ONLY FOR PROF DAN

CLINICAL

CASEBOOK

Child and adolescent mental health Ir Mark Loveli consultant child and adolescent psychiatrist, presents three challenging primary care case histories plus another online

Casei A sulien and uncommunicative 13-year-old is brought to the surgery by his somewhat agitated mother. He is unwilling to speak, but his mother says that she suspects he has been sniffing glue. 'I found out from a neighbour last night and I want to know what to do about it,' she says, 'And i want you to send him for biood or uHne tests so I know if he's using anything eise.'

What symptoms and signs wouid be suggestive of a child sniffing glue? What are the short and longer-term dangers of this activity? Depending upon the substance and how the glue vapour is inhaled, a red rash around the mouth can sometimes be seen.

The main effects experienced are dizziness, difficulties with motor

64 February 2014 Pulse

co-ordination, slurring of speech, hallucinations and drowsiness. This can lead onto coma or respiratory failure. Similar symptoms are seen with other inhaled solvents and aerosols.

Some people experience a 'hangover' afterwards with headaches, low mood and low energy and in others there may be mood swings or aggression.

There are additional risks. It is possible to die from first use, either from cardiac arrest, suffocation from using plastic bags over the head, inhalation of vomit, respiratory depression and blockage of the upper airways by swelling or through misadventure while intoxicated.

Though the inhalation of solvents is not physically addictive - psychological addiction is more commonly seen - tolerance may develop within a few weeks of regular use and withdrawal symptoms including headaches and irritability may be present.

1.5 CPD HOURS Go online to complete this article as a CPD module This module will be available free to all members of Pulse Learning untin4 February pulse-learning. co.uk

What are the clinical and ethical issues posed by the request that an adolescent be 'tested for drugs'? How should the GP respond to this request? Clinical issues • What to test? Drug screens are available on urine which can be done immediately if you have the correct test kits, and saliva can also be used in certain kits. If hair samples are collected, these would need to be sent away to specialist centres. • When to test? Drugs and their metabolites are only detectable within urine for a limited time period. Hair testing covers the period of time that the hair has been growing and drugs are detectable in bands. • Why test? Clinically there is no easily available test for glue snifñng and there has been no speciñc evidence put forward for testing for other drugs. • Who is the test for? The child, the mother or for yourself to direct care?

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Will a result alter any outcome and is it necessary?

Ethical issues In terms of consent, in this instance it is a parental request and is not being mandated by a court as part of criminal justice proceedings. As the boy is below the age of 18, his parents can technically consent on his behalf because of parental responsibility under the Children Act 1989.

It would be good practice to seek his consent if he is Gillick competent. Though Gillick competency allows a child to agree to treatment without parental consent, it does not allow him to refuse treatment consented to by a parent that you deem to be indicated medically and in his best interests. You may wish to seek legal advice before overturning the refusal of a Gillick- competent child but the practicalities of obtaining saliva, urine or hair without his agreement may actually outweigh the legalities.

References 1 NICE. CG159: Social anxiety disorder: recognition, assessment and treatment, 2013 2 Angold A. Costello EJ. The epidemiology of depression in children and adolescents. In: The Depressed Child and Adolescetit {2nd ed.), Cambridge 2001 3 NICE. CG28: Depression in children and young people - identification and management in primary, community and secondary care, 2005

Further reading • NICE. CG51: drug misuse - psychosocial interventions, 2007 • NICE. CG26: Post-traumatic stress disorder (PTSD) - the management of PTSD in adults and children in primary and secondary care, 2005 • NICE. CG159: social anxiety disorder- recognition, assessment and treatment. 2013 • NICE. CGU3: generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults - management in primary, secondary and community care, 2011

There is no right or wrong response here. I would explain that there isn't a regularly available test for glue sniffing and other specific drugs should only be tested for if their actual use is suspected, rather than for peace of mind.

I would encourage the child and their family to attend the local addiction services and drugs advice centre, or if available a GP with specialist skills in addiction, if they have continuing concerns.

