Abstract
You have been asked to see Mrs Jane Cooper in the CAMHS outpatient clinic. She has some concerns about her 12-year-old son Harry, who has been underachieving in class.
Practice Stations
Station 6.1: Attention Deficit Hyperactivity Disorder Collateral History
Station 6.2: Attention Deficit Hyperactivity Disorder Explanation
Station 6.3: Autism Spectrum Disorder Collateral History
Station 6.4: Autism Spectrum Disorder Explanation
Station 6.5: Overdose Risk Assessment
Station 6.6: Overdose Management
Station 6.7: Early-Onset Psychosis History
Station 6.8: Early-Onset Psychosis Management
Station 6.9: Mania
Station 6.1 (90 Seconds)
Candidate Instructions
You have been asked to see Mrs Jane Cooper in the CAMHS outpatient clinic. She has some concerns about her 12-year-old son Harry, who has been underachieving in class.
Obtain a collateral history from Mrs Cooper with a view to establishing a diagnosis, and explore her concerns.
Actor Instructions
You are Mrs Jane Cooper. You have an appointment at the child and adolescent mental health clinic regarding your son Harry, who is presently at school. You appear anxious, as you are worried about the difficulty your son is having at school and the impact his behaviour may have on his academic achievement and future.
Harry is in Year 8. Since he started secondary school last year, you have received numerous reports from schoolteachers about Harry’s ‘challenging behaviour’. Teachers complain about him not listening in class, being too easily distracted, and shouting out when it is not his turn to speak. During classes, he gets up from his seat repeatedly and sometimes leaves the classroom without the teacher’s permission. Teachers have warned you he is disrupting other students’ learning with his behaviour, and he is put in detention multiple times per week. Similar issues were reported at Harry’s primary school, but things are far worse at secondary school – you suspect because he is being expected to sit down and concentrate for longer periods. Harry was usually regarded as average in academic ability at school, but he has been moved down to the lower-ability classes this academic year.
Harry has insisted to you that he tries his best at school but finds it hard to concentrate. He frequently forgets what homework he has been set. He finds it embarrassing to have fallen behind his peers academically and has started to dread attending school due to the criticism and punishment from teachers for his behaviour.
You had a normal pregnancy with Harry, although he was born four weeks prematurely via emergency Caesarean section. Harry was always a hyperactive and energetic child. He has a tendency to talk and act without fully thinking things through, which can get him into trouble. He often acts quickly and sincerely apologises a few minutes later. He can’t concentrate on anything at home for more than 15 minutes. Harry has no physical health problems. He has no history of misusing drugs or alcohol. He has no specific learning difficulties, including no difficulties with reading; no difficulties with communication/social interaction; and no restrictive interests or repetitive behaviours. He has never had much of a problem doing as he is told, and he has no history of involvement with the police. You and Harry’s father can lose your temper with him when he doesn’t listen or sit still, but are not physically punitive.
Your biggest fear is that Harry might end up excluded from school if this behaviour continues. You wonder whether Harry may have attention deficit hyperactivity disorder (ADHD). From reading about the topic, you also suspect his father has (undiagnosed) ADHD.
Feedback Domains
Knowledge
The candidate explores the presenting complaint and history of presenting complaint to elicit the parent’s main concerns.
The candidate identifies that the young person’s history is suggestive of ADHD and explores the diagnostic features, in accordance with the ICD-11 diagnostic criteria:1
Problems with inattention and/or both hyperactivity and impulsivity lasting at least six months
Emergence of symptoms during the developmental period (typically early to mid childhood)
The behavioural pattern must be:
(a) Beyond the normal variation for age and intellectual ability
(b) Causing difficulties in social, academic, or occupational functioning
(c) Not limited to a single setting (e.g. school, home, clinic)
The candidate explicitly addresses each of the three key domains:
Inattention: Distractibility, disorganisation, and difficulty in sustaining attention on ordinary tasks. (Note that ability to attend to highly stimulating or frequently rewarding tasks does not preclude diagnosis.) A patient may present as unable to listen, and forgetful. They may leave tasks incomplete and lose things frequently.
Hyperactivity: Excessive movement/boundless energy, and an intolerance of remaining still for long periods. A patient may be described as fidgety, unduly noisy, and unable to sit still.
Impulsivity: A tendency to act on urges without considering the risks or consequences. A patient may struggle not to interrupt others, or to wait to take turns in games or queues.
