389 Index on child mental health problems This section (to p398) deals with some aspects of chi ldhood mental health \200\224 but many issues in child psychiatry overlap with pages in the adult section of this chapter, and also with pediatrics. The psychiatry of attempted suici de is a good example. Many of these patients will be in the last phases of childhood, and i t is unclear which service will suit them best. As ever, take a holistic view of your patie nt, and design a care plan which takes these facets into account. Abuse, p146 Alcohol abuse , p363 Anorexia and bulimia, p348 Asperger \200\231s syndrome, p638 Attention de \201 cit disorder, p212 Autism, p394 Bedwetting, p211 Bullying, p395 Cultural issues in mental healt h, p492 Depression: children/adolescents, p390 Drug addiction, p362 Dyslexia, p396 Encopres is/enuresis, p210 & p211 Existential crises p390 Family therapy, p386 Holistic assessment p99 \200\223100 Language disorders, p215 Learning problems, p314, p364 Parasomnias, p392 Play therapy, p377 Psychosis and psychosis-like symp toms y r t a i h c y s P in children, p391 School refusal, p212 Sleep disorders, p392 Substance abuse, p362 Suicide, p338 Talking to young people about sex, p328 Tics & Tourette syndrome, OHCM p714 Mental health in adolescence Adolescents face major mental health challenges owing to exist ential crises (p390), changing looks, emerging sexualities, identity problems, exam pressur e, family break-up, ready availability of drugs and alcohol, media pressures, and the onset of adult responsibilities (eg when they get pregnant). Psychotic illness also often starts in adolescence, and may be partly related to urban stress (p391). What can we do to help? Pediatricians, psychologists, psychiatrists, coun- sellors, GPs, and so on all have a role of course \200\224but access to them depends on the fact that a problem has occurred. This is often a bit late \200\224which is why teachers have such an important role in promoting mental health. Some schools off er classroom-based workshops such as MasterMind: Em- power Yourself With M ental Health. MasterMind-type initiatives work by creating a toolbox for mental health by m aking a safe place for discussion of mental health and emotionally charged topics. The aim is to increase student knowledge of mental health issues, and to provide the tools to devel op and maintain mental health (eg techniques in de-stressing). Instructional materi- als ad dress topics identi \201 ed through needs assessment. These and other writ- ten exercises are combined with peer-teaching-peer group activities, individu- al assignments, and open d iscussion. Students can ask questions anonymously, and through interaction they build each other \200\231s self-esteem (provided they are not feeling totally negative). When these in terventions have been evaluated, it is found that students \200\231 enthusiasm and particip ation increases throughout the course, and they give high satisfaction scores to the topics covered.433 Of course, we all want to know what mental illness are prevented \200\224but this is to ask the wrong question. Mental health issues will never be cured or go away \200\224they are p art of what it means to be an adolescent. The question is more \200\234How are these adole scents adjusting to their self-made world? \200\235 and \200\234Is adolescence proving to be a humanizing or an alienating experience? \200\235 The answers to these questions are mo re metaphysical than quantitative. We often have the impression that the incandescent adolescent sitting in front of us is bur ning too brightly within his sullen shell \200\224and our foreknowl- edge of his impending death in a shoot-out, stabbing, or drug-overdose seems inevitable. \200 What is not inevit able is that he should go to his grave without anyone having tried to help. The following p ages may serve as a \201 rst step. Depression in children2% and adolescents5% Accepting that the big task of adolescence is fo rging new independent identi- ties, it comes as no surprise that the main signs of depressi on in this group spell ERSATZ: a German word we use to mean fake.1 Existential hopelessness related to dawning awareness of freedom to narrate one \200\231s own life and death; relat ionship & sexual problems; anger in the face of con \202 icting adult values; tearfulness when it all goes wrong, and overzealous attachment to false gods (eg causing body image dis satisfaction and self-harm). Features as seen in adults: Low mood Loss of interest and self -esteem Socially withdrawn Psychomotor retardation Tearful; feelings of guilt Anxiety Lack of enjoyment in anything 390 Features common in childhood: De \201 ance; running away from home Separation anxiety s chool refusal Complaints of boredom; poor school work Antisocial behavior Insomnia (often i nitial, not early waking) Hypersomnia Eating problems One-to-one interviewing is usually best. Consider the possibility of concealed factors (eg past child abuse, bullying, p395). Parents can be interviewed sepa- rately (ask the child \200\231s permission, and see the child alone, again, if appropriate, after seeing the pare nts, to report back: this helps avoid seeming to collude with the parents). NB: parents are often unaware of depression in their children. Assessment is often hard: questions may be answered by silence or a shrug. y r t a h c y s P i If not getting anywhere, keep listening, or off er silences \200\224but do not give up. Always ask about thoughts of suicide/self-harm. Any past attempts? 