Wiiat advice shouid tiie GP give the mother in terms of managing giue sniffing and, potentiaiiy, other forms of substance misuse in a child of this age? The primary aim would be to stop the glue sniffing. This can be achieved by educating the child and allowing them to choose not to sniff glue, by restricting access to inhalable substances, limiting access to purchasing them, informing local suppliers that the child in question is not using glue for its intended purpose (it is illegal to sell inhalable products if the seller suspects they will be misused), supervising the child and limiting access to 'friends' who also use.

Case 2 A 16-year-oid boy attends the surgery with his father, l-ie is articulate and engaging and explains that he is having troubie with his 'nerves'. He finds that, whenever he encounters situations that seem in any way novel or stressful, he develops paipitations, nausea and gênerai maiaise. This is stopping him being invoived in schooi trips, sleepovers and family meals in restaurants. He is not depressed but is worried that his probiem might impact on his schooi work - he is in his first A-ievei year.

How common are anxiety-based disorders in adoiescent children? What are the commonest underiying diagnoses? Anxiety disorders are relatively common in adolescents and are often associated with other mental disorders or life events. When this occurs, the other mental disorder often takes precedence as the primary diagnosis, with anxiety considered to be a component of it.

Standalone anxiety disorders include: • Generalised anxiety disorder. • Obsessive-compulsive disorder. • Panic disorder. • Phobias (including social anxiety).

These may also be components of: • Adjustment reactions - these are reactions to life events, such as death or separation. • Autism spectrum disorder. • Bipolar affective disorder. • Depression. • Neurodevelopmental problems. • Personality disorders. • Schizophrenia.

What simpie advice can the GP provide in this sort of situation? If the anxiety is normal or low in severity, simple advice would be to let it settle naturally. Relaxation techniques can help, such as progressive relaxation, breathing exercises and the use of imagery to reframe the anxiety or distraction, but these can actually become 'crutches' for people and the actual anxiety-provoking stimulus is never addressed.

Avoidance of stimuli may help in the short term, but then can develop into lifestyle-limiting behaviours and these also reinforce the view that the stimulus is in some way dangerous.

If the individual wants help and is willing to engage with therapeutic interventions then a referral to CAMHS would be appropriate, particularly if the anxiety is a component of another mental illness or neurodevelopmental condition, or if the anxiety is severe enough to be limiting life experience.

Are chiidren and adolescents able to engage successf uliy in CBT? Shouid a chiid of this age, if necessary, be referred to chiid or adult services? Children and adolescents are able to engage successfully in CBT. However, the CBT may need to be modified to compensate for a child's chronological age or level of ability.' CBT requires a willingness to take part, motivation to change and a basic knowledge of triggers, emotions, thoughts and personal actions. There are training courses in child CBT which are above and beyond the usual adult CBT courses. It is important to establish the qualifications and experience of the therapist prior to referral.

The decision over which service to refer to will depend entirely upon your local child or adult mental health service cut-offs and what age limits it operates. CAMHS in most areas accept 16-year- olds, but there may be transition services and adult services may start at age 16 in some areas.

Case 3

Although the next appointment is for a 15-year-old boy, it's his mother that attends. She is extremeiy concerned about him and is worried that he might be depressed. From her account, he has ciassicai symptoms inciuding iow mood, tearfulness, poor sleep and loss of interests. He has aiso made comments to suggest that he is having suicidai thoughts. Despite long conversations with him, his school and his friends, she has not been abie to uncover a precipitating cause. He Is now starting to miss schooi and declined to attend today.

How common is depression in chiidren? Does it tend to present in the same way as in adults and is it

www.pulsetoday.co.uk Puise February 2014 65

CLINICAF

CASEBOOK usually associated with or precipitated by external Stressors? Depression is believed to affect around 3% of adolescents in any given 12-month period.^ The presentation of depression in children and adolescents may be exactly the same as depression in adults, with a combination of biological and psychological symptoms. The younger the child, or the less able the child is (for instance, if they have learning disabilities), the less 'typical' the presentation may be.

