Computer generated transcript

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

Thank you, Christie. Thank you, Shereen. Thank you a sad, thank you soon. Great. Anyway, um if other people could uh put their cameras on be wonderful. Um Anyway, I'm Dennis. You grin. I'm a child psychiatrist. I'm Ukrainian. I'm usually based in East London at Queen Mary University and they work clinically also in East London in, in a place called New um which was in the East. So conversations, they will be about psychiatric diagnosis and I will specifically talk about child psychiatry because that's my main sort of area of research. Um Has anybody ever been part of perhaps or has a knowledge of how psychiatrist might to reach their diagnostics by listening, questioning and missing? Uh But you seem like you are at the same time in both, in two different. Yes, because I had to use because sometimes one downloaded. All right. Could, could, could you say that again? What did you say by questioning and listening the response? Yeah, I think that's the key tool that we have is the body language. Yeah. Yes, indeed. By the language is very important. Thank you Sharon for that contribution. Um Does anybody know what is the the most cost effective investigation in um in our field, talking to patient, say that I can Christian, I would say talking to the patient and I know she could take the feedback would be more feedback. Did you say? No, not feedback? What, what do people think might be the most cost effective thing that we could do as clinicians in our in I feel but I suspect in, in most fields as well in, in any branch of medicine. Listen, that's good. But it's not those cost effective thing we could do. Uh Is it taking, observe, observing? No, I'll tell you it's actually reading uh previous notes. It's, it's in credible, especially if you have an older patient, how, how many investigations and assessments have been done. And uh for some reason, clinicians and I think psychiatry is especially guilty of that. Uh, we tend to always start from scratch and like, um, you know, and in fact, kids would always end, their parents would often tell us that that's one of the most annoying, annoying things that uh they have to repeat their story over and over again to strangers, you know, and who ask exceptionally, exceptionally personal questions. So I always um teach my journey doctors, um and other professionals, you know, um to really spend at least an hour going through previous notes and really understanding what has been done. And also it's one of the things that annoys parents as well and kids if you say, um, you know, in your recommendations, I would recommend, uh, say parenting skills, you know, they'll say we've done 10 times how many, where? And of course, that's quite a invalidating things for the family as well. If you, if you, if you didn't have the time to, to read anyway, look, um, I will go on to, to you to show you a particular tool that we often use in child psychiatrist called the Kid Assad's. There's no reason why you should um have heard about it. Uh I'll try and go ahead and share my screen with you. Um So it's um so it stands for the schedule for effective disorders in schizophrenia, for school aged Children present and uh lifetime version. There is um very similar tool for adults. It's called sad scheduled for effective disorders. Schizophrenia. It was originally developed uh for just effective disorder in schizophrenia. But of course, um over time, it has expanded, it now covers the entirety of child psychiatry. If anybody's interested to get the two, I'm happy to share it's free. Um uh Just drop me a line after this talk and I would be happy to share with you. I just put my email here for also interested. Uh All right, so look, um what's the, what's the principle? So, so the the two is um semi structured. Does anybody know what, what that means? A semi structured interview and most interviews in our field in child psychiatry are semi structure. How does it differ from unstructured or fully structured? Does anybody know? No. So quite a sometimes we have structured interviews. What it means is that? Oh, sorry Christie, did you wanna say something? Yeah, I was going to say so we're fully structured means you will stick to a certain type of questions and you don't go away from that and say MS structured means you have questions half and then you ask patients to explain and you have your questions through, you know, uh combination of both unstructured is that you don't have any question at all. It is just uh you know, open conversation and uh expression from both sides and, you know, trying to collect history. That's, that's exactly right. Uh And so uh an example of an unstructured question would be, how are you, that's a fully open question. How are things uh an example of a fully structured question is if you're having a tool, you know, you will need to read exactly as it says in the tool. So you would say, for example, between the ages of four and five, uh was your child able to make eye contact with people, you know, and that would be exactly as it's just. So that would be an example from a tool called A D I Autism Diagnostic interview, which is fully structured. And you're supposed to ask questions as they are most of our tools and assessments. Uh semi structured. So you will have some guide on what sort of things you might, might inquire about. But at the end of the day, all of us develop our own style of questions and, uh, um, you know, and, uh, it's something that, uh, we would usually, uh, you know, develop over time. Now, the thing about psychiatry is that you often want to have more than one informant. Um, even if you do old age psychiatry, it doesn't really matter what sort of like. I even in, in child psychiatry, it's especially important, you will not be able to make a diagnosis most of the time. Just by interviewing the child observing the child, you will want to know um information from their parents. And very often we would want to get information