Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

great. All right, look, um, so I have to the somewhat unexpectedly, given you the talk on self harm and suicide before it was just putting in for someone else. So today I thought I should just maybe give you a bit of an overview of, uh, child psychiatry, and, uh, it used the key studies that might inform the way you talk to patient's and explain to them what it is that you're doing. Uh, let me just share my screen quickly. So, um, yes. Uh, I assume everybody could see the the the screen. So we look at some key challenges in our field. Look at some evidence base for, um treatment, especially psychopharmacology of common disorders, and then think about what would be a sensible approach in Children and other lessons. Some of the challenges we are facing is that we seem to have more and more kids diagnosed with various disorders and something that really up until recently was not reflected in epidemiological studies. But the number of kids with diagnosis has been increasing. Vary substantially. You can see. For example, in adults, the number of bipolar disorder diagnosed with bipolar disorder increased by 50% of about 10 years. In kids, it's about 400%. So there's something especially interesting about, uh, no giving Children a lot more labels. Um, but as in the US, for instance, number of kids with bipolar disorder were diagnosed. Bipolar disorder increased over 500% over 10 years. Um, so that's the one thing to consider is the number of kids were diagnosed. The second thing to think about is, um uh, no, how unreliable some of our diagnosis are. Uh, when you look at this graph here, you can see the risk of boys being diagnosed with a D h. D. Depending on which months they were born in. Uh, you can see that kids born in September and October have the lowest risk and gets born in July and August seem to have the highest risk. And if anybody has got any thoughts on why this may be, why is there such almost like a two time difference? Uh, in, um, in the risk of of the diagnosis, any ideas, maybe put in the chart to say, temperature or season, Maybe start a your lab thing to say, Did you say the same of seasonal something. Uh, yes, yes, yes. But I don't know whether that is reliable Seasoning. Seasonal What? By the, I think, by the summer, uh, these Children are more. I don't know whether it has to do something that season. The season affects the behavior or the psyche. Uh, I don't think so. That's possible. But any other thoughts? Is it an interesting idea? Yes. And and maybe seasonal is it does have some in, but but not not that great. No, by thoughts. Well, it's almost certainly to do with, uh, how old you are in your class. So if you are born in September and October, uh, your brain has had another 12 months almost to mature, as opposed to kids who were born in July and August. We're the youngest in that class. And so what appears like difficulties were sitting still in the hyperactivity. Uh, is almost certainly to do with being the youngest of the oldest in your class. Um uh, the other thing is, um, the prevalence of so called Western conditions. So, um, uh, one. It would be fair to say that the prevalence of for example, um, certain eating disorders. Um it follows a very clear cultural, um, pattern. I spent some time in Tanzania studying the mental health of hunter gatherers, and they pretty much have all the disorders you would expect in the western population. Um, except for eating disorders, that's something that they didn't have the concept of, Um, uh, which is actually quite an interesting thing. A similar thing happened in in the Fiji, Um before the introduction of Western television, the prevalence of bulimia was about 0%. Um, following the introduction, it was about 11%. Um, then one has to say that a significant proportion of our Children do not really, um, achieve remission in their disorders. If you look at, um, studies of what parents feel our, um, services do, then, um, you know, about the third of them will say that uh, gives are much better about the third will say a little bit better. And then the rest will say there are no no different or worse, uh, teachers views about our services. It's probably even bleaker. So only 8% thing that kids are a great deal better than before they started seeing us. Um, interestingly, satisfaction with our services actually is actually, not so bad. Um, so you can see that the majority of the time, Um, we do a fair job at engaging and keeping our family's happy. Um, be fair to say that in terms of the clinically significant differences again, um, if you look at what we think, uh, you know, the the previous slides were about satisfaction of parents and, uh, teachers and parents views of whether Children improved or not. Uh, now, when you compare this to ourselves, we often think that we're doing a much better job than what teachers and parents think. Uh, the other challenge, um, in our field is, um, costs. So be fair to say that, um, for example, um, the costs of, um, autism on on the UK society is well over a billion