 Hello everybody and welcome to tonight's webinar to the 356 people we have joining us tonight. My name's Steve Trumble and I am facilitating this panel we have for you tonight. So before we introduce you to them, let me just acknowledge the traditional custodians of the land, seas and waterways across Australia, upon which our webinar presenters and participants are located. We do wish to pay our respect to the oldest past, present and future, for the memories, the traditions, the cultures and the hopes of Aboriginal and Torres Strait Islander Australia. So as I've said, Steve Trumble is my name, I'm a general practitioner by background and head of medical education at the Melbourne Medical School where I am at the moment. We did disseminate the biographies for the panel with the webinar invitation so we won't go through those again in detail, but just to introduce people very quickly, actually the first person to introduce then is Dr Andrew Leitch who's from Western Australia. He's currently suffering some of the qualms of the NBN getting across the Nulliball but hopefully we've got you there. Andrew, welcome. Yep, hi Steve, thanks for having me tonight. It's so good to hear your voice, hopefully your image is also moving. I need to ask you Andrew, as a fellow general practitioner, what sparked your interest in working with children in general practice, particularly those with mental health problems? Yeah, I think generally my interest in working with children has come, developed over time, I've come to realise that children do respond well to treatment and it's a really positive thing to actually see that and also making that change and giving them a bit of hope really can go a long way in the future and you can really change the trajectory of a child's life by intervening in small amounts and as a GP seem to have a good role in doing that. So I think it's just built up over time, really enjoy it. Fantastic and you obviously get the sort of practice that you feel most comfortable with and have the most to offer so that's great. I'll introduce our next speaker then who's Professor David Coghill who's a psychiatrist just to actually up the road here in Melbourne. So David, welcome. I think we've got you labelled as guests, you're actually pretty much regular on these webinars so it's good to have you again. It's great to be back Steve, thanks. Excellent Dave, can you tell us about your role in the neurodevelopmental disorders team at the Royal Children's Hospital? What does that team actually do? Yeah, so I'm a child and adolescent psychiatrist and I guess unusual in Australia that my major is in neurodevelopmental disorders and working at the Royal Children's Hospital when I came here just about four years ago realized that psychiatry was actually absent from the neurodevelopmental sphere here. So we've created a multidisciplinary team, a very small multidisciplinary team with two psychiatrists, a neuropsychologist and a nurse and we really manage those complex cases that the pediatricians in the hospital and around Melbourne are having difficulties with. Fabulous, we certainly need your support. You're not Australian by birth then? Not Australians, proudly Scottish by birth. OK, I can pick that up. So good to have you again Dave. And also returning to the webinars is Dr. Georget Fleming. Hello Georgie, you're a psychologist in New South Wales. That's correct Steve, thanks for having me. Well it's good to have you back and you did circulate a paper to us when we were preparing for the webinar which was a review of the callous unemotional traits which can sometimes identify in people at the more severe end of the conduct disorder spectrum. How do you differentiate between typical conduct disorder and what we would label as callous or unemotional traits? Yeah, it's a good question and something that I'll be talking about a little bit later on in the webinar but essentially it's all of the criteria of conduct disorder plus an additional hit of lack of guilt and remorse, lack of empathy, unconcern about their performance and important things and an interesting way of expressing emotions. That's quite instrumental, switching on and off. So if you get the double hit of that, it's important because you tend to have a worse prognosis and worse treatment outcome. OK, we'll look forward to hearing more about that because obviously there's plenty in this case that relates to those sorts of behaviors. So we're looking forward to it and finally, but definitely not least, to welcome David Hogg. Now David, you're a mental health nurse by training but you work in a particular counselling practice. How prevalent is conduct disorder within your practice there in New South Wales? I think conduct disorder in my practice is a minority but I do have a lot of ADHD and ODD, severe ODD behavior with lots of violence and internet addiction. So that has been my claim for some 30 years. OK, we'll look forward to hearing about that. I must say that massage chair behind you has attracted a lot of attention in the preparation of the webinar. I think we all want to go in that. It looks fantastic. But anyway, enough about that. Speaking of high technology, I