The candidate explores risk factors for ADHD: those within this history include a family history of ADHD and premature birth. ADHD is also more likely in children who have a history of acquired brain injury, significant trauma, or other neurodevelopmental disorders (e.g. ASD, tic disorder).
Differential Diagnosis
The candidate considers specific learning difficulties and asks explicitly about any identified or suspected specific learning difficulties (e.g. reading, writing, arithmetic).
The candidate considers autism spectrum disorder and asks about difficulty initiating or sustaining reciprocal social interaction and communication, and about restricted, repetitive, and inflexible patterns of behaviour and interests. They may ask about sensory sensitivities.
The candidate considers oppositional defiant disorder and establishes whether there is any markedly defiant, disobedient, provocative, or spiteful behaviour.
The candidate considers and excludes illicit substance use (intoxication with some illicit substances such as amphetamines can mimic symptoms of ADHD). Patients with a diagnosis of ADHD can be more likely to take illicit substances due to increased impulsivity and ‘self-medication’ via stimulants.
Risk Assessment
The candidate conducts a risk assessment that clearly considers the greater risk of accidental and deliberate harm to patients due to increased hyperactivity and impulsivity. The candidate also clearly considers that there is often a greater risk of impulsive acts of aggression toward others, and of harm from others (e.g. punitive action from parents struggling to manage their behaviour, retaliation from peers). The candidate may choose to preface questions with this information (e.g. ‘Often we find that young people with ADHD can impulsively lash out; is that something you’ve seen with Harry?’/‘ … can be challenging to manage at home and end up being physically disciplined’).
Communication
The candidate balances questions with empathetic and validating statements where relevant and explores the parent’s ideas and concerns within the history.
The candidate asks about symptoms by asking about a range of everyday activities (‘How long can they read before losing interest?’/‘Will they often do something and apologise later?’) rather than just asking, ‘Can they concentrate?’ or ‘Are they impulsive?’, which can be less helpful.
Author’s Note
This station could just as easily be posed as a collateral history from a teacher – or potentially from the patient themselves (probably a relatively chaotic scenario).
Many computer games and other technology-based activities can be highly stimulating, with frequent rewards and minimal planning. As such, they are no real test for concentration – don’t fall into this trap.
ADHD commonly coexists with other neurodevelopmental disorders such as LD/ASD, which should therefore be screened for routinely during ADHD assessments. In clinical practice, it is also important to screen for comorbid anxiety and depressive disorders. The lack of timely recognition and treatment of ADHD in childhood can in some circumstances result in repeated exposure to criticism and punitive treatment from parents, teachers, and peers, which can over time have a detrimental impact on the young person’s self-esteem and mood.
Station 6.2 (4 Minutes)
Candidate Instructions
You are working in a CAMHS community clinic and have been asked to see Mr Alvin Cheung, the father of nine-year-old Jason. Jason was referred to the team earlier this year, after concerns were raised both by staff at his school and by his parents about his difficulties with poor concentration and hyperactivity. There have been concerns raised about his behaviour possibly affecting his safety, as he will often do something before he has paused to think about the consequences.
Following a detailed collateral history from both of his parents, clinical observation of Jason in the clinic, and Conners Comprehensive Behaviour Rating Scale questionnaires, Jason was deemed to meet the diagnostic criteria for ADHD. In particular, Jason’s ADHD affects his ability to pay attention to (and therefore comply with) instructions, to pay attention to road safety, and to sit still for more than a few minutes at a time. He is described as a ‘bundle of energy’, always running around with little awareness of his surroundings. Jason has no other diagnosed mental health problems.
Mr Cheung would like to know more about ADHD and its management.
Please explain the diagnosis and management of ADHD to Mr Cheung, answering any questions he may have.
Actor Instructions
You are Mr Alvin Cheung, a senior surgeon. Your son Jason was diagnosed with ADHD following a clinical assessment two weeks ago at a child and adolescent mental health team clinic. This was a very long appointment where you answered a lot of questions and filled out some questionnaires. You were given some information leaflets about ADHD at the time of his diagnosis, which you have briefly read. During this chat with the candidate, you are generally calm and patient. However, you are eager to know more about ADHD and have many questions (outlined below).
