Academic Unitof Child Adolescent Psychiatry

Annual Report 2009-2010

Summer 2010

ImperialCollegeLondon

&

CNWL NHS Foundation Trust

The Academic Unit of Child and Adolescent Psychiatry Unit is the result of a collaboration between Imperial College London - where it is part of the Division of Experimental Medicine (Head of Division: Professor Martin Wilkins) and the Centre for Mental Health (Head: Professor Peter Tyrer) - and theCNWL NHS FoundationTrust (Chief Executive: Claire Murdoch). It is NHS funded and based at St Mary’s Hospital in Paddington. Its main clinical base is at St Mary’s Child and Adolescent Mental Health Service (17 Paddington Green). The Unitalso has close links with child and adolescent psychiatric clinicians with academic interests in West London.

Unit staff (2009 - 2010)
  • Professor Garralda: Head of the Unit, Professor of Child and Adolescent Psychiatry.
  • Dr Matthew Hodes: Senior Lecturer in Child and Adolescent Psychiatry.
  • Dr Tami Kramer:Senior Clinical Research Fellow
  • Dr Gloria Dura-Vila: Honorary Lecturer.
  • Nicole Hickey:Administrator.

Research staff:
Dr Lorraine Als / Neuro-cognitive function following paediatric critical illness
Dr Lola Picouto
Koplowitz Fellow / Biological stress response following paediatric critical illness
Elizabeth Sanchez-Cao
Koplowitz Fellow / Refugee status and mental health and in young people
Dr Cornelius Ani / Stigma and psychological adjustment in sickle cell disease
Epidemiology of severe childhood psychiatric disorders
Vas James / Epidemiology of severe conversion disorder in the UK
Dr Gloria Dura-Vila / Ethnicity and service uptake for children with intellectual disability
Dr Aaron Vallance / TRICEP study(Treatment response in child and adolescent depression: effects of expectation and personality style)
Dr Olivia Fiertag / Severe withdrawal syndrome: incidence survey and outcome study
Life threatening self harm in adolescents: incidence survey
Dr Mar Vila / Somatic symptoms and somatisation in young people
Dr Victoria Fernandez / Therapeutic Identification of adolescent depression in primary care

Honorary Clinical Senior Lecturers:

  • Dr Alex Doig (Consultant in Child and Adolescent Psychiatry, WLMHT)
  • Dr Cornelius Ani (Consultant in Child and Adolescent Psychiatry, Bracknell CAMHS)
  • Dr Julia Gledhill(Consultant in Child and Adolescent Psychiatry, CNWL Foundation Trust)
  • Dr Sharon Taylor (Consultant in Child and Adolescent Psychiatry, CNWL Foundation Trust)
  • Dr Michael McClure (Consultant in Child and Adolescent Psychiatry, CNWL Foundation Trust)
  • Dr Jovanka Tolmac (Consultant in Child and Adolescent Psychiatry, CNWL Foundation Trust)
  • Dr Catherine Wainhouse (Consultant in Child and Adolescent Psychiatry, Barnet, Enfield and

Haringey MH Trust)

Completed MDStudents:Dr Gledhill, Dr Ani.

Undergraduate Students on Placement: Ms Sau-Ming Hau (Brunel Uni); Ms Seray Vezir (Brunel University); Ms Yasmin Braganza (Brunel University); Ms Cherelle Bertram, (University College London); Ms Judy Addai-Davis (University College London); Ms Sharlene Andrew (University College London); Ms Dalia Levi (EdinburghUniversity).

Activities of the Unit

The activities of the unit include undergraduate teaching; postgraduate training and teaching; research,and clinical commitments withinWest London NHS Trusts.

i)Undergraduate Teaching

The Unit runs undergraduate teaching in child and adolescent psychiatry at ImperialCollege, within both psychiatric and paediatric placements. Several Unit members and associates have obtained educational qualifications (CASLAT) at ImperialCollege. A dedicated teaching packagedeveloped in 2003 was revised again with grant support from ImperialCollege and its Educational Unitin 2008-2009 makinguse of up-to-date educational theory and techniques(led by Drs Cornelius Ani and Aaron Vallance). It has been very well received and evaluated with positive results. Dr Aaron won the best trainee presentation for this work at the 2010 Annual Meeting of the Academic Faculty of the Royal College of Psychiatrists.

