Welcome to the University of Salford | University of ...
GALAXY HOUSE
INFORMATION
PACK
for
STUDENTS | |
|GALAXY HOUSE |
|CENTRAL MANCHESTER AND MANCHESTER CHILDREN’S UNIVERSITY HOSPITAL NHS TRUST |
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|ROYAL MANCHESTER CHILDREN’S HOSPITAL |
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|GALAXY HOUSE |
|HARRINGTON BUILDING |
|OXFORD ROAD |
|MANCHESTER |
|M13 9WL |
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|Phone 0161 701 5197 |
|Fax 0161 701 5165 |
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|CONTENTS |
o INTRODUCTION
o TEAM STRUCTURE
o CONTEXT
o EDUCATIONAL SUPPORT AND LINKS
o SHIFT TIMES
o FIRST DAY
o PRACTICALITIES and PAN Manchester Criteria for students
o WARD MANAGEMENT
o NURSING PHILOSOPHY
o ASSESSMENT AND CONTINUING PROFESSIONAL DEVELOPMENT
o SKILLS FRAMEWORK
o THE HUB AND SPOKE MODEL
o TIMETABLE FOR FIRST WEEK
o THERAPEUTIC APPROACHES
o CLINICAL SYNDROMES
o EVALUATION OF PLACEMENT
|INTRODUCTION |
Galaxy House is a tier 4 Child and Adolescent In-patient Unit on the Royal Manchester Children’s Hospital site. It is part of the Children’s Division of Central Manchester Foundation Trust.
Children can stay as day patients or residential patients and for 5 or 7 days dependent on need and presenting issues. Admissions to Galaxy house are as short as possible but can be between 12 and 36 weeks, with occasional admissions of 12 months. Parents are as essential aspect of the admission and are involved in consultation at every level.
Galaxy House provides assessment and treatment for children between the ages of 8 and 16 years old. The service has twelve beds but occupancy levels vary according to dependency. Dependency is measured using a scientific measure (CAMHSAID), this tool helps match the care needs of the child with the available recourses to ensure that each child who is admitted receives optimum and holistic treatment during their stay. This is evaluated regularly at team meetings.
Young people admitted to Galaxy House have extremely complex needs and may not “fit” a diagnosis. Care is multi-faceted and involves a number of agencies so as to provide the full range of support and intervention that these children may need. User involvement is actively promoted and care is provided within the recognised legal frameworks of the Children’s Act and on occasion the Mental Health Act (1983). When planning care every attempt is made to coincide with NICE (National Institute for Clinical Excellence) guidelines regarding the psychological well being of children and also incorporate recommendations from the NSF (National Service Framework) for Children. More information on these documents can be found on the Department of Health website .uk. The nursing philosophy and other information provided in this pack will give more information on the service Galaxy House provides. We hope you enjoy your time at Galaxy House and that it offers both paediatric and mental health nursing students something unique in terms of a placement opportunity.
|GALAXY HOUSE in CONTEXT |
Child and Adolescent Mental Health Services (CAMHS) promote the mental health and psychological well being of children and young people. They provide high quality, multidisciplinary mental health services to all children and young people with mental health problems by the use of effective assessment, treatment and support.
The term CAMHS tends to be used in two different ways. It is commonly used as a broad concept that embraces all those services that contribute to the mental health care of children and young people, whether provided by health, education, social services or other agencies.
It is also used to describe universal services whose primary function is not mental health care, such as GPs and schools. This explicitly acknowledges that supporting children and young people with mental health problems is not the responsibility of specialist services alone.
However, the term is more often used to refer only to specialist child and adolescent mental health services (in other words, services operating at Tiers 2, 3 and 4 of the four-tier strategic framework - see below).
WHAT DO THEY DO?
CAMHS delivers services in line with a four-tier strategic framework which is now widely accepted as the basis for planning, commissioning and delivering services. Although there is some variation in the way the framework has been developed and applied across the country, it has created a common language for describing and commissioning services.
Most children and young people with mental health problems will be seen at Tiers 1 and 2. However, it is important to bear in mind that, services and young people do not fall neatly into tiers. For example, many practitioners work in both Tier 2 and Tier 3 services,
Similarly, there is often a misconception that a child or young person will move up through the tiers as their condition is recognised as being complex. In reality, some children require services from a number (or even all) of the tiers at the same time.
The model is not intended as a template that must be applied rigidly, but rather as a conceptual framework for ensuring that a comprehensive range of services is commissioned and available to meet all the mental health needs of children and young people in an area, which have clear referral routes between tiers.
TIER 1
CAMHS at this level are provided by practitioners who are not mental health specialists and work in universal services; this includes GPs, health visitors, school nurses, teachers, social workers, youth justice workers, voluntary agencies.
Practitioners will be able to offer general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development, and refer to more specialist services.
TIER 2
Practitioners at this level tend to be CAMHS specialists working in community and primary care settings in a uni-disciplinary way (although many will also work as part of Tier 3 services).
For example, this can include primary mental health workers, psychologists and counsellors working in GP practices, paediatric clinics, schools and youth services.
Practitioners offer consultation to families and other practitioners, provide outreach to identify severe or complex needs which require more specialist interventions and assessment (which may lead to treatment at a different tier), as well as training to practitioners at Tier 1.
TIER 3
This is usually a multi-disciplinary team or service working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and young people with more severe, complex and persistent disorders.
Team members are likely to include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists, art, music and drama therapists.
TIER 4
These are essential tertiary level services for children and young people with the most serious problems, such as day units, highly specialised outpatient teams and in-patient units. These can include secure forensic adolescent units, eating disorders units, specialist neuro-psychiatric teams, and other specialist teams (for children who have been sexually abused, for example), usually serving more than one district or region.
Practitioners working in CAMHS will be employed by a range of agencies. Many (but not all) of those working at Tier 1, for example, will be employed directly by the PCT or the local authority.
CAMHS specialists working at Tier 2 are less likely to be working for the PCT (although some of them might be), and more likely to be working for another NHS trust (or the local authorities in the case of educational psychologists)
Most practitioners working in the more specialised services at Tiers 3 and 4 will usually be working for other types of NHS trust (such as mental health trusts, acute trusts or care trusts, for example).
|THE TEAM |
|Clinical Nurse Manager |
|Mike Smyth |
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|Practice Development Nurse |
|Jane McEneaney |
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|Team Leaders |
|Lucy Billington |
|Andy Wood |
|Pru Toby |
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|Staff Nurses |
|Steve Ward |
|Eddie Corcoran |
|Emma Williams |
|Denise Holmes |
|Martyn Gallagher |
|Nicola Rushton |
|David Neilson |
|Molly Dunn |
|Kim Lee |
|Hayley Sampson |
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|Clinical Support Workers |
|Claire Wilkinson |
|Jackie Ireland |
|Jack Southward |
|Linda Cooper |
|Emma Riley |
|Paul McKenzie |
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|Ward Clerk |
|Clare McKenna |
|Consultant Child and Adolescent Psychiatrist |
|Dr Jane Whittaker |
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|Clinical Psychologist |
|Dr Paul Abeles |
|5327 |
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|Specialist Registrar/s |
|Rotational |
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|Senior House Officer |
|Rotational |
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|Assistant Psychologist |
|Catherine Keen |
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|Occupational Therapist |
|Kirsten Taylor |
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|Domestic Assistant |
|Simon / Caroline |
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|EDUCATIONAL SUPPORT and LINKS |
There are a number of people who can support you during your placement. Galaxy House is linked to both Manchester Victoria University and The University of Salford and accepts students from both the paediatric and mental health branches of the course. The following is a list of individuals from the Higher Education Institutions, the Trust and clinicians from Galaxy House who take a lead with students. All our E and F grades have attended recent associate mentor study days and curriculum updates and should be familiar with your paperwork. The following individuals are all available for advice, guidance and support;
Clinical Placement Development Managers (CPDMS);
Roisin Bradley CMFT
Roisin.bradley@cmft.nhs.uk
Manchester Mental Health and Social Care NHS Trust, Andrea Fox andrea.fox@mhsc.nhs.uk
Academics in Practice/University Link Lecturer
Salford University Moira McLoughlin m.mcloughlin@salford.ac.uk
Manchester University Steven Pryjmachuk steven.pryjmachuk@manchester.ac.uk
Practice Based Educational Support
Practice Development Nurse
Jane McEneaney jane.mceneaney@cmft.nhs.uk
Support is also available from your personal tutor and your clinical guide. The people in the list are involved in evaluating, reviewing and improving the placement standards and the educational experience. This happens through audit, working to agreed standards and benchmarking to promote excellence in learning.
Of course the most accessible people to ask for support will be those you are directly involved with on placement. These include all other staff including NA’s, Clinical Support Workers, nurses, and other students who may have been there longer than you or may be more experienced than you. Your primary source of guidance and support will be your mentor and associate mentor who will be allocated to you prior to your arrival.
|FIRST DAY and the LEARNING ENVIRONMENT |
When you arrival, a member of the nursing team will be allocated to complete your induction. This will ensure you become familiar with issues in relation to security, safety and the geography of the unit. The team structure, hierarchy and function will also be explained to you with a brief outline of the role of different members of the team. The induction package is currently under development so any ideas you have following your induction would be welcome. You should also have the introductory meeting with your mentor and associate mentor.
It is advisable that you familiarise yourself with the trust and Galaxy House policies and guidelines, these are available in the nursing office and on the intranet and will be available throughout your placement.
You may also find it helpful to review any recent literature in relation to child and adolescent psychiatry and any current research, audit and practice development being undertaken within Galaxy House and the wider Greater Manchester CAMHS network. There are various books and resources available in the Family Room. Different members of staff have literature on various topics depending on their area of interest. The Practice Development Nurse can advise you where to access these resources. Evidence Based Practice is seen as a priority at Galaxy House and is promoted through Case presentations and Journal Clubs which the student can attend.
The RMC Hospital site also has a library with copies of numerous journals which the student can access. The Practice Development Nurse is also available to help students with electronic literature searching on a particular topic through electronic databases. Useful websites include;
o aditus.nhs.uk
o nelh.nhs.uk
o .uk
o
o bjp.
o .uk
o .uk
o rpsych.ac.uk
o .uk
These websites have information on research and best practice within the field of child and adolescent mental health as well as published clinical guidelines and integrated care pathways. You can also download the National Service Framework for Children and Young People from the Department of Health website.
|PRACTICALITIES |
o Early shift 07 00 – 15 00
o Late shift 13 00 – 21 00
o Night shift 20 30 – 07 15
These times can be modified to meet the needs of the student however this would involve negotiation between the practice placement manager, your allocated mentor and yourself.
