Table 15.6 Urine drug testing Substance Duration of detectability Amfetamines 48hrs Benzodiazepines Ultra short-acting (e.g. midazolam) 12hrs Short-acting (e.g. triazolam ) 24hrs Intermediate-acting (e.g. temazepam) 40 \200\22380hrs Long-acting (e.g. diazepam) 7 days Cocaine metabolites 2 \200\2233 days Methadone (maintenance-dosing) 7 \200\2239 days (approximate) Codeine/morphine 48hrs (Heroin is detected in urine as the metabolite morphine) Cannabis Single use 3 days Moderate use (4 times per week) 4 days Heavy use (daily) 10 days Chronic heavy use 21 \200\22327 days Phencyclidine (PCP) 8 days (approximate) 15_Semple_Chap15.indd 593 12/7/2012 3:48:02 PM CHAPTER 15 Substance misuse 594 Planning treatment in drug misuse The longer-term goal of treatment will be eventual abstin ence from drugs, but this may not be an achievable short or medium-term goal in an individu al case. Immediate treatment aims are therefore: to reduce drug- related mortality and morb idity; to reduce community infection rates; to reduce criminal activity, including the need for drug users to sell to others to \201 nance their own habit; to optimize the patient \200\231s physical and men- tal health; and to stabilize where appropriate on an alternativ e substitute drug. Make diagnosis Con \201 rm drug use (history, signs of withdrawals, uri ne testing). Assess presence and extent of dependence. Assess severity of current problems and risk of future complications. Explore social, relation- ship, and medical problems. Ass ess stage of change ( b p. 544 and motiva- tion. What are the short-term and medium-term ai ms of treatment? Consider need for emergency treatment Where there is evi- dence of psychot ic illness or severe depressive illness the patient may require inpatient assessment. Engag e in service Treatment of drug misuse cannot be carried out through \200\230one-off \200 \231 interventions. Patients should be engaged in the service by empathic and non-judgement al interviewing, availability of the service close to the point of need, and ability of the service to respond to change in a previously ambivalent patient. Substitute prescribing wi ll be a strong motivator for engagement in some patients, but should always also have a rol e in helping the patient achieve some worthwhile change. Decide treatment goals and methods After assessment and diag- nosis the doctor should discuss with the patient their thoughts about treatment options given the patient \200\231s drug history and local treatment avail ability. The doctor may have strong feelings about the appropriate- ness of a certain treat ment but this will not be successful unless the patient agrees. Plans may include: \200 Return to dependent use as previously present in withdrawals, without other medical, surgic al, or psychiatric reasons for admission, and where there is no history of complicated with drawal, and where there has been no previous involvement in treatment services, it is inapp ropriate to prescribe. The individual should not receive replacement medication. They shoul d be offered the opportunity to attend for further assessment. Counseling and support episo dic use, this may be the appropriate course. Give drug information and harm-reduction advic e, possibly coupled with referral to a community resource. Detoxi \201 cation dependence a nd the patient wishes abstinence, then a plan for detox is considered. This may be communit y-based, with psychological support, symptomatic medication, or reducing substitute medicat ion, or as an inpatient. Consideration should be given to support after detox. How is absti nence to be maintained? Where individuals For non-dependent drug use, particularly (b p. 598, b p. 600) Where there is drug 15_Semple_Chap15.indd 594 12/7/2012 3:48:02 PM PLANNING TREATMENT IN DRUG MISUSE 595 Supported detox without prescription withdraw from drugs of dependence without use of a pre scription. This may occur particularly where other changes in a person \200\231s life (e.g. change of area, break from dependent partner) facilitate abstinence. Unsupported detox wit hout any medical help is frequently reported by users. Supported detox with symptomatic med ication addition to the support mentioned here, the individual is prescribed other, non-rep lacement drugs to ameliorate withdrawal symptoms (e.g. lofexidine in opiate withdrawal). Co nversion to substitute drug with aim of detox Here the aim is to convert the individual \200\231s drug use from street-bought to prescribed, then, from a period of stability, atte mpt supervised reduction in dose, aiming towards abstinence. Some individuals can Here, in Conversion to substitute drug with aim of maintenance the aim again is to convert from stre et to prescribed drugs, with stabilization via maintenance prescribing in the medium term. In a dependent user who does not feel that they can move to abstinence in the short term, m aintenance prescribing to suitably selected patients is useful and associated with overall health bene \201 ts. Here Address other needs The drug treatment service should consider part of its role as being a gateway to other services which the drug user may require but be reluctant or unable to app roach independently. Patients with social, \201 nancial, or physical health needs should have these explored and the need for referral considered. Do not make such referrals withou t the knowledge and agreement of the patient. Review psychiatric symp- toms which have been attributed to drug use to assess their resolution. Consider \200\230in-house \200\231 or specialist psychiatric treatment of residual anxiety/ depressive symptoms. 