Age 12 to 18(?

)
By Akira Naito
SAS psychiatrist

“When I was a boy of 14 my father was so ignorant I could hardly stand

to have the old man around. But when I got to be 21, I was astonished
at how much the old man had learned in seven years”

- Mark Twain (1835 - 1910) quoted since1 1915

Plan of this session (aim to give you a flavour and contact)
Case examples & Case discussions Slide 3 - 7 & 29 - 34
Context where we (CAMHS psychiatrists) are in Slide 8 - 9
Mental health & Adolescence
Models to apply in Psychiatry esp. CAMHS Slide 10
Recovery model & BPS model
Adolescence - Transition to adulthood Slide 11 - 18
Neurobiology - Maturational process
Cognitive / Emotional development
Societal (Cultural) expectations for transition
Approach to take as a CAMHS psychiatrist Slide 19 - 28
Enquiries for Assessment & Safeguarding
Intervention (Psychosocial MDT approach, Psychoeducation/Medication)
2
 A
A is 12, and wanted to cut her mother open with scissors to find the
codes she knew would prove her mother was a robot.
A also believed her younger half-sister, aged 8, was a robot.
She barely spoke to us.
A was in hospital in total for 2.5 years, going at the age of 15 to a
special school for children with autism.

3
 P
P is 12, and is in her first term at secondary school. She is admitted
to a psych unit following the abrupt cessation of food intake
requiring an emergency paediatric admission.
P is on the 95th centile for height, and 10th for weight. Her LMP was
three weeks previously.
P is described as shy, determined, with a few close friends and her
parents had no concerns about her development.

4
 H
H is 15, admitted to a hospital following an attempt to hang herself
at home. H has been hurting herself through cutting and overdosing
for 2 years.
H is the younger surviving child of her parents, who had a stillborn
daughter 18 months before H was born.
H had her menarche at the age of 8, was bullied through primary
school and into secondary school.

5
 D
D had a 4 day history of change in personality and behaviour –
appearing preoccupied and anxious about his college work – before the
abrupt onset of a state in which he neither moved nor spoke for hours
at a time, with no food or fluid intake.
D is 16, second term at sixth form; living with mum and step-father
who run a ‘dodgy pub’.

6
 F
F is 17. Mum & Dad separated when F was 10. He mostly lives with
Mum who has a ‘unique’ value in life and her spirituality.
Recent episode of his close friend being prosecuted for inappropriate
image on his mobile and rapid deterioration of his mental state shortly
after. He was staying with Dad & his partner since the deterioration and
became withdrawn, terrified and preoccupied with the thoughts that
“people are not real”.
He was disengaging to support and escalating his self-neglect over 2
months. EIS was involved.

7
Context where we are in The World Health Report 2001
Mental Health:
New Understanding, New Hope
https://www.who.int/whr/2001/en/

8
 Mental health & Adolescence

50% of mental problems starts

from the age 14 & 75% by 24

1 in 8 of aged 5-19 have a

mental health condition. CYP-
MHS in England treated 325k
CYP in 2017/18 , i.e. only
30.5% (cf. 25% in 2014/15)
From The Inequities of Mental Health Research Nov.2020 From Fundamental Facts About Mental Health
9 2015
and NICE Guidance Mental health and Wellbeing
 Models to apply in Psychiatry esp. CAMHS
Recovery model (& Trauma-informed + Resilience weighed)
cf. Medical model
Bio-Psycho-Social model with developmental considerations
• Neurobiology/plasticity + Growth and Pubertal development
Esp. Prefrontal Cortex / Limbic development
• Cognitive/Emotional development (incl. Attachment & Reasoning)
• Societal (cultural) expectations for “Behaviours” in transition
Systemic enquiries (+ Family life cycle & Parenting, “Social media”)

10
 Adolescence - Transition to adulthood
Situated brain - Individual experiences in their environment
• Biological (Neural, hormonal & bodily) development in:
https://kidshelpline.com.au/teens/issues/your-brain-when-youre-anxious

Neurocircuitry & Hormonal changes + Neuroplasticity/Sensitivity

Puberty [Physical (+ sleep/eating) & Sexual, incl. Identity, development]
• Cognitive / Emotional development
Novelty/Sensory seeking, Risk-taking (for exploring the outer world)
Transition – ?2nd phase of “Separation/individuation”
• Societal (Cultural) expectations for “Behaviours” in transition
11
 Neurobiology - Maturational process
Brain of an early adolescent differs significantly from a late adolescent
• Increased connectivity:
Limbic system (Matured by the age 10-11)
Prefrontal cortex (Maturation spur btw age 11-12 & mid 20’s)
• Connectivity becomes more complex and more efficient (next slide):
Grey matter reduction through synaptic pruning (‘use it or lose it’)
White matter increase through myelination
• Plasticity:
Experience-dependent: New learning at any age
Experience-expectant: There are ‘Sensitive periods’