pounds. Um, And as you can imagine, the more complex the needs and the services are, the more costly they are. So one really has to, uh, consider this. I mean, the total costs of, um, um of mental disorders in the UK runs into hundreds of millions of, uh of bounds per month. Mhm. Um, and then the other problem that we have is that um, we often have a lot of non evidence based interventions. Our field child psychiatry seems to be especially blessed with this. Uh, they have a lot of, uh, things like Dalton therapy for autism and so on so forth, which really has no evidence base and often makes Children worse. Um, sometimes at a great cost to their families. Um, so one thing to, um, orient you a little bit too. Is that and I feel we often think about a hierarchy of evidence base. So when you say about an evidence based intervention, one often has to say, Well, what is you know, where in this evidence base does it actually fit and really in our field? You think that the matter analysis of our CTS of these random mice controlled trials is probably the top of the hierarchy? Followed by single are CTS, followed by other trials with know random ization, and then followed by comparative studies and then at the bottom. Um, of this hierarchy is what I'm telling you, which is, uh, expert expert opinion. A really good source of all evidence, um, in our field, in child mental health and also in many other fields A nice guidelines if you if you haven't seen them before, I really recommend uh that you have a look at this website. Now, let's start a little bit with, uh, with a d h d. Be fair to say that around 5% of kids will fit somewhere. Um, on the spectrum of a d h d. Um, Although the number of kids diagnosed in in different countries vary substantially from about 50.1 point 5% in the UK to nearly 10% in the U. S. Um, we really do not see any evidence that the prevalence of a d. H. D is is increasing, uh, over many years, including, by the way, uh, during covid and post covid. Nonetheless, the risk of being diagnosed with a D. H d, uh, varies greatly from country to country, and even within the single country, you can see that in the US, for example, your risk of being diagnosed with a D. H. D depends on the state where you live. Um, and of course, um, one of the key driving forces, uh, is the rise and rise of medication treatment in the US The greatest rise in the number of kids treated for a disorder occurred it in 2000, 2004 has somewhat plateau since then since then, but still, every year we have more and more kids prescribed something and sometimes an interesting combination of things. So for a d h d. Um, medication is, uh, really, um uh I mean, the first line, uh, of treatment of a d h d. Um, according to nice guidelines in 2008 and now revised in 2016, Uh, is methylphenidate? Um, this is a medication that, uh, has been known for many years, and it comes in different formulations. Um, it comes in a four hour duration. Um, formulation eight hour, 12 hours, even more. Uh, so and it's something that they really recommend as the first line. Uh hm. Oxygen, which used to be a first line medication, is now relegated to the second line. So is dexamphetamine. Um And really, um, we have been having various other molecules added to the list over the last eight years. Um, one really important edition is, uh is this molecule called list eggs amphetamine, which now is something that we use really as the second, uh, most commonly used molecule in in a d h. D. So in my clinic, uh, usually start with methylphenidate. Uh, and if that doesn't achieve, uh, full improvement often switch to, um l van's, um, which is the brand name of Lisdexamfetamine. And then after that, we think about other combinations. But that is a very rare event. Often, Children really respond very well to, uh, either Ritalin or it's, um, or albums. Um, quite often families wonder. Well, why is it that, uh, that stimulants work for young people who seem to be overly stimulated? Uh, for, you know, as they are. And really, the answer is, um, comes from, uh, Neurosciences. And, um, what we know from neuroscience is is that very often the frontal, uh, parts of the brain of Children with a d. H. They seem to be hypoactive. And so what stimulants often do is they stimulate that part of the brain, which is just just behind your frontal lobe, which then results in in in improvement of, uh of symptoms and really, with the first molecule, both mental candidates, one could one could expect improvement in vast majority of kids as schizophrenia. Um, as relatively rare in Children. Um, p concert of, um, schizophrenia is really someone, um, in the late teens, Uh, and late twenties. Probably a little bit, um, a little bit later in, um, in females. It's a very genetic disorder. If you're an identical twin with schizophrenia, then, uh, your identical twin risk of developing the same disorder about 50%. And then the fewer genes you share, uh, than the the lower the concordance for schizophrenia. Um, I can see it's an interesting sort of slightly more protracted. Um, uh, you know, as females seem