Dr Hodesleads the teaching in developmental neuropsychiatry for the medical student BSc module in Developmental Neuroscience and is Academic Lead for the Human Behaviour teaching in Imperial’s BSc in Biomedical Science.

ii) Postgraduate Teaching and Training

a)ST 1-3 grade: Teaching

The Unit co-ordinates the Child and Adolescent Psychiatry teaching for the MRCPsych course and is involved in the clinical training of ST1-3 trainees during child and adolescent psychiatry placements

b)Specialist Registrar Grade (ST 4-6) in Child and Adolescent Psychiatry

The Unit oversees St Mary’s Higher Training Scheme’s academic programme. The Scheme has 15 full-time trainee posts and is one of the largest in the country with a particularly strong academic programme. Drs Hodes and Doigare Scheme Directors. In 2010 Dr Cornelius Ani’s Academic Programme Co-ordinator role was taken over by Drs Jovanka Tolmac & Sharon Taylor, and Dr Julia Gledhill took over fromProfessor Garralda as research co-ordinator.

c)Overseas visitors

Overseas psychiatric trainees from Europe and elsewhere visit our Unit on a regular basis. The Unit – together with the Institute of Psychiatry in London, and three academic units in the USA [Columbia University Medical Centre (New York), Western Psychiatric Institute & Clinic (University of Pittsburgh), and Bellevue Hospital Centre(New York University)]is part of the Koplowitz Foundation’s prestigious internationalAdvanced Training Fellowship network that contributes to the training of academic child and adolescent psychiatrists from Spain by providing academic and clinical training. At the Unit the latter is providedin collaboration with CNWL NHS Foundation Trust.

iii) Clinical Service Developments

Academics are actively involved in clinical care, trainee supervision and service developments. Dr Hodes is CNWL NHS Foundation Trust’slead clinician adviser for Westminsterand has overseen important developments in local Child and Adolescent Mental Health Services. Professor Garralda researched and initiated the use of outcome measures by Child and Adolescent Mental Health Services within CNWLTrust. Dr Hodes’work hasinfluenced the development of clinical innovations such as outreach mental health services for young refugees and obtained a CNWL Innovations grant to train service staff in interpersonal therapy, an evidence based technique for the management of adolescent depression.

iv) International Teaching, Training and Research collaborations

Professor Garralda and Dr Hodes lecture regularlynationally and internationallyas invited speakers. Professor Garralda is Senior Book Editor for IACAPAP (International Association for Child and Adolescent Psychiatry) and Associate Editor for the British Journal of Psychiatry. Dr Ani taught a course on CBT for African Child and Adolescent Mental Health Practitioners as part of the IACAPAP study group in Abuja, Nigeria in October, 2009.

External research collaborations include: University College London (Prof Iliffe - adolescent depression in primary care);University of Cambridge (Prof Barbarah Sahakian – neuropsychological function in paediatric critical illness ); University of Warwick (Prof Swaran Singh – transition mental health care or adolescents); Autonomous University of Barcelona (Profs Domenech and Jane - somatisation in adolescents, anxiety disorders in children); Swiss Tropical Institute, Basel (Prof Mitchell Weiss – ethnicity & learning disability); Lagos State University Teaching Hospital (Dr Bolanle Ola – stigmatisation of sickle cell disease in school children); River State College of Education, Nigeria (Dr Joseph Kinanee – stigmatisation of sickle cell disease by teachers).

v)Research

The Unit has primary research interests in:

  • The interface between physical and mental health in children and adolescents.
  • Cultural influences on child and adolescent mental health.
  • Service utilisation and evaluation.

Additionally, we are developing research interests in

  • The mental health of young offenders.

The specific areas of research activity are:

A. Interface between physical and mental health in children and adolescents

Links between physical and mental health and disorders are widely acknowledged. It is appreciated that many children present with distressing and impairing physical symptoms lacking ina medical explanation, and that paediatric disorders can affect the mental health of children and family members - which in turn can have a deleterious effect on their physical health. Our research seeks to document the epidemiology and health burden of severe psychosomatic disorders and to examine mechanisms through which physical health impacts on child and family mental health.