wanted to spend a few moments introducing you to this webinar platform for those who haven't used it before. There's plenty going on behind the scenes and I'll give you a little bit of introduction to some of the things that make a webinar so much better than just a broadcast lecture. The opportunity is there to interact. There's a chat box you can access by the purple button there on your screen and people have already been chatting there. It's a great way of communicating with others about things that are coming up in the conversation that you want to have a bit of a chat about in real time. If you want to ask a question of the panel, we've already received a number of questions that we'll be looking at during the course of the webinar but also if a question comes up, you want to ask more immediately, the blue button is where you enter your question. So please click on that and enter a question. We'll try and pull them together so that the most important questions emerging during the webinar are answered. The slide, the slide set and other resources that we might make available, you can download by hitting the like blue button when they're all posted and if things go wrong with the webinars can happen. There's a help button which you can use and that will take you through to the conference providers read back directly or there's also a phone number you can call which I think is on your screen so what we're going to do is obviously work our way through the case because there's plenty in there to discuss. Each of our panellists will give a short discipline-specific presentation and then there'll be a period of questions and answers we'll discuss between the panel members about the best way to deal with this case and other ones like them. So that's the way it all works. What I need to do now is to get on with taking us through the presentation. I just want to look at the learning outcomes first of all because they're really important, obviously. The first thing we're going to do is make sure, I hope we can make sure that when the webinar is complete we hope we'll be able to describe the biological, genetic, environmental, psychological and social factors that can contribute to conduct disorders. That's not a simple matter. We'll also hope that you're able to identify the challenges, merits and opportunities in evidence-based approaches, seem the most effective in treating and supporting children and adolescents who are experiencing contact disorder. And finally, because this is all about collaboration between health professionals, we hope you'll be able to implement a referral pathway to support children and adolescents with contact disorder, including, of course, involving the school which has been a major feature that's come up in the questions that have been posed in the preparation so far. So there the learning objectives will now get ready to move on to the first presentation and we'll be hearing from Dr Andrew Leitch, our GP. Andrew, five hot minutes from you on the GP's approach. I think you might be muted. Andrew, have you got your sound up? Can you hear me now, Steve? Yeah, there's no wire to your headsets as well. What's going on there? Yes, I know. Very confusing, isn't it? Yeah. Can you see my slides? OK. Yep, we've got your slides up. OK, excellent. Look, I think it's important to start with looking at the DSM criteria for conduct disorder to actually figure out if Aaron fits into this criteria and this diagnosis. And looking at those criteria, they're actually quite overwhelming. There's about 15 different criteria. But only three need to be fulfilled and one in the last six months. And certainly looking at Aaron and some of these subheadings you can see here, the criteria of aggression to people, animals, destruction of property, deceitfulness of that and serious violation of rules. I could pluck out a few of those and looking at threatening others, physical fighting at school, truancy from school and often staying out at night was just about enough to clinch that diagnosis of conduct disorder. So I'll talk a little bit more about other donors that might come into play here. But I guess the initial thing is looking at how we're going to engage Aaron in health care as a whole. And GPs are a good first point of call for this to happen. I think in general practice, we have the ability to follow up patients like this over time. And so letting Aaron know that this is a safe space to talk about how things are going to really to elaborate on his story, to discuss it with us and to really help to work out where things are going and some of the issues that are arising. I think it's important as well to engage the family in that first few consults. So, you know, talking about, you know, how the dynamics at home between him, his mum, which clearly have been very challenging, as well as any other care providers that might be involved. The other important aspect is obviously establishing his risk. He's indicated, you know, that he might use a knife or equivalent. And so establishing that he is safe and where we need to really raise the security of the situation and whether he has access to tools such as that. Moving on, though, I