from other sources. And the idea in our field is that in order to, to determine if, if a patient has got a particular symptom, you want to ask as many sources of knowledge as possible as a minimum. You know, I feel we want to have a parent and the child very often, it's helpful to have a teacher. I would say in the vast majority of cases, I want to have a teacher, teacher report. Um And then in many cases, uh you know, for example, if you have a very unwell child with psychosis who presents um acutely to hospital, then the only thing you have really is nursing observation are the professionals who can observe the child. Um a lot of the time when we talk about um disorders in Children, we want to understand two things. One is what is the current state of the child. So which symptoms the child has now or the or the adult? And then we also want to know about the timeline of these symptoms. So what actually was happening before? And typically, we want to know about the most severe past symptoms. So for example, if a child presents with low mood, now, they want to know is this the worst low mood they've ever experienced or has there been a time in the past when it was even worse, longer, more severe? Uh And for that, um we would usually have a, you know, you know, in our mind, this is the framework of, of the present what's happening now and also passed, which is the most severe passed. It is especially important for episodic disorders. So we have, you know, I feel some disorders that are fairly continuous and change very little over time and somehow our episode, it'll come and go. Does anybody know about an example of an episodic disorder like psych psychosis? Yeah, psychosis is a good example. Bipolar disorder. Bipolar disorder is a wonderful example. Indeed. Yes. But can I ask you a question? Uh but bipolar disorder doesn't come and go like it stays. Yes, I know what you mean. So, uh I know what you mean. Yes. Uh So, however, what, what comes and goes and you're right uh is um disturbance of moot. So you will have, you will have times when the child is uh manic and sometimes the child will be depressed and, and a lot of times child will be euthymic. So they will have a normal mood. So you're right. The underlying problem is that could A D H D B episodic is um no, it's it's continuous. It cannot be episodic, cannot be episodic. It's, it's one of the examples of a continuous disorder. Um it certainly could be worse. Depression, depression is episodic very often, especially in Children in Children for the first episode of depression, most of them will recover 90% plus will, will improve and will will be euthymic. Uh The trouble is unfortunately is that uh the recurrence is very, is very often the cats. Yes, indeed. It's just for, just for understanding, there are some disorders that are continuous. An example would be autism. For example, that's something that changes very little. It does improve in some cases. But uh but doesn't, doesn't, doesn't often A D H D and that will be uh intellectual disability, for example, is, is fairly started. Uh And then you will have episodic disorders, which is that the majority of our disorders. Um typically, when we think about current symptoms, we usually bear in mind a particular duration of time. It could be, for example, two weeks in most research studies which I conduct uh present is in the last couple of weeks, in the last few weeks. Um And in order to have a past diagnosis, there, there must be some considerable time between the current state of the child and the previous episodes. In a lot of research studies, obviously all of the star started arbitrary. But in a lot of studies, you would have some sort of a duration of normal state in the child or, or an adult. In most of my studies, we agree that the symptoms should be absent for at least two months in order to, for them to be coded as a separate uh disorder as opposed to the current district. So, um I mean, usually when we do an interview, we start with unstructured interviews and we'll talk about demographics, history, presenting complaint, um past treatments and then functioning in um in these uh really four main domains. So in, in any child, um you will need to think about four domains at school, a family life after school activities and leisure activities, friendships. So you'll have these four main domains and every child functions in these four domains in some ways for adults, obviously, the work uh as opposed to school. Um and if there is one thing that I would like you to remember from this talk, it's not having symptoms by themselves is insufficient to have a psychiatric diagnosis. So if that, if that were the case, then all of us would have something because all of us are scared of something. All of us have unusual ideas about stuff, you know, there'll be no end. So the reason why most people don't have some casual diagnosis is because they function well and the key to psychiatric diagnosis. One thing you need to remember from this talk is that to have a diagnosis, you need to have a certain number of symptoms of certain duration which you can look up in. Uh things can be a semi five or I C T 10. And then plus you must have a dysfunction, an impairment of function of some kind. So in in the child's case, you must demonstrate that these symptoms cause dysfunction in either school life. So the child doesn't detect that school in family life. So the the child cannot have a functional normal relationship with the family, friendships. The child is losing friends that cannot establish friendships and leisure activities. So the child is unable to function. And after school experiences, that's the key to understanding everything about our diagnosis. Symptoms on them in themselves are not enough. You need to have certain symptoms, certain duration plus impairment. Yes and uh okay. You, you're muted, you're muted, sorry. Sorry. So does it have to be all of these five domains or it could be any one of? So besides the dysfunction, what if it's just causing