“I Just CAHMS Get Enough”

Joint CAHMS/Paediatric study day: 10/01/2020
Dr Celyn Kenny ST3

​Considering how often we refer to the CAHMS team as Paediatric trainees we have very little opportunity to work with the service and more importantly learn from the service. What better way to learn than from an integrated joint CAHMS and Paediatric study day.
 
The study day was held at the brand new CUBRIC building at Cardiff university which was as modern as they come! You really could see how the University is now up and coming within the research world from its facilities. The programme for the day was varied and the topics diverse with up to date evolving research especially in the Neurodevelopment world.
 
What better way to start the day than with a talk given by Kate Burke, who has the talent of making the most complicated of topics understandable and interesting, that topic being Genetics. Kate gave us an update on genetic testing for children and adolescence and how it’s now becoming part of mainstream medicine especially with the Neurodevelopment pathway.  More children are having genetic testing done as there are more test available and also there is now a greater scope of phenotype. Requesting a CGH array has now become a normal part of every working day within Community Paediatrics and Neonatal medicine. They are very easy to order however we learnt that awaiting the result can take up to a year with the increasing demands on the genetic services. Kate also gave us of the brief different types of genetic testing available and why we use them.

Genetic Tips

This was then followed by Safeguarding cases. In small groups we worked through four different cases and focused on how we would take the history and manage the patients. As an ST3 trainee I found this very useful as it gave an overview of how to manage different Safeguarding topics from a child in need, to Munchausen by Proxy, Sexual Exploitation and the importance of when a Section 47 is indicated.
 
 
Safeguarding tips:
 
Section 47:
A Section 47 Enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. The enquiry is carried out by undertaking or continuing with an assessment in accordance with the guidelines.
 
 
Sexual exploitation:

• Contact duty social worker who will then contact the police
• Complete a SERAF (sexual exploitation referral assessment framework)
• Forms available in all A&E departments

 
 
Fabricated induced illness:

• Form a chronology
• Speak to and involve as many members of the wider MDT as possible
• Involve the safeguarding officer and social services
• Use the RCPCH document - Fabricated or Induced Illness

 
Following some coffee and cookies the next talk was given by Dr Joanna Martin a research fellow in Child and Adolescent Psychiatry. Dr Martin spoke of her recent research work in ADHD and sex differences. It is well documented that boys are more likely than girls to be affected and diagnosed with ADHD; every 3-7 boy to every one girl. Most studies have found that ADHD symptoms and impairment levels are similar in diagnosed girls and boys however girls may in fact have more inattentive difficulties. This raising the questions are there sex specific symptoms? Girls may show their ADHD traits through social interactions and impulsivity whereas boys have more of classic ADHD symptoms. Research is emerging that girls displaying traits of ADHD may be missed as they have genetic protective factors; and if picked up correctly and commenced on medication these patients may respond better. These girls are more likely to get diagnosed with anxiety and depression in future. I found this talk interesting and eye opening and will make me more open minded for future cases.
 
After lunch came a Neurodevelopmental Update. In Wales, this essentially encapsulates Autism and ADHD however it should be seen as impairment in growth and development of brain. This includes ADHD, ASD, intellectual disability, tics, specific learning disorders, motor co-ordination disorders all are part of developmental trajectory which presents in childhood. Statistics from the ND steering group showed that 80% CAMHS workload is related to Neurodevelopment. The funding from 2016 of ‘together for children and young people’ was spent in forming a national pathway for ND, with guidance for assessment, autism toolkit, ADHD toolkit and how to do assessment – a very useful and practical resource which can be found on 1000 lives Wales website. ‘Together for children and young people’ finished in October and is now moving to more integrated whole-systems approach. every team now has single point of access (now have data for referrals, accepted and rejected). Over the next few years we are likely to see expansion in these services…… watch this space.

This then led nicely into a talk on Autism in females and other aspects of variation by Consultant Community Paediatrician Cath Norton. The female phenotype is now recognised as being camouflaging by hiding unwanted autistic behaviours and or explicitly using more socially acceptable behaviours. When it comes to social relationships they are interested in making friends but do not quite get it right and may be more interested in relational objects e.g youtube, animals, reading. They have internalising difficulties. There are mental health implications for camouflaging and sadly one of leading predictors of suicide in autistic adults.

We then learnt from work conducted by Rutter in 1996 on the “Quasi autism”; autistic type symptoms seen in children adopted following an early experience of institutional care and who also can get deprivation linked ADHD which can be pervasive. There is a higher prevalence of ASD and ADHD in LAC population (as well as prevalence attachment issues, trauma, neglect etc) and maltreated children more likely to be hypervigilant. The term attachment disorder likely overused, and possible presumed due to this social background. A useful resource is the Coventry grid when looking at autism in LAC children as they may have different attachment needs. In the future, there is going to be more training to look at a holistic approach assessment of these children i.e. no further unilateral diagnoses or doing autism and not ADHD. The work from steering groups in this development is working towards integrated services with education, families and social services. And the hope is to adapt national IT systems so there is a place the information can all be pulled together forming a ‘clinic profile’. The information in one place, including what families are hoping to get from their experience. To finish we learnt of the integrated autism service who do the assessments in people over 18 years and is where we refer patients when they transition. This service cares and provides for older children with neurodevelopmental variation and functionality in college and workplace.

The last topic of the day was about ACEs, a topic we are now getting more familiar with and used to recognising. Public health Wales Adverse Childhood Experiences study back in 2015-2018 which looked at traumatic experiences in childhood and their impact this included child maltreatment and indirect trauma from childhood household e.g. parental separation, DV, mental illness. It is know well known that ACEs increase individuals risks of developing health-harming behaviours (high risk drinking, unintended teenage pregnancy, smoking, prison and interestingly from recent American studies also affects academic potential and contributes to developmental delay. We discussed a case of a 14year old whose parents had been exposed to many significant ACEs which has subsequently affected the nurturing environment for the chid to grow up. This encompasses that ACEs are vicious circle and interventions are required for both child and parent. 
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To close we touched briefly on attachment disorder, an emotional and physiological dysregulation and how it can present clinically. These children often have a poor self-concept and a fragmented sense of self (i.e. child doesn’t have a sense of their own body so doesn’t recognise hunger etc), poor social interaction and sensory processing difficulties. With attachment, the intervention will depend on developmental stage of child. There is a lot of focus on something called ‘theraplay’ which is based on helping the carer enjoy the relationship with the child. It is clear that in order to make an impact we have to help the child and the parents to help build their relationship to create a therapeutic environment.
 
Reflecting on this study day it really was a whistle stop tour into the work done by our community colleagues and as a current ST3 community trainee and excellent crash course to consolidate what I have seen and learnt over the last few months. I would like to thank the organisers for a very interesting and diverse day, I highly recommend attending!
 
Celyn Kenny
ST3