Younger children or children with intellectual disabilities may present with crying or withdrawal, or symptoms that are predominantly biological such as lowered energy, altered sleep or appetite. Alternatively they may actually present with a regressive state - they revert to presenting like a younger child. The psychological presentations may also be much 'simpler' and not have the more sophisticated cognitions traditionally associated with adult depression, such as negative thoughts about the self or suicidal thoughts with plans.

Depression in younger children is less common, with a prevalence of about 1%, but is more likely to be brought on by a Stressor like bereavement or bullying. In younger children, many of the same factors as those seen in adults may be present.

How can the GP encourage engagement of the child with medical services? What options are available and what action should the GP take if suicidal ideas appear to escalate? The child can be engaged either indirectly through his mother, friends or school, or directly (by writing to him or inviting him to attend the surgery) with an explanation of concerns that have already been expressed.

My preferred approach would be directly in person - either in the surgery or at home. If the child refuses to answer questions, then giving examples of how other young people may feel in similar circumstances, why they might feel that way and the possible solutions and treatment options can help show him that his situation is being taken seriously.

You have the following options: • Do nothing. • Keep him in primary care (including counselling). • Refer to secondary care (CAMHS).

With depressive symptomatology and suicidal ideation, an urgent referral to CAMHS would be indicated.

If the suicidal ideas escalate and he won't attend an appointment, an assessment under the mental health act may be required with treatment in hospital. Direct contact with child and

Asperger syndrome Go online to read an extra case on autism and Asperger syndrome, including the key features to look for in primary care pulsetoday.co.uk

adolescent psychiatry would need to be made and in Fngland and Wales an assessment arranged with an approved mental health practitioner.

What is the current view on the use of antidepressants in this age group? Should they ever be initiated by the GP? NICE guidance recommends fluoxetine for depression in children and adolescents if the depression is moderate to severe, along with CBT.3 It is also recommended if psychological therapies have not worked.

Antidepressants are not used in isolation as first line.

Antidepressants should not be initiated in primary care for children and adolescents, though shared care between CAMHS and GPs is valued. Most antidepressants are off licence in children and should be prescribed in secondary care. The CAMHS team offer a multidisciplinary approach and work with the child, their family, school and in a variety of settings.

Dr Mark Lovell is a consultant child and adolescent learning disability psychiatrist at Tees, Esk and Wear Valleys NHS Foundation Trust, and is a board member of the Association for Child and Adolescent Mental Health (ACAMH)

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j2/need some changes.docx

Source #1 from Credo

MLA Citation for Source #1 (1 point)

//citation//

General Reflection (3 points)

Write a brief 3-5 sentence paragraph where you reflect on your article. List three relevant bolded/linked words or three new keywords. Describe the disciplinary perspective (subject such as business, education, criminology) of the book by examining the book title and/or about section and why this perspective is a useful one for your research. List something new you learned from reading this entry and at least two new questions that have emerged (none is not an acceptable answer).

The three key words that have been used in this article are Naloxone, Opiate and Opioid. The article is from the subject of medicine. /why this is useful/ This is useful because to get the information I needed, I had to look for an article from the subject of medicine. Have learned that before taking naloxone, I have to consult a doctor since even though it helps, it is not supposed to be taken without being prescribed for by the doctor. Does Naloxone really treat opioid overdose? What contributes to the overdose of Opioid? (Horzemp, Joseph 15).

Author/Editor Reflection (3 points)

You will likely have to search for the author or editor online to find this information. Write a brief 3-5 sentence paragraph including all of the following: The author’s name and qualifications for writing about this subject, whether you feel this author is qualified to write about this subject and why. Besides a person with this professional background, who else (by profession, identity, or experience) might provide an additional angle on your research question? For example, if this person is writing from a particular subject background, what other subject background might be useful? Or if this is an academic source, would you like to hear from a news source or from someone with personal experience? Why?