15_Semple_Chap15.indd 595 12/7/2012 3:48:03 PM CHAPTER 15 Substance misuse 596 Substitute prescribing 1: principles Withdrawal syndromes Any drug consumed regularly and h eavily can be associated with withdrawal phenomena on stopping, even if not a clas- sical w ithdrawal syndrome. The severity of withdrawal symptoms experi- enced by individual patient s does not correlate well with their reported previous consumption and so it is best to rel y on objective evidence of withdrawal severity. Clinically signi \201 cant withdrawal phen omena occur in dependence on alcohol, opiates, and benzodiazepines and are occasion- ally s een in cannabis, cocaine, and amfetamine use. In general, drugs with short half-lives will give rise to more rapid but more transient withdrawals. Detoxi \201 cation refers to the p rocess of managed withdrawal from drugs of dependence which can be aided by psychological s upport, symptomatic prescribing, or by prescription of reducing doses of the same or simila r drug. Substitute prescribing In many circumstances the management of a drug user will inc lude prescription of substitute medication. This may be to enable detoxi \201 cation from a dependent drug, or maintenance prescribing \200\224 a move from unstable street use to pr escribed dependent use to facilitate change now with abstinence later. The prescription of a drug should not occur in isolation, but should be part of a comprehensive management plan , previously agreed with the patient and with relevant members of the multidisciplinary tea m. Prescribing for drug users should be guided by local procedures and practice, by the Hom e Of \201 ce document Drug misuse and dependence \200\224guidelines on clinical management , and by the British National Formulary (see Box 15.4). Substitute prescribing may have the following indications \200 To acutely reduce or prevent withdrawal symptoms. Where detoxi \201 cation is planned, a \201 rst step can be the conversion of all opiate or BDZ use to a single prescribed drug, which can then be reduced in a planned manner. Short-term prescription of a substitute drug may also be indicated to alleviate symptoms of withdrawal complicating the assessment of a dependent patient presenting with a medical or surgical emergency. To stabilize drug intak e and reduce secondary harm associated with street drug use. In patients who are not consid ering detox in the short term, substitute prescribing can be a means of harm reduction (e.g . by reducing risk of accidental overdose [OD] or by changing from IV to prescribed oral us e). In addition, having a stable, legitimate supply can reduce the need to resort to crimin al activity to fund drug use, reducing the secondary, wider social harms of drug use. To be gin a process of change in drug-taking behavior. A major aim in substitute prescribing is t o fully supply the dependent drug and to move the patient away from extra, recreational dru g use and chaotic, polydrug misuse. After stabilization, the user should be encouraged to d iscontinue contact with dealers and friends who continue to use drugs in a chaotic fashion. To provide an incentive to continued patient contact and involvement with treatment servic es. 15_Semple_Chap15.indd 596 12/7/2012 3:48:04 PM SUBSTITUTE PRESCRIBING 1: PRINCIPLES 597 Substitute prescribing should only be considered where: \200 There is objective evidence of current dependence. This should include a history of daily c onsumption, description of withdrawal symptoms, history of drug seeking to relieve or preve nt withdrawals, and consistent presence of the drug on urine screening. The patient display s realistic motivation to change their drug use in a way which would be aided by prescripti on (e.g. to cease IV heroin use on instigation of oral methadone prescription). The doctor believes the patient will co-operate with the prescription and that circumstances exist to allow adequate monitoring. Assessing need for substitute medication Before prescribing substitute medication for detox i \201 cation or mainte- nance, the treating doctor should positively con \201 rm depende nce via: \200 Positive history of daily use with features of dependence syndrome. \200 