15 \200\22320% make furt her attempts ( \200\200risk if: conduct disorder, \200\200alcohol use, hopelessness, or in local authority care). Self-harm may be a form of communication \200\224a mes- sage in a b ottle; not always \200\230picked up \200\231 and sometimes it is diffi cult to decipher th e teenager \200\231s exact intentions. Refer urgently if risk is considered signi \201 can t. Adolescents with conduct disorders can be manipulative and extremely dif- \201 cult to assess \200\224an urgent second opinion is frequently of help. Management Ideally this sho uld be a combined approach: 1 Social: addressing sources of distress (eg bullying) and remo ving opportuni- ties for self-harm (eg no paracetamol at home). Improve sense of belonging- ness, especially if he/she feels on the margins of society (eg for reasons of sexuality, o r because of substance abuse).434 2 Psychological: encourage verbalizing of moods; explore the vocabulary of in- ternal states. Counselors, good teachers, and youth workers help here. 3 Cognitive therapy (CBT, p373) helps (often unavailable in primary care). 4 If criminality and gang culture is at work, peer mentorship may help.435 5 Drugs: often disappointing (and dangerous); but as 1 \200\2234 above is often insuffi - cient in major depression, drugs (eg \202 uoxetine or escitalopram 10mg/day436 need to be considered. NICE exclude 1st-line use, even in sever e depression, but this obsessively self-exculpating ban may do more harm than good.437 If m arked sleep disturbance, consider mirtazapine. If drugs are used: \200 Evaluate risk/bene \201 t ratio (try to include parents in the discussion). \200 Monitor suicide ideation \200\206weekly for 1st month, then \200\206 every other week. \200 Before an antidepressa nt is initiated, a safety plan should be in place with an agreement with the patient and fa mily that the patient will be kept safe and will contact a responsible adult if suicidal ur ges get too strong. \200 Ensure the availability of psychiatric help 24/7.438 Speci \201 c drugs to avoid if <18yrs old, if possible (BNF/CSM): citalopram, par- oxetine , sertraline. Also tricyclics, venlafaxine, and \202 uvoxamine.439,440 1 All constructed identities are fakes, adult or adolescent, but in adulthood we have more time to reassem- ble our selected fakes into coherent patterns. For this reason adults are not simply burnt-out adolescents. 391 \200\230Psychotic \200\231 symptoms may not mean psychosis (angels, demons, etc) In many c enters, early-onset schizophrenia is diagnosed with the same cri- teria as adults (p358) as it seems to be continuous with later-onset forms (eg more males being aff ected).441 This is simplistic, as delusions and hearing voices are common in children and are essential to some forms of play. \200 Visions may relate to folklore or religion, eg nocturnal halluci nations in up to 40% of teenage boys studying in stressful ultra-orthodox Yeshivas where th ere is a belief in demons and dead souls who visit at night.442 N=302 \200 Another exampl e is delusional erotomania (p640) which is commoner in adolescents living in places such as China where expressing sexual interest has to be indirect. There are many other examples w here to equate delu- sions and hallucinations with psychopathology would be wrong.443 \200 Hearing unwanted tunes (earworms) is common: if there is any psychopa- y r t a i h c y s P thology, it will be more likely to be obsessions rather than psychosis. Hallucinations are more common in the isolated and withdrawn; here their importance may lie in alerting you to this fact.444,445 Some hallucinations should receive very serious attention: \200 Those which are imperative ( \200\234kill so-and-so \200\235) or exciting strong emotions. \200 Those heard unambigu ously outside the head. \200 Those referring to ideas that the person feels are not their own. \200 Multiple voices talking at once, and especially voices talking to each other. So metimes hallucinations resist diagnosis. This is not in itself a problem as the diagnosis w ill sooner or later become clear. Meanwhile, ask yourself whether these odd ideas are likel y to indicate that your patient is at in- creased risk of serious outcome, eg suicide.446,4 