to have, um uh, sometimes later onset. So for schizophrenia in Children, um, nice recommends using pretty much the same medication as for adults. Um, for a listed specifically, which is a respected on olanzapine aripiprazole Inco type in, um, and close up in, uh, as a molecule that is very special. Um, only mentioned in relation to risk of side effects and very often reserved for those Children who did not respond to, um two or more, um, other other antipsychotics. Clozapine, interestingly, in adults is one of only two molecules that reduces the risk of suicide, but also it's associated with significant side effects. Uh, including, um, some blood related, uh, side effects like neutropenia, which could be could be very dangerous. Um, one of the most common side effects of antipsychotic. So pretty much all of the ones that have been listed in the previous slide as the metabolic syndrome. Um, and we we do need to be especially mindful of that in Children because quite often, Children who start taking antipsychotics, uh, will continue to take them for a very long time. And sometimes for life. Bipolar disorder, uh, was a very controversial diagnosis. Um, for a very long time. Um, uh, there was such a thing as, uh, East Coast mania. Uh, kids with irritability were diagnosed with bipolar disorder in the US, the UK, I think, uh, a lot more conservative with this diagnosis. And really without euphoria in relation for a considerable period of time, it is very unusual to diagnose a child in the UK with bipolar disorder. Um, it's so roughly the wife and prevalence is, um, in adults. Uh, probably a lot more subthreshold diagnosis in in adults. Um, and, uh, really, My part of disorder is a very complex disorder, and it has a lot of potential targets in different parts of the brain. Um um, really 11 thinks about too particularly risky types of behaviors and kids with bipolar. Uh, one is, um they very often have very profound depressive episodes linked with significant, uh, suicidal thinking. And then, um, sometimes they do a very risky thing, perhaps even riskier than adults when they experience a manic episode, Um, for treating bipolar disorder in kids. Nice guidelines. Um, specifically mentioned aripiprazole for many mania. Um, and they also specifically mentioned that Val parade is not recommended for the lessons of child bearing age E All the girls. Um, when you think about the acceptability and efficacy of different drugs, uh, for medical mixed episodes, then you can see that risperidone Alonzo peon are probably the two leading molecules. Um, aripiprazole is probably a little bit less, um, efficacious, although, um, it's acceptability. Is is better now, emotional disorders, um, are very common in kids, especially anxiety. It has different forms, depending on the age of the child. For example, if you have a very small child, you might expect them to experience separation anxiety. Um, disorders than in middle childhood. Um uh, G a D. Which stands for generalized anxiety disorder becomes a lot more common. Social anxiety becomes more common in, uh, teenage years. Um, OCD really, um, doesn't differ that much by age. Now, in anxiety disorder. Uh, really. One needs to think about, uh, this particular study which I really want you to remember. Um, as far as medication goes, we often prescribed Children with s a rise, um, most commonly with circling. And the reason why we do this is because of this very large study which it might be useful for you to remember. So if you take Children and randomly allocate them to either circle in um or CBT or a combination of the two or placebo so you have four groups very large study, multimillion dollar study, then what you will achieve 12, 12 weeks, um is roughly this about about the same improvement on CBT or sertraline, 55 60% and then about an 80% improvement on the combination of surgery and CBT placebo will give you a response of about 25%. And by response, I mean a reduction in symptoms of 50% or more in O C. D. Um, when we can look at the very similar study, we will see, Um uh, that, uh, sexually and CBT again will be, uh, somewhat similar, and the combination will be will be a lot better. The difference here, uh, is that placebo is really very ineffective for OCD. Um, a CBT is probably more effective than, uh, medication alone. And the combination is, as always, seems to be a better in anxiety. And OCD, I mean depression. We have two studies which, uh, which, which are good to know. Um, our general approach to this is that we start with flu oxygen for depression. Um, when we consider medication, of course, psychological therapies come come before that, Um And then if the oxygen doesn't work, we'll then follow it with either sexually or citalopram. One of these two molecules, according to Nice again. The reason why we say this is because of this study. Um, in this study, very similarly, you have four groups. You have placebo. You have CBT alone, you have pill oxygen alone. And then you have a combination of low oxygen, plus CBT to do that, then placebo will give you a huge response. At 12 