you distress? You have all the symptoms that it causes a significant amount of distress. A disorder. That's a good question. So, uh a lot of there's some uh in a lot of there's some disorders criteria, you have significant distress. Now, in my clinical practice, um it's very difficult to, to imagine a child with significant distress with no impairment. They often go together these two things. Um So I, but, but the stress is um is a very subjective thing. So, you know, if you ask a child, are you, are you distressed? The child would say yes, you know, and, and it's very difficult to objectively measure what it actually means. So I always insist that my juniors actually needs to demonstrate dysfunction, which as you rightly say, and as often is the case that significant distress will lead to dysfunction. It's very hard to imagine a significantly distressed child that functions well in all four domains. Mhm. So how do you measure distress? And it's, it's a very subjective thing. Okay. I don't know what it means. You need to ask because you know the difference between normal stress and this stress is very arbitrary. It's very hard for me to understand how, how you can draw a line. Okay. Thank you. Yeah, which is why everybody on this function anyway. So that's the key thing to to this, this function is the key to diagnosis. All right. So how can we then decide if, if someone has got the previous um episode of something or not. Um, for this, I would like to have a volunteer, please. Um, I can be the volunteer. Thank you very much. Um, so can you be, oh, Christy. Did you want to be a volunteer to, if you do then it's even better. Uh, let's, let's have Christie. Did you have a question? Did you want to, uh, I propose someone else? Sorry, you proposed someone else to be a volunteer? Is that what you say? Yes, I'll give an opportunity to someone else. No, no. But let's, let's have to, that's even better. So you, you could be Mom Chris if you don't mind and Anna's you could be the child. Is that okay? Okay. Yeah. All right. How old do you want to be honest? And what would you like your name to be? Anus? His name is fine and seven years old. Can you be like 17? Okay. Yeah, it's more because seven, but we have a very short timeline and it's difficult to demonstrate stuff. Okay. Can you be like 15 or something? Or 14? 17 is fine? All right. Whatever you think is okay. Uh All right. So look, uh so what it is is this um you can see we have a little timeline here, like a little graph. I'm going to um uh are you familiar with, have you done like graphs at school? And uh yeah, you know how they work? Like X and Y, this kind of thing. All right. Um So look what I'm going to plot here on this axis is mood, is your mood? Okay. Have you ever come across this idea? Over 0 to 10 mood scale? Yeah, I have bipolar disorder so I understand it. Yeah. Uh so every child, every child that has ever seen a professional will will be familiar with this scale. We love this scale of some reason. 0 to 10. So zero means really, really bad. Five is like in the middle and 10 is like off the scale on top of the world for no obvious reason. That's the scale five is normal. In the middle of zero is the lowest possible 10 is like unhealthy high. Is that okay? And then here at the bottom we will plot your, your age. So you're currently 17, right? Um And when you think about, you know, when young people think about, uh you know, the age, they sometimes think about the years, like when I was 17, 16, 15 and sometimes they think about school, school, school years, like when I was in year one year to year 10. So on which way do you think about the past uh year one year to like school time? All right. So you've been year 13 now, right? You're, you're, you're 17, I'll use the UK system. I don't know about other kind like uh assume in Ukraine kids, um it's a bit different but you can adjust. So and then look, so we will start the 17, which is year 13 and then we will go back in time. So from 17, 16 and so on, it was just, uh, brought it back. Okay. So we're going back from, from the age of 17 all the way down to like when you were like 67, when you started school, would that be right? And here, um, we'll ask so and um, so the idea is, is that when when kids are born they usually born at a five. So we don't, we don't talk about babies who are super high or super low in mood, right? Would, would you agree with them? Do you agree that the babies cannot be, well, very rarely could be seen as high or low in their mood? Yes, you say so, I would believe that because I don't know about this. Well, that's why we have your mom, you have your mom. So we're going to ask her in a minute. But, but usually, usually most kids cannot remember what their mood was like when they were like three or four. Do you, do you remember much about that time? So, Christie, when, when you think about Anna's when he was little um you know, before he started school at the age of say five or something, um Do you remember whether his mood was in any way? Unusual, especially high, especially low or was it was he pretty much with like most other kids, I don't know what I'm expected to say but uh uh because I have read uh that Children can show symptoms of uh mental health even very young age, as young as two. So, yeah. So uh I mean, the depression is a very rare disorder in, in these very young Children. Um I mean, I in the UK, at least uh I do not think we've, I've seen a child uh with the diagnosis of depressive disorder below the age of about nine. Unusual. I mean, I know actually, no sir, I have seen 14 year old girl, one uh which uh but you know, she's so unusual that she really sticks in my mind. She would have these like very typical depressive cognition saying I'm rubbish, my parents, my mom should throw me in the rubbish bin, you know, this kind of, it's very unusual uh this stuff. So she really sticks in my mind, but typically it would be a very unusual disorder to have below the age of say nine uh eight or nine. So most kids