Approach to diagnosis is different between adult and adolescent psychiatry- Dr. Sobia Khan


 Recent developments in Child and Adolescent Psychiatry-IV

Approach to diagnosis is different between adult
and adolescent psychiatry - Dr. Sobia Khan

Comprehensive evaluation is important for diagnosis and
treatment of autistic disorders - Dr. Shafique Tahir

Anti depressants are less effective in children as
compared to adults - Prof. Gordana Milavic

LAHORE: On Second Day of the 9th international conference on psychiatry highlighting recent advances in Child and Adolescent Psychiatry held here at Lahore from February 26-28, 2015, Dr. Sobia Khan from UK conducted a workshop on “Transition from adolescent to adult services.” She referred to teen age pregnancies in UK and family independence. At eighteen or nineteen years of age, the children used to leave parents home but now the situation is changing. People from 20-80 years all have to work. Adolescence begins with puberty and completes with highly social transactions. Now the banks no longer provide mortgage facilities, hence the children who left the parent’s homes wish to go back and stay with their parents. They require parental support. Problem with these adolescents is that they have no parents support. Maternal health issues also arise.

Since the children leave education before minimum age, there is risk of unemployment. There is early family formation and anti social behaviour is high. Speaking about the age related service model, she said that it was not working anymore for us now. At the St Andrews Health Care Center, childhood services are available upto nineteen years of age. There is mushroom growth of services to fill this gap between services of adolescents and adult age to cater patients between the ages of seventeen to twenty five years. Patients develop psychosis early. Transition service looks after patients between the ages of 18-25 years. Prevalence of anxiety and depression is 12% among people between the age of 11-16 years and 20% between the ages of 16-24 years. Co-morbidity is also high. Anorexia Nervosa is high in girls and now it is increasing in adolescents. They have no home as  they run away from homes. These children suffer from learning disabilities, ASD and eating disorders.

Dr. Afzal Javed, Mrs. Afzal Javed, Dr. Shujat Naqvi, Mr.Shaukat Ali
Jawaid photographed at the dinner held at Fountain House  during the Int.
Psychiatric Conference held at Lahore during February 2015 which highlighted
recent advances in Child and Adolescent Psychiatry.

Speaking about the challenges in mental health services, Dr. Sobia Khan said that often the health services say, this patient is not right for their service. Adolescents cannot go to adult services as there are criminals who will eat them away. These are people who are rejected by the family and society. Approach to diagnosis is different between adult and adolescent psychiatry but adult psychiatrists have no exposure to adolescent psychiatry and vise versa. ADHD, AST, eating disorders lead to early psychosis. In UK there is different funding for adult and adolescent psychiatry. It is difficult to convince the administrators who have no clinical background. Soft posture problems are not taken by adult psychiatrists but they are referred to GPs as they have too many schizophrenics to deal with. Dr.Sobia Khan remarked that at time in the interest of the patient to treat them, we have to change the diagnosis. It is not scientific but it is a reality, she remarked. She also talked about emotional relationship and behaviour difficulties and said that these patients can indulge in self harm and suffer from developmental disorders. They have less access to primary care services. Young people are often difficult to engage. Forensic issues, Dr.Sobia Khan said is acknowledged but they are not addressed. We need secured children homes. Instead of punishing ten years old, they should be rehabilitated. Criminal history, Dr. Sobia Khan said starts early. She then presented few case studies which were followed by lively discussion.

Dr. Shafique Tahir from UAE spoke about Autism-Mystery, Hopes and Challenges. He pointed out that when a part of the brain is affected, it involves everything. Autism, he opined, is a multifactorial disease as regards brain. Inability is associated with autistic disorders. Communication is a big problem in autism. He was of the view that if parents feel that the child is different, they must take prompt help. One consultation with a specialist will not hurt majority but it needs proper management and refusal to start service early will have disastrous consequence. These children can be helped if diagnosed early. Speaking about behavioural taining and management, he said, autism children can have other mental health problems as well. Hence comprehensive evaluation is important for diagnosis and treatment of autistic disorders. To manage these children the multidisciplinary team should consist of psychiatrists, occupational therapists, social workers and speech language therapists. Be careful while making diagnosis but wrong diagnosis can be a dilemma. Parents may not accept it, they may argue. He emphasized that one should never delay the diagnosis. Managing these patients is a team work. Do not single out and do not say autistic child as they may improve. Patient may be having disorder. He also talked about community support groups, parents training, Self Help Groups. These, he said, are online groups. They will help these patients not to go in wrong direction. Talking about stories as regards alternate therapy, he said that they have no scientific evidence to link autism with the use of vaccines. His conclusions were that early diagnosis and early intervention makes the difference.

