Diagnosis LATHA HACKETT CAROLINE BOND 1 2 TH J U N E 2 0 1 4 Learning Outcomes 1b.3 understand the need to provide service users (or people acting on their behalf) with the information necessary to enable them to make informed decisions 2a.4 be able to develop psychological formulations using the outcomes of assessment drawing on theory, research and explanatory models 3a.1 understand the structure and function of the human body, relevant to their practice, together with a knowledge of health, disease, disorder and dysfunction 3a.1 understand psychological theories of, and research evidence in, child and adolescent development relevant to educational psychology Activity In pairs discuss: 1. Your experience so far of working with diagnostic labels 2. Thinking about a case you have been involved with: - who made the diagnosis? - How were you made aware of the diagnosis? - Did it involve contact with other professionals? If so, how did this informed your work? - How did the diagnosis informed your assessment and intervention? What is diagnosis? the identification of the nature of an illness or other problem by examination of the symptoms. the distinctive characterization in precise terms of a genus, species, or phenomenon. Diagnostic Systems International Classification of Mental and Behavioural disorders. Version 10- ICD 10. World Health organisation. - Children/Young people – Multi-axial Classification. Diagnostic and Statistical Manual of Mental Disorders – fifth Editions. American Psychiatric association. – DSM5. Clinical Formulation. What is classification It is like a language. Aids communication. Aids in thinking about a complex problem. Good Scientific Classification Clarity. Comprehensiveness. Acceptability to users. It should change when understanding changes. Each class is a concept not a thing. Why do we need diagnostic systems? Improve reliability of diagnostic judgements. Guidelines for diagnosis – enhances the agreement among clinicians and investigators. Proper use need specialised clinical training (knowledge and clinical skills). Reflect a consensus of current formulations of evolving knowledge in our field. Does not encompass all the conditions. Purpose Provide clear descriptions of diagnostic categories to enable clinicians to diagnose, communicate, study and treat. In mental health – face a remarkable collection of phenomena. So we will need different classification for different purpose. Early ones – Psychoanalytic theory – reliability was low among clinicians. . Purpose Provide clear descriptions of diagnostic categories to enable clinicians to diagnose, communicate, study and treat. In mental health – face a remarkable collection of phenomena. So we will need different classification for different purpose. Early ones – Psychoanalytic theory – reliability was low among clinicians. . Research Purposes Good diagnostic Schemes. Groups of children have to be homogenous. Replicable. Hypothesis testable – ODD under the age of 8 and WS parent training. Obsessions and stereotypies – treatment for one tried on the other. ADHD and Mania – study of neurotransmitters. Clinical Purposes Practitioners need to know – application of research to clinical practice. Communication between clinicians. Statistical record keeping. Audit of response to interventions. Communication between users and carers. Abuses. When they are considered as things rather than a concept. E.g. teacher – not really ADHD but all due to social reasons. Child with disproportionate difficulty in learning to read does not come up to MLD so no statement. Principles of a Multi-axial framework Diagnosis – needs several elements Mental disorder, Mental retardation, presence or absence of a brain disorder In most cases it is multiple reasons that a child has difficulties. Remember Conditions such as Pathological Gambling. Paedophilia Does not imply they meet legal or other non- medical conditions that constitutes a mental disease, Mental disorder or Mental Disability. (individual responsibility/disability determination/competency) Remember Coding for diagnosis – refers only to the persons current situations. NOT to the person himself/herself. Carry no implications about permanency & irreversibility – so not appropriate for labelling of individuals. Coding should not be basis for recommendations for institutional placement etc. Psychiatric diagnosis are descriptions and not explanatory. ADHD – a description of symptoms and not why the child behaves the way he does. Remember Categories do not provide aetiological basis for the disorder exception PTSD. But they are defined as a gp of symptoms only used if they meet the criteria. Reactive attachment disorders of Childhood & Disinhibited attachment disorder of Childhood – they need to have the behaviours to make this diagnosis. Remember Depressive illness in children – adult depression differs in heritability, presentation and response to medication. Tricyclic antidepressant are ineffective in children No age bar for diagnosis. Child being brought to see you – so he must be disordered the child’s behaviour may be adaptive to nurture. ADHD – pattern of beh changes with age – adolescents less over activity and more disorganisation Not all children with Autism are the same – descriptions such as autistic and brain damaged are not useful. ICD 10 – Multi-axial classification 6 axis – Multi-axial classification. First 4 axis – ICD 10 categories Axis 1 -Clinical Psychiatric Syndromes Axis 2 – Specific Disorders of Psychological development. Axis 3 – Intellectual level. Axis 4 Medical conditions. ICD 10 – Multi-axial classification Axis 5- Associated abnormal psychosocial situations. Axis 6 – Global association of Psychosocial disability. Multi-axial classification in child psychiatry Avoid