47 Causes of odd ideas Substance abuse; drugs; schizophrenia; anxiety/de- pression; hypoman ia; head injury; epileptic aura; migraine; Charles Bonnet syndrome (p438); SLE; encephalopa thy (eg lead exposure); infections (herpes, EBV-associated Alice-in-Wonderland syndrome, OH CM p708); stress; abuse. Tests MRI/CT may be indicated, eg in olfactory hallucination.448 M anagement \200\207Early intervention helps, and may reduce chances of later chronic schizo phrenia, so refer promptly.448 If you are the child \200\231s GP, ensure there is a treatme nt plan with a named worker, incorporating antipsychotics (if indicated, p360) with psycho- educational, psychotherapeutic, and social components. New antipsychotics (p361) are rarely speci \201 cally licensed for children, but their use in well-monitored environments is e ncouraging.449 SEs are legion; they may not be as bad as older drugs see p361.450,451 Socia l interventions in deprived urban areas Risk of psychosis rises when young people with a ge netic predisposition (expressed as poor social and cognitive functioning) have to cope with urban life,452 poverty,453 isola- tion,454 crime,455 and inequality.456 What can be done t o alleviate urban stress and gang culture? \200 Autonomy for housing estates (Housing Ass ociationuk may help) \200 Wardens drawn from the local community \200 Training schemes \200 Clubs (for art/self-expression) \200 Sport \200 Debates \200 Very local radio4 57 \200 Skills/ time banks (where those with skills deposit hours of help which others ca n \200\230cash \200\231) \200 Cycle repairs (if you learn to \201 x an unclaimed bike, you keep it)458 \200 Children \200\231s centers \200 Saturday school/healthy living \200 Prostitution and drug abuse initiatives agreed with police \200 Avoid punishment/im prisonment.459 Prognosis Spontaneous improvement of psychotic-like symptoms occurs in the m ajority of children. In one follow-up study, many developed chronic mood disorders; <50% me t diagnostic criteria for a major disorder (schizo- aff ective or bipolar disorder, depress ive disorder, \200\230psychotic disorder not otherwise speci \201 ed \200\231). In those not developing a mood or psychotic disorder, disruptive behavior disorders are very common. 460 Sleep problems and the parasomnias Not falling asleep Try plenty of daytime activity (each hour of sitting \200\200sleep latency by 3mins).461 Insist on a routine wind-down 1 hour b efore bed \200\203warm bath for 10min \200\203a story \200\203then straight into a darkened bedroom.Gurney method Waking at 3am (ready to play, or wanting entry to parent \200\231s b ed) For those not appreciating these visitations from the pure of heart, consider refusing to play and buy earplugs to lessen the impact of screaming \200\224or let the child into th e bed. Or try extinguishing the behavior by attending to the child ever more distantly: cud dle in bed \200\203cuddle on bed \200\203sitting on child \200\231s bed \200\203voice from doorway \200\203distant voice. Try to avoid hypnotics. If essential, consider Weldorm Elixi r (cloral betaine); dose if >2yrs: 30mg/kg, max 1g/day. Other sleep disturbances Hunger/c olic (infants); poor routines (preschool); worry (adolescence). Bedroom TV may be to blame. Try behavioral therapy before hypnotics. Day-time sleepiness: Causes: night sleep \200\201 ; depression; sleep apnoea (OHCM p186); narcolepsy;1 encephalitis lethargicans (rare in chi ldren): suspect this whenever sleepiness occurs with extrapyramidal eff ects, oculo- gyric crises, myoclonus, inversion of diurnal rhythms, obsessions, and mood change. Possible caus es: in \202 uenza; \202 u vaccination; measles; Q fever; myco- plasma; hypothalamic lymp homa. MRI: subcortical involvement. Sleepwalking & parasomnias2 Of all our non-insane autom atisms, somnam- bulism is the most familiar and striking, literally (rarely) as households may be endangered when the bloodiest dreams of junior somnambulists are enacted. The young are by far the best sleepwalkers (the old may emulate them eg if stress is augmented by exc ess alcohol or caff eine use, and lack of stage IV sleep \200\224our deepest sleep). Any ps ychic event associated with sleep may be termed a parasomnia. Parasomnias comprise: \200 Arousal disorders (sleep- walking; night terrors; \200\230confusional arousal \200\231) \200 Sleep \200\223wake transition disor- ders (rhythmic head-banging disorder) \200 REM sleep parasomnias (rapid eye movement sleep associated nightmares, sleep paralysis, halluc inations, and REM sleep behavior disorder (box 1). \200 Others.1 392 y r t a h c y s P i Suff ering from night terrors is often a familial problem. The child awakens frightened, hallucinated, and inaccessible \200\224and is obviously alarmed. It is common to observe movement in children during sleep: it is their repeti- tive nature which allows the diagnosis of rhythmic movement disorder. The movement may be body-rocking, leg-rolling, or head-banging (this \200\230jactatio capitis \200\231 may lead to subdural s, fractures, eye injuries, and false accusations of abuse). Tongue-biting may suggest epil epsy. But do not try to be too ob- sessive in diff erentiating parasomnias from nocturnal e pilepsy, for 3 reasons: 1 Our de \201 nition of epilepsy is tested to destruction by the p arasomnias ( \200\230epi- lepsy is intermittent abnormal brain activity manifesting as simp le or complex seizures \200\231). 