weeks, about 35% of kids will have a response on placebo. It's a very different disorders, say two OCD. The placebo has no effect in Children. CBT again SSRI Um uh, CBC will be about 45% response SSRI about 60% and then a combination about 71%. Um, it's something that is worth remembering when you prescribe. Or when you, when you talk to families about treatment of depression, um, very often then families could decide for themselves what they would prefer and then finally, um, when the child did not respond to the first SSRI usually fluoxetin. What happens after that is that if you switch an SSRI to a different SSRI, for example, from the oxygen to search Elin or two citalopram, then you'll get about a 40% response rate. And if you add CBT to it, you'll get the 55% response rate. This is in the ones who did not respond to the first molecule. What happens after that? We don't know. There are no studies. Um, what happens if if the child did not respond to, um, uh two molecules usually to accessorize. Uh, then we sit down with the family and we look at the adult literature and we say, Look, child psychiatry finishes here. Uh, but we could look, um, at what we know from adult psychiatry and decide what the next step might be. Um, remember that, uh, family are really crucial at all stages. And your decision making your task often is to give family's information about what what to expect and not to tell them what to do. So, um, let's just look quickly at some other disorders. Um, for oppositional defiant disorder and conduct disorder. The advice is not to use medication at all. Um uh, two exceptions. One is, uh if there is a co morbid a d h d which often happens with oppositional defiant disorder. Then stimulants are, uh, like methylphenidate. Um indicated. And then there is a small caveat In guidelines saying that, um consider respected, respected on short term for severe aggression, uh, in o d d N c D. In reality, we very rarely use it. Um, psychological therapy place by far of the key row for anorexia nervosa again, Uh, the advice is not to give medication routine. Lean. Um, but the truth comorbid disorders. Uh, kids with anorexia are almost always depressed. Um, and the treatment for that depression is not under the presents. Um, it's food for a S D for autism than, uh, the advice is not to give medications routinely, uh, trepca more with disorders again. A THC. It comes very often with a s. Dean. Um, and in the UK, there are two molecules that have licenses for severe aggression. In A S D one is risperidone, and one is AeroPEP. Result, and melatonin is frequently used for initial insomnia. Really, too. Too often, too, too. Good effect. Um, so that's pretty much a whistle stop tour of our field. Um, a final thing to say is that, um, you know, when you have a child with a psychiatric disorder, be very, very, very rarely start with, uh, pharmacology. Uh, it probably is an exceptional situation, perhaps a very high risk situation such as severe mania or severe schizophrenia. Um, very rare. Um, they usually standard psychological therapies, which often have about the same effect as medication. But the difficulty of psychological therapies, um especially CBT, which is by far the most commonly used psychological therapy in my field is inaccessibility. Um, and sometimes poor training of people who actually, um, deliver it in Ukraine. Interestingly, there is a wonderful school of psychological therapies, Um, based really mainly in love IV in you cou um they have a C d T. School, which is a lot better than many Western schools of CBT. Uh, has a very comprehensive program, um, but trains a very small number of people with a huge competition to enter about 67 people for one place. Um, but really, when you when you refer for CBT one really has to ask a question. Well, is this person properly trained that they registered with the appropriate, um, body in the country that they are based in? Um, when we do start, uh, pharmacological treatment for our disorders, then the general approach is to always start low and go slow. Uh, very rarely start with adult doses of cycle of pharmacological agents often start with half or less than half of what would be a normal starting dose. For example, the normal starting dose of flu oxygen in adults is 20 mg. Uh, we would almost never start with that, uh, we would start with 5 mg of perhaps 10, then, Um, the other important principle is that, um you really want to have a good idea of which side effects Oh, potential side effects or symptoms that might look like side effects already exist at baseline Before you even start, it might sound like a somewhat weird things. How can you measure side effects even before you start medication? But remember that, uh, once you've started, it's very hard to disentangle the symptoms of the disorder from side effects from some other, um, symptoms that start or stop. And and so really, a very good idea in your practice when you prescribe in our field is to administer some sort of a scale, uh, for potential side effects of that medication that you give, um, to have a baseline. And