Presence of drug in two urine specimens at least 1wk apart. \200 Objective evidence of wi thdrawal features at assessment. Box 15.4 Requirements for a controlled drug prescription \200 \200 \200 The prescription may be printed but must be signed by hand. States patient \200\231s name, age, and current address. Gives name, concentration, and type of preparation required (e.g. methadone, 1mg in 1mL, sugar-free suspension). States required dose and frequency. States total quantity of drug to be dispensed in both words and \201 gures (not required for tem azepam). Clearly signed and dated. \200 15_Semple_Chap15.indd 597 12/7/2012 3:48:04 PM CHAPTER 15 Substance misuse 598 Substitute prescribing 2: opiates Opiate detoxi \201 cation Opiate withdrawal In an opiate -dependent individual, withdrawal symp- toms appear 6 \200\22324hrs after the last dose and typically last 5 \200\2237 days, peaking on the 2nd or 3rd day. The withdrawal following d iscontinuation of the longer-acting methadone is more prolonged with symptoms peaking on th e 7th day or so and lasting up to 14 days. Symptoms of opiate withdrawal: sweating; dilated pupils; tachycardia; hypertension; piloerection ( \200\230goose \202 esh \200\231); wate ring eyes and nose; yawning; abdominal cramping; nausea and vomiting; diarrhea; tremor; joi nt pains; muscle cramps. Symptomatic medication Several non-opiate, oral medications are effective in ameliorating s ymptoms of opiate withdrawal. Unlike opiates, they are not liable to abuse or diversion to the black market. \200 Lofexidine bd, increased in 200 \200\223400-microgram steps up to maximum of 2.4mg daily gi ven in 2 \200\2234 divided doses. Measure baseline BP and monitor BP while raising dose (ri sk of symptomatic hypotension). 10-day course, withdraw over 2 \200\2234 days. Loperamide F or treatment of diarrhea. 4mg initial dose with 2mg taken after each loose stool for up to 5 days. Maximum daily dose: 16mg. Metoclopramide of 30mg daily. Ibuprofen maximum of 1600mg daily. Alpha-adrenergic agonist. Starting dose: 200micrograms For nausea and vomiting. 10mg dose, up to maximum For headaches and muscle pains. 400mg dose, up to Substitute prescribing Several opiates are used in detoxi \201 cation regimes. Where it is planned to continue prescribing on a maintenance basis, cur- rently methadone is the drug of choice. \200 Methadone is therefore suitable for daily dosing (which can be supervised) (see Table 15.7) . At daily dose >80mg it produces near saturation of opiate receptors, minimizing the \200 \230reward \200\231 of further consumption. It is prescribed as a colored liquid, unsuitabl e for IV use, at concentration 1mg/1mL. A sugar-free form is available. Licensed for use in opiate withdrawal and maintenance. Buprenorphine dependence. Available in once-daily subli ngual preparation. 8mg 7 = 30mg methadone. Believed to produce less euphoria at higher dose s than methadone. Abuse potential, as tablet can be prepared for injection. Dihydrocodeine dependence. Occasional use in reduction regimes in patients already on a stable dose of str eet dihydrocodeine or in \201 nal stages of dose reduction in patients on doses of methad one <15mg daily. Need for 2 \200\2234 times daily doses means that all dosages cannot be su pervised. Long-acting synthetic opiate. Its half-life is 24hrs and it A partial opiate agonist. Licensed for treatment of drug Short-acting opiate. Not licensed for use in drug Opiate maintenance In maintenance prescribing, the aim is to prevent under-dosing (risk of use of street opiates, withdrawal symptoms) and overdosing (sedation, more drug available t han required with diversion to the black market). There 15_Semple_Chap15.indd 598 12/7/2012 3:48:04 PM SUBSTITUTE PRESCRIBING 2: OPIATES 599 is research evidence that a methadone script reduces street usage, crimi- nality, and drug- related mortality. For outpatient initiation of methadone maintenance, arrange to review th e patient in the morning with them hav- ing consumed no opiates for the previous 24hrs. Ass ess withdrawals and dispense methadone as follows: \200 \200 \200 l no prescription. Review following day. None or mild Moderate (aches, dilated pupils, yawning) Severe (vomiting, piloerection, hype rtension) l 10 \200\22320mg methadone. l 20 \200\22330mg methadone. Review after 4hrs and repeat dose if severe withdrawals continue, up to 30mg. Review daily over the \201 rst week with dose increments of 5 \200\22310mg daily if indicated. Methado ne reaches a steady state 5 days after the last dose change. Arrange regular review after \201 rst week, making subsequent increases by 10mg on each review up to 7120mg. Stabilizat ion may take up to 6 weeks to achieve. For maintenance monitoring, see b p. 602. Dose reduc tion After stabilization and complete abstinence from street opiates, a decision should be made as to whether the aim is dose reduc- tion or maintenance prescribing. Rapid