will be pretty okay. I would say uh except for a very small number. So you can, you can say what everyone. It's not about the veracity of this stuff. It's about just demonstrating the two. So I would say from, from the age we started from age seven till nine, he had a normal childhood. Okay. So, but from from the moment that he was born until about say, did you say nine? Uh was his mood was about about here? Right. So it's at the fight, right? All right. So, uh now going back to you and uh do you remember like when you were about nine years old? That would have been something like year four, uh sort of getting closer towards the end of the primary school. Uh um Do you remember what your mood was like? Would you say still a five as far as you could, you could remember was one down, one down? So, at, at the age of nine you would say it was about a four. Is that right? Like three, about three? Oh, gosh. What, what happened then? What happened to you from my dig? Sorry, something very traumatic, very traumatic. Okay. Some sort of a trauma. Okay. And then, so we were going from like a five to about the three when you're about nine. Um, and then when you think about the last couple of years of, of primary school. So that would have been like a year four, year, five, year six. So when you were 10, 11, would you say it stated about a three or did it go up or down the last primary years? Uh, sorry, the last year of primary school? Yeah. Last two years. Yeah, up went up one top. Okay. It's about a four, right? Okay. So, so, so, so, so whatever the trauma was you've recovered a little bit too. About the four, right? Ok. Then moving on to secondary school. So year seven when you're about maybe 12, 11, 12. Um, do you remember what that was like for you? You're 11, 12. Uh So, yeah. Yes. So that would be about a year seven, grade seven. Yeah, grade seven. It's pretty much the same, but about the four and Christie just to check with you. Um, do you recognize sort of that description of, of analysis? So, you know, normal, normal mood until about the age of nine, then it then, you know, went down to three when he was about nine and then moved up to four. Um in the last couple of years of primary is called, do you recognize that? Yes. Uh There's an episode, it changes, isn't it? So, yes. And this trauma that he's talking about you, you know what he's talking about, right. Yes. Yeah. All right. Um then um what about, so Christa, by the way, we can't see you as well so we can only see you're now we can see. Um okay. So then secondary school and as you were saying, was still about a four, did you say? So, you know, sometimes young people when they moved from primary to secondary school, there is a period of time when they're not very happy, but in your case, you didn't find that was okay for you, right? It was about the force. Yeah. So it was like something traumatic happened and then over time I start, I got used to it, it was a continuous trauma but you just did. So, and then I was doing well academically. So my movement up. Okay. So when you move on to like when you were about 13, 14, uh, so that would have been like year nine, year 10. Um, would you say it remained at about the four or did it go up or down? Seven? Oh, it was seven? Gosh. Wow. So you actually recovered by the age of 13? Really? Well. Uh and then again, 14 15, did it remain at seven or did it go up or down? 14 15? Uh Yes, same level I would say about the 70 really enjoyed it. And then what about when you were 16? And you know, so like the last year did remain at seven or did it go up or down remain the same? Okay. All right. So we've got, and Christie just to check with you, would, you, would you agree with this that, you know, and this is telling us that he, it was at the five to begin with, then went down to about the three at the age of nine, then recovered, graduate of four and then moved up to about a seven and remained at that, at that level. Is that, is that the sort of thing you would recognize or because sometimes what you see from the outside may be different from what the child experiences. Uh because I find it quite difficult to understand whether uh about the age of 15, whether it could go all the way up to seven when you score of three. So I would say it is only just remained between five and six, not went all the way up from your point of view. And it's something that we see all the time, you know, because parents don't always know what goes through the young person's mind, you know, and so what it is for you may be different from, from what your mom it observes, but is everybody clear about, about the, about the method? So, um so, so typically when we see a child for a psychiatric diagnosis consultation, they'll be at a very low mood, so they'll be at zero or one or something like that. Uh Otherwise they wouldn't be coming to see you. Um And the question that you want to understand is uh whether it's the first episode of say low mood in the child or whether there was some previous episode. So in this case, we have found a traumatic experience and, you know, when we do our diagnostic work, we would want to inquire about that period um as well as about what, what brings them to, to our um to our session. Now, any questions about this? So now this when the mood went up, would you see that as mania or it's just normal fluctuations in mood. Well, they would want to know what, what the mother is saying. So the mother is saying it's actually not, not as high as that. And obviously, um yeah, you, you would want to, I understand, you know how um so one thing that they could exclude is that this child probably doesn't have a previous depressive episodes beyond this trauma that people want to explore in the, in the further investigation. So that's important. And then as, as so the child is saying to us that he's at about a seven um out of 10, you know, that's a subjective thing. But we would want to know uh whether that represents a hyper mania and then we will, you know, asking questions about that