It is advisable to vary your shifts to obtain a greater understanding of the service and to gain an insight into a 24 hour period on Galaxy House. You should aim to work the majority of your shifts alongside your mentor.
You must notify the ward and the university as soon as possible should you require time off, study leave or if you are off sick. When telephoning Galaxy House you should ask to speak to the shift co-ordinator. Study days are not routinely allocated during the placement as the course structure allows for these to be taken whilst the student is at University. If you are researching a topic related to a clinical/practice development issue pertinent to the placement you could request ward based study time to facilitate this. Support will also be given if a student is basing an academic piece of work on their placement experience e.g. a reflection, care study.
WARD MANAGEMENT
Handovers are at 07.00 am, 09.00 am, 13.00 pm and 20.30pm. You will be expected to attend the handover at the start of your shift. They are held in the “family room”. Handovers are read from the documentation in the patient’s notes which will have been completed prior to handover.
SHIFT CO-ORDINATOR
Qualified staff take turns in co-ordinating individual shifts. They will allocate team members to individual young people dependent on who is in whose care team. This person will be responsible for all aspects of a young persons care throughout the shift including contemporaneous documentation. The practice is to follow the primary nursing model rather than task allocation. If there is a particularly challenging patient you will only be caring for them with the close supervision of a qualified nurse. Dependent on your level of training you will get the opportunity to co-ordinate a shift by shadowing a shift co-ordinator.
TEAM MEETINGS
These are every Monday morning from 0930 to 12.00. Everyone from the team can attend. Once you are more confident you can present at this meeting and provide feedback afterwards.
SECURITY
All students must have been police checked. The ward is locked not to detain patients but to prevent intruders. Entry is gained via an intercom system, or by using a swipe card. Your university identity badge must be worn at all times. There are car parking facilities near by, but these come at a cost. There is some parking available on the roads nearby.
OFF-DUTY REQUESTS
Your off duty will be negotiated with your mentor. Please be aware that the aim is to have no more than two students a shift and that students are not to alter the sheets themselves. Students are reminded that they cannot take annual leave days outside the leave already granted by the university. Promptness, reliability and good organisation will be reflected in the student’s final assessment.
UNIFORM POLICY
We don’t wear a uniform at Galaxy House. Smart casual attire is fine, jean and trainers are acceptable too provided they are not too scruffy. No lip/eyebrow piercing, open toed sandals, high heels, g-strings on show, crop/low cut tops, mini skirts, hot pants or low hipsters. Please be sensitive to the client group, and think about what may be provocative. Skirts are okay but are not very practical when pursuing more active activities. Students who wear spectacles should also be aware of the additional risks to them during outdoor activities.
STAFF FACILITIES
Staff and young people share meals together in the dinning room. This provides a good role model, encourages a sense of community. You can have the hospital food or bring your own. Outside this you are entitled to a half hour break away from the unit. This will be allocated at the start of the shift by the co-ordinator. Decent facilities for taking breaks are limited. There is a staff toilet; this is located just off the ward. There is a staff room; here you can keep your bag and coat.
CHILDREN’S FACILITIES
Play is one of a range of creative activities used in CAMHS settings. It is can be initiated by staff with specialist training i.e. play therapists and occupational therapist but also by the nurses. Staff employed with Manchester Hospital Schools and Home tuition services provides education. School starts at 9 30 am and finishes at 3 15 pm. There are 15-minute breaks at 11 00 am and 2 00 pm and an hour for lunch between 1200 and 1300. The nursing staff serve meals and promote a sense of community and normalisation by sitting down and eating our meals with the young people. Breakfast is between 8.30 and 9 00 am, lunch is at 12.00 and tea is at 17.00 pm. The young people also have snacks at break times. Some young people will be on fairly structured eating programmes. These are care planned and must be rigorously followed. Young people who do not have an individualised dietary regime have a tendency to put weight on in in-patient units. Therefore sweets and chocolates should be given out sensibly and healthy eating promoted at all times.
Visiting time is between 18.00 and 20.00 pm and is more flexible at weekends open at the weekend. There are no visits on Monday &Thursday evenings; this is the young people’s activity evening. There is now parent accommodation, off the ward at the newly opened Ronald Mcdonald house. Young people have access to the TV in the main lounge and can watch this after school.
Dependent on age and normal routine all the children have individual bedtimes, however a rough guide is, primary school age bath time, lights out and settled down by 20.30 pm and for secondary school age by 22.00pm.
Young people have access to the hospital chaplain and other religious services if needed, we also devise culturally sensitive plans of care if a child has a particular spiritual needs e.g. support with fasting during Ramadan, a quiet space for praying, halal/kosher diet.
ACCOUNTABILITY AND RESPONSIBILITY
All students should be aware of the limitations of their role contingent with where they are up to in their training. Students must never carry out a task unsupervised if they feel uncomfortable doing so. In reality this applies to most 1st and 2nd year students. It is in the 3rd year where students will be expected to practice more autonomously with less direct supervision. The student must always
o Be supervised doing a drug round
o Be accompanied by a substantive member of staff when escorting a patient
o Only do special observations in their 3rd year and ideally have done them elsewhere first. This must be an exposure, not a routing part of your working day.
o Be supervised giving a handover and reading out reports/ feedback and team meeting and 6 weekly reviews
o Be supervised for their initial sessions during individual work
o Be supervised doing family work
o Students will never be involved in safe handling techniques of a patient when the patient is highly aroused. If they do so they will be acting outside the limitations of their responsibility and putting the patient, the staff and themselves at risk, this also applies to rapid tranquillisation. Alongside this if a patient is being held the student is not to enter the room to observe, the patient will be extremely distressed and unnecessary people being involved is a breach of their privacy and dignity. In such circumstances the student is expected to use their common sense and take the other young people to a safe area and engage them in a safe recreational activity away from where the aroused young person is being held.
We have developed a set of criteria to aid your learning and to link to the taxonomy that guides both theory and practice learning for pre-registration nurse education. This is also be linked to your practice assessment documentation, so that when you are preparing for final summative assessment with your mentor you will have been supported and enabled over the period of your placement to achieve the learning outcomes in a specialist child and adolescent mental health service.
PAN Manchester nursing assessment documentation outcomes.
Proficiency Evidence that must be provided to achieve in this area
Professional & Ethical
1). Using a copy of the Code of Conduct explore expectations and document in initialplan.
Yr3 provide an example of how you have utilized the C of C during placement.
2). Be able to describe ‘informed consent’ and ‘Frazier guidelines’ (Gillick).
Yr 3 Provide an example of consent.
3 ).Reflective piece ready for mid-point meeting
Care Delivery
4). For mid-point discuss stages of therapeutic relationship with mentor.
Yr 3 describe the stages of the therapeutic relationship. Highlight any particular problems associated with this client group.
5). Entry in nursing notes or care plan. Entries in notes or care plans with relation to
promoting health
6). Attend ‘assessment’ or ‘New case clinic’ (NCC), or ‘home visit’ (H/V).
Write up the ‘assessment’ using documentation.
7). Care plan - must be signed by Nurse YP and carers.
8). Choose 1 medication - Discuss risks and benefits.
Locate a copy of the CMMC ‘side effect medication questionnaire‘.
9). Verbally reflect on the assessment documentation completed for 6
10).Complete ’team meeting’ document, and action the points agreed.
11). Attend ‘Intake & Allocation’ meeting.
Observe how decisions are made, and discuss what factors could influence the outcome of the decisions made.
Care Management
12). Evidence of reporting ’jobs’ ’Job reporting book’ of completing an ‘incident form‘.
13). Attend a ‘Review’ meeting. Document recommendations in the nursing notes, and handover to the team at next shift.
14). Look at guidelines for ‘Role of the Co-ordinator’ Co-ordinate shift, and discuss time management & organizational skills.
15). Can use the report from the NCC or H/V or assessment as at point 6.
16). Calculating weight charts, and medication administration.
17). Evidence of a typed report stored on computer in the correct place. This could be report from 6, or care plan from 7, or inc rep from 12
18). Attend ‘care team’ meeting or ‘Nurse business meeting’, or assessment with a nurse, as at
Personal /Professional Development
19). Attend Friday teaching sessions. Observe a ‘Quality Care round’ audit.
20). Regular documented meetings with associate mentor / mentor.
Co-ordinate shift as at 14
Provide evidence of learning a new skill to mentor, in the form of a teaching session. E.g. Following eating plan, preparation, supervision and documenting. Blood sugars. Urine dipstick. Describe ‘behaviour reward’ programme.
|GALAXY HOUSE PHILOSOPHY |
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At Galaxy House we are committed to providing holistic evidence-based care with a focus on a family-centred approach. We aim to respect difference and diversity by providing care that is individual and un-biased by age, race, gender or the child’s learning and developmental level.
Individualised plans of care are provided for young people with complex needs, who often present with two or more diagnoses. We promote a culture of user and carer involvement in care planning to ensure the young people have their say in their care, and we encourage a collaborative approach promoting honesty, trust, and open communication and feedback. Young people and their families are valued as an integral part of the care team and their views are treated with respect. The care we provide for the young people is multi-faceted using a variety of interventions with an emphasis on cognitive behavioural and psychosocial approaches. We place a strong emphasis on the development of therapeutic relationships as foundation for the development of future intervention. These relationships are based on empathy, warmth, a non-judgemental attitude and a strong sense of self-awareness on behalf of the nurse.
We endeavour to be holistic in our care drawing on models of nursing that use a variety of theories and approaches. Underpinning the nursing care is the Therapeutic Milieu model which looks at the individuals needs through safety, support, structure, involvement and validation, and Maslow’s hierarchy of needs, which highlights the need to provide young people with shelter and nourishment but also encourage and empower them to fulfil their potential. By focussing on needs rather than problems we attempt to build and nurture young people?
At Galaxy House we work with young people who present with challenging behaviours. Young people are encouraged to take responsibility for their behaviour and the impact it may have on others, in order to develop respect and empathy for others. Bullying amongst the peer group will not be tolerated and is dealt with fairly and assertively. Our approach to challenging behaviour is non-punitive and focuses on re-enforcing the positive and avoiding re-enforcing the negative. This is to build self-esteem and develop the insight and social skills of the young people so they can begin to make more positive choices about their lifestyle and future.