During the discussion it was pointed out that there is no wrong question but answer can be difficult. Children can express their emotions non-verbally. Eye contact is important. Replying to a question regarding differences between autism and schizophrenia, it was stated that autism is a twenty four-hour disorder while schizophrenia is fluctuating. Psychosis goes up and comes down but it is not the case with autism.

Prof. Khalid Mufti along with Dr. Sohail chaired the next session wherein Prof.Helen Herman from Australia was the guest speaker and she spoke about “Responding to the mental health needs of young people across countries. She pointed out that young people between the ages of 15-24 years comprise one fourth of the world population. Almost 90% of them live in middle income countries. She also referred to lack of learning facilities, lack of employment, health and family citizenship besides growth in mental and physical intellectual maturity. Mental health, she opined, was the leading cause of disability between 10-24 years and it comprise 45% of overall disease burden. Almost 25% of young people have some mental disorder and 75% of people with mental health disorder have first onset at the age of twenty four years. Mental disorders, she further sated are chronic diseases. These problems are at time  ill defined. Awareness and advocacy is fragmented. There is wide gap between prevalence. Service users are more at young age of 16-24 years. Suicide is the leading cause of death of young people in India and it is high between the ages of 15-29 years.

She then gave details of young mental health programe in Australia. The government has initiated a programme whereby by 2020 all people in the country will have access to mental healthcare. Children need youth friendly services. Early intervention has reduced disruption. She then referred to education, arts, sports, e health and self care and said that GPs, teachers, counselors, Youth work as community health workers and they are all involved. Specialists Youth Mental Health services are now available. Those suffering from anxiety, depression, and substance abuse get early intervention. Federal government has increased funding. There are school based programmes, family support and home based treatment is available. She concluded her presentation by stating that treating mental health disorder in young will prevent suicide. Promotion of mental health in young people needs intensive thinking and partnership. There are new ways to engage people, their families and care givers. There is need to provide accessible ways adoptable to local needs of the community.

Prof. Gordana Milavic from UK discussed  treatment controversies in depressive and bipolar disorders in children and adolescents. She pointed out that almost twenty million children are not going to schools and 20% of them suffer from mental health problems. There are not enough trained mental health workers, no child legislation and low funding. She then spoke about epidemiology, clinical characteristics, assessment, practice guidelines, change in mood, change in thinking, and classification of depression by severity. Speaking also talked about pre-school children between one to five years of age and diagnostic criteria for major depression. They do tend to commit suicide though it is rare. If left untreated, about 6-10% becomes chronic. About 3% of post pubertal children suffer from mental health disorders. Rick factors for early onset of depression include poverty, child abuse and genetic factors account for almost 37%. Off springs of depressed parents do suffer from depression twenty years later. Similarly those involved in substance abuse, suffering from anorexia nervosa, malnutrition all lead to depression in later life. Assessment of these children needs multidisciplinary approach. She also talked about Childhood Depression rating scale, self reporting questionnaire and NICE guidelines. Since 2005, we practice the same way, she added. There are four tiers of service which includes school social services, mental health professionals, community health and specialist indoor facilities.

Speaking about treatment Prof.Gordana Milavic said that combination of CBT and SSRIs gives better results. In countries where CBT is not available, early pharmacological therapy is used. Fluoxetine in a dose of 20-40mg is quite effective. Overall response to anti-depressants is 40% and anti depressants are less effective in children as compared to adults. She also talked about resistant depression and suicide tendencies associated with SRIs and said that the manufactures have been asked to print suicide warning on boxes of these medications. However, combined therapy works better for childhood depression. Severe depression should be treated with fluxoteine while CBT works better in mild to moderate cases over a long period of time but resistant depression remains a problem, she added.

In the afternoon session Dr. Shafique Tahir from UAE discussed suicide in children and adolescents. He pointed out that Muslims have a low suicide rates as compared to Hindus and Christians. Suicide is a leading cause of death among college students while accidents are No. 1. About 28% of those who commit suicide do share their thoughts with their caregivers. Patients are asked to make a promise that they will not harm themselves but it did not work in reducing suicide. Suicide, he said, is more related to family dysfunction, physical, sexual abuse, substance abuse and schizophrenia. Suicide behaviour in childhood increases the risk that suicide will be completed in adolescence. According to WHO about two hundred thousand children between the ages of 15-25 years commit suicide annually. Suicide is intent to die whereas self harm is not intent to die. Single parent children are at greater risk of committing suicide. They withdraw from family, friends and it must be ensured that they do not have access to lethal weapons.

Dr. Shujaat Naqvi from USA made a presentation on rational and irrational psycho pharmacotherapy in autism, speech disorders and developmental delay syndrome. He also talked about ASD treatment targets. Almost 40-60% of parents report aggression in these children. His advice was that one should not use drugs with same mechanism of action as it is redundant. Irritability can also be seen in anxiety, depression and mania. He concluded his presentation with a quotation from Hazrat Ali which says that “ You are allowed to be NADAN but not JAHIL.