um or whether it represents a normal euthymic uh state and the child typically hyper mania doesn't last for years in this way. So chances are this, this is, this is probably a, a state that is normal, maybe the child is enjoying their, their life. All right. Anyway, um any questions about this uh brief exercise. So this would be the the beginning of the uh investigational consultation. Yes. Uh Yes. What about the consecutive, the next appointment if you're giving them one, would you be using the same zero to? Uh Yeah. Yeah, I mean, you could, you could do that. But the the point of this is is not to establish the diagnosis which you know, you will do the rest for the rest of your consultation. The point of this is to understand whether this is a fluctuating disorder. So, has the child had previous concrete episodes? How bad they were in the beginning? Um And then also about the present state of the child uh where they are now, uh Professor, what if there's a lot of discrepancies between the parents and the Children? So, child, who is? So how, how do you uh that's a good question. So um typically speaking, well, it's actually quite a complex question but, but there are a few of the rules of thumb. So first of all, when it comes to Externalizing disorders such as A D H D conduct disorder, oppositional defiant disorder, something that you can actually see from, from the outside, easily autism, then you would be a lot more likely to rely on the parental account provided the parent is sensible because, you know, sometimes you have a parent who comes drunk or high on drugs, uh uh just doesn't want to speak to you. There's, there's all kinds of options there when it comes to internalizing disorders. So for example, the the thinking that the child has the their emotions. Um and especially for all the teenagers, it would be a lot more likely to go with the team because very often parents, I have no idea what the child feels like inside and you would often, you know, and they would be sometimes surprised. So when you ask about suicidality, for example, in the child and the child says, yeah, I think about suicide all the time. You know, for many parents are such a shock, they would never have thought about this or sometimes the child. But there's, there's also a thing because the parents have got more expectations on the Children and that's going to affect as well. Could be in small ones. You will sometimes have an interesting discovery. You know, when you talk about separation anxiety from the child and whether you know whether the child has got any um thoughts that something horrible is going to happen to the parent. Uh A little one would say, oh, you know, I have these horrible images in my mind that there'll be a car crash and my mom and dad will die and I will never see them again. And for, for many parents, it's also like a shock and the discover is like, really, I have no idea that you, you're so worried about this and uh and think about this all the time. But as a general rule, you would want to go with, with a sensible perent on account when it comes to first of all younger Children and second of all Externalizing disorders. Yes, assad uh is it sometimes uh difficult to get a proper report on the basis of whether the parents are present or not? Because sometimes parents don't take care of Children. They're outside, it's a guardian or a maid, uh, what we call a, uh, kindergarten teacher or a caretaker or nanny. They have Monday might take, but they are just doing as job as possible but they have differences like some might do just for the sake of money. Some might do take the Children a bit seriously. And that account, the, the incidence is, and the reporting of the case and the moods will also defer and it will be much, much more challenge. That's exactly right. Yes. And uh now look most of it, I mean, I've, I've done thousands of these maybe even tens of families interviews. The vast majority of the time there will be no discrepancy. They will agree. You know, if a child is severely depressed, you will, they will agree. If a child is severely manic, there's no, you know, they will, uh there's, and sometimes you do have small discrepancies and they're not important, really not enough. So for example, the parents would say, I don't remember whether my like, you know, for, for autism want to understand the functioning of the child between the ages of four and five. Marvel say actually, I can't, I have five Children. I can't remember. But, but, but then you say to the parents, first of all, you need to explain to them that they shouldn't feel bad about this because sometimes the parent begins to blame themselves. I'm a bad parent. They can't remember these things. So even before you do this, you say, you know, no one can remember these things. It's, you know, however, what they would want to tell you is that if it was something significant, something I would want to know, you would never have missed it. So for example, if a child doesn't smile back to you, when you smile to the child at the age of four, no parent will ignore that. It's, it's a very a new and we are not interested really most of the time in our field in tiny little normal variations in the symptom, what we are interested in our clinically important stuff. And that's something that you will not miss. Yes, I know. I just wanted to say that I agree with you Dennis because like a lot of times what you said earlier, like child sexual abuse, for example, a lot of times goes unreported in that case, like even the parents don't know like what is happening with the child, the child might not even share that with anyone. So there's a lot of cases of childhood trauma that goes on another question I wanted if you allow me. Yeah. Well, so you said like taking the history is very important in order to know if it's a recurrent diagnosis or like what information I can tell you why is it so important to know about their history? Oh, that's hugely important. So uh so first of all you want, you want to