We provide a nurturing, relaxed home for young people during their stay with a strong commitment to the “therapeutic day”. This is a day that is structured to provide meaningful, recreational, therapeutic and educational activities appropriate for each young person. It also encourages young people to develop their organisational skills, a meaningful regime and pride in their environment. Adherence to the therapeutic day discourages boredom and frustration, which in turn can trigger negative and aggressive behaviour. The environment is designed as such to provide the right amount of stimulation and young people are encouraged to be as autonomous as possible.
Every effort is made to promote and up-hold strong multi-disciplinary team working and interagency working in order to provide clinical excellence for young people. We aim to continually diversify and change practice according to evidence based recommendations, clinical audit and published guidelines. We have an active interest and commitment to provision of care that is culturally sensitive for all ethnic groups. We also act as advocates on behalf of the young people and access other agencies such as the Patient Advocacy and Liaison Service (PALS) to support this process.
Nursing staff have the right to feel valued and supported and are encouraged to access clinical supervision to develop self-awareness and reflect on practice issues. We also have a thorough induction and appraisal process to identify staff’s strengths and development needs, and accordingly access training for their personal and professional development. All nurses’ practice within the Nursing and Midwifery Council code of professional conduct for nurses, midwives and health visitors and professional development is positively encouraged. We are committed to developing evidence based care and change accordingly and lastly our service continually seeks to enhance user involvement and consultation.
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|ASSESSMENT PROCESS |
First week
Your initial discussion with your allocated mentor should take place within the first week of the placement. Within this meeting you will agree on an action plan, resources and support required to assist you to achieve outcomes during your placement. The date for your mid-point interview will be agreed at this meeting.
Mid-point
Learning opportunities will be negotiated and supervision of activities will be carried out on an ongoing basis. Specific skills observed, taught or performed should be recorded in your clinical skills log. Further learning needs should be identified and a final assessment meeting should be arranged. This interview should be used as a forum to discuss any concerns either party may have regarding the progress of the placement and draw up SMART action plans detailing how to address them.
Final point
At this interview the student and mentor will meet to pull everything together and sign off the assessment documentation and supporting evidence. Progress and development will be discussed and identification of future learning needs and specialist areas of interest. This is also a time to reflect on and evaluate the placement highlighting positive aspects and possible areas for future development.
|SKILLS FRAMEWORK |
The level of nursing skills you have achieved will depend on what point you are in your course. However it is likely CAMHS will be new to you and you will have the opportunity to learn some unique skills here as well as developing some of your core nursing skills. You could think about incorporating skills development into an individual action plan that you could work on during your placement. Galaxy House will also provide you with the opportunity to enhance your core skills so as to become a more holistic and competent practitioner. The following are skills we would hope you develop here at Galaxy House;
|CORE SKILLS |
INTERPERSONAL SKILLS AND COMMUNICATION SKILLS
SHIFT CO-ORDINATION, ORGANISATIONAL AND DELEGATION SKILLS
PROBLEM SOLVING SKILLS
ADMINISTRATION OF MEDICATION SKILLS
This is a practical skill you will have learnt about on other patients; however the medications used at Galaxy House are sometimes called “psycho-tropic medications” and have complex clinical indications and side effect profiles. Select 2 of these medications (e.g. and anti-depressant and a benzodiazepine) and list their indications, contra-indications side-effects, dosage range, adverse reactions and what the NICE guidelines are in relation to these medications used in CAMHS,
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PHYSICAL OBSERVATIONS
LIAISON WITH OTHER DISCIPLINES/MDT WORKING/TEAM WORKING
o What other disciplines does the nursing staff at Galaxy House liaise with?
o Why is this so important?
o Outline any problems you anticipated related to MDT working/team working. What might happen to a patient if team working breaks down?
REFLECTIVE SKILLS/DEVELOPING SELF-AWARENESS
o Why is self-awareness important in an environment like Galaxy House?
o If self-awareness is absent how may this affect your nursing care?
o Describe the process of reflection you would follow after spending time at
Galaxy House,
o How could this improve your practice?
o What systems are in place at Galaxy House to support the reflective process?
HOW TO CONDUCT AN EFFECTIVE HANDOVER
o Why is this important at Galaxy House?
o What is the aim of handover meetings?
o Identify barriers to an effective handover?
o Identify essential information to be included
o What can be left out?
INCIDENT REPORTING
ADVOCACY SKILLS
o Why do we need to advocate for patients?
o In what circumstances would you need to advocate for a child?
o What does advocacy involve?
o What external advocacy services exist for the young people and families?
HEALTH PROMOTION SKILLS
o How would you promote health at Galaxy House?
|SPECIALIST CLINICAL SKILLS |
These are skills that you will be introduced to during your time at Galaxy House. You may not observe all of them but through time spent with the young people you will have the opportunity to see some of these techniques being implemented.
Below are a list and a brief explanation of some of these specialist skills. Think about how you can include development of these skills into your action plans and how you may be able to take them forward for use in the future in other practice areas.
Special Observations
Also called “specialling”, “1;1s” and “close observations”, or Level 1 observations. This is only used in exceptional circumstances when a patient is posing extreme risk to themselves, or other people, or is very vulnerable due to their mental health status/learning disability. It should only be used after thorough discussion and review by the team and after all other interventions have failed. It should not be used as a “knee jerk” reaction to risky situations or as a simplistic way of managing a “problem” patient. There are several levels of special observations; before implementing special observations the team must consider all the risk factors, ethical and moral issues involved. Progress plans should also be formulated as soon as an individual is placed on special observations, i.e. in what circumstances should the level of observation be reduced and the intervention and necessity for it must be reviewed daily.
1. Arms length, this is rarely used and only if there is risk of near fatal self harm or serious assault/extreme agitation. This type of special observation is very intrusive and invasive of the patient’s personal space and has huge impact on their privacy and dignity particularly as it involves entering toilets and bathrooms. Students should not be involved in this type of special observation, only those staff who have received training in positive handling techniques.
2. In sight and hearing distance This is more commonly used as it maintains the patient’s safety but is not as intrusive as arms length observations. When patients are using the bathroom/toilet they can be monitored by the member of staff putting a foot in the door or letting it close without locking and maintaining verbal contact throughout. However there are still big implications for the patients privacy, dignity and autonomy and this type of observation should also only used for as short a time as possible.
3. Intermittent Observations this is when the patient is observed at discrete intervals and is usually part of the process when someone is being weaned off 1:1 observations. The intervals will typically be 1 in 10, 1 in 15 then I in 30 minute intervals in graduated steps over a distinct period of time decided by the MDT. The steps should be graduated over a time period that is in context to the severity of the problem. Each reducing regime from 1:1 back to general observations should be unique to the individual concerned and be carefully care planned with criteria for when the Obs should be reduced and also when they may need to be put back up again.
There is a wealth of literature about special observations, representing different legal and moral standpoints. From a young persons point of view the most recent research suggests that although at first being on special observations can be a comforting and reassuring experience it soon becomes intrusive, ineffectual and burdensome and actually exacerbates the symptoms/behaviour the staff and young person wants alleviation from. The decision the implement special Obs should be multi-disciplinary, in collaboration with the young person and continually reviewed and evaluated.
Therapeutic Groups
Group work is an essential part of the treatment programme at Galaxy House. Groups provide a vital forum for expression of feeling and emotion and also a space in which a young person can define their strengths and difficulties. Although groups are also about having fun they need clearly defined rules and boundaries with a shared focus. They aim to promote self-expression, social interaction, collaboration, teamwork and enhance self-esteem and confidence through positive reinforcement and building on achievements. Groups currently being run at Galaxy House include the Gardening Group, the Creative Group, the Social skills group and 3x weekly community meetings. They are also a useful way of assessing the young people and how they “gel” with each other, who plays what role within the group i.e. leader, passive participant, negotiator etc.
Observational skills related to monitoring mental state
These skills can be picked up through observation of positive role models. They can be learnt both experientially and also by spending time with more experienced persons. Some of the cues that a young person may be experiencing deterioration in mental state are commonly mistaken for bad behaviour. Psychopathology, particularly in younger children presents as very “behavioural”. Through monitoring a young persons sleep, appetite, interactions, gait, non-verbal communication, tone of voice, role in the group, mood and behaviour you will learn a lot about psychopathology and how it relates to different conditions. You will also learn what indicates a young person may be hearing voices or having intrusive thoughts, such as them being easily distracted, vague and irritable.
Preparing reports for multi-disciplinary reviews
These reports encompass all the assessment and care activities that have taken place with a young person and often are focussed around the 5 different dimensions of the self. They cover issues such as social functioning, development, mental state, risk, family life, education and discharge planning. They also include a set of recommendations for future care planning with people assigned to each one within an agreed time frame. They need to be detailed, concise and relevant making sure all the main points are explored in enough depth without digressing or rambling and they need to be fairly tightly structured, a lot like an assignment! It is also important they are written in sufficiently enough of a scholarly style with good spelling and grammar. Parents, referrers and commissioners read these reports, amongst others.
Organising social, recreational and therapeutic activities
In addition to the groups, nursing staff are responsible for the overall milieu making sure the environment is a therapeutic tool in its own right. To achieve this there must be the correct balance of structured and unstructured time so the young people are neither bored nor over stimulated. Each young person will have an individual time table that will include a mixture of relaxation, education, free time, therapy and recreation time. Activities are achievement orientated and fun. They include cooking, games, pool, table tennis, art, music, going out for walks and more organised trips to places like Heaton Park or Knowlsley Safari Park. Young people have free time to read, listen to music or just chill. Tidying their bed spaces and doing their laundry and personal care is also incorporated into their daily routine.
Organising de-brief following an incident
De-brief happens following a particularly distressing, difficult or dangerous incident. It often occurs following acts of aggression, violence or self-harm. It also occurs following the discharge or a particularly challenging or difficult patient. Good practice indicates that time for de-brief should be protected time. Due to the emotionally and draining nature of working in CAMHS there is de-brief time at the end of each shift. This is facilitated by the shift co-ordinator and is a time and space for staff to ventilate their feelings, reflect on how the shift has gone and share their experiences and frustrations with their colleagues. Students can participate in de-brief but are not expected to lead on it as it is something that should be done by a more experienced facilitator. This opportunity to share and talk through things has been shown to ease some of the pressure staff may feel and go some way to ensuring staff don’t feel isolated or burdened, it also reduces the risk of burn out. It should not be confused with clinical supervision or the staff consultation group, which are other more formal forms of staff support.