  • Incidence surveillance of severe psychosomatic problems in children: Unit members are centrally involved in the running of CAPSS (Child and Adolescent Psychiatric Surveillance System). Our national survey of severe conversion disorder in children has obtained the largest sample in the literature so far: we now analysing data on clinical features and outcome, and working on surveillance studies of other severe psychosomatic problems (Pervasive Withdrawal Syndrome and Life threatening self-harm in adolescents). We are also working on an outcome study of Pervasive Withdrawal Syndrome(Dr Ani, Prof Garralda, Dr Fiertag).
  • Functional physical symptoms in schoolage young people: using research instruments- validated by us in British samples - and data from large general population samples, we continue to investigate how physical and psychological symptoms interact and impact different populations of young people (Dr Vila; Prof Domenech, AutonomousUniversity of Barcelona)
  • Mental health of children following critical illness: previous work from our unit has documented surprisingly high levels of psychiatric disorder in children followingcritical illness and sepsis. We are now investigating neuro-psychological deficits, exploring anomalies in the biological stress responseand links with neuropsychological and psychiatric sequelae. We are also planning paediatric interventions to help reduce psychiatric morbidity following critical illness. (Collaborative work with Drs Simon Nadel & Mehrengise Cooper, St Mary’s Hospital, Dr Christine Pierce, Great Ormond Street Hospital; Professor Barbara Sahakian ,University of Cambridge; Prof Vivette Glover, Imperial College London).
  • Psychosocial impact of Duchenne Muscular Dystrophy: we have identified risk and protective mechanisms for sibling emotional health and maternal coping. We are now investigating “therapeutic misconception” and other factors which may cause an emotional impact in genetic trials. (Collaboration with Prof Francesco Muntoni,Institute of Child Health and Dr Anita Simonds, The BromptonHospital).
  • Stigma in children with sickle cell disease:Our study has shown for the first time that stigma theory is applicable to sickle cell disease and that stigma contributes to psychological difficulty in children affected by the condition

B. Cultural and ethnic aspects of child and adolescent psychiatry

Research into cultural and ethnic issues has investigated the psychopathology and service utilisation of refugee children, and successfully evaluated outreach clinics in schools for psychologically distressed refugee children.

  • Our studies have investigated psychopathology and social function amongst unaccompanied asylum seeking children and shown them to experience high levels of war trauma and psychological distress (posttraumatic stress symptoms), especially noticeable in those not living in a high-support arrangement such as foster families. Our epidemiological study of adolescent ethnic minority and refugee pupils in an inner London secondary school has identified further risk and protective factors, and shown that refugee background and ethnicity are not associated with increased psychological distress (posttraumatic stress and depressive symptoms)
  • A survey of London’s adolescent psychiatric inpatients has demonstrated a high representation of black youngsters amongst adolescents with psychoses. A large proportion is accounted for by Black African adolescents many of whom were refugees. We have also shown young female refugees have elevated risk for violent deliberate self-harm.
  • Investigation of psychotic symptoms amongst young adults has shownhigh levels amongst African Caribbean ethnic groups compared with South Asians. This is being further investigated by identifying a white British group and investigating perception of social life (social coherence) (Collaboration with Prof T Barnes and Dr T Weaver, ImperialCollege, London).
  • Investigation of families in which a child has intellectual disability has shown culturally mediated variable perception of the child’s predicament and service needs and we have gone on to show systematically that South Asian children with intellectual disability have reduced service contact compared with white British and Black groups.
  • We have recently started to investigate cultural factors associated with the age when adolescent treatment decision making is regarded as appropriate.
  • Investigation of idioms of distress in Spanish and Latin American adults.

C. Health services utilisation and evaluation

In contrast with the wealth of research in adults, very little has been done to examine the potential of primary care services to attend to child and adolescent mental health problems and to study specialist health service provision.

  • Work by our Unit has pioneered this research area and demonstrated high levels of persisting co-morbid depression amongst child and adolescent primary care attenders and developed and evaluated a general practitioner training programme specifically addressing the identification and management of adolescent depression. This has been shown to be acceptable and efficacious and we are continuing to field test this intervention. The work recently received national recognition when the Unit & Lonsdale Medical centre won the BMJ PCT of the Year award. (Collaboration with Prof Steven Iliffe, UniversityCollegeLondon & Lisa Miller Lonsdale Medical Centre).
  • We have surveyed and provided important national data on bridging posts between primary care child and adolescent mental health services(Primary Mental Health Worker posts) and identified areas for further work including the implementation of training and development, modes of working, and role evaluation. We have identified gaps in CAMHS paediatric liaison provision and have been involved in a multi-method study of transitional mental health carefor adolescents which highlighted gaps in current service provision. (Collaboration with Professor Swaran Singh, University of Warwick).

