P Primary Child and Adolescent Mental Health Volume I r i m A PRACTICAL GUIDE a r Second Edition y C Volume I:Overview • General issues h i l Rewritten with the new primary care environment in mind, this greatly expanded and updated d edition of Child Mental Health in Primary Careextends the structured approach of the first a n edition to adolescent mental health. As in the first edition, Primary Child and Adolescent Mental d Healthcovers each problem in a uniform way, offering definitions, assessment outlines, detailed A management options and indications for referral. Numerous case examples further illuminate d aspects of many conditions. o l e Comprehensive and practical, the forty-eight chapters of Primary Child and Adolescent Mental s c Healthcover the full range of difficulties and disabilities affecting the mental health of children e and young people. The book is divided into three volumes, and can either be read from cover to n t cover or used as a resource to be consulted for guidance on specific problems. M This book is vital for all healthcare professionals including general practitioners, health visitors e n and other staff working in primary care to assess, manage and refer children and adolescents t with mental health problems. School medical officers, social workers and educational a l psychologists, many of whom are in the frontline of mental health provision for children and H young people, will also find it extremely useful. e a l t h Reviews of the first edition Other books of related interest Primary S 'This very comprehensive and detailed book THE OTHER SIDE OF ADHD e c provides the tools for primary care health Attention Deficit Hyperactivity Disorder o professionals not only to assess a child's exposed and explained n Child and Adolescent d needs but in many cases also to implement Angela Southall E an initial package of care.' d JUST FOR NURSES LISTENING TO CHILDREN AND YOUNG itio Mental Health PEOPLE IN HEALTHCARE CONSULTATIONS n 'I have no reservation in recommending the Edited by Sarah Redsell and Adrian Hastings book to all people working with children and families in any capacity. An important training DIFFICULT CONSULTATIONS WITH AQ text for a variety of professions. A very ADOLESCENTS lisoue A PRACTICAL GUIDE effective text to be used in daily practice for Chris Donovan and Heather Suckling nn Dtin quick reference.' with Zoe Walker, Janet Bell, Tami Kramer a S CHILD AND ADOLESCENT MENTAL HEALTH and Sheila R Cross viep se Second Edition ,n 'This book is well produced and clearly INCREDIBLY CARING (DVD) Jede written. A useful book for anyone interested or Department for Children, Schools and Families nr, n J involved with children.' FAMILY PRACTICE yu Md 'I looked through the book again and again urith Quentin Spender pB but could not find anything missing.' ha yr Judith Barnsley NURSING TIMES n s le K28202 y, Alison Davies Volume I 6000 Broken Sound Parkway, NW Suite 300, Boca Raton, FL 33487 ISBN: 978-1-85775-262-5 711 Third Avenue 90000 Jenny Murphy New York, NY 10017 an informa business 2 Park Square, Milton Park Abingdon, Oxon OX14 4RN, UK 9 781857 752625 www.crcpress.com Child Mental Health in Primary Care Quentin Spender, Niki Salt, Judith Dawkins, Tony Kendrick and Peter Hill Forewords by David Hall Professor of Community Paediatrics Institute of General Practice and Community Health Trust Sheffield and Jackie Carnell Director Community Practitioners’ and Health Visitors’ Association Cartoons © 2001 Dave Colton www.cartoonist.net Chapter 3 © 2001 Sangeeta Patel CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2001 by Quentin Spender, Niki Salt, Judith Dawkins, Tony Kendrick and Peter Hill CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20160525 International Standard Book Number-13: 978-1-138-03032-9 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site http://www.crcpress.com Contents Forewords v Preface viii List of contributors ix Part 1 Introduction 1 1 Assessment in child mental health 3 2 Referral, consent and confidentiality 15 3 Cultural and ethnic issues 35 Sangeeta Patel Part 2 Problems that may present at any age 47 4 Temperament and resilience 49 5 Disorders of language and social development 57 6 Behaviour problems 67 7 Family issues 91 8 Separation, divorce and reconstituted families 101 9 Chronic paediatric illness 111 10 Effects of parental mental illness on children and families 115 11 Child abuse 121 12 Sexualised behaviour 135 13 Post-traumatic stress disorder and adjustment disorder 139 14 Death, dying and bereavement 143 15 Imaginary friends, voices and psychosis 149 Part 3 Problems that may present in the first few years 155 16 Postnatal depression 157 17 Crying and colic 169 18 Feeding problems in pre-school children 179 19 Sleep problems 189 20 Breath-holding 199 21 Head-banging and body-rocking 