reduction regimes reduce the dose over 14 \200\22321 days (perhaps using the drugs outlined in Sympto matic medication b p. 598, as adjuncts). Usually reduction is more gradual. Slow reduction is over 4 \200\2236 months, reducing by 75 \200\22310mg each fortnight. In reduction regime s, make the largest absolute cuts at the beginning and make smaller, more gradual cuts as t he total dose falls (i.e. aim to keep the percentage drop in dose similar). In general do n ot carry out reduction against the wishes of the patient as it is better to carry on a main tenance script rather than return to street use. Occasionally \200\230tread water \200\231 then restart reduction. Opiate relapse prevention In previously dependent opiate users who have successfully comple ted detox, the opiate antagonist naltrexone may be used as an aid to relapse prevention. Ta ken regularly it will prevent the rewarding, euphoriant effect of opiate consumption. Naltrexone Prescribed to aid abstinence in formerly dependent patients who have been drug f ree for >7 days. Starting dose 25mg, increased to 50mg daily. Total weekly dose of 350mg ma y be divided and given 3 days/ wk (e.g. to aid compliance, or to enable supervision), give 100mg Monday and Wednesday and 150mg on Friday. Naltrexone is also used in specialist inpat ient facilities to facilitate rapid detox over 5 \200\2237 days. Table 15.7 Converting opiate dose to methadone dose Drug Daily dose Methadone equivalent Street heroin 0.5mg \200\2231g 50 \200\22380mg Morphine 10mg 10mg Dipipanone (Cyclizine) 10mg/30mg 4mg Dihydrocodeine 30mg 3mg Pethidine 50mg 5mg Codeine phosphate 30mg 2mg 15_Semple_Chap15.indd 599 12/7/2012 3:48:04 PM CHAPTER 15 Substance misuse 600 Substitute prescribing 3: benzodiazepines Benzodiazepine detoxi \201 cation Benzodiazepine withdrawal Chronic BDZ use leads to development of dependence, with a characteristic withd rawal syndrome. The symptoms appear within 24hrs of discontinuing a short-acting benzodiaze pine, but may be delayed for up to 3 weeks for the longer-acting preparations. Symptoms of benzodiazepine withdrawal: anxiety; insomnia; tremor; agita- tion; headache; nausea; sweati ng; depersonalization; seizures; delirium. Substitute prescribing As for opiates, BDZ substitute prescribing should only be undertaken where there is clinical evidence of dependence, a clear treatment plan, and suitable patie nt monitoring in place. Substitute pre- scribing in BDZ dependency uses the long-acting dia zepam. In prescribing for patients with BDZ dependency, convert all BDZ doses to diazepam u sing Table 15.8. The aim is to \201 nd the lowest dose which will prevent withdrawal symp toms (which may be well below the amount the patient has been taking). Divide the daily dos e to avoid over-sedation. Benzodiazepine maintenance Unlike methadone maintenance in opiate dependency, there is no e vi- dence that long-term BDZ prescription reduces overall morbidity. There is evidence that long-term prescription of >30mg diazepam daily is asso- ciated with harm. New prescription s should be for 30mg or less with patients already on higher doses reduced to this amount. Dose reduction Cut dose by 71/8th of total dose each fortnight. For low dose 2.5mg fortnigh tly; for high dose 5mg fortnightly. Review and halt or temporarily increase if substantial symptoms re-emerge. If patient is also opiate-dependent and on methadone, keep methadone st able while reducing benzodiazepine. Table 15.8 Conversion to equivalent diazepam dose Drug Dose Diazepam 5mg Nitrazepam 5mg Temazepam 10mg Chlordiazepoxide 15mg Oxazepam 15mg Loprazolam 500micrograms Lorazepam 500micrograms Lormetazepam 500 \200\2231000micrograms 15_Semple_Chap15.indd 600 12/7/2012 3:48:04 PM This page intentionally left blank CHAPTER 15 Substance misuse 602 Monitoring of maintenance prescribing Detoxi \201 cation and stabilization on maintenance medication are often followed by rapid relapse despite successful completion. It is importa nt to build monitoring of compliance into treatment strategies from the beginning. Review R egular review of all patients on maintenance prescription is indi- cated at least monthly. At each review: \200 Is dose suf \201 cient? Is there evidence of withdrawals? Obtain feedback from pharmacist/ community nurse. If dose insuf \201 cient? Consider small weekly increases in dose. Stop i f evidence of intoxication. Con \201 rm use of illegal drugs via history, urine testing, a nd observation of evidence of IV use. Plan movement towards goals. Consider intervention in mental health/other issues. Consider need for period of increased supervision. \200 \200 Supervision of substitute prescribing The aim of supervised con- sumption is to ensure that the drug is being used as prescribed. \200 Supervised consumption usually for initial minimum period of 3mths, taking into account wor k and childcare issues. Consider ongoing supervised consumption (e.g. in drugstore). Once-d aily dosing with daily pick-up of drugs. No more than 1wk \200\231s prescription at a time. Advice re children and methadone. Close liaison with pharmacist and GP. Thorough and clear records should be kept. No replacement of \200\230lost \200\231 prescriptions. \200 \200 \200 \200 \200 \200 Discontinuing a failing treatment Where there is persistent non- compliance with treatment and where attempts to improve compliance or modify treatment goals have failed then the mai ntenance should be discontinued. \200 \200 \200 Discontinue via reduction regime. Offer involvement with other services. Inform GP and phar macist. 