The authors name is Joseph Horzempa. And I believe he is qualified in writing this article since he is from the department of health sciences. I would really like to hear more about the information from an individual who has undergone opioid overdose and if naloxone is really helpful in reversing it. /Tell me a bit more about Joseph Horzempa. What is his background? What has he studied? Where does he work? Having personal accounts in your article to provide examples to illustrate your point is a great idea. But you need to base your arguments on the facts that are found through scholarly research./

Source #2 From Wikipedia

//citation//

Locate a relevant Wikipedia article. Read the entire article and then the “talk” or discussion page.

MLA Citation for Source #2 (1 points)

//citation//

General Reflection (3 points)

Write a brief 3-5 sentence paragraph where you reflect on your article. List three relevant bolded/linked words or new keywords. List something new you learned from reading this entry and at least two new questions that have emerged (none is not an acceptable answer).

The relevant bolded words are firearms license, gun control and firearms. I have learned that many countries have got restrictive firearm controlling policy and very few legislations have been regarded as being permissive. Ball, Molly (56) Does gun control decrease the rate of suicides? Is it right for anyone to own a gun in the name of self-protection?

Research Conversation Reflection (3 points)

Talk pages (also known as discussion pages) are administration pages where editors can discuss improvements to articles or other Wikipedia pages[footnoteRef:1].” [1: ]

Read the “talk” page and select one subsection within the talk page to examine that is either the most interesting to you or has the most content. In a brief 3-5 sentence paragraph, reflect on the “talk” section of the Wikipedia page. Summarize the problem being discussed, explain the different positions/points of view (if available), changes suggested, changes made, and any resolutions suggested or made. What is something new you learned in examining the “talk” page?

The talk section from this article is on international and regional civilian firearm regulation. The section discusses on why particular countries give civilians the right to buy guns’ subject to various restrictions. Although the information stated in the section is not part of the debate of UN, eight regional agreements have been made about possessing the firearms. There was a suggestion that signatories could establish this illegal possession of the small guns as being a crime offense under the national laws in their countries (Ball, Molly 76).

Research Journal (3 points)

Answer the following:

1. Now that you have a better understanding of your topic, formulate a specific research question. Keep in mind the suggestions from the module you completed before writing your Research Proposal, the information you’ve gathered in the Credo and Wikipedia articles, feedback from classmates, and keyword activity in class.

The research question that I can formulate from my Credo and Wikipedia article is, does the gun control policy reduce the number of robbery, murder and suicides committed in various countries?

1. How does Wikipedia and Credo each contribute, albeit differently to your research?

Wikipedia contributes differently in that, the information it has is not well organized and at some point, one may not get a connection between various paragraphs. Its information is not reliable too. When it comes to Credo, it provides up to date information and it contributes differently in that, it offers recent information compared to Wikipedia.

1. What type of information are you looking for going forward?

Am looking for the information on gun control laws. I would like to find how the laws are helpful to a society and whether once incorporated can reduce the offenses relating to guns.

Looking ahead (1 points)

In the next library workshop, we’ll be exploring news articles and website sources. Watch the video below and answer the questions.

· https://mediaspace.wisc.edu/media/Popular+Sources/1_7b7ybg6j

· What is a popular source? They are those sources used in providing background information

· Why would you use popular articles for your research?

Provide excellent background information.

Report finding for the general public to understand.

Even if they are not scholarly, they offer images and personal views on a topic and can help in reporting findings.

Works cited

Horzemp, Joseph NS DSM-5 Psychiatric Diagnoses, and Opioid Use Disorder. J Addict Res Ther 8:310. doi:10.4172/2155-6105.1000310. 2017, pp. 15

Ball, Molly.  Don't Call It 'Gun Control'  The Atlantic. Retrieved: September 24, 2016.pp. 56-80(the source should be from Wikipedia)

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