D. Mental health of young offenders
  • Adolescent female offending is poorly understood. We are conducting a retrospective comparative analysis of the offending careers of adolescent females and males using a 1980 offending cohort, from the Ministry of Justice, with a 26 year follow-up. We are also investigating the often voiced claim of a change in female adolescent offending over time by comparing the offending characteristics of a 1980 and a 1990 cohort of female adolescent offenders.
  • Social aggression by young people is an increasing problem & the technological advancements achieved in recent years have seen an increase in a form of aggression referred to as cyberbullying. Members of the Unit are currently developing a research protocol to explore the associations between exposure to cyberbullying and mental health problems.

Plaudits
  • Dr Lorraine Als won the 1st prize for Oral Presentations at the Paediatric Intensive Care Society meeting (Cambridge, September 2009).
  • Dr Aaron Vallance won the top prize for Best Trainee Presentation at the Annual meeting of the Academic Faculty of the Royal College of Psychiatrists (February 2010).
  • In partnership with Lonsdale PCT the Academic Unit won the British Medical Journal Primary Care Team of the Year (May 2010) [for collaborative research on managing depression in young people in primary care].

Funded Research (2008-2010)

Fundacion Alicia Koplowitz Fellowship Programme (2004 – 2012) £1,080,793

Meningitis Research Foundation (2006 – 2010): £154, 165

  • Neuro-cognitive function in children following hospital admission with septic illness and meningo-encephalitis (Professor Elena Garralda, Dr Simon Nadel)
  • Mechanisms of memory defects in children following critical illness - the effects of cortisol(Lorraine Als, Dr Simon Nadel, Prof V Glover, Prof Garralda)

BUPA (2008 – 2010): £73,814

A surveillance study of the incidence, associated factors and short-term outcome of conversion disorder in children in UK and Ireland. (Dr Cornelius Ani, Prof Garralda)

The Sir Jules Thorn Charitable Trust (2005 – 2009): £8,900

Self-perceived stigma and fear of negative evaluation (FNE) in young people with sickle cell disease; associations with psychosocial distress (Dr Matthew Hodes, Dr Cornelius Ani, Prof Elena Garralda.

WeLReN (Oct 2006 – Apr 2009): £15,000

The recognition of depression in adolescent seen in general practice: testing “therapeutic identification” (Dr Steven Iliffe, Professor Elena Garralda, Dr Tami Kramer, Dr Julia Gledhill).

Department of Health SDO Programme (Mar 2006 – Jun 2008): £368,786

Transition from CAMHS to Adult Mental Health Services (TRACK): A Study of Service Organisation, Policies, Process and User and Carer Perspective (Dr Swaran Singh, Dr Tami Kramer, Dr Tim Weaver and colleagues).

CNWL NHS Trust Innovations Fund (Apr 2009 – 2011): £33,668

The Provision of Training to Child and Adolescent Mental Health Practitioners in Interpersonal Psychotherapy for Depressed Adolescents. (Dr Matthew Hodes, Dr Julia Gledhill).

ImperialCollegeLondon (Jun 2007 – Jun 2008): £3,500

Teaching Development Grant (Professor Elena Garralda, Dr Cornelius Ani).

Travel Grants to attend and contribute to meetings £1,197

Hallinan Travel Grants, ImperialCollegeLondon:

i)African Psychiatric Association Conference, Ghana, April 2008 (Dr Cornelius Ani)

ii)with COSMIC: ESPNIC Conference, June 2009 (Dr Lorraine Als)

Royal College of Psychiatrists/Welcome Trust Annual Academic Meeting, Feb 2009.(Dr Aaron Vallance)

PUBLICATIONS 2008– 2010

Peer review journals:

Ellis, J., Tan, H.K., Gilbert, R., Muller, D., Henley, W., Moy, R., Pumphrey, R., Ani, C., Davies, S., Green, H., Salt, A., & Logan, S. (2008) Supplementation with antioxidants and folinic acid for children with Down’s syndrome: randomised controlled trial. British Medical Journal, 336 (March), 594 – 597.

Elison, S., Shears, D., Nadel, S., Sahakian, B., & Garralda, E. (2008) Neuropsychological function in children following admission to paediatric intensive care: A pilot investigation. Intensive Care Medicine, 34(7), 1289 – 1293.

Hodes, M., Jagdev, Chandra, N., & Cunniff, A. (2008) Risk and resilience for psychological distress amongst unaccompanied asylum seeking adolescents. Journal of Child Psychology & Psychiatry, 49(7), 723 – 732.

Singh, S., Paul, M., Ford, T., Kramer, T., & Weaver, T. (2008) Transitions of care from child and adolescent mental health services to adult mental health services (TRACK Study): A study of protocols in Greater London. BMC Health Services Research, 8:135 doi:10.1186/1472-6963-8-135.