guess the GPs role is really about collaboration and involving a team. I don't think I could deal with this on my own. I think I'd be quite overwhelmed. And it's, you know, it's OK to recognise that. But who are we going to involve and how we're going to involve them is a really critical step for general practitioners. So that initial contact, as I said, establishing his risk and then moving on and getting him back to follow up to work out a plan. And that plan can be incorporated into the mental treatment plan. And he would be eligible to use this as a tool for accessing psychology. But there's probably going to be other providers that we need to use for Aaron. The other benefit of the mental treatment plan I find is listing goals. And I keep those goals quite direct and quite simple. So how are we going to improve his thinking, his situation, his attendance at school? What strategies can we really implement? And how can we improve his overall his overall life, really? Equally as important is mum and clearly she's suffering and struggling and she's frustrated and she's self-treating with alcohol and she has a history of drug use as well. So we need to really improve her situation, inviting her back for her own discussions and treatment and potentially referring her on and looking at whether we can involve dad at all or stepdad. So overall, I guess looking at that as a whole is offering support. We have that unique ability to really hold the family, get them back whilst they attend other appointments. We can get them back afterwards to see how they're going, looking at where it didn't work out in the past. Why did he engage with the psychologist previously? How can we make that easier for him? And chipping away at this, seeing him on his own, really gathering and building that rapport with Aaron. It's also important to mention the role of the GT in looking at the diagnosis. We've already mentioned conduct disorder as a diagnosis, but there's no doubt Aaron has other diagnosis occurring here. And he's already been diagnosed with ADHD and ODD. ODD is a little bit different, more a defiance and sort of being, you know, less cooperative than being actually aggressive and causing damage and danger. So he probably does have crossover into all those other areas. Also, I like to do medical testing, sometimes looking at whether he's sleeping OK, does he need a sleep study, does he need any blood tests, is there a nutritional underlying problem going on? So it is really multifactorial. And this slide really paints the picture nicely that conduct disorder, I'll do the, just, there we go. That's OK, Andrew. That slide's got a bit disjointed there. Conduct disorder, sorry, my slides went a bit haywire. That conduct disorder doesn't rarely occur, rarely occurs on its own in isolation. And it's often crosses over to mixing with other conditions as we've seen with Aaron already. So I guess in summary, we need to take this step by step. We can't rush it, we need follow-up, we need regular steps along, and regular touching base with Aaron along the way and building up that picture of what's going on. Looking at him, also looking at the family situation, knowing that that's really important to his well-being, that a positive home environment is going to make a big difference. Talking to the school, the GP does have a role in talking to the school, but it's not always easy to contact the school. So it may involve other team members as well in having that interaction in school and putting some things in place. And then also onto the management, which we're going to talk about, and that might be referring on to a pediatric psychiatrist or a pediatrician. So just bring up the summary slide here. That's OK, we are having some connection problems, so you're buffering a little bit, but we can hear you, which is the main thing. Yeah, yeah, yeah, that's good. Yeah, in summary, I guess, speaking with each of those people in turn, Aaron is the centre of this with his treatment, getting that effective communication with him, referring him to a child psychologist, maybe a pediatrician or a psychiatrist, and then involving the parents, which might be a positive parenting program that you could refer them onto, the family as a whole, and touching base with something like Relationships Australia to really work on family counselling, all the psychologists as well, integrating them, and then the classroom. So it's a whole system approach to Aaron, and it's not going to happen quickly, but if it does work out, it will be very rewarding. So thank you. OK, good, thanks very much indeed, Andrew, and certainly the GP's got a central role there in developing that trust with all the important people in Aaron's life, so thanks for taking us through that. Well, now, so as a GP, you've made a referral to the psychiatrist and you're lucky enough to get in to see David Cockill. So, David, please take us through the psychiatrist's perspective. Thanks, Steve, and thanks, Andrew. I mean, the first thing I want to say is, if I had all of my referrals with as much consideration as you've put to them, Andrew, then life would be much easier. I think often we're strapped by a lack