15_Semple_Chap15.indd 602 12/7/2012 3:48:04 PM This page intentionally left blank CHAPTER 15 Substance misuse 604 Psychotic illnesses and substance misuse The association of substance misuse and psychotic features is a com- mon and problematic one in clinical practice. The key to management is a ccurate diagnosis. Psychotic symptoms represent underlying psychiatric abnormality in this group of patients as in any other. There is not a general \201 nding of \200\230low-grad e \200\231 psychotic features in substance users and apparent psychotic features should not be attributed to effects of substance use without further inquiry. Psychotic features duri ng drug intoxication Substances with hal- lucinogenic or stimulant activity can produce psy chotic features during acute intoxication. This is not consistent and varies by drug dose a nd set- ting. These are characterized by a rapidly changing pattern of symptom type and sev erity and include visual and other hallucinations, sensory distortions/illusions, and perse cutory and referential thinking. They are characteristically rapidly \202 uctuating hour by hour and show resolution as the drug level falls. Psychotic features during withdrawal I n patients with physiologi- cal dependency on alcohol, BDZs, or cocaine, withdrawals may be compli- cated by delirium in which variable psychotic features may be prominent. These wil l occur in the context of the general features of delirium (b p. 790). There may be \202 uctuating visual or tactile hallucinations and poorly formed persecutory delusional ideas. Residual psychotic illness (drug-induced psychosis) In some indi- viduals, psychotic featur es continue after the period of acute intoxication and withdrawals has passed. These may be symptomatically more typical of primary psychotic illness and, once established, should be treated as for acute episodes of schizophrenia (b p. 192). Genuine comorbidity Many indivi duals with primary psychotic ill- nesses will misuse substances. In addition to the intrins ic risks of substance misuse, this carries risks in this group of diminished treatment comp liance, risk of disinhibition leading to violence, and exacerbation of the primary illness. In view of the sometimes obvious (to others) causal link between drug use and relapse it i s worth asking why patients persist in substance use. Reasons include: \200 Endemic drug use within patient \200\231s environment (e.g. home or social setting) or with in other individuals with mental health problems. As means of self-medicating distressing p ositive and negative symptoms (which may be improved by addressing these symptoms directly) . 15_Semple_Chap15.indd 604 12/7/2012 3:48:05 PM This page intentionally left blank CHAPTER 15 Substance misuse 606 Legal issues related to drug and alcohol misuse Fitness to drive It is the patient \200\231 s responsibility to inform the DVLA of any \200\230disability likely to affect safe drivin g \200\231. The DVLA regards drug mis- use as a disability in this context. Group 1 license s cover motor cars and motorcycles, group 2 licenses cover HGVs and busses. Decisions regar ding licensing are made on a case-by-case basis; however, the DVLA \200\231s current guidel ines are as follows: \200 Alcohol misuse: (group 2) period of abstinence or controlled drinking has been achieved wit h normalization of blood parameters. Alcohol dependence: 3-year (group 2) period of abstine nce, with normalization of blood parameters. Consultant referral and support may be require d. Dependency/persistent use of cannabis, amfetamines, MDMA, LSD, and hallucinogens: loss o f license until 6-mth (group 1) or 1-yr (group 2) period of abstinence. Medical assessment and urine screening may be required. Dependency/persistent use of heroin, morphine, cocaine , methadone: loss of license until 1-yr (group 1) or 3-yr (group 2) period of abstinence. I ndependent medical assessment and urine screening prior to relicensing. A favorable consult ant report may be required for group 1 and will be required for group 2. Subject to annual review and favorable assessment, drivers complying fully with a consultant-supervised metha done maintenance program may be licensed. loss of license until 6-months (group 1) or 1-year loss of license until 