2 Those with clearly de \201 ned parasomnias are at risk of developing tonic \200\223clonic nocturnal seizures later in life. 3 Some parasomnias ar e signs of autosomal-dominant nocturnal frontal lobe epilepsy (ADNFLE). ADNFLE is associ- a ted with abnormalities in genes coding nicotinic acetylcholine receptor \200 4- subunit (c hromosome 20). EEG: rhythmic slow anterior activity; video polysom- nography: sleep-related violent behavior, sudden awakening and dyskinetic or dystonic movements, and complex behav iors enuresis).462 Antiparasomniacs: Bedtime clonazepam; amitriptyline; carbamazepine. I f not working, consider self-hypnosis or waking h before the expected event.463 1 In narcolepsy we succumb to irresistible attacks of inappropriate sleep vivid hallucin ations, cataplexy (sudden hypotonia), and sleep paralysis (BOX 2). Mutations lead to loss o f hypothalamic hypocretin-contain- ing neurons, via autoimmune destruction. HLA DR2+ve. \201\227: 1 Methylphenidate, 10 \200\22315mg PO after breakfast and lunch) may cause depend ence and psychosis 2 Moda \201 nil ( 200mg/d PO, before noon; SE: anxiety, aggression, dry mouth, euphoria, insomnia, BP \200\200, dyskinesia, alk phos \200\200 3 Gamma-hydroxybutyr ate (GHB).464 2 Sleep-related dissociative disorder, sleep enuresis, exploding head syndrom e, hypnagogic or hypnop- ompic hallucinations, catathrenia (end-inspiratory apnoea + groani ng), sleep-related eating disorders, drug-induced parasomnias, myoclonus nocturnus; nocturn al bruxism, ie teeth grinding 393 Sleep architecture and REM sleep behavior disorder We sleep in one of two states: rapid eye movement sleep (REM sleep \211\210 25% of all sleep) and non-rapid eye movement (NREM, wh ich has 4 stages). In REM sleep, breathing is irregular, BP rises, and tone lapses (atonia; paralysis). EEG during REM sleep is similar to that in wakefulness and associates with dre am- ing. Tricyclics, SSRIs, and serotonin-norepinephrine reuptake inhibitors may all suppre ss REM. In REM sleep behavior disorder, REM paralysis is incomplete or absent, with acting out of d reams that are vivid and violent (with shouting, punching, kick- ing, \202 ailing etc eno ugh to endanger bed-partners). Associations/causes: Par- kinson \200\231s disease, dementia (may be an early sign), alcohol and drug withdraw- al (eg SSRI). Polysomnography: Muscle t one \200\200 during REM sleep. Treatment: Sleep alone; remove all dangers from the sleep e nvironment. Put the mattress on the \202 oor. Clonazepam 0.5mg at bedtime may help. Sleep paralysis When we sleep we trawl forbidden seas, arranging and being rearranged by the \202 otsam and jetsam of our waking lives. As our nets descend through the various stages o f sleep, our Sovereign Reason or Will usually remains quietly on deck, but if by chance it descends with the nets then, like the tail wagging the dog, it adopts and propagates a life of its own, which may be full of danger. Because our vessel has been vacated, Marie-Celest e-style, we are judged, in Law, not to be responsible for our actions while asleep \200\224 be they theft, arson, or homicide. Without will or wind, our vessel, like Coleridge \200 \231s Mariner \200\231s (see poem below), is moved \200\230onward from beneath \200\231 by secret forces. So here we have the model of Reason and Will residing, during sleep, either upstairs or downstairs: but in sleep paralysis, neither is the case \200\224the tail canno t wag the dog, nor the dog wag his tail. Sleep paralysis may involve complete paralysis of all voluntary muscles, even the diaphragm. For anyone who has experienced it, it is frighte ning, unforgettable, and diffi cult to describe \200\224like being aware during anesthesia with total neuromuscular blockade. y r t a i h c y s P Sleep paralysis was \201 rst described by Ishmael during a reverie on deck, sleeping betw een Queequeg, the cannibal whaler from the South Seas, and his harpoon, before Herman Melvi lle embarks them on the Pequod \200\231s voyage to track down Moby Dick: \200\234At last I must have fallen into a troubled nightmare of a doze; and slowly waking from it \200\224ha lf steeped in dreams \200\224I opened my eyes, and the before sunlit room was now wrapped i n outer darkness. Instantly I felt a shock running through all my frame; nothing was to be seen, and noth- ing was to be