201 Part 4 Problems that may present in school-age children 205 22 Attention-deficit hyperactivity disorder 207 23 Specific and generalised learning disability 229 iv Contents 24 Bullying 237 25 Enuresis 243 26 Faecal soiling/encopresis 251 27 Obsessive-compulsive disorder 257 28 Anxiety, worry, fears and phobias 261 29 School refusal 265 30 Recurrent abdominal pain 271 31 Physical presentations of emotional distress 277 32 Tics and Tourette’s syndrome 281 Part 5 Problems that present mainly in adolescence 287 33 Depression 289 34 Overdose and other self-harm 297 35 Eating disorders 305 36 Chronic fatigue syndrome 315 37 Substance misuse 321 Part 6 Detailed treatment options 325 38 Behavioural techniques for use by enthusiastic professionals in primary care 327 39 Formulary 349 Foreword I saw my first child psychiatry case as a second year medical student. A mother brought her three-year-old son to the clinic, with the apparently trivial complaint that he was taking things out of her handbag. It took the psychiatrist just a few moments to ascertain that his father was in Wandsworth gaol for burglary, and his mother was convinced that the boy was already embarking on a life of crime. I was deeply impressed. I know now that few cases are so purely psychological and that few are so easily solved, but most paediatric problems have a psychological dimension. Unless these are addressed, the consultation will fail to satisfy either parents or the child. Every primary care physician and every paediatrician must be familiar with the psychological problems and psychosomatic disorders of childhood. This knowledge is not an optional extra, but an essential part of everyday practice. Without it, many opportunities will be lost to relieve anxiety, intervene promptly for serious problems, and avoid unnecessary investigations for non-existent organic disease. I have over the years accumulated a large collection of books on child psychiatry and psychology, but until now I had never found one that I could confidently recommend to our junior doctors training for general practice or paediatrics. I wanted one that offered a theoretical basis for its approach, without being too abstruse; a common sense approach that recognised the realities of clinical consultations; some guidance as to what is or is not suitable for the non-specialist to tackle without referral; and short snappy chapters that could be accessed quickly. At last, here is a book that matches that specification. The Audit Commission recently reviewed services for child mental health problems across the country and revealed some very disturbing facts. Most striking was the remarkable disparity between districts in the provision made for these children. There is an obvious need for greater investment in this area. But part of the reason for the inadequacy of services and the long waiting lists is the tendency to refer every problem straight to the child psychiatry team, without considering if there might be a solution that could be applied by the non-specialist. If general practitioners and general paedi- atricians equip themselves with the basic skills and knowledge outlined in this book, the rate of referral will go down, parents and children will be more satisfied, and the specialist teams will be able to concentrate on those more complex, baffling or intract- able cases that really need their skills. Every trainee in general practice and in paediatrics should buy this book, read it, and read it again. And those whose job it is to teach them will need a copy as well. David Hall Professor of Community Paediatrics Institute of General Practice and Community Health Trust Sheffield November 2000 Foreword The recent strong emphasis by government ministers on the importance of primary care, as outlined in the NHS Plan and the White Paper Saving Lives, Our Healthier Nation, provides the perfect backdrop for this excellent book Child Mental Health in Primary Care. Having read this book with great interest, I am convinced that it will quickly become a standard text for health visitors, school nurses and community practitioners because of the wide and embracing scope adopted by the distinguished band of contributors and through the excellent use of case studies. Having had more than 20 years’ experience in this field, both as a health visitor and now as a manager, I know that child mental health issues are ones on which primary care professionals spend much time and energy. And it is by tackling these issues in a sensitive way that many long-term problems affecting the child and family can be overcome. Children develop at a bewilderingly fast rate. The contributors cover the problems that may arise in the early years, through to the school-age years when, for example, bullying may occur, and on to the emotional minefield of ‘being a