Research based outcome measures and assessment tools
As part of the holistic assessment at Galaxy House and in line with clinical guidelines and evidence based practice the team use a number of standardised outcome measures and assessment tools. These are empirical measures that are used to evaluate the efficacy of care (outcome measures) and assist in gaining a deeper understanding of each Childs clinical picture and the severity of their symptoms. They are a very useful aid when “picking apart” the complex threads of a young person’s presentation. They are used alongside, not in place of the teams more ongoing qualitative observational assessment of symptoms. They are often presented in a questionnaire/multiple choice format. Some the young people can complete themselves unsupervised, some are observation only and some are for the young person and staff member to go through together. Afterwards they are scored to give an indication of the severity of the problem. Staff can train students to use these tools whilst on placement. They shouldn’t administer them without some form of training first and must be supervised when interpreting the results. Below is a table with some of the more frequently used tools.
|Tool/Measure |What is assessed? |
|C.D.I |Adapted from the adult version the Beck’s Depression Inventory, measures |
| |presence and severity of depressive symptoms |
|Childhood Depression Inventory | |
|Cheat / SABS |Tools utilised to measure behaviours surrounding food / mealtimes |
|Conners |Measures extent of ADHD symptoms, administered by clinicians, in schools |
| |and by parents to gain an overall accurate picture |
|HoNOSCA |Outcome measure used in CAMHS to assess efficacy of intervention and |
| |progress/deterioration over time, a good indicator of whether a particular|
|Health of the Nation Outcome Scales for Children and |approach is effective or not with an individual |
|Adolescents” | |
|Spence |Assesses presence and severity of anxiety symptoms |
|Impact of Events Scale |Assesses how severely a young person may have been affected following a |
| |stressful event and whether this has triggered post traumatic stress |
| |disorder |
|Benny-Anthony |Family relationships assessment tool, assesses how the child perceives the|
| |different members of their family and their relationship to themselves |
|P I P S |Assesses whether an individual is experiencing psychotic symptoms, their |
| |frequency, intensity and duration |
|Psychotic in-patient schedule | |
|P A N S S |As above but looks more closely at negative symptoms such as withdrawal |
| |and social isolation |
|Positive and Negative Symptom Scale | |
Family work
Working with family is an essential part of the treatment process as without this all the care planning and implementation would be futile. Family work is provided regularly by the child’s consultant and a consultant family therapist. Tom O’Neil.
Individual Sessions
One of the key tasks of the nurse’s role is to build a therapeutic relationship with the young people they are key nurse for and from this address specific therapeutic tasks such as social skills, expression of thoughts and feelings, confidence building, self-esteem work, anger/anxiety management, development of insight, self-monitoring of thoughts and symptoms and relapse prevention. The nurse will do this through individual sessions. A timetable for these sessions will be planned in advance in collaboration with the young person. At first the sessions are fairly unstructured and are focussed on development of trust and honesty, as they move on however and key issues and themes begin to emerge the sessions will become more structured and focussed and each one will have a goal and expected outcome. It is important the nurse demonstrates their commitment to the therapeutic relationship by adhering to the time table and being on time for sessions and protecting the time allocated for them. Failure to do so will lead to disengagement on behalf of the young person and a lack of trust in the nurse.
Behaviour programmes
The fundamental underlying principle behind these types of programmes is positive re-enforcement to reward good behaviour, therefore re-enforcing the appropriateness of this behaviour and hoping some social learning takes place. At Galaxy House we try to avoid negative approaches such as sanctions or punishments although at times we have to be fairly assertive in our limit setting due to the challenging and damaging nature of some of the behaviours. As far as possible we ignore the negative and reward the positive. Behaviour programmes identify target behaviours they want to increase or reduce. An activity is chosen that the young person really enjoys and the programme is geared towards them having access to more of that activity. For younger children it is usually sticker charts and is fairly visual and the activity may be something such as time on the play station or in the ball pool. Each sticker gained contributes to more time spent doing that activity. E.G. child x swears a lot, each half hour without swearing equates to 5 minutes on the play station, to be taken at 6.00pm. For older children (young adolescents) the reward may be a bit more substantial, not using stickers but verbal re-enforcement and may be something like a trip out or unescorted time off the unit.
|HUB AND SPOKE MODEL |
This is essentially exactly what it says. Galaxy House is the main “hub” placement as the central or main placement and where all the action planning takes place. From Galaxy House there are a number of contextually related “spokes”. They are linked to Galaxy House by referral pathways, clinical similarity or interagency networking. By going on meaningful spokes the student will gain a deeper and more holistic understanding of the patient’s journey, where they have come from and where they may be going. It is also a very interesting experience for the student to find out more about the specialised nature of CAMHS.
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Please find a list of possible spokes around the Greater Manchester and wider North West region enclosed below. The list is not exhaustive however and you can do your own research to find relevant spoke placements that you may be able to access. It isn’t solely down to your mentor to sort this out for you, it’s a collaborative effort and you need to be proactive and take charge of your own learning. Initiative in doing so will be reflected in your final assessment documentation when your achievements are signed off.
NORTH WEST CAMHS UNITS FOR POSSIBLE SPOKE PLACEMENTS
Bolton CAMHS Eating Disorders Clinic
01204 390659
Gardener Unit, Forensic Adolescent Service
Contact: 0161 772 3425
McGuiness Unit
Contact: Tel; 0161 772 3678
Orchard Adolescent Unit, Cheadle Royal
Contact: Ward Manager Mark Gilligan, Tel; 0161 4289511
Pine Lodge Young Peoples Centre, Chester
Contact: Ward Manager Tracy Kempster 01244 364776
The Priory Hospital Altrincham Adolescent Unit
Contact: Ward Manager Shepherd Nhariwa Tel; 0161 904 0050
Red Oak Child and Family Services, Lancaster, Lancashire
Contact: Unit manager Terry Drake 01524 842266
LOCAL DISTRICT CAMHS TEAMS (TIER 3)
Central Manchester, The Winnicott Centre Contact Alison Knowles Tel: 0161 248 9494
South Manchester - The Carol Kendrick Unit Contact Deborah Kay. Tel: 0161 291 3733
Hope Unit – Fairfield Hospital 0161 918 8505
Chronic fatigue service – Alex Woore 14517
Rochdale CAMHS - Contact Mark Wood Tel 01706 754349
Bury CAMHS contact John Henstock Tel: 0161 705 3526
In addition placements could be arranged with
- clinical psychology
- the child and adolescent psychodynamic psychotherapist (Simon Cregeen)
- the family therapist (Tom O’ Neill)
- Galaxy House School (Jim Riley)
- the Webster Stratton Nurse Practitioner (Paula Grimes)
- the social development clinic (Dr. Jonathon Green)
These all count as spokes; you can find their numbers on the ward or by going through switchboard.
|TIME TABLE FOR FIRST WEEK |
Your first 3 days will be 9-5s to allow for orientation and induction. Following this you will have worked out your shifts with your mentor. The activities you undertake will be dependent on your shifts, however below is a range of some of the activities you can do in your first week. Some of you may also need to incorporate a study day into your time-table (Manchester University BSc students).
| |Monday |Tuesday |Wednesday |Thursday |Friday |
|Am |Introductions |6 weekly review of a young person|New Case Clinic |Spend time with young people in |Community meeting |
| | |CPA review | |school |Prepare young people for the weekend |
| |Orientation to ward, commence | | |Or Social Development Clinic | |
| |induction | | | | |
| |Community meeting | | | | |
| |Team meeting | | | | |
|Lunch |Attendance at handover |Lunch with young people, handover|Handover, lunch with young people |Handover, lunch with young people|Some young people home for the weekend |
|Pm |Case presentation |Familiarise yourself with |Familiarise yourself with |Staff meeting |Practice Development Education group |
| | |procedures. |documentation, assessment tools | |Or |
| |Admission meeting |Read through clinical notes | |Young peoples activity evening |OUR Group |
| | |Social skills group | | | |
| |Creative group | | | | |
This time table isn’t prescriptive but may help give some structure to the first week and an overview of Galaxy house. There may be other activities/ experiences going on that you can become involved with. So feel free to plan these with your mentor.
|THERAPEUTIC APPROACHES |
Galaxy House has an eclectic approach to treatment and care delivery. A variety of therapeutic approaches are used depending on the need and clinical presentation of each young person. There is no one all encompassing therapy that fits everyone so each programme of care is tailored to meet the individual’s needs. All treatment approaches have a strong evidence base and are empirically supported by clinical trials, case studies, audit, published guidelines and other forms of clinical evidence. The list below summarises the main therapeutic modalities that are used with young people with mental health problems.
Cognitive Behavioural Therapy
One of the most effective and widely used therapies for both young people and adults this approach is based on the underlying principle that thoughts feelings and behaviour are inextricably linked. Through a guided process the therapist will explore the person’s automatic negative beliefs, unhelpful or negative thoughts and subsequent maladaptive coping behaviours. The client is then encouraged to replace or modify their negative thoughts through skilled questioning and appraisal techniques and carefully planned behavioural experiments. Relaxation and social skills work is also undertaken. Originally CBT was used for anxiety and depressive disorders but it is now widely being used with a huge range of mental health conditions including eating disorders, psychosis, and even some personality disorders. In CAMHS, pictures, charts and other visual aids are used to aid the process and young people need to self monitor using a thought and mood diary. It requires a certain level of commitment from the young person due to the “homework” tasks that are involved.
Psychodynamic psychotherapy
Less commonly used than CBT and also over a much longer timescale. There are various types of psycho-therapy including Gestalt therapy, person centred and transactional analysis. It originates from the theoretical schools of Freud, Rogers, Jung and Adler and became popular in the first half on the 20th Century. It is based on the premise that many of our desires, dreams, conflicts and motivations are governed by the unconscious mind which remains largely hidden to our conscious state. Where early issues and conflicts have not been resolved maybe as a result of trauma or neglect this manifests itself in problematic feelings and behaviour which interfere with our everyday functioning. Psychotherapy involves sessions with the client where the therapist encourages the client to talk freely about past experiences, thoughts and feelings. With skilled reflective techniques and questioning the therapist and client come to a greater understanding of the client’s internal world and hidden conflicts and can then look at ways to address them. This approach is often used with somatic disorders, phobias, pervasive refusal syndrome, dissasociative states and other complex states such as multiple personality disorder. It requires a long term commitment from the therapist and client often several months or even years.