for, you know, there are many, many reasons for this. Uh for example, if you, if a child it comes to you with depression and you don't do this and you miss a manic episode in the past, then if you give that child antidepressants, you will often flip them into a severe media if you just give them unopposed into depressant. If you don't do, if you don't do this, for example. And if you, uh you know, for example, ticks that Children get, you know, the peak age of answer is about seven for ticks. And um and sometimes they don't come back, you know, unless you give them, for example, anti A D H D medication, in which case they might come back, you want to know that sort of stuff. For example, if you have a child um with the past episode of psychosis, for example, and the child comes to you with anxiety now, you know, you, you really want to know this uh especially have to say uh previous suicidology, that's such an important thing. If a child, if you, if the child comes to euthymic now, uh and then you miss that they have this severe past episode, you know, depressive episode was significant suicidology, then your risk assessment will be totally out of mark. You will, you will, you could, you could make, you know, miss a very severe a presentation of the child. So there are lots of very good reasons to do this. Plus, uh the other thing which is really important is as, as you do the timeline, you often look for triggers. Uh So in your case, obviously, you talked about some sort of trauma, you don't want necessarily to push the child immediately what it was. But you need, you need to make a note of that. And in your interview, you will come to be PTSD where you will be asking structured questions about past trauma, both physical sexual and uh and neglect, emotional and emotional. And you, you may want to, to do, you know, to ask these questions then and then of course, you will want to interview the child separately from the parents and parents separately from the child at the end always uh sometime just for the for the child because as you rightly say, if it's intrafamilial uh sexual abuse, for example, the physical abuse than uh the child will not tell you often in front of the parents. And even if sometimes it's the parent abusing the child, they wouldn't confess to that. Of course, of course not. Yes. So you need to uh interview them separately. All right. Look, uh let's just uh think about then um uh 11 particular disorder um and just to think about the principles of that. Um So does anybody know uh what symptoms, depression has? So if, if people, people could maybe right, if you, if your symptoms in the, in the chat that you're familiar with. Um. Mhm. Yeah. A loss of interest. Low mood. Yeah. One lack of energy. Always sleeping could be, uh, feeling of guilt. Very good. Lack of appetite. Yes. Being inactive. Yeah. Mhm. Very good stuff. Slow. So, suicidal thoughts. Indeed. Indeed. Well, yes, for performance. That's interesting because somebody's talking about, about now function, which is, as you say, denial. Despite interesting, that's not really part of the diagnostic uh criteria, but often happens together with depression. You're right. So let me just uh isolating. Interesting. Yeah. So that's um that's like a consequence, isn't it? Um All right. Let's have another couple of um let's have another couple of um uh volunteers. Uh So not, not Christie and Anna's. Could you have two more, please? Could anybody please volunteer? Uh Thanks Assad. Uh I think that's good. Anybody else wants to quickly volunteer? It's uh all right, let's have just uh um so is that how old are you going to be in the, in the role plane? Um Let's just take 17 again. 17. Okay. And let's say that you're, you're coming to me with uh severe first episode, severe depressive episode. That, that'd be right. So, you know, roughly what, oh psychosis and I was going to talk about psychosis. All right. Look, I'll just show you a few questions about, you know, just a general approach to diagnosis. You know, how, how you might ask questions and um and then we will, we will um pause for uh you know, if your questions including psychosis. So, is that, um let's say that you uh just a minute ago and now you're, you're this sort of 17 year old, you know, about the 0 to 10 scale, right? And um, so that's what I wanted to ask about. Is this um in the last couple of weeks, um, you've told me that you have low mood, right? Quite, quite a bit of the time. But in the last couple of weeks, from the moment when you wake up in the morning until the moment when you fall asleep at night, how much of the time would you say? Roughly speaking, you, you feel low mood, too much was 20% of the time, did you say 70%? Yeah, from morning to about 70 to sleep. So most of the time, most of the time, okay. And then that sometimes young people tell me that they only feel low mood. Uh and sometimes they also feel low mood and also irritability being really irritable. Do you know that word? Irritability? Yes. So easily triggered by snagging or just buy some, somebody's trying to reach and just say no, I don't want to talk. Exactly. So would you say that it's just made the low mood that you have or do you have low mood and irritability at the same time? Both, both and is it also 70% of the time or less than that, let's just say low mood is 90% irritability is only when someone tries to approach. And would you say that it's most of the time, like more than 50% of the time or less? Yes. Yes. More than 50. So you, you, you feel quite irritable at home. The other thing that happens to young people is that when, when they have low mood and irritable mood sometimes is that they seem to not be able to enjoy things that they used to enjoy before they started. So you were saying to me that your mood started, depends, depends for me. Like when I had problems uh in real life, not as this case, things which I could enjoy alone I could enjoy. But when it involves people or participation, you could, then it was a bit uh got it. But, but so