of information being transferred between professionals. One of the things I would want to consider first, in fact, I certainly would consider first when I'm thinking about this referral, is who else is already involved? And I'm not thinking just of the health professionals. I'll come back to them slightly later on in the story. But in particular, social work, child protection, have been involved, and are they currently involved? And if they aren't, involved, why? And my reason for doing this is that often people have perhaps unrealistic expectations about what health professionals can and ought to be doing in cases like errands. And for me, it's, again, very important to let the referer know and let the family know when I meet them on the limits of what I can and can't do. I'm not trained in social work. I don't have a statutory child protection role, although, of course, I'll be reporting any child protection issues. And I'm not there 24-7. So not always able to respond to social crises or domestic crises. So we need to make sure that those kind of supports are there. What I can do is I can provide a broad and comprehensive mental health and developmental assessment. And that would really be the first part of my intervention. Specifically, I personally would be looking for other mental health disorders. We've already heard possibility of anxiety, depression, post-traumatic stress disorder. Sometimes even episodes of serious mental illnesses like bipolar disorder that may well be contributing. So to confirm or exclude them would be one of my first tasks. I'd be particularly interested in the current risks for Aaron. And again, when we get a referral of a child and we hear that that child has been aggressive, has been violent, has been causing difficulties, we often jump to just think about the risks for those around Aaron. And certainly, there are risks for those around Aaron from his violence, not just his family, but has he been violent to other children and how are we going to make sure those risks are managed? But also, there are many risks for Aaron himself. He's putting himself at risk. He's at risk of exploitation, at risk of substance misuse, as we've heard, sexually transmitted diseases. And actually, something we can't forget is suicidality. Children may come as a surprise to many of the subscribers to the webcast, but children with ADHD have a 10 times higher risk of suicide and suicidal behaviors than those without. So I would be very interested in Aaron's ADHD. Does he still have significant symptoms and impairment? I'd also be interested in understanding whether Aaron's father and or mother have undiagnosed and untreated ADHD. One of the things we know about the relationship between ADHD and conduct disorder is that the relationship flows from ADHD to conduct disorder. And because of that, actually treating the ADHD can have a big impact on the conduct and aggressive behaviors itself. I'd also want to know about current home, school, and work situation. And that's really because we need to understand where the current resources are, who has a connection with Aaron, who has a relationship with him, who sees him on a regular basis, because this is all going to become part of the treatment plan. And also to understand from Aaron himself, what's he doing with his time? What's his views about his current life? What does he enjoy? Is there anything that he enjoys about his current life? Part of that's about engaging, but again, looking at opportunities for where we can step in and support him and build up his strengths. So if ADHD is a problem, I'd be first looking to treat this for Aaron and getting his parents assessed and treated as required. As I said, this can actually have a big impact on the conduct disorder and other problems he has. If we're thinking about treating the conduct disorder itself, though, a psychiatrist on his own is going to make very little difference. And I look to the team that can be built around Aaron that I can work with, and we're going to hear from psychology and from family therapist in that respect. And we use an approach called multi-systemic therapy. It's the best evidence treatment for conduct disorder, and it involves a social learning model, but with interventions that are actually towards the individual, the family, the school, criminal justice system, and at a community level. Unfortunately, it's very expensive to do well. It's manualized and we can teach how to do it, but it's not readily available in that pure form in Australia. But I think as we'll hear from other presenters that if we can think laterally and put a package together, as long as everyone's on board and motivated, then we can actually look to help Aaron, help his family, and improve the situation. I just very briefly mentioned something called collaborative problem solving that you might like to take a note of and go and look up. It's an alternative approach to challenging and explosive behaviors, developed by a guy called Ross Green in the States, and now really quite well developed as a different way of dealing with challenging behaviors. Thank you. Thanks very much indeed, Dave. And I'm going to preempt a question, or