Creative Therapies
This is an umbrella term for a range of therapies that involve creative activity, art, music, drama and play. All these mediums allow the young person to express themselves more freely and naturally. With the exception of the most articulate young person many struggle to ventilate their feelings verbally and may “act out” difficult feelings and conflicts through acts of aggression, self-harm or self-enforced isolation and withdrawal. Creative mediums give young people an acceptable outlet for these feelings and a therapeutic process is started from which the young person can explore coping strategies and work around building self-esteem and self-confidence. Young people do not have to be particularly talented at a particular artistic medium to benefit from it although through engaging in the process they often discover “hidden talents”! Art often gives the therapist a clue as to what the young person is experiencing in their internal world and how chaotic, intense and frightening that must be. Through drama a young person can role play a character safely i.e. a drunken angry man without fear of reprisals and this allows them to experience and create an outlet for these emotions. For many young people the use of creative therapies can be a cathartic and fun experience.
Psychosocial Interventions
Psychosocial interventions are a range of strategies that are used for people who are suffering from long-term severe mental illnesses such as schizophrenia and bi-polar disorder. They are mainly used in treating psychotic disorders. Symptoms are carefully assessed using a range of evidence based assessment tools and the nurse/therapist then works with the client and family around ways to alleviate and prevent symptoms from reoccurring. The work focuses on looking at triggers and working out someone’s individual relapse signature. The interventions are based on the stress vulnerability model of mental illness and attempts to make psychological environmental and social changes to increase a person’s resilience rather than just using medication. Once a relapse signature is identified the therapist and client will work together to on relapse prevention and a relapse “drill” of things to do when someone starts to deteriorate. They also look at coping strategies for hallucinations and fluctuating mood and how the client can adopt these independently. They are often simple things like listening to a certain type of music or spending time alone in a quiet low stimulus area. Family work is also essential with a lot of Psychoeducation around expressed emotion in the family environment, as high levels of this have been found to adversely affect those suffering from severe mental illnesses. Activity planning and social skills training is also part of the work. The approach has very successful treatment outcomes and due to it’s practical nature can be learnt and implemented by any practitioner working in mental health.
Family Therapy
Information about this approach is included earlier in the booklet. When young people are admitted family work is seen as integral to the treatment process and all other treatment will be ineffective if the family is not completely involved right from the beginning. Some families may just need support and education but others may need more formal psychodynamic input from a qualified family therapist.
Multi-sensory Therapy
This type of therapy is often implemented using a multi-sensory room or “snoezelen” room. This is a special space that has been equipped with a variety of sensory materials to stimulate and soothe all the senses. Usually they contain bubble tubes, projectors; glitter balls an array of cushions and fabrics of different textures, vibrating cushions/mats, hand held massage devices and fibre optic strands. The room may also have more interactive materials such as switches that activate lights and music. In addition to this many have aromatherapy burners to complete the sensory experience. Rooms vary in size and provision; some services even have sensory pool areas and large soft play rooms. As well as the multi-sensory room, other activities and environments are used to enhance the senses such as sensory gardens and ball pools. There are also numerous sensory learning materials available. Sensory therapy is often used with young people who have autistic spectrum disorder or learning disability with measurable success. These children are often sensory impaired and use of certain materials can enhance their sensory experience and encourage development of these senses. For other children the use of the multi-sensory room in particular can be a profoundly relaxing and soothing experience and can provide a safe haven where they can have therapeutic time away from the other young people. Staff always accompany young people into the room and use various guided relaxation techniques and exercises to encourage complete relaxation. The benefit of these environments cannot be emphasised strongly enough, in many cases proactive use of them can divert the need for more restrictive measures such as time out or PRN medication. The multi-sensory room should not be used indiscriminately, it should be individually care planned in every case. Care should be taken with some clients such as those who are hallucinating as if not used correctly it can actually worsen symptoms. The therapist should also be guided by the young person with regards to accessing the different types of sensory stimuli in the room, they may only want a couple of things or it could be over-stimulating it is important to check this out with them as you go through the different sensory experiences.
The therapeutic milieu
Milieu is a French word, the literal translation being “middle space” which we can interpret as middle ground, safe ground or safe space.
The objective of using the therapeutic milieu is to provide patients with a stable and coherent social environment that facilitates the development and implementation of the treatment plan.
As professionals we accept the responsibility for the management of the environment to create a safe space.
Why do we use the therapeutic milieu?
- Containment
To provide physical and emotional safety.
- Support
Staff help the patients feel better and enhance self-esteem
- Structure
Predictable organisation of time place and person
- Involvement
Patients actively attend to their environment and interact with it, having a sense of ownership
- Validation
Individuality of staff and patients is recognised and accepted.
|Clinical Syndromes |
PSYCHOSIS
Psychosis describes a persons lose of contact with reality or their perception of reality being distorted. When an individual cannot tell the difference between what is real and what is not they are said to be experiencing a psychotic episode (Stuart & Sundeen, 2002). The symptoms of psychosis can be divided into 5 main categories
COGNITION
This relates to the problems in information processing, these are often known as cognitive deficits. These can include aspects of memory, decreased attention & concentration, form & content of speech, decision making & thought content. This can materialise as memory problems, for example, pressured speech, incoherence, word salad, poor decision making, lack of insight, illogical thinking, lack of planning & problem solving, difficulty initiating tasks. Delusions can take many forms paranoid, grandiose, religious, somatic, nihilistic, thought broadcasting, thought insertion & thought control.
PERCEPTION
Refers to identification & interpretation of a stimulus based on the information received through the 5 senses. These include hallucinations auditory, visual, olfactory, gustatory, tactile, kinaesthetic (feeling bodily functions), and kinesthetic (sensation of movement whilst still).
EMOTION
Can be hypero/hyperexpressed in an incongruous manner. Mood may vary from hour to hour, from euphoria to suicidal ideation.
MOVEMENT & BEHAVIOUR
Responses can cause behaviours that are odd, confusing, difficult to manage and that can be distressing to others. Examples of odd movements are catatonia, abnormal eye movement, grimacing, apraxia, echopraxia, abnormal gait. Behaviours associated with psychosis are poor personal hygiene, aggression/agitation, repetitive behaviour & volition.
SOCIALISATION
Is the ability to form relationships. Effects seen in patients who are experiencing a psychotic episode are social withdrawal, isolation, low self-esteem, inappropriate behaviour, disinterest, gender identity confusion, ultimately, a decreased quality of life.
It is vital important when communicating with an individual that is experiencing psychotic symptoms that all communication is simple & clear, & where required repeated, or even in written form for the individual to keep. It is common that the individual will need help to fulfil their daily activities of living whilst experiencing the episode. They will also need reassurance and support.
BIPOLAR AFFECTIVE DISORDER
Bipolar Affective Disorder is a severe biological brain disorder in which a young person will have extreme changes of mood (thoughts and feelings), energy and behaviour. They experience periods of being unusually 'high' (manic episode) and periods of being unusually 'low' (depressed episode). This condition is sometimes called 'manic-depression'. The symptoms of mania and depression can also occur simultaneously this is termed a 'mixed' episode. In the acute episodes of bipolar affective disorder the young person's life can be at risk.
MANIA
Mania can present as exaggerated feelings of well-being, energy and optimism. Such feeling can be so intense that there IS a loss of contact with reality - where the person can believe strange things about themselves, make bad judgments, behave in embarrassing, harmful and dangerous ways, thus making life hard to deal with in an effective way. Some signs of mania could include
Subjectively
- Expression of being very happy or excited
- Appearing to have or expressing high energy
- Having lots of new/exciting ideas
- Feeling more important than usual/defiance of authority
- Irritability that others are not as 'happy' as them
- Complaining of boredom
- Expressing own abilities which defy the laws of logic e.g. believing they
have the ability to fly
- Hearing voices that others do not hear
Objectively
- Jumping very quickly between ideas
- Overactive/moving very quickly
- Speaking very quickly, making speech hard to understand
- Agitation
- Excessive involvement in multiple activities
- Dare-devil behaviours
- Inappropriate sexualised behaviour
- Hostile, suspicious
- Verbally or physically explosive
DEPRESSION
Depression presents as very low mood lasting for long periods, which makes it harder for the person to tackle daily living and everyday tasks. Some signs of depression could include:
Subjectively
- Losing interest in things/unable to enjoy things
- Finding decision making hard
- Feeling tired and restless
- Marked loss in self confidence
- Feeling useless/inadequate & hopeless
- Very little or no motivation
- Expressing thoughts of self harm or suicide
- Being mute
Objectively
- Appearing very flat in mood
- Speech is drawn out with no variation in pitch
- No eye contact
- Unresponsive to questions
- Irritable
- Pre-occupied
- Wearing a puzzled bewildered look
- Increasingly withdrawn
- Poor self care
- Isolating self
- Physical symptoms for both mania and depression could include:
- Little OR excessive eating
- Weight fluctuation
- Little OR excessive sleep
- Unusual fast movements (as though startled)
Bipolar Affective Disorder is a chronic, lifetime condition that can be managed, but not cured, with medication, psychological and psychosocial interventions (a multi-modal treatment package aimed at the individual and their family).
PREVALENCE
Bipolar Disorder affects fewer than 1 in 100 people (Royal College of Psychiatrists 2004). It is extremely rare before puberty, but becomes more common in teenage and adult years. Although causes are not fully understood bipolar disorder tends to run in families and early onset could be triggered by particular life/stressful events, physical illness, substance use/misuse.
IMPLICATIONS for HEALTH
The exaggeration of thoughts, feelings and behaviour affects many areas of the young person's life, including
- Family and social relationships
- Interference with education
- Behaviours that place the individual at significant risk
- Loss of confidence and sense of control over their life.
Also consider the effects of long-term hospitalisation. High doses of medicine that can affect physical appearance and motor activity. Compliance to treatment is affected because of having an enduring or limiting illness and can be displayed as anger
SUGGESTED READING
Kowatch. A. et al. Treatment guidelines for children and adolescents with bipolar disorder. Journal of American Academy for Child and Adolescent Psychiatry, 44:3, 2005.