You have heard of ADHD and know it is associated with hyperactivity and problems concentrating, but you don’t have much of a deeper understanding of the condition. You want to know why your child has ADHD and others don’t – you worry it has something to do with the way you raised your child. You have heard people say that ADHD is ‘just a modern-day excuse for bad behaviour’, and honestly you are inclined to think along the same lines. Ask the candidate to explain the distinction between the two. You want to know whether you can ‘cure’ your child of ADHD or whether he will have it ‘forever’. Ask about the management of ADHD. You are aware that children with ADHD can be ‘medicated’ and are curious about the benefits and risks of medication.
If at any point you find the quantity of information overwhelming, and/or if the candidate has not checked for a while that you’re keeping up, then interrupt and let them know.
Feedback Domains
Knowledge
The candidate explains in layman’s terms that ADHD is a neurodevelopmental disorder; that is, it is likely to be caused by abnormalities in the way the brain develops and subsequently functions. ADHD is a common disorder, more frequently affecting boys than girls (although it is also likely underrecognised in girls).
The candidate outlines the causes/risk factors for ADHD – the exact cause of ADHD is unknown, but it involves the interplay of multiple genetic and environmental factors that are thought to lead to altered brain neurochemistry and structure. Genetic factors (heritability) in particular play a substantial role. Environmental factors include low birth weight, preterm delivery, maternal smoking, and alcohol and other illicit substance use during pregnancy.
The candidate outlines recommended management of ADHD:2
Psychoeducation and support (for the young person, parent, and teachers).
Environmental modification both at home (e.g. parenting strategies) and at school (e.g. educational needs assessment).
Medication is indicated to improve attention and to reduce hyperactivity and impulsivity, if impairing symptoms persist despite environmental modifications. The first-line medications are stimulants. Side effects commonly include gastrointestinal disturbance (nausea and, more rarely, vomiting), dizziness, and appetite suppression, potentially leading to growth suppression. Stimulants are contraindicated in cases with a history of cardiac abnormalities, or where palpitations or hypertension is detected during treatment. Regular and baseline monitoring (including height, weight, blood pressure, and heart rate) otherwise manage these risks.
A course of CBT for ADHD should be offered for young people who have benefited from medication but still have difficulties in social interactions with peers, problem-solving, self-control, active listening skills, and managing emotions.
The candidate may explain the prognosis of ADHD: over time, inattentive symptoms tend to persist while hyperactive-impulsive symptoms tend to recede. A minority (15%) of children retain the diagnosis in adulthood, whereas most (65%) enter ‘partial remission’ (persistence of some symptoms and continuing functional impairment) and the remainder are asymptomatic.3
Communication
The candidate (as in all explanation stations) starts the station by establishing the parent’s current level of understanding about the condition and whether they have any specific questions they would like to be answered. The candidate then tailors their explanation to the individual and covers all specific queries raised.
The candidate employs a ‘chunk and check’ strategy – regularly pausing to check that the relative is keeping up and isn’t overwhelmed by the information. The candidate offers the opportunity to ask questions before moving on to a new topic. They avoid medical jargon where possible.
Both the RCPsych website and NHS leaflets are good sources of information for patients and their family and carers; the candidate may signpost to these or offer (imaginary) leaflets to be read to allow information to be better retained.
Author’s Note
It is not always expected that a candidate is able to share all of the above information within the time constraints of the station. In clinical practice, explanation of a new diagnosis in a young person and development of a management plan would likely take place over a number of appointments. The main goals of a station like this are to explain the main characteristics of the condition, its causes/risk factors, and the general principles of management, with the patient (or in this case, a relative) at the centre of the consultation.
Station 6.3 (90 Seconds)
Candidate Instructions
Mrs Bernie Saunders, mother of five-year-old Andrew, has attended a CAMHS clinic to discuss her concerns about her son’s speech.
Please obtain a collateral history from Mrs Saunders. You do not need to conduct a risk assessment.
Actor Instructions
You are Mrs Bernie Saunders, and you are attending a child and adolescent mental health appointment due to your concerns about your son Andrew’s speech and behaviour. You are polite and cooperative, but speak with urgency as you are very worried about your son.
Andrew’s speech has always been different from his peers; he started to speak later than other children his age, and his speech appears to have some rather unique characteristics. You first noticed a difference when Andrew started babbling and speaking later than other children of the same age. When he started speaking, he had a fairly limited vocabulary and frequently used what appeared to be made-up words. He has more variety to his speech now, at age five years, but he tends to communicate only when he wants or needs something. He has had testing for hearing and vision, which were reported as normal.