a lot of questions that have been asked about the use of medication. From what you've just told us, really the only role for medication, as I see it, is in maybe managing the initial ADHD. Is that really what you're saying? Very reluctant to use medications to manage conduct disorders. Unfortunately, there's a lot of medication that is used, a lot of atypical antipsychotics, sometimes SSRI antidepressants. Really the evidence for them being a core treatment for conduct disorder is pretty slim. They can help sometimes more in those with other neurodevelopmental disorders like autism in reducing aggressive behavior, but they have horrendous long-term side effects. And if we are going to start medications, then the one thing that I insist on having is an exit strategy. So we need to know that this will be short-term and how we're actually going to move away from it. Okay, so this is where obviously a psychologist would be involved. Let's now hear from Georgie and your thoughts, Georgie, on what your approach would be in assessing Aaron and his family. Yeah, thanks, Steve. So from a clinical psychology perspective, you're obviously driven by your assessment. And as mandatory reporters, as a couple of the other presenters I've already mentioned, we're assessing for risk. So risk of harm to both Aaron and to Aaron's mom as well. And depending on who is your client. So if your client is Aaron, you may not be able to provide what mom needs. And so it will be very important to be linking mom in with her own services and getting a team happening around mom. Chances are you're gonna have to lodge a report with the appropriate child protection agencies and involve the necessary services to case manage a presentation like Aaron's. I also wanna draw our attention to a couple of other things in terms of our assessment. So number one, that there's an early diagnosis of attention deficit hyperactivity disorder and oppositional defiant disorder, which suggests that Aaron's conduct problems have an early onset. And this is important for reasons I'll get into in a second. Also wanna know that there's a family history of antisociality and substance use, which is again important from a heritability perspective and whether Aaron has a genetic predisposition towards this sort of presentation. And finally, I'm interested in the previous treatment history. So what was low adherence related to in terms of the psychostimulant use? Was it noncompliance? Was it side effects? Because working with psychiatrists, you wanna know what was getting in the way of that being an effective intervention. And finally, what's going on with the psychological intervention that he had in the past? Why was it just with him? Why not mom? What did they work on? What worked and what didn't? So after this, you're obviously going to move on towards your presenting problems, which as we've heard are consistent with a diagnosis of conduct disorder and probably a couple of other things in there as well. But really, this is ultimately toward establishing a clinical formulation, which is really a clinical story of how this family, how this child got to be where they're at and what's keeping them stuck in this dysfunctional cycle of interaction or of behavior. And really, we use our clinical formulation then to identify our points of intervention. So I wanna draw our attention to a couple of things. So number one, again, the family history. Can't change that. That's kind of a developmental factor in the formulation. But what we might be able to change is some other things. So in particular, significant strain in the mother-child relationship, there's a lot of parental harshness happening from mom, as well as a lack of parental warmth, which may be important, as well as a lack of or inconsistent use of consequences. In terms of what Aaron's bringing to the table, because this is always bidirectional, I'm noticing some impulsivity which may be playing an important part of the story. As well as a possible punishment insensitivity, does discipline work with him? And why not if it doesn't? As well as difficulty with responsibility taking and expressing or experiencing remorse or guilt for his behavior. Finally, there are a couple of environmental things as well. There's a lot of modeling going on, so his witnessing violence and substance use is probably hanging out with some deviant peers and there's a low socioeconomic status probably operating here as well. What I wanna move into talking about why the formulation is important is a couple of other diagnostic considerations before we get into treatment planning. So number one, as we've already mentioned, we're assessing for mood and substance use, particularly around suicidality, anxiety, and depression. But I also want to go into the other diagnostic specifiers for conduct disorder, which number one is determining the age of onset. So did Aaron's conduct problems first onset before the age of 10? And if they did, can we give him the specifier of childhood onset? And this is important because we know that these are the kids who have a different prognosis, who are more likely to stay on this antisocial trajectory as they move forward. But