USEFUL WEBSITES
- Child and Adolescent Bipolar Foundation
- Young minds Mental Health Charity
DEPRESSION
Depression describes a range of moods, from the low spirits that we experience, to a severe problem that interferes with everyday life’ (Mental Health Foundation, 2004). ‘Over the last few decades it has become widely accepted that children can suffer ‘adult-type’ depressive disorders.’ (Barker. P. 2004).
PREVALENCE
Whitaker and colleagues (1990) suggested that in 14-17yr olds the prevalence rate of major depression is about 4%, the rate in girls(4.5%) being higher than in boys (2.9%). The rate is lower in pre-pubertal children.
Depression can affect anyone, of any culture, age or background. Causal factors include
- Genetic factors.
- Stressful events.
- Insecure attachment.
- Separation experiences, losses and bereavement.
- Other psychiatric conditions.
- Physical illnesses and drugs.
SYMPTOMS
Emotional Tearfulness.
Hopelessness and helplessness.
Low self esteem.
Worthlessness.
Anxiety.
Disproportionate guilt.
Dejection.
Irritability.
Anger.
Feeling flat and “empty” (anhedonia)
Physiological Lethargy, psychomotor retardation
Agitation psychomotor over activity
Sleep disturbances
Vomiting
Un-explained physical illness e.g. chest pain
Loss of libido
Over/under eating
Catatonia (in extreme cases)
Cognitive Confusion.
Difficulties with concentration.
Indecisiveness.
Uncertainty.
Pessimism.
Ambivalence
Incongruous emotional response
Rumination, self-blame, self deprecation
unhelpful thoughts
Social and behavioural Aggression
Substance misuse
Intolerance
Withdrawal
Poor personal hygiene
Drop in activity levels.
Isolation
Over dependency/rejection
TREATMENT
Using the stress vulnerability model, looking at relevant stressors in the persons life and devising a coping strategies “toolkit” as well as alleviation of certain stressors using environmental manipulation
Antidepressant medication.
Cognitive behaviour therapy (CBT).
SUGGESTED READING
Barker, P. (2004). ‘Basic child psychiatry’. Oxford: Blackwell Science Ltd.
Whitaker, A., Johnson, J., Shaffer, D., Rapoport, J.L., Kalikoe, K., Walsh, B.T., Davies, M., Braiaman, S. & Dolinsky, A. (1990). ‘Uncommon troubles in young people’. Archives of General Psychiatry, 47, 487-496.
Graham, P, Hughes C, (1995). ‘So Young, So Sad, So Listen’. London: Gaskell.
USEFUL WEBSITES
ANXIETY
Anxiety is the body's natural response to situations that evoke 'fear' in us. At various ages children experience different fears that require the child to adjust their anxieties, this is part of development. For example - At 2-4 years imaginary creatures, intruders or the dark are the most common causes of fear. In early childhood animals, earthquakes or injuries are the most common. Between ages 8-11 not doing well at school / sports can cause such feelings and in adolescence exclusion by peers is most significant.
Children are most often referred to services for help with anxiety when a fear becomes irrational or anxiety dysfunctional. Anxiety can cause the child to not want to attend school or to stop socializing with their friends.
CAUSES
- Peer relationships - whether these are positive or negative is very important.
- Conditioning Process - if a child has been frightened by something, the same thing can bring about the same reaction again at a later date.
- Traumatic life events.
- Genetics - anxiety disorders often run in families.
- Parenting and family emotional environment parents/ caregivers’ behaviours and family processes influence a child’s anxiety level and coping skills.
- Problems with attachment - anxious and troubled attachments from parents/caregivers can lead to insecurity and anxiety in the child.
TYPES
- Specific phobia (fear of a particular object/ situation)
- Generalized anxiety (many aspects of the environment are perceived as threatening)
- Separation anxiety (separation from an attachment figure results in anxiety)
- Panic disorder (panic attacks occur as a result of anxiety)
- Obsessive Compulsive Disorder (obsessions/compulsions are engaged in as a way of attempting to avoid anxiety)
- Post Traumatic Stress Disorder (a traumatic event which occurred has resulted in prolonged or delayed anxiety response)
SYMPTOMS
Anxiety affects the way the individual feels, thinks and behaves. These three components are characterized by
Physical symptoms (feels) - palpitations, nausea, weak limbs, stomach churning, shakiness, shortness of breath, dry mouth, sweating, feeling flushed and/ or tingling sensations.
Psychological symptoms (thinks) - feeling frightened/ worried, feeling tense/ irritable, feeling a loss of control or of wanting to escape, that you are losing your mind or that something terrible is going to happen, thinking that people are staring at you/ commenting about you, thinking that you are going to have a heart attack or have a brain tumour, that you will faint if you do such a thing.
Behavioural symptoms (behaves) avoiding situations/places/people or objects, going somewhere when it is quiet, making excuses, rushing away from situations, using props before or when out, avoiding being alone or going out alone.
An individual experiences several components of anxiety which reinforce each other and result in the individual avoiding situations which makes the situation harder to cope with in the long term and so the opportunity for overcoming anxiety is taken away.
TREATMENT
- Education about the components of anxiety and behaviours that can help to address them
- Monitor the anxiety in different situations, identify antecedents and consequences
- Exposure to the object or situation
- Relaxation techniques
- Cognitive restructuring such as positive self-talk/ Cognitive Behaviour Therapy
- Reward systems
- Modelling, involving the family which is crucial in helping the child to learn positive and effective methods of coping with anxiety
- Medication
SUGGESTED READING
Barker, P. (2004) 'Basic Child Psychiatry' (7th Edition), Blackwell: Oxford.
Puri, B. K., Laking, P J, Treasaden, I H. (1996) 'Textbook of Psychiatry' Churchill Livingstone: London.
OBSESSIVE-COMPULSIVE DISORDER
OCD is an anxiety disorder. Other types of anxiety disorders include: separation anxiety, phobias, generalized anxiety disorder, panic disorder, and post traumatic stress disorder.
OCD is characterized by recurrent and persistent obsessions and/or compulsions that cause distress, or interfere with a child's everyday life. It is usual for a child suffering with OCD to experience high levels of anxiety throughout their daily life; this may result in the child repeating actions or thoughts in order to try and gain some control over their feelings. Children with OCD can exhibit bizarre behaviour that is distressing both for the individual and their family. OCD is exhausting and causes much mental anguish for its sufferers. This can be further exacerbated in children who fear they are 'going crazy' and develop elaborate ways to hide the disorder from parents, teachers and friends. This is why it may be beneficial for a child with OCD to attend Galaxy House as a seven-day in-patient for a thorough assessment into the extent of their disorder and the impact it has on their daily life.
DEFINITION
Obsessions are involuntary thoughts and feelings that arise repeatedly in a child's mind these may be unpleasant for the child, or they may become frightened or disgusted. The child will not want to have the obsessive thoughts, may find them intrusive and create a feeling of being out of control. The child may recognize that their obsessions don't make rational sense, during individual sessions with their key nurse at Galaxy House or, when talking to parents. Examples of obsessions include feelings that something bad will happen to a loved one and fears of contamination or getting sick.
Compulsions are repeated behaviours or rituals that are done rigidly and in response to an obsession. Children with OCD try to remove their obsessions by performing compulsions. For example a child with an obsession about contamination may wash constantly to the point where their hands are raw.
"Unlike compulsive drinking or gambling, OCD compulsions are not pleasurable.
Rather, the rituals are performed to obtain relief from the discomfort caused by the obsessions" (O-C foundation, 1998).
CLINICAL FEATURES
These can be described under six headings
Perceptions
Specific situations, for example, those involving the child getting dirty, may be perceived as scary.
Cognition
Obsessional thoughts, images or impulses that may intrude into consciousness and may involve themes of contamination, sex, or aggression. The child tries to exclude these thoughts from consciousness.
Affect
The obsessions cause anxiety.
Arousal
Ongoing moderate hyper arousal occurs. Hyper arousal occurs when the child resists the compulsions.
Behaviour
Motivated by their obsessional beliefs, children engage in compulsive rituals which they believe will prevent a catastrophe from occurring or undo some potentially threatening event which has occurred. These rituals are usually unrealistic.
Interpersonal Adjustment
Members of the child's family or social network may become involved in helping the child perform compulsive rituals and inadvertently reinforce them.
CAUSES
The exact causes of OCD are unknown; however, it will probably be due to a combination of factors. According to learning theory, OCD is a result of the individual 'learning' negative thoughts towards normal situations as a result of life experiences, e.g. a child may develop a ritualistic system of food preparation and cleanliness as a response to having bad food poisoning. Performing ritual acts will ease the anxiety provoking thoughts about it happening again.
Another theory, supported by recent research into the positive effects of tricyclic antidepressants, practically selective serotonin reuptake inhibits (SSRI's), suggests OCD is caused by an imbalance of the brain chemical and neurotransmitter called serotonin.
PREVALENCE
It is estimated that OCD affects 1-2 percent of the population at any time, which is more prevalent than childhood diabetes. Up to 80 percent of cases develop before the age of 18. Untreated, OCD in children can be particularly devastating as it coincides with a crucial period of social and emotional development. Schoolwork, home life and friendships are seriously affected.
TREATMENT
The overall goal is to ensure that children and adolescents suffering from OCD can benefit from correct diagnosis and appropriate treatment. They may then go on to lead more confident lives now and minimize the risk of developing additional health complications in the future.
Cognitive behaviour therapy (CBT) is generally viewed as the most effective form of treatment for children with OCD in the UK. CBT involves the use of such techniques as interrupting negative thought patterns, the gradual challenging of irrational behaviour, gradual desensitisation aimed at reducing reaction to stressful triggers, and monitoring thoughts, feelings and actions.
Research shows us that the use of selective serotonin reuptake inhibitors (SSRI' s) for the treatment of OCD in adults has had good success. However medication should only be given concurrently with CBT, as medication cannot address the underlying psychological problems suffered by the child. Research studies carried out in the USA found that both behaviour therapy and SSRI medication to be highly effective for OCD with success rates of up to 80% for children completing treatment
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) AND HYPERKINETIC DISORDER (HKD)
ADHD and HKD are related conditions that differ in their severity and precise clinical definition.