1-year (group 1) or Travel abroad Patients receiving a methadone prescription can travel abroad with a supply. Amounts up to 500mg do not need a license; amounts above 500mg require a Home Of \201 ce l icense, obtained by appli- cation by the prescriber to the Home Of \201 ce stating the pat ient \200\231s name and address, the strength, form, quantity, and daily amount of the drug prescribed, and the date of departure and return. In both cases the Home Of \201 ce advis es patients to carry a \200\230To whom it may concern \200\231 letter, indicat- ing that t he drug has been legitimately prescribed. This advice applies only to the right to take the drug out of the UK and return with any surplus. Travelers are advised to contact the embas sy or consulate of the destina- tion country prior to travel to ensure that import of metha done is allowed under local laws: countries \200\231 regulations vary widely. Registration of drug addicts Compulsory registration of all drug addicts to the Home Of \201 ce registe r of addicts ceased in 1997. Since then data have been collected on a regional basis via th e anonymized regional drug misuse databases. Details regarding supply of forms in each area can be found in the BNF. 15_Semple_Chap15.indd 606 12/7/2012 3:48:05 PM LEGAL ISSUES RELATED TO DRUG AND ALCOHOL MISUSE 607 Drug testing and treatment orders (DTTOs) A form of com- munity sentence introduced in the UK in 2000. The court makes an order requiring offenders with drug problems to undergo trea tment and follow- up with a drug treatment service. This may be part of another commu- nity order or a sentence in its own right. The sentencing court monitors compliance via mandato ry urine testing. Sentence plans may change in response to individual progress or problems. May last 6mths to 3yrs. 15_Semple_Chap15.indd 607 12/7/2012 3:48:05 PM This page intentionally left blank 609 Chapter 16 Child and adolescent psychiatry Introduction 610 Assessment 1: principles 612 Assessment 2: practice 614 Development 616 Re silience 618 Attachment 620 An approach to behavioral problems 622 Conduct disorders 624 At tention de \201 cit hyperactivity disorder (ADHD) 626 Drug treatment of ADHD 628 Autism sp ectrum disorders (ASD) 630 (Gilles de la) Tourette \200\231s syndrome 632 Other tic disorde rs 633 Language, learning, and motor co-ordination disorders 634 Enuresis 636 Encopresis 63 7 Other behavioral disorders 638 Anxiety disorders: overview 639 Separation anxiety disorde r 640 Generalized anxiety disorder 641 Panic disorder/agoraphobia 642 Social phobia, simple phobias, and selective mutism 644 Post-traumatic stress disorder 646 Obsessive \200\223com pulsive disorder (OCD) 648 Eating disorders 650 Depression in children and adolescents 652 Suicide and self-harm in young people 654 Bipolar disorder in children and adolescents 656 Psychosis 658 Substance abuse in children and adolescents 660 Child abuse 1: general issues 662 Child abuse 2: the duty of care 663 The looked-after child (LAC) 664 Prescribing in ch ildren and adolescents 665 Family therapy (FT) 666 Parent management training 667 16_Semple_Chap16.indd 609 12/7/2012 3:48:59 PM CHAPTER 16 Child and adolescent psychiatry 610 Introduction Child psychiatry is an enormously stimulating and varied area of psychiat- ric practice. Practitioners see children and their families throughout their development and w ith a multitude of presentations, from anorexia to autism, depression to drug misuse and pa renting problems to psychosis. Child psychiatrists make use of multiple psychotherapeutic a pproaches, as well as drug treatments. The multifactorial nature of children \200\231s dif \201 culties means that multidisciplinary and multi-agency working are the norm. The links between childhood disorder and the later development of adult men- tal disorder are becomi ng more apparent and there is the opportunity to make a real positive difference to a child \200\231s development and future. What is CAMHS? The term CAMHS (Child and Adolescent Mental Health Services) is used in two different ways. One includes all services that contribute to the mental health care of chil dren and young people; the other applies speci \201 - cally to specialist child and adoles cent mental health services, provided in Tiers 2, 3, and 4 (see The tier concept of CAMHS). The remit of specialist CAMHS has expanded recently to provide services up to the eighteen th birthday, and in some areas to transfer care of learning disabled children into CAMHS fr om learning disability services. The tier concept of CAMHS \200 Tier 1 CAMHS is provided by professionals whose main role and training is not in mental hea lth, for example GPs, health visitors, pediatricians, social workers, teachers, youth worke rs, and juvenile justice workers. Tier 2 CAMHS is provided by specialist mental health prof essionals with training in child development, working primarily