just when you think about the last two weeks back to your 17 year old, would you say that you're able to enjoy most of your activities you used to enjoy before? Would you say that you are unable to enjoy this? Interesting? Yes, unable this interesting. Most of your activities, right? The one thing I would say a lot that uh tiredness or body a lot. Yeah. Like sleeping people. Come on. Come on. Yeah, it seems like if I sleep a lot, most of the problems will be solved. I know which I mean, people come on to this if you have the time. So, um, sometimes young people who, who feel low in their moods, uh, think about death and dying a lot. Do you think about death and dying a lot or not? Not much, not much. And sometimes they think about killing themselves. Do you think killing that? I do understand like, what is that? And if that is going to solve but to self inflicted killing and is, uh, that's a bit too much because anything can happen. And at this time, I think like my life is not alone. There are the people as well close to me. If I do this, I think I had as well. What repercussions we can have, avoid it. I think of it, but I don't do. Got it, but just to check that I need to be clear about this. So, in the last couple of weeks with your low mood and irritable mood, very rare. A lot of people think about killing themselves. Do you have these thoughts or not? Just once, only once? Okay? And to the point where you made the plan or it was, it just the thought in your mind. Just a thought. Just planning would be too much. And just to check whether you've actually harmed yourself in any way in the last two weeks. Not in particular. No, no, not in a manner. Just being alone and being sleepy, being alone, being sleepy. All right. Got it. All right. So these are five questions that you start uh depressive interview with that. There's another about 10 or so which we don't have the time necessarily to, to go into. But, but just to demonstrate to you, uh you know, the type of a style that you may want to uh to take. So you may want to always um first of all, be clear whether you're talking about the current episode or any past episodes. In this case, for brevity, we just decide it's going to be just a present episode. And then you typically want to go through each individual symptom of depression. I've gone through five. So I've gone through low mood irritability, um uh anhedonia, unable to enjoy things, uh suicidality and self harm. Uh And you would want to ask about the rest of the questions including appetite, sleep, concentration, uh feelings of guilt and so and so forth. So, um any questions about this sort of general approach to questioning. So just, just to then emphasize three things here. One, typically in our field, we are interested in symptoms that are most of the time. If it's occasional, the rare, I'm not particularly interested in that it needs to be clinically significant. So most of them, more than 50% of the time, a lot more days than not. And secondly, uh you want to um not make the child feeling guilty or ashamed about things. So, my general studies to say a lot of kids with this will also experience that. Do you have it like a lot of kids with low mood but often think about killing yourself. Do you have that sort? And the key thing here is that, you know, it's, it's a, it's a very personal question, but you don't want to um increase the stigma by somehow tiptoeing around these questions. You just need to say this is something that comes with low mood is a symptom, like cough is a symptom of the flu. There's nothing shameful about this and just explain this to, to the parents as well. It's very important to be open about this. And, and so there's been no what these symptoms are and then we'll be able to help you better if uh if you uh if you understand what we're dealing with. Uh yes and uh thank you. So I had two questions. What if the sometimes the patient self assessment could be wrong as well or they might not be very sure. And secondly, uh what if the patient lies to you? So typically, if you think that obviously the ability of the child to report their symptoms increases with age, you know, a very small child uh rarely is able to uh to accurately report things to you. All the Children are a lot more reliable. So the uh importance of parental account and collateral history is significantly greater in younger kids than in, in all. However, I don't think that it's, it's, it's a, it's a waste of time to speak to young Children. Not at all. I mean, a lot of the time they could be very insightful. They could tell you, especially about the like, thoughts and images or body responses that parents will not know about. And uh and as you say, young Children are pretty much unable to lie, uh they will always tell you the truth. Um It's, it's the, you know, you need to have pretty developed frontal lobe to lie, especially convincingly which kids small kids don't have. Now lying is not something that we often come across, I mean, and also kids and teenagers not, not very good at this. So, you know, they will, they are much more likely to say no, no, go, I don't know. Don't bother me. It's all my mom's fault. You know, it's none sort her, this kind of sort of oppositional style. Sometimes it's uh like, sorry, like sometimes it's not like lying per se, but it's more like, you know, they don't want to disclose some information to you, for example, about suicidality or self harm for whatever reasons or like uh they might be experiencing hallucinations or delusions that they might not tell you about those. Of course, how do you, you normally you normalize this stuff, you validate, normalized? I mean, that's the key thing you need to explain to the child that this is a symptom of a treatable disorder. There's nothing to be ashamed about and you encourage them in this way, you can model. I mean, for example, when it comes to hallucinations to have this true story, I always say, say to a child when I was a junior doctor actually was in Labib, not in the like