then, um, one needs to really monitor side effects very carefully and inform the family in detail about side effects and give them a leaflet to read as well, so some side effects need to be monitored regularly. Um, an example of this would be if you prescribe a child with a stimulant medication like methylphenidate for a d h d. Then at the very least, you need to monitor the child's pulse. Blood pressure heightened weight regularly. Um, another example of this would be, uh, blood monitoring for close up in in kids with, um, schizophrenia. Um, then, um, one very often wants to aim for remission. So you know, when you prescribe something to a child and the family comes to see you, uh, you know, you're sort of maybe administer scale of some sort, and you might see some improvement in some of the symptoms you ask them. They say, Well, maybe they feel a little bit better, like 20% by some. It often isn't isn't enough. I mean, one really needs to aim for remission. And the way that you think about remission is that in our field you can only have a disorder if you have a certain number of symptoms for a particular duration, plus dysfunction impairment. So the child is unable to do something, and with the remission in our field means that the child is now able to function in whatever it is that they hadn't been able to function in before. Um, and when you think about this a child can function for main domains. It's the school performing at school, family with their family members, friendships with their friends and then after school activities. And really and I Field one wants to aim for good function in all of these four areas, and it rather is achieved by psychological therapies or pharmacological therapies alone. One often has to add social interventions, school based interventions, and so and so forth. But that should be the aim. The aim should always be good function in all four domains school family friendships and after school activities. You want to adhere to guidelines. So, uh, you know, nice produce their guidelines for all disorders and especially when you start treatment when you you know, when you start treatment, when you maybe I'm not so experienced, it's a really good idea to to read what it is that, um, some reputable guidelines tell you to to do, um, as you become more experienced and as you especially treat more complex Children, uh, that will go beyond what you can find in guidelines. Then you know, 11 could become, um, uh, you know, a little bit more. Um uh, well, one really is then should use, um, other sources. But in the in the very beginning, I would really recommend that you stick to, uh, reputable guidelines. And if you're lucky enough to have local protocols, that's probably even better. Um, and then finally, really one, uh, should think about the family is the main key decision maker. So when you give them, um, information when you say Look, uh, these are the percentages to give the child placebo do nothing. They will improve about 35% of the time in depression to give, um, CBT 45. You know, if you give, um, fluoxetin about 60 and a combination about 75 you know, then one needs to think with the family about pros and cons of each side effects availability. Um, uh, You know how severe the disorder is, how severe the dysfunction is. And really, the family, uh, need to drive this decision making. Sometimes families will tell you. Well, we don't know what's best. What would you do if If you know what? What would you recommend? And then you need to ask yourself, it was my child with that particular disorder. What would I do? Um based on all of the knowledge that I have and you need to be open. And I often say, Look, for my own child with this disorder, I would do X. And that seems to that seems to convince many penalties. All right, And then, uh, just the final, um, slide here. Um, let's see if anybody could. Could guess. So look at the the fast A flu. Occident escitalopram sertraline citalopram. It hasn't been all the vaccine. So what would people say? Is this list about which, which those order would people say it is supposed to treat? Could anyone guess a d h d? So just the plain oxygen escitalopram searching citalopram. It hasn't been in the fax and put out an Arabic resort. A lot of antidepressant. If you're under psychotics, which disorder might that be? And then that would be the, uh, depression. Yes. Yeah, that's that would be, um, depression. Obviously, the antipsychotics here, uh, will be mainly used for psychotic depression, which sometimes happens in kids. What about this lithium Val parade carbamazepine, uh, risperidone maniac? Because I know lithium is for acute maniac. That's right. Yeah. So that would be, uh, let's just hear from somebody apart from apart from hazards. Let's just look at this final one. So aripiprazole salons have been respected on clozapine, which, which does or that would people say this could be for I know that you probably know as that anybody else would hazard a guess. No. Yeah. All right. As I do want to say, you probably want to be a second. Could be either