Neurodevelopmental Disorders Sunderland Pathways

1. Neurodevelopmental Disorders Sunderland Pathways Dr Uma Geethanath and Dr Thamara Athauda Consultant Child and Adolescent Psychiatrists SoTyne CYPS (Tier 3 CAMHS)

2. Mental Health presentations in children and young people • Behaviouraldisorders: (Parenting, Psychosocial, attachment based) • Oppositional defiant & Conduct disorders • Attachment/ relational difficulties • Neurodevelopmental / Neuropsychiatric: (More biological basis) • Hyperkinetic disorder / ADHD • Autistic spectrum disorders • Tic disorder/ Tourettessyndrome • Psychiatric Disorders : • Depression disorder, Anxiety disorders • Psychosis, Schizophrenia, Bipolar Affective disorder • Anorexia / Bulimia • Substance misuse

3. Biopsychosocial model

5. Oppositional Defiant disorder • Refuse to do as told • Cheeky, argumentative, swear and have tantrums. • Low frustration tolerance, angry outbursts, getting into fights • If the child continues to behave badly for several months or longer, diagnosable ODD

6. Conduct disorder • Seriously breaks the Family and societal rules • Low frustration tolerance, violence, damage property, fire setting etc • Lie, steal, break the law, without remorse • Truant, run away from home • Take more risks with their health and safety : illegal drugs or unprotected sex • This has a huge impact on family, social, school functioning.

7. BEHAVIOUR PROBLEMS: Causes: • Child factors: • Difficult temperament • Learning or reading difficulties - difficult to understand and take part in lessons, get bored, feel stupid, misbehave • Depressed/ Unhappy/ abused/ bullied child • ‘Excitable child’ - difficulties with self-control, attention Parenting factors: • Inconsistent rules, inadequate supervision, focus on negatives. • Parents mental health issues: depressed, exhausted or overwhelmed. • Marital discord, Domestic violence, poor role modeling • Attachment issues • Child learns that they only get attention when they are breaking rules. • Child learns they can their way if push boundaries hard enough

8. What works for ODD/ Conduct : Multiagency approach: • Practical support for child and parents • Positive Behavioural approach • Parenting guidance • < 5: Health visitor • Universal / Webster Stratton Parenting programmes • School Behavioural Intervention Team • Early Help / Child and Family support services • YOS • YDAP

9. Maslow’s Heirarchy of needs Love and belonging

10. Attachment theories: Bowlby • Attachment: biological instinct in which child seeks proximity to an attachment figure when it senses threat or discomfort. • The type of attachment behaviour will be based on the type of responses they have had this far. • Early patterns of attachment, in turn, shape the individual's expectations in later relationships.

11. Attachment types: • Secure attachment : considered to be the best. Child feels secure in the presence of their caregivers, feels appropriate separation anxiety when they leave, but is quickly settled on their return. • Anxiousattachment(? Parental Depression/ Anxiety) : Child feels heightened separation anxiety when separated from his caregiver and does not feel reassured on their return. • Avoidant attachment (? Neglect) Child avoids their parents, doesn’t show much of a response when they leave. • Disorganized attachment (? Abuse/ LAC) There is a lack of a consistent attachment behavior, indiscriminately friendly, but can be rejecting at the same time.

12. Attachment difficulties can present as • Child in a constant state of hyperarousal • In threat, fight or flight mode • Focus on seeking proximity with adults • Preoccupied with trying to get attachment needs met rather than play/ academics • Struggle to self soothe • Struggle to trust people, to ask / accept help • Struggle to make and sustain relationships • Superficially can appear like ODD/ ASD/ ADHD

13. Neurodevelopmental disorders • ASD • ADHD • Global learning difficulties • Specific learning difficulties: Dyslexia/ Dyscalculia • Dyspraxia (Co-ordination difficulties) • Speech delay/ disorders • Tic disorders and Tourettes Syndrome

14. ASD LEARNING DISABILITY ADHD SPECIFIC LEARNING DIFFICULTIES TICS ATTACHMENT ANXIETY

15. ASD/ ADHD: • ASD: 1% of school age children • ADHD 3-5% school age children • Form 50% or more of our referrals in CYPS • All services including schools, ED Psychologists and social services stretched, so increased demand for assessments and diagnoses as a route into support services. • Also increasingly parents seek medical model explanation for behaviours Vs parenting or attachment • Increased demand ++ and waiting times • 40% of referrals not reaching diagnostic threshold, particularly ADHD