heard; but a supernatural hand seemed placed in mine. My arm hung over the counterpane \200 for what seemed like ages piled on ages, I lay there frozen with the most awful fears \200 thinking that if I could but stir it one single inch, the horrid spell would be broken. \200\235 Moby Dick p44 Penguin T ill noon we quietly sailed on Yet never a breeze did breathe: Slowly and smoothly went the ship, Moved onward from beneat h. Under the keel nine fathom deep, From the land of mist and snow, The spirit slid: and it was he That made the ship to go. The Rime of the Ancient Mariner Samuel Taylor Coleridge (part v) Autism spectrum disorders (ASDs) ASDs are the lifelong pervasive developmental disorders of our times.1 Preva- lence: \211 1 : 200465 \200 : \200 \211\210 4 : 1. Managing autism is a huge challenge. It is a triad of: 1 Impaired reciprocal social interaction. 2 Impaired imagination ( abnormal verbal and nonverbal communication). 3 Restricted repertoires of activities and interests.466 Cause Unknown; severity correlates with testosterone in amniot ic \202 uid. Genes (on chromosome 11p12 neurexin) play a part.467 If one child is aff ected, risk of the next pregnancy being aff ected is 5 \200\22310%. Blood glutathione leve ls are low and this may jeopardize CNS & GI antioxidant activity.468 There is associ- ated epilepsy in 30%. Any association with MMR vaccine (p151) is thought to be due to changing d e \201 nition of autism at the time that MMR was introduced.469 Diagnosis \200\2066 items , with \200\2062 from \200\230A \200\231 symptoms, and one each from \200\230B \200\231 and \200\230C \200\231. Telling comments before the age of 2yrs are: \200\234he does not respond to his own name; he hates his routine being changed; he is not interested in toys. \200\235470 Impaired reciprocal social interaction ( \200\230A \200\231 symptoms) \200 U nawareness of the existence and feelings of others (treating people as fur- 394 niture; being oblivious to others \200\231 distress or need for privacy). Abnormal response to being hurt: he doesn \200\231t come for comfort; or makes a stereotype d response, eg just saying \200\234Kiss it better kiss it better kiss it \200\235. \200 Impaired imitation (eg does not wave \200\230bye-bye \200\231 or copies/echoes witho ut understanding, eg waves on passing a door when no one is in fact leaving). y r t a h c y s P i Repetitive play: eg solitary, or using others as mechanical aids. \200 Bad at making frie nds (lack of empathy). If he tries at all, the eff ort will lack the social conventions, eg reading the phone directory to uninterested peers. Impaired imagination ( \200\230B \200\231 symptoms; part of abnormal communication) \200 Little babbling, few facial expressions or no gestures in infancy. \200 Avoids mutual gaz e; no smiles when making a social approach; does not greet his parents; stiff ens when held. Does not act adult roles; no interest in stories; no fantasy/pretend play. \200 Odd speec h, eg echolalia (repetitions); odd use of words ( \200\234Go on green rid- ing \200\235 for \200\234I want a go on a swing \200\235); odd use of pronouns ( \200\234You \200\235 inst ead of \200\234I \200\235). Diffi culty in initiating or sustaining reciprocal roles in conversations. Poor range of ac tivities and interests ( \200\230C \200\231 symptoms) \200 Stereotyped movements (hand- \202 icking, spinning, head-banging). \200 Preoccupation with parts of objects (sniffi ng or repetitive feeling of a tex- tured object, spinning wheels of toys) or unusual attachme nts (eg to coal). Marked distress over changes in trivia (eg a vase \200\231s place). \200 Insists on follo wing routines in precise detail. \200 Narrow \201 xations, eg lining up objects, or ama ssing facts about weather. CHAT screening test: sensitivity 38%; speci \201 city is 98% if done at 1 yrs old.471 N=16,235 Treatment Early intensive behavioral intervention (EIBI) speech thera- py472 special schooling. EIBI starting at 3yrs old can \200\200IQ in >6 0% and en- hance motor, social, and living skills.473 Selfhelp:uk 020 81830 0999. Parent tr ain- ing helps communication, enriches parental knowledge of autism, enhances parent \200 \223child interaction, and \200\201parental maternal depression.465 Encourage parents to a ttend more to \200\230good \200\231 behaviors, and to have clear rules. Social skills trai ning/role-play can help. Get bene \201 ts/Disability Living Allowance. uk Other partly suc cessful behavioral approaches include that of Lovaas.474 Drugs have a small role: \201 sh oils475 (may help tantrums and self harm); atom- oxetine476 (hyperactivity); risperidone ( irritability; repetition; social withdraw- al; SE: weight \200\200).477 Diet: Eliminating g luten & casein is popular but unproven.478 Outlook 70% remain badly handicapped; 50% have u seful speech; 15% lead an independent life. 1 There is overlap with: Asperger \200\231s; mu ltiple complex developmental disorder; schizoaff ective disorder.479 395 Bullying Boys will be boys \200 The unacceptable alibi? \200\207Every individual should h ave the right to be spared oppression and re- peated, intentional humiliation, in school as in society at large.480 Bullying is important not just because it is unacceptable, but als o because it leads to depression, somatization, withdrawal, submissive behavior, school pho bia,481 vomiting, sleep disturbance, drug abuse, poor communication, and suicide.482 \200 \207Most parents don \200\231t know their offspring are bullies or being bullied.481 \200 \207Bullying is bad for bullies: antisocial behavior persists into adulthood with impaired reciprocal diadic relationships ( \211\210poor love life).483 Incidence 27% of primary and middle school children report bullying each term, and 10% of secondary pupils. In a study o f prevalence, 4% were direct bullies, 10% bully/victims (both bully and victim), and 40% vi ctims. Pure vic- tims have poor health. Pure bullies have fewest health problems.484 Bullyi ng behavior Rumor-spreading \200\203excluding others \200\203racial abuse \200\203hos- tile staring \200\203punking1 \200\203victimization \200\203pushing \200\203violence \200\203to rture \200\203murder. Risk factors Isolation, looking diff erent, being small, or gay, or s eeming gay.485 Interventions targeting bullying or emotional distress may reduce the sever- ity of both problems.486 Liaise with the school. School-wide policies do work.487 Psychoth erapy has a role. Ensure that the bully doesn \200\231t prosper from bullying, so learning to \200\230achieve dominance over others by the abuse of power \200\231. 488 y r t a i h c y s P The hardest task is to combat the ethos among bystanders, which allows bullying to continue as if it were \200\230none of my business \200\231. 489 This implies that we all have a role in minimizing bullying. Bullying in health services is well-documented,490 and most of us have suff ered from insecure people abusing positions o f power. We fear to act when we are bullied as we might get a bad reference or because we d on \200\231t think our own humiliation is important. It is easier to take a more rational v iew when we see others be- ing bullied: we must not allow it. Remember that the bullier may not be able to stop the behavior without help \200\224which is available: see www.nhs-expo sed.com. School-based anti-bullying interventions are successful in primary schools but les s so in secondary schools.491 Homosexual bullying: Teachers are of- ten aware of homophobic bullying but are confused, unable, or unwilling to help. Citizenship education programs ma y be important here.492 When the teacher is the bully: Problems may become very deep-rooted . Studies of bul- lying by teachers reveal the subtlety and complexity of teachers \200\231 strategies for distancing themselves from being held accountable for intimidation.493 On a universal level, we can recognize that we are all potential bullies, when stressed, fr ightened, overworked, or threatened by uncontrollable events (such as patient demand). We s top ourselves from being bullies, more or less successfully, by intrapsychic appeals to wel l-respected mentors who \200\230would never behave like that \200\231, and by communicatin g our feelings to our colleagues directly before they are forced underground only to resurf ace as bullying. Try: \200\234I \200\231m feeling rather stressed at the moment: tell me i f I seem bullying or hec- toring \200\224but we \200\231ve got to get this job done, and I suggest doing it like this \200 \200\235 False accusations of bullying You are trying to b ully me is a phrase which may be used correctly, or it may be an attempt to stop someone in authority from pursuing her proper role. The test is: \200\234Is this action tyrannical, and is its purpose to belittle me, or is it that I am being asked to do something I don \200\231t want to do by someone who is honestly trying to make an institution work? \200 \235 Professors of Organizational Behavior emphasize that everyone suff ers if dy- namism a nd the promotion of change are mistaken for bullying.494 1 Punking is male-on-male violence, humiliation, and shaming to affi rm masculinity, toughn ess, domi- nance and control.495 When boys who believe they merit privilege are instead har assed or called gay, they can be driven to avenge \200\230wrongs \200\231, and assert a vi ctorious masculinity. Mass shootings may result.496 Dyslexia Reading ability usually goes hand-in-hand with intelligence, but when this is not so, and someone with, say, an IQ of 130, \201 nds reading diffi cult, the term dys- lexia is often used. The term \200\230speci \201 c learning diffi culty \200\231 is preferred by some people, as \200\230dyslexia \200\231 is often a term used by parents to help cope with having a child whose general intellectual skills, including reading, are less than hop ed for. NB: dyslexia can be associated with other speech and language disorders: consider r eferral to a speech and language therapist (SALT). Essence There is a problem with apprecia ting phonemes, eg that \200\230cat \200\231 com- prises /c/, /a/, and /t/. Breaking up unf amiliar words into phonemes and hav- ing a go at stringing them together is the central act of learning to read. This is what needs to be taught, educationalists say, and children sh ould not be made to rely on unstructured guesswork (the \200\230look and say \200\231 appr oach) which is now discredited as the sole means of equipping children for reading. 