most importantly, as I was talking about at the start of the webinar, is there evidence for limited pro-social emotions? And this is known in the research world and in some clinical circles as well as callous, unemotional traits. Now in terms of kind of a practical take home thing, you can screen for callous, unemotional traits using a freely available measure called the inventory of callous, unemotional traits. And there's a parent version, a teacher version, and a self-report version as well. So what are callous, unemotional traits? And how does a child obtain a diagnosis of one? So in order to obtain a diagnosis of this specifier of with limited pro-social emotions, currently a kid has to meet diagnostic criteria for conduct disorder and then demonstrate two or more of the following criteria. O's are a period persistently of 12 months in more than one across multiple settings and relationships. So it has to be persistent and it has to be pervasive. And these symptoms are a lack of remorse or guilt, are unconcerned about the effect of behavior on others, a lack of empathy, so a callousness, a lack of concern about other people's feelings, particularly their distress, and unconcerned about their performance in important activities. So this might be at school or in a part-time job or in extracurricular activities. They just don't really care about how well they do. And then the shallow or deficient effect, which is this interesting emotional responding style where you see a lot of an instrumental use of emotions or switching of emotions on and off in order to obtain some sort of goal or reward. And the reason why I'm choosing to focus on this subgroup of kids is because these are the kids among all of those who have conduct disorder who tend to have the worst prognosis. They have more stable problems, more severe problems, more aggressive problems, highest risk of delinquency and crime later on. We also know that they have different risk and maintaining factors. So the clinical story, that formulation is different for these kids. It's much more heritable, more highly genetic, less environmental factors playing in here. And for this reason, our traditional treatments don't tend to work as well for these kids because we're kind of targeting the wrong things. So in terms of the treatment planning for specifically this group of children with conduct disorder and callous unemotional traits, we wanna get a multi-component treatment happening. So this is what Dave was talking about before, but specifically in your practice with this type of kid, thinking about less of a focus on adjusting mum's parenting coerciveness or her inconsistency because the research suggests that's less important, but what's more important is the relationship between parent and child. We wanna up mum's warmth and affection to really strengthen their bond because we know this is an incredibly protective factor. I wanna de-emphasize punishment, both in the context of your sessions, but also what mum's doing at home and then what teachers are doing at school. What we know about these kids is that they have a fearless temperament style which is associated with punishment insensitivity. These kids don't learn as well from punishment. They're less affected by it, but on the flip side, they're highly driven by rewards. So I'm gonna use that to my advantage in order to increase the behaviors I wanna see more of and reduce those I wanna see less of, use rewards. And finally, I'm gonna spend a lot of time working one-on-one with Aaron to improve his emotional skills. So in particular, I'm gonna use CBT style approaches to increase his emotional literacy, so micro expression training, particularly around other people's distress cues. We know these kids are less good at recognizing and responding to sadness in others, fear in others in particular. I'm gonna teach him how to do perspective taking to facilitate empathy. And finally, we're gonna work with him on social problem solving, more appropriate ways of responding to other people in particular situations. And like we've mentioned before, my take home message is that this is gonna be a multidisciplinary intervention. Thanks very much. Great, wonderful. Thanks very much indeed, Georgie. And it's interesting that a couple of interesting questions have come up that I don't know if you wanna address now. Particularly, people saying that the police can often get involved in these sorts of cases and that it looks like different states have different approaches to dealing in the justice system with children in particular with conduct disorder. Do you have any thoughts on that before we go to David? Not so much. I think it's hard because it's going to be state by state. So you want to make sure that that the appropriate people are involved. And if the criminal justice system has been involved and we know that these kids often present in juvenile justice or juvenile correction facilities that the people who are working with them in that context are also aware of the most evidence-based approaches for intervening with these kids if they are criminal justice system involved. Sure. Okay, well, thanks very much indeed again. Now