false dichotomies from having to decide between two diagnosis. Autism & Mental retardation. Has to be a coding on each category – this is more complete and less ambiguous e.g. Autism and no mental retardation. Axis 1 and axis 3. Avoids artefactual unreliable results – a child with psychosocial difficulties and other difficulties will have codes on all categories. Clinical Diagnosis and Formulation. Convenient and economical communication. Statistical recording and Audit. Diagnosis does not automatically generate a plan of management – eg Autism with challenging behaviour and Autism without. IQ, Peer relationships etc Diagnosis is only one part that guide decision making Co-occurrence of different symptom patterns Co-morbidity – 2 or more separate and independent disorders are present in the same person Tourette’s disorder and ADHD is common ASD and ADHD common ASD with anxiety disorder common Example Autism ICD-10 and DSM5 ICD-10 (WHO, 1992) categories F84 Pervasive Developmental disorders (Childhood Autism, Rett’s Syndrome, Other childhood disintegrative disorder, Asperger’s Syndrome, Atypical Autism, PDDNOS) F84.0 Childhood Autism - a pervasive developmental disorder defined by the presence of abnormal/and or impaired development that is manifest before the age of 3 years - Characterised by abnormal functioning in a)social interaction, b) communication and restrictive c) repetitive behaviour - Boys: girls 3:1 or 4:1 Example Autism ICD-10 and DSM5 F 84.1 Atypical Autism - Differs from autism in terms of age of onset or failure to - - fulfil all 3 criteria or insufficient demonstrable abnormalities in 1 or 2 of the 3 areas (social interaction, communication and restrictive, repetitive behaviour) F84.5 Asperger’s Syndrome Qualitative abnormalities of reciprocal social interaction and restricted and repetitive activities/interests No language or cognitive delay Clumsiness common Boys:Girls 8:1 Example Autism ICD-10 and DSM5 DSM5 (APA, 2013) categories Neurodevelopmental disorders (intellectual disability, communication disorders (incls. pragmatic), Autism Spectrum Disorder, ADHD, specific learning disorder, motor disorders) Autism Spectrum Disorder A. Persistent deficits in social communication and social interaction across multiple contexts B. Restricted, repetitive patterns of behavior, interests, or activities Severity categories and co-occurrence descriptions e.g. with/without language impairment or intellectual impairment http://www.md-fm.com/Vreport-vid-61-comefromback.html Evaluation of DSM5 Social communication disorder not discreet and could create a new category for those who don’t quite meet autism criteria (Tager-Flusberg, 2013) Intellectual disability diagnosis an improvement as focuses on adaptive functioning not just IQ (Kaufmann, 2013) A more dimensional approach to ASD which signals a range of needs that service providers will need to address including severity (Baron Cohen, 2013). This more multi-dimensional approach is also likely to improve research and identification for girls Clinical Diagnosis and Formulation Like a Map for navigation – to be aware of what you may encounter. Without it – you could get into difficulties. Danger is relying on development of treatment protocols – may inhibit the process of tailoring services to individual needs. Product of assessment – full clinical formulation. This encompass more than a diagnostic label. Agreement Ratings by experienced clinicians – moderate concordance Training can improve diagnosis Increased rules in ICD 10 has increased inter rater reliability Unrealiability in diagnosis – is not ambiguous classification – clinicians trying to fit their hypothesis with diagnosis - anchoring Mental Health Services, Referral and Joint Working Tier model of treatment Tier 1 –services which deal with MH problems, but have different primary focus e.g. SS, GPs, schools, probation Tiers 2 & 3 – services whose primary aim is dealing with MH problems in a locality (CAMHS) Tier 4 –specialist regional MH services Levels of need for treatment 0.075 % children will need Tier 4 1.85% Tier 3 4 7% Tier 2 Tier 3 15% Tier 1 7% Tier 2 15% Tier 1 75% Thinking about involving CAMHS Mental health interventions cannot treat problems of social adversity Like other medical services, attendance at CAMHS is voluntary Same standards of consent apply as for medical treatment generally Medical standards of confidentiality Problems to discuss with CAMHS Presenting features outside normal range for child’s age, intellectual ability, or culture Severe enough to interfere with everyday life Sudden apparent change in behaviour, emotions thoughts that is persistent (2 wks) Problems persisting despite tier 1 interventions Referral letter Essential – Description of Problem, who wants to change, how the decision to involve CAMHS was made, background information needed to understand the problem. Optional – Background info- family composition & structure, developmental history, school performance, medical history, medication and past history of CAMHS involvement. Referral Pathway. Direct referrals – General Practitioners, Community Paediatricians, Hospital Paediatricians, School nurses. Other referrals from education psychologists, School Attendance Improvement Service - Referrer has discussed with the GP/ School doctors/Com Paed. Copied to the GP, Health Visitors, School Nurses, Surestart Children’s Centres and daycare providers. HV, SN – referral discussed with the GP or Com Paed, referral copied to the GP. Children Families and Social Care – Multi-agency & Liaison meetings Mental Health in Schools CAMHS Professionals Child and Adolescent Psychiatrists Child and Adolescent Clinical Psychologists. Nurse Practitioners and CPN’s Community Psychiatric Nurses Child & Adolescent Mental