396 Quite often, distortion/jumbling of text during reading is reported. Visual aids have been used with some success to improve reading.497 N=47 Children with dyslexia also have diffi culty in telling how many syllables there are in a w ord (don \200\231t we all? \200\234How many syllables are there in strength? \200\235 anal yt- ical dyslexics may ask). They also have diffi culty with verbal short-term memo- ry \200\224eg for meaningless strings such as phone numbers. There is also a problem with tell ing if two words rhyme or not, and in distinguishing phonemes which sound similar (eg /k/ a nd /g/). There may also be left/right muddle. Genetics: Boys are more affl icted than girls , and show stronger genetic eff ects (up to 50% of boys are dyslexic if their fathers are). Genes on chromosomes 1, 2, and 15 are implicated, and linkage on chromosome 6 near the HLA complex may explain associations between dyslexia and autoimmune diseases.498 Biology Boys learn language later than girls and are more prone to dyslexia. Finding candidate genes (e g DYX1C1)499 seems easy, but remember: genes don \200\231t specify cognitive processes; the y code regulatory factors, signaling molecules, receptors, and enzymes that interact in com plex ways, modulated by environ- mental in \202 uences, in order to build and maintain a p erson \200\231s brain. y r t a h c y s P i CNS examination shows left-sided cerebral lesions (rare) or changes may be seen postmortem, eg in perisylvian regions unusual asymmetry of the ple- num temporale (Wernicke \200 \231s area), with cortical dysplasia and scarring. In vivo characterization of this asymmet ry is becoming possible.500 Perhaps dyslexia re \202 ects weak connectivity between anterior and posterior parts of th e language areas of the brain, and the angular gyrus. Positron emis- sion images show that when dyslexic adults perform rhyme judgments and verbal short-term memory tasks they activa te less than the full set of centers normally involved with these tasks. www.shianet.org/ r eneenew/hist.html Note that there is functional MRI observation of speci \201 c involvement of one subsystem of the visual pathways which prevents rapid processing of brief stimuli presented in quick temporal succession (magnosystem hypothesis).501 Tests The GAPS test aims to diagnose chil dren before school starts.502,503 Management Make sure the \200\230dyslexia \200\231 is no t from lack of teaching. The per- son may gain insight by discussing his or her problem wit h fellow suff erers, and by \201 nding out about past dyslexics such as Leonardo da Vinci . Special educational programs are available for addressing dyslexic problems, as the phone tic approach to learning to read usually presents problems. NB: \200\230wait-and-see \200 \231 is not wise \200\224studies support identi \201 cation before school with exercises i n sound categorization using rhyme and alliteration, with special teaching of letters.504 You may be asked about dietary supplements with highly unsaturated fatty acids (HUFA, eg Ef alex ). These do play a role in neurodevelopment, but evi- dence of bene \201 t in dyslex ia from large randomized trials is sparse.505 They ap- pear to reduce dyslexia-associated d elay in dark adaption.506 n=10 Patient pathways: descending the \200\230dark spiral \200\231 1 of madness, as tweeted fro m a straightjacket in 1855 The next pages concern the psychiatrist as jailer. To re \202 e ct on this let us follow one patient \200\231s journey, along the edge of chaos, to his str aightjacket via a series of verbatim tweets from the manic streets of Paris (with proposed timings). 3pm 397 Bought two velvet screens covered with hieroglyphic \201 gures \200 to consecrate the for giveness of heaven. Met my friend George \200 wet through and tired out laid on his bed. Marvelous goddess appeared to me saying \200\234I am the same as Mary, the same as your mo ther \200\235. Said to George \200\234Let \200\231s go out \200\235. 4pm 6pm 7pm 7.15pm Crossing Pont des Arts explaining the transmigration of souls to him. 7.20pm Tol d George \200 I have the soul of Napoleon in me commanding me to y r t a i h c y s P do great things. 