-weekly sessions. It can be offered in very differ ent settings: from school meetings to paediatri- cians \200\231 of \201 ces, or can even b e integrated into psychiatric practice. Techniques \200 The main goal of PMT is to help parents promote prosocial behaviors and decrease deviant be havior for their children. To accomplish that, the parents are trained to identify and conc eptualize their children \200\231s problem behaviors in new ways. Hands-on practices/rehear sals are typically part of the training. Parents are taught to use positive reinforcement c ontingently, frequently, and immediately when children demonstrate \200\230good \200\231 b ehaviors. Mild punishment can also be used, but harsh or severe punishments are usually dis couraged. Indications \200 PMT is the main component of the treatment of children with oppositional behavior disorder. It is helpful in the treatment of ADHD. It has been recognized more recently to also be ve ry helpful in the treatment of children with anxiety disorders. Its preventive potential ha s also been demonstrated, as PMT decreases the chance of children evolving with delinquent and antisocial behaviors when their parents receive the intervention. 16_Semple_Chap16.indd 667 12/7/2012 3:49:06 PM This page intentionally left blank