12
From
https://www.psychiatrictimes.com/view/neurobiology-borderline-personality-disorder

From Rethinking Schizophrenia (Nature) 13

https://www.nature.com/articles/nature09552
Boys Girls

14
15
Boys Girls

16
 Cognitive / Emotional development
• Predicated on neurobiological processes & stage of “Theory of Mind”

• Founded on child’s attachment

• Significant incidences / Trauma(s) (?+ developmental trauma)

• Developmental tasks of the “Separation & Individuation”

cf. Individuation refers to a process
“by which a person becomes increasingly differentiated
from a past or present relational context (Karpel, 1976)

17
 Societal (Cultural) expectations for transition
Influences from Socio-Economic state & Immediate Peers/surroundings
• Audience effect (Age 12-14: influenced more by teenagers’ opinions re. risks)
Independence
• Freedom of choice in the face of ‘Responsibility’
• Relative lack of external Structure / Containment – anxiety provoking
Family life cycle (Stage 2,3,4&?5) - Shifts in relationships & roles in:
• Jobs, Education and Leisure activities (Societal trends & Friends in real + online)
• Family: Own romantic relation & carer’s role (as a parent and a family member)
Cf. Parental relationships, own experiences of attachment & serious Incidence

18
 Approaches to take as a psychiatrist
Enquiries with Curiosity for understanding of & nurturing “Epistemic trust” with the CYP
• Attempts of mentalising & advocating the needs for the CYP
Assessment
• History taking + Mental State Examination (e.g. snapshot blood test results)
• Formulation, Diagnosis (ICD & DSM), RDoC & (CH)ARMS
• Risk (Static + Dynamic) & Safeguarding (Whose need?, Who’re involved?)
cf. “Resilience matrix” [Resilience-Vulnerability axis + Adversity-Protective axis]
Intervention / Care-planning:
• Psychoeducation & Psychological/Social/Occupational intervention
Lifestyle advice: Sleep, Eating, Exercise/Activities, Social media, Habit (caffeine/substance)
Resiliency promotion (Learning & Unlearning) in light of neuroplasticity
• Medication if appropriate 19
 RDoC project (started by NIMH in 2009)
The 6 RDoC circuit based functional dimensions:
1. Negative Valence (acute/potential/sustained Threat & Loss)
2. Positive Valence (Reward responsive, learning & valuation)
3. Cognitive system (attention- perception-memory-Control)
4. Social Process (Affiliation-Attachment-Communication-Self/Others)
5. Arousal & Regulatory system (Circadian rhythm - Sleep)
6. Sensorimotor system (Motor action - Agency - Habit)

Two additional RDoC frameworks:

1. Neurodevelopmental "Trajectories"
2. (Bi-directional) Interactions with "Environment"
20
 Diagnosis: ICD-10 framework
F00 & F10 orders – Organic & Substance related (Brain)
F20 order – Psychotic episode related
F30 order – Affective disorder related
F40 order – Anxiety and stress related
F50 order – Behavioural syndromes (incl. Eating disorder)
(---)
F80 orders – Disorders of psych development (incl. ASC)
F90 orders – Behavioural and emotional disorders of development
(incl. ADHD, disorder of conduct & emotions)

21
 Medication
• Risks (allergy, overdose, diversion, side effects, effect on development)

• Licenses (Fluoxetine, Sertraline, Risperidone, Melatonin + ADHD meds)

• Start low go slow + Monitoring (e.g. QTc prolongation, Wt/Ht)

• Genetic responses

22
Fluoxetine (SSRI)
1 in 6 may respond
10% difference between placebo and response rates
Peak response weeks 1-2 but maybe longer in children
See at least weekly in first month
Treatment emergent – Agitation/Suicidal thoughts/urges
No increase in completed suicide (in comparing to untreated depression)
Side-effects: headache; GI; sexual dysfunction; hypo Na+; GI bleeds; rash
Discontinuation effects
Serotonin syndrome
Long half life; enzyme inhibitor

23
Risperidone (2nd Generation Antipsychotic)
Licensed for :

Over 12yrs (expert supervision) - Psychosis / Manic episodes

Over 5 yrs for aggression in ASC/CD at lower doses and dependent on weight.