7.30pm In the Rue Du Coq I bought a hat. While George is waiting for my change I went to th e Palais-Royal \200 everyone staring at me. 7.50pm A persistent idea is \201 xing itself in my mind \200 there are no more dead. 8pm Went through the Galerie de Foy saying \200 \234I have committed a sin \200\235. 8.10pm Somewhat interested in little girls dancing in rings. 8.15pm Caf de Foy \200 Dense crowd \200 nearly suff ocated. 8.20pm Extricated b y 3 friends \200 into a cab \200 taken to Hospice De La Charit . 3.02am Walking about vari ous wards \200 I \200\231m like a god with powers of healing. 3.05am Laying my hands on som e patients now. 3.20am Going up to a statue of the Virgin Mary \200 3.21am Taking off its crown of \202 owers in order to test the power in me. 3.29am Talking in an animated way o f the ignorance of men who think they can be cured by science. 3.40am Bottle of ether on the table \200 3.42am Drinking it in one gulp 3.43am Hospital as sistant with face like an angel trying to stop me 3.45am Tell him he does not understand my mission. 3.55am Doctors coming along. 4am 4.02am Thrusting me into a straightjacket G rar d De Nerval 6am Aur lia 1855 G rard De Nerval, whose tweets these are, was famous during his colorful life for extravagant orgies, eating ice-cream out of skulls507 and for taking his pet lobster for walks in the gardens of the Palais Royal on a blue silk lead. Harangue on the impotence of their art. Am in an asylum outside Paris \200 He hanged himself from a Paris street light in 1855.508 After his death his critics read an d reread his masterpiece Les Chim res (a fragment of which appears below), \201\201 procl aiming it to be an in \201 nite hall- ucination set in a jewel of immense value.509 We hon or G rard De Nerval here to remind ourselves that the next patient we imprison using menta l health laws deserves our in \201 nite respect, however rough their diamonds appear to be . \201\201 1 Un arc-en-ciel trange entoure ce puits somber, Seuil de l \200\231ancien chaos dont le n ant est l \200\231ombre Spirale engloutissant les Mondes et les Jours! Around this tunnel plays a strange rainbow arc On the edge of primeval chaos whose hollow f orm is the spiral dark That swallows up Worlds and Days! Translation JML Compulsory treatment: law in England AC AMHP approved mental health professional ASW approv ed social worker CTO community treatment order ECHR European Convention on Human Rights ECT GSCC General Social Care Council IMCA IMHA LHB Before reading the subsequent pages which r e \202 ect the 1983 Mental Health Act it is vital to understand how the Act has been amend ed and added to by the 2007 Mental Health Act \200\224which does not replace it \200\224but rather sits beside it. Imperatives governing use of Mental Health Acts (required in the 20 07 act) \200 Respect patients \200\231 past and present wishes and feelings. \200 Minim ize restrictions on liberty and involvement of patients in planning, de- 398 (1983, 2007) approved clinician LSSA MCA Mental Capacity Act 2005 MHAC Mental Health Act Commission MHRT Mental Health Revi ew Tribunal NHSFT NHS foundation trust primary care trust PCT responsible clinician RC resp onsible medical offi cer RMO SCT supervised community treatment SOAD Second Opinion Appoint ed Doctor local social services authority electro-convulsive therapy independent mental capacity advocate independent mental health advocate local health board veloping and delivering care and treatment appropriate to them. Avoid unlawful discrimination. \200 Pay due attention to the eff ectiveness of treatment. \200 Respect the views of carers and other interested parties. \200 Respect for divers ity, including, in particular, diversity of religion, culture and y r t a h c y s P i sexual orientation (within the meaning of the Equality Act 2006). Patient wellbeing and safety, and public safety need balancing. 2007 Mental Health Act In 2 007, three key measures were introduced: 1 Community treatment orders (CTOs) allow compulso ry treatment in the com- munity. As a safeguard, there is a duty to consider what risk ther e would be of a deterioration of the patient \200\231s condition if he were not detained (a s a result, for example, of his refusing the treatment he requires for his mental disor- de r). CTOs have the same duration and renewal periods as section 3 (p400): 6 months initially , then renewed for 6 months, then renewed annually. 2 The criteria for a CTO is that the patient is detained after an application for admission for treatment, and it is necessary for his health and safety or for the protection of othe r persons that he receives treatment, which can be provided outside hospital (subject to a power of recall). CTO roles: \200 Ensuring the patient receives the treatment stipulated. \200 Preventing harm to the patient \200\231s health or safety. \200 Protection of other