Health Practitioners Child Psychotherapists Family Therapists Specialist Speech and Language Therapists Specialist Social Work Practitioners CAMHS in Manchester – Tier 2 3 & 4 CAMHS directorate - Tier 2 & 3 North – Psychology, Psychiatry – Booth Hall CH. Central – Psychology & Psychiatry – Winnicott Centre. South – Psychology & Psychiatry – Carol Kendrick unit. 16-17 Community Mental Health Team -Emerge Specialist teams – Children’s and Parents Service - CAPS (0-5 Years), CAPS TIP – Training in Partnership (5-8 yrs) CT-LAC – Consultation & Therapeutic Services for Looked After Children, Manchester Link etc. Tier 4 Galaxy house (RMCH), McGuiness Unit , Hope & Horizon unit (Pennine care) All services are made up of a small number of clinicians. Multi-agency working in CAMHS Consultation and liaison with other agencies (school nurses, health visitors) Integrated service delivery in: SCAIT – Social Communication Assessment & Intervention Team (Education Psychology, Diversity & Inclusion, Community Paediatrics in Team) CTLAC CAPS/CAPSTIP (Parenting Groups with other agency professionals) Mental Health in Schools (S M/cr pilot includes CAMHS worker in school team) Referral Times Routine referral – Seen within 11 weeks (psychiatry) or 13 weeks (psychology). Urgent referral – Prioritised. Emergency – seen within 24 hours or next working day. 9-5 weekday on call service. Out of hours on call service. CAMHS Assessments & Interventions Varies in complexity and lengthy Assessments include liaison with other agencies ( e.g. schools, social services, community health services) Partnership with child/family (consent for contact, unless CP concern, letters copied) Partnership CAMHS/ other agencies Assessment The first interview with patient and their family The first interview may take up to l½ hours. Who should be there? Parent or child or young person seen first? Presenting difficulties, the severity and impact on the family or wider society e.g. school. Factors that triggered, exacerbated or maintained the presenting problems. The strengths of the family and child and whether they are motivated to working on the issues. The expectations and ideas that the family have about being seen by CAMHS. Further assessments may take place in school, clinic, home or nursery Assessment heading Current difficulties History of current difficulties Past health – mental and physical health problems Developmental history starting from Pregnancy Family history of mental and physical health problems Interview with the child Depends on age and cognitive ability Setting up the session – crayons, age appropriate toys Adolescent – more an interview as in an adult Observation of play, interaction, language, motor difficulty etc Mental State Examination Appearance and behaviour: dress, physical appearance, motor activity, co- ordination, involuntary movements. Language: expression, comprehension, speech – spontaneous, quantity, rate, rhythm, and complexity. Mood: subjective, objective, symptoms/signs of depression, suicidal feelings, anxiety, panic, anger, aggression, and irritability. Abnormal beliefs, experiences, thought content, hallucinations, delusions, worries, fears, preoccupations, obsessions, fantasies or wishes. Social response to interviewer: humour, rapport, eye contact, empathy, and co-operation, shy, confident. Cognition: attention span/distractibility, draw a person (note grip, handedness), write name, give days of week, months of year, counting, simple arithmetic, orientation, memory, general knowledge, reading skills/level of attainment. Example - assessment of ASD 46 National Autism Plan for Children Guidelines Multi-agency -Psychiatry, Clinical Psychology, Speech Therapy, Community Paediatrics, Educational Psychology, Specialist Teachers Set time scales Multi-modal – developmental history, school obs, direct assessment Assessment and intervention provided Example ASD assessment 47 Information from Parents – Detailed developmental history, behaviour – covering all aspects of social communication, imagination, flexible thinking, onset, co-morbid features, pregnancy, birth, medical , family, psychiatric history etc etc Autism Diagnostic Interview (ADI) & Diagnostic Interview Schedule for Social and Communicative Disorders (DISCO) Vineland Adaptive behaviour Scale – a semi-structured interview with parents – measures functional ability – three domains communication, daily living and socialization Information from other professionals – interviews, reports and questionnaires Investigation – medical if appropriate, usually if there is dysmorphic or other features – suspicion of syndromes etc & Medical Genetics assessment. Formulation Once all the information has been collected, it is possible to produce a formulation. This is a brief description of the child’s presenting problems, any precipitating, predisposing or maintaining factors. It helps to consider the factors under Biological, Psychological & Social categories. PREDISPOSING PRECIPITATING MAINTAINING PROTECTIVE Types of treatments offered after initial assessment Supportive counselling. Individual therapy e.g. psychotherapy, play therapy. Cognitive behavioural therapy. Solution focused brief therapy. Parent training. Family Therapy. Systemic work. Group therapy. Medication. Example ASD intervention Central Manchester treatment as usual: Information for parents/carers re process of diagnosis and who will be involved Attendance at parent’s post diagnostic group Joint meeting with parents and school or education provider Additional interventions provided by specific members of team e.g. social skills groups, Hanen programme (SLT), school training and IEP planning (EP), behaviour management at home, Cygnet (CP, MHPs) Any other questions regarding diagnosis or ASD?