alone, rather than in a tea m. Their role may include direct contact with young people, consultation to Tier 1 and trai ning. Tier 3 services are provided by a multidisciplinary team who see young people with mo re complex mental health problems. Tier 4 services are very specialized services in residen tial, day patient, or outpatient settings for children and adolescents with severe and/or c omplex problems requiring a combination or intensity of interventions that cannot be provid ed by Tier 3 CAMHS. The role of the multidisciplinary team Child and adolescent (C&A) mental health care exempl i \201 es the relevance of and need for a multidisciplinary approach. The professional gro ups represented in a team vary but may include psychiatry, psychology, nurs- ing, family th erapy, child psychotherapy, social work, and occupational therapy. Additionally a newer gro up of primary mental health workers has been developed, largely operating at Tier 2 but lin king with Tier 3 CAMHS. For medically trained professionals who are used to \200\230leadin g the team \200\231, C&A work may be at \201 rst a little bewildering. As young people ar e embedded within family, social, and educational systems, their problems must be understoo d and treated from a holistic perspective which draws 16_Semple_Chap16.indd 610 12/7/2012 3:48:59 PM INTRODUCTION 611 on the various models available within the team, of which the medical and psychiatric persp ective is one. CAMHS in context There is an emphasis on specialist CAMHS being part of a child-centered in tegrated network of services (including other health providers, educa- tion, social care, a nd criminal justice) which work together to meet the needs of the child. Even when CAMHS ar e not directly involved in a child \200\231s care, through consultation it can be useful to have a mental health per- spective in thinking about the child. The barb in the arrow of childhood suffering is this: its intense loneliness, its intense i gnorance. Akhenaton (1354 BC), Egyptian king If there is anything we wish to change in the child, we should \201 rst exam- ine it and see whether it is not something that could better be changed in ourselves. Carl Gustav Jung (1875 \200\2231961) 16_Semple_Chap16.indd 611 12/7/2012 3:48:59 PM CHAPTER 16 Child and adolescent psychiatry 612 Assessment 1: principles The biopsychosocial approach Understanding and managing successfully the mental and behavio ral problems of children depends upon the thoughtful consideration of all the biological, p sychological, and social factors that may play a role in the generation of symptoms. It is important to remember that several fac- tors may interact in a dynamic two-way fashion, giv ing rise to symptoms. The \200\230biopsychosocial approach \200\231 is useful at all stage s of the evaluation and intervention provided to a child. Children and families When a young person comes into contact with mental health services th ey are more likely to have been referred for help than to have sought help themselves. This is important to remember, since \200\230the patient \200\231 may have no say in their ref erral and this may have implications for the thera- peutic relationship. In addition, one i s rarely dealing with the young per- son alone \200\224they are usually dependent upon care givers, whether they are parents or other adults. Thus one is commonly confronted by a room full of people who may have differing experiences and interpretations of the young person \200\231s problems and of what is needed to improve the situation. The professional in this situation needs to be aware of the various dynam- ics and be vigilant in remaining objecti ve and non-partisan, while engaging with each family member. It is important to bear in min d that although the family has come hoping for help, they may also have feelings of failure or guilt related to their child \200\231s problems which one must be sensitive to. Who should attend the assessment Flexibility is important when assessing children and their families. Usually it is advisable to invite the child along with whoever lives in the fami ly home. The standard \200\230nuclear family \200\231 is far less common nowadays with sin gle par- ent and reconstituted families, kinship care, and professional foster care featuri ng prominently. It is helpful to \201 nd out who is in the room with you at the start of the assessment. Older adolescents may live away from home, perhaps alienated from their fam ilies. Thus sensitivity to individual circumstances is mandatory. Sometimes it is helpful f or other people to attend, e.g. the social worker, where this would aid in understanding a family \200\231s dif \201 culties, facilitate joined-up working, or support the family in attending and using the appointment. Communication A number of factors in \202 uence how one communicates with the family membe rs in the room, including: the level of the child \200\231s development; the presence of me ntal or physical disorder, e.g. autistic spectrum disor- der, deafness; and the language sp oken (an interpreter may be required). Developing skills for communicating well is essentia l for making a good assessment. 