teenager’, when depression, substance abuse and eating disorders could come to the fore. With the aid of case studies, the book lays out strategies that could be adopted to resolve the child’s distress and provide support structures for the family as a whole. It also approaches cultural and ethnic issues, appropriate for a multi-cultural society. The book’s common sense and straightforward direction can only inspire confidence in the health professional, many of whom are hard-pressed with giant caseloads to deal with. It will contribute to greater understanding and this in turn will facilitate smoother team work within the primary care setting. The more that health visitors are able to understand the complexity of child mental health issues, the fewer the families that will need to be referred to the specialist services. I know, remembering my days as a health visitor, that I would have greatly appre- ciated and benefited from having a book such as this on my desk. It is comprehensive, easy-to-read and thankfully free from the liberal use of jargon that sometimes bedevils such publications. The excellence of this book, however, can’t disguise the fact that the campaign for enough resources to sustain and develop work in this field must continue. Under the NHS Plan, more money and more staff are promised and this is to be greatly welcomed. But there will be the inevitable struggle by competing priorities for their share of additional resources, and those of us working in primary care must be conscious of this. Foreword vii I was pleased to have been asked to write this foreword as the subject goes to the very core of what we, at the Community Practitioners’ and Health Visitors’ Association, believe in and promote on a daily basis. Every health professional working in primary care is well advised to study this book at some stage, preferably sooner rather than later. It will increase their circle of knowledge. Jackie Carnell Director Community Practitioners’ and Health Visitors’ Association November 2000 Preface This book aims to help general practitioners, health visitors and other professionals working in primary care settings to assess, manage and refer children and adolescents with mental health problems. Recent reorganisations in the health service in the UK have encouraged the provision of services at the primary care level, rather than exclusively within specialist services. Some parts of the book may also be useful for school medical officers, social workers and educational psychologists, many of whom are in the front line of mental health provision for children and young people. The book is composed mainly of chapters with a uniform structure that is designed to emphasise what can realistically be done in primary care. Each of these chapters starts with an introduction, including definitions, and then proceeds to an outline of assess- ment, followed by management options, and finally indications for referral. The introductory chapters give an overview of general themes. Illustrative case examples are included in almost all chapters, and most of these examples are based on real individual cases, or amalgams of several cases. We often use the terms ‘child or ‘children’ to refer to both children and adolescents. In most places we refer to the child as ‘he’, except when the condition in question is more common in girls. A single parent is usually referred to as ‘she’, but the comments should be taken to include single fathers. We are grateful to a number of colleagues who have advised us about the content of some of the chapters. These include Professor David Candy, Deborah Fulford, Dr Pat Hughes, Ann Kimber, Karen King, Dr Rebecca Park, Dr Josephine Richards, Julia Robb, Dr Andrew Singleton, Dr Jean Sherrington and Dr Jeremy Turk. QS, NS, JD, TK, PH November 2000 List of contributors Judith DawkinsMBBSBSCMRCPSYCH Sangeeta Patel MRCGPMA Senior Lecturer in Child and Adolescent General Practitioner Psychiatry Balham, London, UK St George’s Hospital Medical School Clinical Lecturer London, UK Department of General Practice and Consultant in Child and Adolescent Primary Care Psychiatry St George’s Hospital Medical School Surrey Hampshire Borders NHS Trust London, UK Guildford, UK Niki Salt MBBSDCHMRCP(PAEDIATRICS) MRCGP General Practitioner Thurleigh Road Group Practice Peter Hill MAFRCPFRCPSYCHFRCPCH Professor of Child and Adolescent London, UK Psychiatry Hospital for Sick Children Quentin SpenderMBBSDCHMRCP Great Ormond Street (PAEDIATRICS) MRCPSYCH Senior Lecturer in Child and Adolescent London, UK Psychiatry St George’s Hospital Medical School London, UK Tony Kendrick BSCMDMRCPSYCHFRCGP Professor of Primary Medical Care Consultant in Child and Adolescent Medical School, University of Psychiatry Southampton Sussex Weald and Downs NHSTrust Southampton, UK Chichester, UK