for a d h d or, uh well, let's get that schizophrenia. Uh, so here, here. Methylphenidate, dexamphetamine, uh, Alvin's and autumn oxygen. What would that be for? So that's just here. Methylphenidate. Anybody remembers what? What? Which medication? Which? Which? Ritalin, which which does or that's used for a D h d. Yes, indeed. Well done. All right, look, um, I think let's just, uh, finish that, um probably have a couple of minutes for questions. Does anybody want to ask any questions before they finish? Could you name that hospital? You said in Live IV, which was better in CBD? Yes. If anybody's interested in CBT that stands for cognitive behavior behavior therapy, Uh, that's the most commonly used, um, psychological therapy, especially good for anxiety disorders. And, uh, the university, that is Does this is called Ukrainian Catholic University, Um, and specifically the Institute of Mental Health. Uh, I really would struggle to think of a better course in CBT in the UK than the one that they run. I think they probably have now courses like this, um, in other cities to, um I used to teach that at the very beginning. Um, and I do have a look at at the quality of their work, and I must say it is exemplary. Any final questions? How would how could we, uh, spread the A fairness in the countries where the mental health of a child is not taken seriously? For example, in our country in India, uh, nobody knew about dyslexia until somebody made a film about it. A very famous film, very famous actor. So by the time it the film was released, everybody used to think dyslexia was a a child who is mentally retarded or, uh, not not able to do anything about a failure. Yes. That's, uh, such a huge question, isn't it? Uh, I mean, you have a lot of very good specialists in India in our field. I know many colleagues who work in the UK from India. Um, well, it's a huge question, isn't it? Um, I know many examples when things changed when a senior politician would have a child with psychiatric disorders. A very good example of this, uh, is something that happened in the U. A. E in Dubai and Abu Dhabi. Uh, when we were approached at the Maudsley by a senior, uh, person who had a daughter with anorexiant that really made a huge change in the services. Um, but you know, there are many different routes into this, but it's such a huge question that will not have enough time to. So it's like saying until until the politicians get it, nobody gets anything, uh, saying like, uh, like in America when, uh, the more research was in neurology or such as a neurological diseases. We're giving more preference. Until a former presidente might have the same neurological disease like some might have Parkinson's. Some might have dementia. Then people might think, Oh, there's something like this and it's serious. It happened to Presidente, and it can happen to anybody by nobody. By the time nobody would give any attention to that. Uh, sometimes if you have a very strong lobby of parents like ASD. Autism seems to always, uh, generate a lot of interest in a very strong lobbies of parents who actually will pursue their agenda. Problem with parents is they're they're not specialists in medicine. There are specialists and just being a parent, so they might come out that might come with a different uh, they might be very, very susceptible to misinformation as a have you You might have recently heard about this pandemic vaccine. So many people didn't want you to get vaccine because that's due to some rumor's or no clinical proof that vaccine might cause autism, which is because they have There's no clinical proof for it, That is right. Yes. Um, well, but then, you know it's not. It's not the parents fault that we misinformed them. Uh, you know, we we need to do a better job in informing and collaborating with with bands, right? One more question from anybody. If not, then I wish you a wonderful, wonderful day. And, uh, if you have any questions, do drop me a line. Cheers. Okay. Okay. Thank you, doctor Grin. Um, also, I'm gonna put the certificates, Uh, in the chat, Uh, in just a moment or two. Um, please. I've put in the Also put in the chat the link to the feedback form. Please fill that in because we need feedback in order to, uh to, uh, keep keep our school going and, uh, show our funders how we're doing. And also so we can improve the quality of the teaching constantly. So please, please, please fill in the the feedback form. Also, I'm going to put into the chat. There's, um, WhatsApp group for students at at the CRF. So, uh, please, please join that as well, but thank you all very much. Wonderful, speculator boy. Uh, and if if you have a if you have a problem picking up the certificate, it'll take me a few minutes to get it into the chat. If you have a problem with that, I'll also put, um, uh, an email that you can contact to get your certificate from. There are some, uh, some machines. Perhaps, um, perhaps ipads you can't pick up the the the certificate from so thank you all very much. And just bear with me while I get the certificates and everything in the chat