Side effects

Very common (>1 in 10): headache, EPSE/Akathisia(+sweating), postural hypotension

Common (<1 in 10): hyperprolactinaemia, weight gain, constipation, sleepiness

Uncommon (1 in 100): sexual dysfunction, sight problems (blurred vision), skin rashes

Monitoring required

24
Risperidone use in NICE [in CG158: 1.6]
https://www.nice.org.uk/guidance/cg158/chapter/1-recommendations

Antisocial behaviour + Conduct disorders in CYP: recognition and management

Clinical guideline [CG158]
• 1.6.1 - Do not offer for the routine management of behavioural problems
• 1.6.2 - Offer methylphenidate or atomoxetine, within their licensed indications in line
with ADHD (NICE clinical guideline 72).
• 1.6.3 - Consider risperidone for the short-term management of severely aggressive
behaviour in young people with a conduct disorder who have problems with explosive
anger and severe emotional dysregulation and who have not responded to psychosocial
interventions.
• 1.6.4 - Provide young people and their parents or carers with age-appropriate
information and discuss the likely benefits and possible side effects of risperidone incl.:
• Metabolic (including weight gain and diabetes)
• Extrapyramidal (including akathisia, dyskinesia and dystonia)
• Cardiovascular (including prolonging the QTc interval)
• Hormonal (including increasing plasma prolactin)
• Other (including unpleasant subjective experiences).
25
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27
• Ensure antidote injection is available
• Procyclidine for antipsychotics: Acute dystonic reaction, less likely for 2nd generation
• Flumazenil to reverse effects of Lorazepam injection.
• The max dose of Olanzapine is 20mg/24 hours by any (combined) route(s)
• Not more than 3x IM doses in any 24-hour period.
• Wait 2 hours between doses.
• Olanzapine & Lorazepam must NOT be given within 1 hour of each other
• Promethazine:
• < 12 years → 5-10mg (max 25mg/day)
• > 12 years → 10-25mg (max 50mg/day) 28
 Case discussion
Formulation for immediate action (MDT + Multi-agency Interventions)
• RDoC (+ Development & Environment) for Differential diagnosis (incl. ? ARMS)
• Negative Valence (Acute/Potential/Sustained Threat & Loss)
• Positive Valence (Reward responsive, learning & valuation)
• Cognitive system (Attention- Perception-Memory-Control)
• Social Process (Affiliation-Attachment-Communication-Self/Others)
• Arousal & Regulatory system (Circadian rhythm esp. Sleep)
• Sensorimotor system (Motor action - Agency - Habit)
• Safeguarding [re. abuse & exploitation (Physical, Emotional, Sexual & Criminal)]
Psychoeducation (+ ?re. Medication)
• Condition & Intervention
• Lifestyle (Sleep, Exercise, Eating, Habit, Social network)
• Development (brain / puberty)
29
 A
A is 12, and wanted to cut her mother open with scissors to find the
codes she knew would prove her mother was a robot.
A also believed her younger half-sister, aged 8, was a robot.
She barely spoke to us.
A was in hospital in total for 2.5 years, going at the age of 15 to a
special school for children with autism.

30
 P
P is 12, and is in her first term at secondary school. She is admitted
to a psych unit following the abrupt cessation of food intake
requiring an emergency paediatric admission.
P is on the 95th centile for height, and 10th for weight. Her LMP was
three weeks previously.
P is described as shy, determined, with a few close friends and her
parents had no concerns about her development.

31
 H
H is 15, admitted to a hospital following an attempt to hang herself
at home. H has been hurting herself through cutting and overdosing
for 2 years.
H is the younger surviving child of her parents, who had a stillborn
daughter 18 months before H was born.
H had her menarche at the age of 8, was bullied through primary
school and into secondary school.

32
 D
D had a 4 day history of change in personality and behaviour –
appearing preoccupied and anxious about his college work – before the
abrupt onset of a state in which he neither moved nor spoke for hours
at a time, with no food or fluid intake.
D is 16, second term at sixth form; living with mum and step-father
who run a ‘dodgy pub’.

33
 F
F is 17. Mum & Dad separated when F was 10. He mostly lives with
Mum who has a ‘unique’ value in life and her spirituality.
Recent episode of his close friend being prosecuted for inappropriate
image on his mobile and rapid deterioration of his mental state shortly
after. He was staying with Dad & his partner since the deterioration and
became withdrawn, terrified and preoccupied with the thoughts that
“people are not real”.
He was disengaging to support and escalating his self-neglect over 2
months. EIS was involved.

34
Any question or your thoughts ?

35
 ? Useful (free) IT tools & skills ?
• Mendeley

• Instapaper

• Notion & OneNote

• Desktop shortcuts & Pinning function

36
Useful keyboard shortcuts & pinning function
Keyboard shortcuts
• “Ctrl + C” (copy) & “Ctrl + V” (paste)
• “Ctrl + Z” (undo)
• “Ctrl + F” (find)
• “Windows key + →” & “Windows key + ” (Two programme side by side)
• “Windows key + D” (desktop) & “Windows key + L (Lock)”
Virtual desktop function
• “Windows key + “Ctrl” + “→” & “Windows key + “Ctrl” + “” (Switch btw)
Pinning function
• Pin your frequently using “Folders” & “Programmes” within the Task bar
• then Pin your Files within the Folder & within each Programmes

37