16. Kaizan Events • Two 3 day events hosted by CCG, facilitated by NHS improvement team • Looked at ASD and ADHD Pathways individually • Aimed to improve effectiveness and efficiency by refining and better alignment of existing pathways • Ensure Pathways compliant with NICE • Reduce unnecessary delay and duplication • To get patient the right input first time

17. Autism & Autistic Spectrum Disorders (ASD)(Autism…....Aspergers …...High functioning Autism…PDD NOS)

18. ASD Diagnostic assessment: • Led by Paediatrics or Child Psychiatry/ Psychology • Detailed history: ADI (Autism Diagnostic Interview) • ADOS (Autism Diagnostic Observation Schedule)/ other structured observation eg OT assessment group • ASD specific School reports and observations; Home observations • Speech and Language therapist, OT, Educational psychologist assessments • MDT Discussion to conclude diagnosis/ formulation.

19. Differences in Sunderland ASD Pathways • Paediatric Pathway: -Much quicker pathway, Medical model, Paediatrician (History) and SALT (school assessment), ADOS and case discussion by both. • Better suited for younger children with severe core Autism, Genetic syndromes etc • -Not as MDT -No Psychology input -Difficulty unpicking attachment or psychosocial factors in formulation

20. Sunderland CYPS ASD Pathway • MDT approach, access to Psychologist + Psychiatry (for ADOS and case discussion) • Scope to consider various differentials ie ND disorders, emotional, attachment, psychosocial factors • Less Medical time available, so not always seen the child being discussed • Long waiting list ; long assessment period • Patient moving from one ND Pathway (ASD/ ADHD) to another without meaningful intervention

21. Key outputs: ASD Kaizan • Revised age threshold: >/= 9 yrs for CYPS, < 9 Paeds • CYPS MDT Meeting extended to Paediatrics + access to MH/ Psychology input where necessary. • 6m SALT time 1 day/ week for extra ADOS and case discussions to address long CYPS internal waiters • Improved internal processes and patient flow, by streamlining the Developmental interviews, school obs, school reports etc for ASD +/- other co-morbidities considered.

22. ADHD/ Hyperkinetic disorder Hyperactivity Impulsivity Inattention/ easy distractibility Extreme for the age and stage of development, and been present before age 7 yrs. Present in 2 or more settings (e.g., school/work, home, recreational settings) Not explained by another disorder Clinically significant impairment in social or academic/occupational functioning

23. ADHD???? • These features are shared by other neurodevelopmental difficulties: • Specific/global learning difficulties • Learning disability • Autism Spectrum Disorder • Anxiety • Tic Disorders • Attachment disorder.

25. What should we expect from medication • not 100% effective in all cases, • all symptoms might not disappear, • helps more with concentration, • Outcome depends on support from home/ school in understanding and fine tuning the management to child’s difficulties

26. CYPS ADHD assessment: • ADHD assessment mainly in CYPS, not Paediatrics • History from parents + Developmental interview • Corroborative reports from school • Clinical observation • ADHD symptom rating scales: Connors: P & T • School observation & Home observation • Psychometric assessment if relevant • OT assessment if relevant • Assessment of differential diagnoses/ co-morbidities. • MDT case discussion

27. NICE recommended Treatment options: • Heavy focus on Parenting approaches • Try Behavioural approaches first, particularly for mild- moderate ADHD • Parenting/ behavioural approaches also effective for other behaviours: ODD • Medication first line only for severe ADHD or moderate ADHD when above has failed + ongoing impact on functioning.

28. Issues : • ADHD referrals without parenting /behavioural/ educational intervention • CCAMHS parenting excludes Special circumstances • Cuts in Social Services run parenting programmes • CYPS do not have capacity to offer parenting support to all of these new referrals and to existing ADHD cases • Long CYPS waiting list • Children stuck in assessment Pathway for months • 30-40% of these patients do not reach ADHD diagnosis on case discussion and therefore do not receive an intervention after months of assessment

29. Main outputs of ADHD Kaizan • CCG to agree additional parenting places with CCAMHS, Social Services and Education. • Agreed that a first line parenting/ behavioural intervention needs to have been tried before ADHD assessment once interventions become available • CCAMHS to accept referrals from CYPS if ADHD assessment concluded no diagnosis, but parenting input stil needed. • CYPS to have dedicated staff trained and delivering parenting/ behavioural support as needed post-ADHD diagnosis

30. Any Questions?...