ADHD is defined by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM IV). Whereas HKD is defined by the World Health Organization International Classification of Diseases (ICD-IQ) and has more stringent criteria for diagnosis.
Both ADHD and HKD require that there is clear evidence of significant impairment in social, academic or occupational functioning. ADHD and HKD clinical features include -
- Inattention, manifests as inability to concentrate, are easily distracted and fail to complete tasks
- Hyperactivity, manifests as having difficulty waiting to take their turn i.e. in games, conversation or in a queue
- Impulsivity, manifests as suddenly doing things without thinking first
- Pervasive Symptoms - across two or more settings
- Onset before the age of 6 years
- Are > 6 months duration
- And are maladaptive and not in keeping with developmental level.
Negative consequences of ADHD for Children with the condition
SCHOOL Poor classroom behaviour
Poor academic performance school exclusion
Special educational needs
COGNITIVE Problems with verbal and non-verbal memory
Problems with motivation
Problems with productivity
Lower intellectual capacity and learning difficulties
LANGUAGE Excessive talking
Problems with verbal reasoning
Reduced ability for expressed emotion and ideas
Impairments in speech
PREVALENCE
ADHD is the most common psychiatric disorder in children, with an estimated prevalence of 3-7% in school-aged children. The estimated prevalence of HKD the more severe form of ADHD, is around l% in school-aged children. (2004).
CAUSES
Genetics: strong suggestion to be hereditary.
- Adoption studies have shown that the incidence of ADHD in children and parents who are biologically related is higher than in children and parents where the child is adopted
- Twin studies have shown that there is greater risk of incidence of ADHD amongst identical twins than non-identical twins
- Gene for specific dopamine receptor is implicated
DIET/TOXINS/ALLERGY
- Post encephalitis hyperkinetic symptoms (rare)
- Effects of recreational drug use during pregnancy
- FAS (foetal alcohol syndrome)
- Diet - food colourings
PSYCHOSOCIAL FACTORS
- Parenting is more of a challenge
- Importance of good/consistent parenting crucial
- Effects on attachment relationship
SUGGESTED READING
ADHD. Diagnosis and Management. Janssen-Cilag Ltd 2003. UK
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM IV). 4TH Edition. Washington, DC.
World Health Organization. International Classification of Diseases, 10th Edition. 1992.
National Institute for Clinical Excellence - Young Minds Mental Health Charity - Royal College of Psychiatrists
AUTISM
Pervasive Development Disorders are a varied group of conditions that have certain features in common.
Autism is the name of the disorder used to describe a group of children that fall under this umbrella term, but who tend to be more impaired in their everyday functioning when looking at a range of abilities.
PREVALENCE
- Between 4 and 5 per 10,000 children
- It is more common in boys than girls by a factor of at least 3
- The cause of autism remains largely unknown. It is thought to have a large genetic component but, as no specific gene has been identified, there is no test available
- It is an organic condition, rather than one that is psychologically caused
- The onset of autistic symptoms is within the first three years of life
- Children can experience a period of normal development, even with the acquisition of some spoken words, followed by regression and, often, loss of any speech that has been acquired, but in many cases the condition appears to have been present from birth
Children with autism experience problems in 3 main areas
Social interaction
There are impairments in reciprocal social interactions i.e. lack of ability to take turns. They seem unable to 'read' their environment in the same way that most of us do. They have a difficulty with both verbal and non-verbal communication, often having no awareness of gesture or expression, so cannot read a person's emotion behind the spoken word. They also lack the capacity for empathy with others and do not understand that two people can feel very differently about the same things.
Some parents report that their children were unresponsive to being kissed and cuddled as babies. The social smile may have appeared late and they are typically slow to distinguish between parents and strangers. This obviously makes these children extremely vulnerable so a high level of supervision is necessary at all times.
Communication
Both verbal and non-verbal language development is delayed. Not only do these children fail to develop normal, or sometimes any speech, but they also fail to communicate effectively by gesture, body movements or facial expression. They differ in this respect from children with developmental language disorders who often point to what they want, pull people towards things and make their wishes known in other non-verbal ways.
Normally gesture, tone of voice and facial expression all link together to communicate how a person feels with what they show and what they say. Characteristically in autism these factors do not link together properly and are all out of sync. This obviously leads to great problems in their ability to communicate effectively.
Most behavioural problems associated with autism are as a result of anger and frustration related to their viability to make their needs known.
When autistic children do develop speech, they usually fail to sue it to communicate socially in the usual way. Instead they may exhibit echolalia, the repeating of words or phrases spoken by others. These are used out of context and inappropriately. The echolalia may be immediate or delayed. If delayed, the words may come out of the blue much later, so that what they say seems like nonsense.
Some children with autism acquire a few stock phrases that they repeat in parrot fashion, regardless of what is going on around them.
Behaviour
The behaviour of autistic children is characterised by rigidity, stereotypes and inflexibility. The range of their behaviours is limited and they tend to impose rigidity and routine on a wide range of aspects of day-to-day functioning.
Minor changes of routine e.g. having bath time changed can upset some children with autism. They can be taught new skills but have great difficulty in generalising them to other areas.
They often develop unusual interests that can take all of their attention and in which they are able to become experts in e.g. trains.
The play is generally repetitive and tends not to be symbolic or imaginative. Toys are rarely used as the objects that they represent. Other behaviours include checking and touching rituals, always dressing in a particular way, rocking, twirling and head banging. These behaviours are often made worse when the child is under stress.
Other non-specific abnormalities of behaviour include over activity, disruptive behaviour, outbursts of temper and over-sensitivity to certain stimuli and senses.
Self-damaging behaviours such as head banging and biting the arms, wrists or other body parts may occur.
SUGGESTEED READING
Re: Barker P (2004), Basic Child Psychiatry, 7th edition, Blackwell, Oxford
PERVASIVE REFUSAL SYNDROME
Pervasive Refusal Syndrome was first described by LASK 1991 when they reported four cases of girls between the ages of 9-14, who refused to walk, talk, eat, drink and look after themselves in any way. The children were clearly extremely ill both physically and psychologically and took many months to recover.
What is the Condition?
Whilst often presenting as an eating disorder, pervasive refusal syndrome is clearly far more complex and pervasive. Eating disorders are characterised by a morbid pre-occupation with weight and shape. However these children have far more pervasive symptoms and are not worried about weight or shape.
Children present with elective mutism and mobility, anxiety states, phobias, depression, conversion disorder.
Can present with physical elements
• Abdominal pain
• Headaches
• Pains in legs and arms
• Blurred vision
• Feeling nauseous
At the beginning of illness all physical elements are investigated and the results come back as normal. However the children can experience dramatic pain and it can be very anxious time for them and their families when not diagnosed at this time.
Treatment
When pervasive refusal syndrome has been diagnosed the child must be in a hospital setting where they feel safe and can stay for as long as necessary.
Patience and sympathy are paramount.
The ward milieu is valuable in that the other young people often help these children to make progress by sharing their sympathy. Groups are important for the children to feel involved although the children may not actively participate - those who have recovered often say that they have valued the concern and sharing.
Individual timetable is very important staff acknowledging their physical elements with rest periods or time to express their pains therefore the child feels contained and safe.
Individual therapy is best offered in a cognitive rather than psychodynamic framework. However what often seems to appear valuable is the opportunity to talk with a trusted member of staff on a regular and frequent basis.
Parental counselling and family therapy are an essential component of the treatment.
Medication is not used.
Clearly a therapeutic alliance is required between the parents and the therapy team and this should be characterised by cooperation, cohesion, consistency and open and clear communication.
EATING DISORDERS
Food, weight and eating behaviour is a factor in many disorders and psychological problems, but in everyday conversation; the term “eating disorder” has come to mean anorexia, bulimia and binge eating, which you will find defined below.
ANOREXIA NERVOSA: The relentless pursuit of thinness.
- A person who refuses to maintain their normal body weight for their age, height and gender.
- A person whose weight is 85% or less than is expected for their age, height and gender.
- In the case of women, their menstrual periods stop.
- In the case of men levels of sex hormones fall.
- With young girls they do not begin to menstruate at the appropriate age.
- The person denies the dangers of their low weight.
- They are terrified of becoming fat.
- They are terrified of gaining weight even though they are markedly underweight.
- They report feeling fat even when they are very thin.
In addition, anorexia nervosa often includes depression, irritability, withdrawal, and peculiar behaviour such as compulsive rituals, strange eating habits, and division of foods into “good/safe” and “bad/dangerous” categories. The person may have a low tolerance for change and for new situations; they may fear growing up and assuming adult responsibilities, and an adult lifestyle. They may be over engaged with or dependent on parents or family members. They dieting may represent their avoidance of, or their ineffective attempts to cope with the demands of a new life stage such as adolescence.
BULIMIA NERVOSA: The diet-binge-purge cycle.
- The person binge eats.
- They feel out of control whilst they are eating.
- They vomit, misuse laxatives, over exercises, or they fast to get rid of their calories.
- They diet when not bingeing. They become hungry and binge again.
- They believe their self-worth requires being thin. (It does not).
- They may shoplift, be promiscuous, or abuse alcohol, drugs and credit cards.
- Their weight may be normal or near normal unless anorexia is also present.
Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Their friends may describe them as competent and fun to be with, but underneath, where they hide their guilty secrets, they are hurting. Feeing unworthy, they have great difficulty talking about their feelings, which almost include anxiety, depression, self-doubt, and deeply buried anger. Their impulsive control may be a problem too; e.g. shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of risk-taking behaviour. These people can act with little consideration of the consequences.
BINGE EATING DISORDER.
- The person binge eats frequently and repeatedly.
- They feel out of control.
- They may eat rapidly and secretly, or may snack and nibble all day long.
- They feel guilty and ashamed for they binge eating.
- They may have a history of diet failures.
- They tend to be depressed and obese.
People who have binge eating disorder do not regularly vomit, over-exercise, or abuse laxatives like bulimics do. They may be genetically predisposed to weigh more than the cultural ideal (which at present is exceedingly unrealistic), so they diet, make themselves hungry, and then binge in response to that hunger. Or they may eat for emotional reasons: to comfort themselves, avoid threatening situations, and numb emotional pain. Regardless of the reason, diet programs are not the answer.
EATING DISORDER NOT OTHERWISE SPECIFIED (ED-NOS)
- The phrase describes atypical eating disorders.