If the candidate asks about other symptoms and it is clear they mean symptoms other than language, disclose that you have concerns about the way he interacts with others in general, and the way he plays:
Since infancy, he has avoided making and maintaining eye contact, and feels uncomfortable with physical contact with others. He tends to play by himself, and you have noticed that he prefers to play with the wheels of his toy cars specifically, rather than the toy as a whole. He also lines and stacks toys up. Before his current interest in toy cars, he was obsessed with toy dinosaurs and refused to play with anything else. He is fussy with food and clothes, and seems to dislike certain textures. When change is introduced, such as in his meals, toys, or routine, he can have severe tantrums. During these, he sometimes strikes himself repeatedly in the head, which is very distressing for him and you.
You know he is different from other children his age and worry for him – mainly that he is missing out socially. It sometimes upsets you when he rejects your physical affection.
If asked directly, you had a normal pregnancy with Andrew, and his birth was at term. You and he bonded well emotionally from the outset. You did not notice any other obvious delays in his developmental milestones. He started school last year, and he is currently placed within the low- to medium-ability classes.
Andrew is an only child and lives with you and his father. He has no significant physical health problems and does not take any regular medication. You are not aware of any mental health problems in the family.
Feedback Domains
Knowledge
The candidate explores the presenting complaints(s) and history of presenting complaints(s) to elicit the parent’s main concerns.
The candidate’s selection of questions suggests that they identify a high likelihood of autism spectrum disorder (ASD), and they explore the diagnostic features of ASD. Autism should be considered if there is a history of impaired development (usually but not always evident from early childhood, as the disorder is neurodevelopmental rather than acquired) in at least one of the following areas:
Receptive or expressive language as used in social communication
Development of selective social attachments or reciprocal social interaction
Functional or symbolic play
(All three symptoms are present in the scenario.)
The candidate’s history covers information relevant to whether diagnostic criteria for childhood autism (in keeping with ICD-11) have been met:4
Developmental origin – Symptoms first evident during the developmental period (typically early childhood). This includes any delayed language development. Young people with autism spectrum disorders can also often experience difficulties processing sensory information, leading to sensory hypersensitivity ranging from the mild to the meaningfully functionally disabling.
Difficulty with reciprocal social interaction – Ongoing difficulty with (or lack of interest in) both initiating and sustaining reciprocal social interaction and social communication. This may contribute to a possible lack of interest in the company of others. Social communication is often also associated with difficulty in people with ASD, as nonverbal communication can be more challenging to interpret and utilise.
Restricted interests – Restricted, repetitive, and inflexible patterns of behaviour and interests. Lack of imaginative or pretend play is often observed. This may relate to feelings of anxiety or discomfort in being confronted with unpredictability or change. These may be countered by reassuring or soothing repetitive motor mannerisms. A child with ASD may use objects for play in unorthodox ways, often focusing on components rather than the whole.
Disabling result – Functionally disabling with regard to personal, family, social, educational, or occupational life.
Differential Diagnosis
Although the station does not require a diagnosis to be made or discussed, the candidate’s history ideally considers common differentials and comorbidities to ASD:
Developmental language disorder – Persistent difficulties (arising during the developmental period) in learning or using language (spoken or signed) are noted, with no other features to support ASD.
Schizophrenia or other primary psychotic disorders – It is worth remembering that ASD is by no means protective against psychosis(!), but even where one occurs in isolation, diagnostic uncertainty is not unreasonable. The two can share significant impairments in reality testing, unusual or apparently delusional thinking, reports in keeping with hallucinations, and unusual behaviours. Social behaviours of ASD might suggest negative symptoms. However, the presence of persistent delusions, persistent ‘true’ hallucinations, thought disorder, experiences of bodily passivity and control, and ‘true’ negative symptoms (including blunting of affect, avolition, and psychomotor disturbances) tend to support psychosis.
Reactive attachment disorder – A failure of healthy attachment between a child and their primary caregiver can generate difficulties in reciprocal social interaction that mimic ASD. It is more common in children in the care system, and in those with a history of abuse or neglect.
Rett’s syndrome – This very rare condition almost exclusively affects females. It can be distinguished from ASD as there is normal early development followed by developmental slowing or regression, slowed growth of the brain and head, distinctive hand movements (wringing/washing), intellectual disability, and sensory impairments such as deafness.
Of note, ASD is strongly associated with a number of comorbid conditions, which should also be routinely screened for in an ASD assessment, including ADHD, intellectual disability, anxiety, and behaviour that challenges. Here, the candidate chooses to screen for these briefly or may refer to a future assessment where they might be addressed.
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