16_Semple_Chap16.indd 612 12/7/2012 3:48:59 PM This page intentionally left blank CHAPTER 16 Child and adolescent psychiatry 614 Assessment 2: practice Starting the interview with the family \200 \200 Introduce yourself and clarify who is in the room with you. Allow the family to settle by e xplaining the purpose and duration of the appointment. If a one-way screen is in use explai n this. Discuss con \201 dentiality and the limits of this, particularly in relation to ch ild protection. Identify who will be sent copies of any letters produced following the asse ssment. It is common practice for letters to be copied to families if they wish this. Provi de age-appropriate toys and drawing materials to younger children. Establish \200\230rules \200\231, e.g. all toys are put away at the end of the session. Taking a history \200 \200 \200 Throughout the history, facilitate each person \200\231s participation. Obtain a descriptio n of the problem as each person sees it. Obtain the family history and construct a genogram . This is useful in gathering information about family members \200\231 relationships, upbr ingings, and mental and physical health. Enquire about school, hobbies, and peer relationsh ips. Take a developmental history for each child in the family. Particularly with adolescen ts, enquire about substance use and forensic activity. What has already been tried and have any other agencies been involved? Often there will be aspects of the history which either the child or the adults are unwilling to discuss in front of the other. It is important to allow individual time for a full history to emerge, while remembering that people often eit her know or suspect these secrets. \200 \200 Mental state and observations \200 Observe family functioning and interactions. Note patterns of communication, degree of warm th, power dynamics, alliances, etc. The mental state examination follows a similar pattern to that for adults, but with allowance for the child \200\231s level of development. It wil l be dif \201 cult to conduct a formal mental state examination on children under age 12, but one can comment on observable aspects, e.g. levels of activity and attention; physical and mental level of development; mood and emotional state; quality of social interaction; r esponse to boundary setting. Sometimes it is appropriate to carry out physical examination at this interview \200\224e.g. low weight anorexia \200\224usually have a parent/other chap erone present. 16_Semple_Chap16.indd 614 12/7/2012 3:49:00 PM ASSESSMENT 2: PRACTICE 615 Interview with the child alone \200 It is usually helpful to offer to meet with the child alone, particularly for adolescents f or whom greater independence is developmentally appropriate. Establishing rapport and gaini ng the child \200\231s con \201 dence are primary objectives of the \201 rst interview. Young children should be invited to play, draw, etc. Clarify con \201 dentiality and excep tions to this again with the child, using age-appropriate language. Begin with subjects wel l away from the presenting problem (e.g. interests and hobbies, friends and siblings, schoo l, holidays). Progress to enquiring about the child \200\231s view of the problem, worries, fears, sleep and appetite, mood, self-image, peer and family relationships, experiences of bullying or teasing, abuse, persistent thoughts, fantasy life, abnormal experiences, suici dal thoughts, etc. (It may take more than one interview to obtain a full picture.) Gathering other information \200 Obtain consent to contact school for a classroom observation, meeting, or report from teach ers. Consult other caregivers, health professionals who have treated the child, social agen cies that have been involved with the child and/or family, and educational psychology if in volved. Consider using rating scales (e.g. Connor \200\231s Questionnaire, Moods and Feelin gs Questionnaire, CY-BOCS, K-SADS as indicated). It will sometimes be appropriate to reques t other assessments, e.g. speech and language, occupational therapy, neuropsychology, educa tional psychology, or to arrange physical investigations, e.g. hematology, chromosome studi es, EEG, CT. Formulation of the problem \200 Consider the problem in terms of biological, psychological, and social aspects, and identif y predisposing, precipitating, perpetuating, and protective factors. Use this along with a risk assessment to develop a management plan. Involvement of the family in this, and in its execution, is likely to be bene \201 cial. Consent/capacity/legislation \200 An assessment of a young person \200\231s capacity, and ability to give consent, is importa