- Including situations in which a person meets all but a few of the criteria for a particular diagnosis.
- What the person is doing with regards to food and weight is neither normal nor healthy.
MEDICAL PROBLEMS
If not stopped, starving, stuffing and purging can lead to irreversible physical damage and even death. Eating disorders can affect every cell, tissue and organ in their body. The following are a partial list of the medical dangers associated with anorexia nervosa, bulimia, and binge eating disorder.
- Irregular heartbeat, cardiac arrest, death.
- Kidney damage, death.
- Liver damage (made worse by substance abuse), death.
- Destruction of teeth, rupture of esophagus, loss of muscle and bone mass.
- Damage to lining of stomach gastric distress.
- Disruption of menstrual cycle, infertility.
- Delayed growth and permanently stunted growth due to under-nutrition. Even after recovery and weight restoration, the person may not catch up to normal height.
- Weakened immune system.
- Icy hands and feet.
- Swollen glands in neck, stones in salivary duct, “chipmunk cheeks”.
- Excess hair on face, arms and body.
- Dry, blotchy skin that has an unhealthy grey or yellow cast.
- Anemia, malnutrition. Disruption of body fluids/mineral balance (electrolyte imbalance, loss of potassium; can be fatal).
- Fainting spells, seizure, sleep disruption, bad dreams, mental fuzziness.
- Low blood sugars (hypoglycaemia), including shakiness, anxiety, restlessness, and a pervasive itchy sensation all over the body.
- Permanent loss of bone mass, fractures and lifelong problems.
Anal and bladder incontinence, urinary tract infections, vaginal prolapse, and other problems related to weak and damaged pelvic floor muscles. Some may be related to chronic constipation, commonly found in people with anorexia nervosa. Structural damage and atrophy of pelvic floor muscles can be caused by low estrogen levels, excessive exercise, and inadequate nutrition. Surgery may be necessary to repair the damage. If a binge eating disorder leads to obesity, this can include the following risks.
- Increased risk of cardiovascular disease.
- Increased risk of bowel, breast, and reproductive cancers.
- Increased risk of diabetes.
- Arthritic damage to joints.
PSYCHOLOGICAL PROBLEMS.
- As painful as the medical consequences of an eating disorder are, the psychological agony can be worse. It is sad irony that the person who develops an eating disorder often begins with a diet, believing that weight loss will lead to improved self-esteem, self-confidence, and self-respect. The cruel reality is that persistent under-eating, binge-eating, and purging has the opposite effect. Eating disordered individuals typically struggle with one or more of the following complications:
- Depression with the risk of suicide.
- The person feels out of control and helpless to do anything about their problems.
- Anxiety, self-doubt.
- Feelings of guilt, shame and/or failure.
- Hyper-vigilance. Thinks other people are watching and waiting to confront or interfere.
- fear of discovery
- Obsessive thoughts and preoccupations.
- Compulsive behaviours, Rituals dictate most activities.
- Feelings of alienation and loneliness. “ I don’t fit in anywhere”.
- Feels hopeless and helpless, can’t think of way out to make things better. May give up and let despair take over, fatalism, or suicidal depression.
CONDUCT DISORDER (INCLUDING OPPOSITIONAL-DEFIANT DISORDER)
INTRODUCTION
All children are defiant at times and it is a normal part of adolescence to do the opposite of what one is told. Oppositional-defiant disorder mainly applies to children whose functioning at home and at school is impaired by constant conflict with adults and other children. Conduct disorder mainly applies to adolescents whose behaviour goes to antisocial extremes; many are excluded from school or in trouble with the law.
PRESENTING COMPLAINTS
- In younger children: marked tantrums, defiance, fighting, and bullying.
- In older children and adolescents: serious law breaking such as stealing, damage to property, assault.
- Can be confined only to school or only to home.
DIAGNOSTIC FEATURES
A pattern of repetitive, persistent and excessive antisocial, aggressive or defiant behaviour lasting six months or more.
These features must be out of keeping with the child’s development level, norms of peer group behaviour, and cultural context (e.g. isolated tantrums in a three-year-old should not be regarded as abnormal). In younger children (say, three to eight year-olds), the behaviours are characteristic of the oppositional-defiant type of conduct disorder: angry outbursts, loss of temper, refusal to obey commands and rules, destructiveness, hitting, but without the presence of serious law breaking
In older children and adolescents (say, nine to 18 years olds), the behaviours are characteristic of conduct disorder per se: vandalism, cruelty to people and animals bullying, lying, stealing outside the home, truancy, drug and alcohol misuse, and criminal acts, plus all the features of the oppositional-defiant type
DIFFERENTIAL DIAGNOSIS AND CO-EXISTING CONDITIONS
Co-existent disorders are common and do not rule out the diagnosis; they are easily missed so should be carefully checked for:
- Attention-deficit/hyperactivity disorder
- Hyperactivity.
- Depressive disorder
- Specific reading retardation i.e. dyslexia
- Generalized learning disability
- Autism spectrum disorders
- Adjustment reaction (this follows a clear stressor, such as parental separation, bereavement, trauma, abuse, or change of caregiver).
Parenting problems are commonly associated and include a lack of positive joint activities with the child, insufficient praise, inconsistent discipline, harsh punishments, hostility, rejection or emotional abuse, sexual abuse, and poor monitoring of the whereabouts of older children.
INVOLVING PATIENT AND FAMILY
The child is likely to be temperamentally different from their siblings, and cannot easily control their actions.
Antisocial behaviour is learned and can be corrected (unlearned).
The long-term prognosis is not good without intervention (they do not ‘grow out of it’) but is good with appropriate management, especially parent behavioural management training
Promote daily play and positive joint activities between parent and child for at least 10 minutes per day, despite both sides’ initial reluctance.
Encourage praise and rewards for specific, agreed desired behaviours. If appropriate, monitor with a chart. Negotiate rewards with the child and change target behaviours every two to six weeks and rewards more often.
Set clear house rules and give short specific commands about the desired behaviour, not prohibitions about undesired behaviour (e.g. 'Please walk slowly', rather that 'don’t run').
Provide consistent and calm consequences for misbehaviour. Many unwanted behaviours can be ignored, and will then stop (but may increase when this technique is first tried). Distracting the child from an unwanted behaviour is likely to be more effective than saying, 'Don’t do it'. If neither ignoring nor distraction is appropriate, ‘time out’ (to avoid the unwanted behaviour receiving positive reinforcement) may be effective. This can involve leaving the child alone to calm down or sending them to a quiet, boring ‘time out’ room (or other space in the house) for no more than one minute per year of age, and 10 minutes maximum. Avoid getting into arguments or explanations with the child, as this merely provides additional attention for the misbehaviour.
Reorganize the child’s day to prevent trouble. Examples include asking a neighbour to look after the child while going to the supermarket, ensuring that activities are available for long car journeys, and arranging activities in separate rooms for siblings who are prone to fight.
Monitor the whereabouts of teenagers. Telephone the parents of friends whom they say they are visiting.
Liaise with school and suggest similar principles are applied. Parents should put pressure on the child’s school to look hard for specific learning difficulties such as dyslexia.
MEDICATION
Medication is of limited use in the disorder. Methylphenidate is effective for co-morbid hyperkinetic disorder and may reduce conduct problems in children with both problems
LIAISON AND REFERRAL
If problems are mainly or exclusively at school, parents should request that the school involves educational services, such as the Educational Psychology Service (for assessment of specific learning difficulty), the Educational Welfare Service (for attendance problems) or local behaviour support teams. Some schools employ school counsellors or specialized teachers who may be skilled in anger management training.
Referral to a local Child and Adolescent Mental Health Service (CAMHS) should be considered for cases that fail to improve, where the behaviour is leading to major impairment, or where co-existing problems such as hyperkinetic disorder or autism spectrum disorder are suspected.
For adolescents whose delinquent behaviour has involved them with the police, youth-offending teams can provide an intensive intervention package for the duration of the court’s involvement. This may include parenting groups for behavioural management training
For preschool children, health visitors are trained to educate parents in behavioural management techniques. Local parent support agencies such as Sure Start may be able to provide more intensive input
Social Services must be involved in cases of suspected abuse (of any sort), when a young person’s behaviour is beyond the control of parents, and with adopted children. They may not have the resources to help in more straightforward cases.
RESOURCES FOR PATIENTS AND FAMILIES
- National Family and Parenting Institute 020 7424 3460 - Email: info@ website:
-
- Royal College of Psychiatrists ():
SUGGESTED READING
Kazdin A. Psychosocial treatments for conduct disorder in children. J Child Psychol Psychiatry 1997, 38: 161-178.
Scott S, Spender Q, Doolan M et al. Multicentre controlled trial of parenting groups for child antisocial behaviour in clinical practice. Br Med J 2001, 323: 194-197.
Woolfenden SR, Williams K, Peat J. Family and parenting interventions in children and adolescents with conduct disorder and delinquency aged 10-17 (Cochrane Review) In - The Cochrane Library, Issue 2, 2003. Oxford: Update Software. (AI) Eight trials were analysed.
|PLACEMENT EVALUATION FORM |
Please help us improve the learning experience at Galaxy House. Your comments to the following questions will help and would be greatly appreciated.
Do you feel that your learning needs were met? Yes No
If not, why not?
Was your mentor allocated prior to your arrival? Yes No
Did all your Assessment meetings occur when scheduled? Yes No
If not why not?
Were you given the opportunity to access relevant spoke
placements both in-house and externally? Yes No
Where were they?
How helpful were they?
Were the staff friendly, approachable and helpful? Yes No
Please comments
Did you receive any teaching sessions from staff within?
the service during your placement? Yes No
Please give a brief description.
What aspects of the placement did you enjoy?
Why was this? Please Comments
What did you least enjoy?
Why was this? Please comments
Do you have any suggestions for improving the learning experience at Galaxy House?
Thank you for your time and on completion please send this evaluation to the Practice Development Nurse, Galaxy House, Royal Manchester Children’s Hospital.
-----------------------
McGuiness Unit
Horizon Unit (Fairfield)
Local District Tier 3 services
Galaxy House
Tier 4
Clinical Psychology,
CAMHS psychotherapy
Services for young substance misuser’s e.g.
Eclipse
Emerge
Hope Unit,
Bury
Local Education initiatives e.g. Connexions
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