in the Western Ukraine. Uh and I was walking down the corridor at night and then I was quite tired after a long shift and then, um I heard my name being called and I turned around, there was no one around. So I just model this and say this is something happened to me. Does it ever happen to you that you hear noises and voices? And there is no one to know one around, for example. And then the child is a lot more likely to tell you. Um If you model that it's a normal, it's, it's an experience that everybody could have, which is true. Um I mean, if you have a, if you have a child who really feels, I mean, and obviously with experience, uh I mean, I, I, you know, when, when you start, when you're not very confident, when you ask awkward questions and stupid questions, kids will close down and more a lot more than when you're a lot more experience. So, uh I don't think that you will be immediately interviewing. Uh psychiatric patient's very professionally. Uh You need to allow yourself space to develop your own, your own questions. You need to ask these questions many times and get feedback from parents and kids and especially from kids because parents sometimes could be you're a doctor and it's so very formal, they might think you're an idiot but they will not tell you but, but kids will tell you're, you're an idiot. Uh And that's very valuable um thing uh to get and then you, you know, as you but don't give up, you know, you, you just need to ask these questions in different ways, modify, think it, think it through get the feedback from kids and parents. And then as you get more, more experienced, you will ask fewer and fewer stupid inappropriate questions. Uh and they will like you more. All right. Um Shall we take some more questions or, or shall, shall we just do one final thing which I wanted you to remember? I don't see any focus. So let's just ask, let's just find a way to um ask about abuse. That's something that is a very, as uh was saying is it is a very uh difficult thing to do. Uh Typically. So uh the way I talk about this is this uh I have a list on the kid decide to have a list of horrible things that happen to Children. So I would say, for example, you know, in the whole of your life, have you ever been in the car accident? Know, in the fire, know, witnessed a disaster, know, uh witnessed the violent crime now. And so you have a whole list of things. Um, so that, you know, a lot of the times Children respond better to, I mean, it's good to ask them open questions, especially maybe all the teenagers but, but sometimes it's overwhelming, they don't know what to say to you. So if you have a list, they respond better to this a lot of the time. And then I talk about war and domestic and then you say domestic violence was. So have your parents that have fought with each other? And then, um and then when it comes to physical, you know, um have you ever been hit? So uh that you had bruises and marks on your body? You asked that and then for the sexual abuse, um the way that I phrased the question is I would say, has anyone ever touched you in your private parts when they shouldn't have done? That's the question that uh that I think most kids understand and it's not the horrible question. So they would say yes or no uh to this. Um So yes. So I think the question about suicidality and sexual abuse of two most difficult questions in the interview and the way I phrase about sexuality, I say, look, a lot of kids with low moods have that. Do you have that? And for sexual abuse, I don't say it's common I just say, has anyone touched in the private parts when they shouldn't have done? Uh, I have seen the cases of the sexual abuse part in which this uh patient. You think the children's don't see any, they're usually very quiet. But uh when they're left alone in their leisure time, whatever they do, it reflects that what happened to them. So it was seen in like many cases like it was a case in us, which was uh a father like a father has in a church pastor used to abuse them and in the leisure time they used to draw like drawings and everything and used to defect the scenario in the structure that they get the often uh draw with the trauma that they happen or, or recreating playing at all. All right guys. So look, just to summarize quickly. The key thing that the one key thing I want you to remember from this is that the key to our uh diagnosis is symptoms plus impairment symptoms alone. Don't count. You need to demonstrate impairment in one of the four areas which is school, family, uh friendships and after school activity in kids um and adjusted for adults. Um The second thing to say is that uh you want to um no the symptoms of the disorders that, that you work with and ask about them specifically for each individual symptoms and understand whether their clinically significant. I er they, most of the time do they cause impairment. And thirdly when it comes to the most difficult questions, you need to, you know, practice and ask them confidently, uh and find your own way of asking these difficult things which we need to know. Uh And they are very significant for, from the point of view of management with that, I'm afraid I have to leave you. Um have a great rest of the day and uh if you have any questions, do drop me, drop me a line or perhaps I'll just 11 more second if you, if you're interested in um uh listening a bit more about psychiatry and uh uh and you know, and what people have to say about this then uh do do have a look at my youtube channel. There's plenty more both in Ukrainian and in uh in English. So will you be doing more of these sessions in the future? Uh I usually do one on civil from, but I think I've done it this year. I don't know, I don't think you were there. Uh No. So this is the only one or you will do this again. Uh It will need to be agreed with with uh Crisis Rescue Foundation. I'm not entirely sure how, how these things work. Okay anyhow, have a good rest of the day and all the best years. Bye bye. Thank you so much. Bye bye.