we'll go to David, your family therapist and mental health nurse. Can you tell us what your approach would be to working with somebody in our own situation? Well, one of the most important thing is that I will come from a very systemic perspective to appreciate conduct disorder in the home environment, the school environment and in the community. And there's a study by Langer, which is on your slide here, that study on family factors associated with ADHD and emotional disorder, high stress, lack of support, low parental quality of life, family functioning difficulties, low parenting satisfaction and parental psychological health problems may all be dissolved biologically vulnerable youngsters to develop worst psychological problems the day my other wife said. Clearly, this particular study has reflected very much on Aaron. If you think about it, he doesn't really stand much of a chance. If you look at what's happened to Aaron, he's progressively deteriorating, leading to severe conduct problems. And then when you look at the next slide, which is more ADHD in the family system, this particular book I by Aaron and Aaron identify ADHD in the family context. What are the common themes that emerge in families with a ADHD child? You talk about vertical loyalties and dependency. And what that really meant is that a lot of adult ADHD or young adolescents have really not separated or individuated from a family system. And part of that is that you can just appreciate adolescents going through adolescenthood. The process of autonomy and separation is a key point of development. It's not uncommon that they're developmentally arrested. So it's also not uncommon they're treated more like 10 or 12 years old when they're 16. So this sense of overprotectiveness can cause a lot of frustration with young people, partly because they are more likely to do wrong things with their impulsive behavior. So parents are more likely to keep them at home, for example. Then when you look at vertical loyalties, if you look at a lot of adults with ADHD, they're more loyal to their parents and to their spouse. And they can contribute to a lot of horizontal conflict between the spouse relationship. Also not uncommon as you can appreciate, even with Aaron's story, there's a lot of conflict around marital relationship, poor parental control and interaction. A party like Georgia has touch on harsh parenting, abusive parents, dysfunctional family conflict patterns. And I'm very interested to look at the dynamic that contribute to the interaction of patterns around a problem, particularly, particularly when you have authoritarian parenting style and more likely to be quite harsh. How often though, when we look at Aaron's story, we can say how much is Aaron scapegoated in his own family system? And because it's not uncommon as well, scapegoating get transmitted across generation. How often two normal siblings miss out because of Aaron's difficulties? Bearing in mind in family system therapy, you want to know that the normal child don't get miss out because they're more likely to become very resentful and reject of Aaron. The part that really strikes me the most when I work with ADHD for some 30 years now is a sense of poor self-worth. How often though, and it's such a pervasive problem across academic, social and occupation, and how often these young people have become so sophisticated and avoiding learning, and now it's become like, like they prefer in their construct, in their head, is that they prefer to do bad things and naughty things and perhaps to think that perhaps they're stupid, but in fact they're not stupid. They just have learning difficulties, undinos and untreated. So I particularly want to make it overt or make it explicit, the concept in their head because once you make it explicit, then the likelihood is that you can play with it. The framework that I tend to work with ADHD and family system is very much from a multi-generational family narrative. And Dolfi, as you can see on this multi-generational side, said being born is like being thrown already people by characters and stories. It is to be exposed to a reality whose rules are already written. Our presence will alter the threat of this narrative, which is a positive thing because history doesn't have to be our future. Perhaps even the ending, but we will never be able to separate ourselves from the pages that precede our entrance. And those pages will inevitably influence us because we are their children. So in this particular side, I'll be very curious about the family of origin experiences of Aaron's parents. Bearing in mind, there's a strong genetic loading on ADHD. We're talking about 75% or more. ADHD with a kid with ADHD are more likely to also have ODD. We're talking about 50% to 80% of kids with ADHD who have ODD behavior. And the further 40% will have some form of learning difficulties. So if this is, so you're dealing with a trifecta, so all my cases are trifecta. And then you also want to learn how much is the social learning theory around violence and anger. Did they learn how to be violent because they see at witness violence? But more importantly for me, I want to go beyond the violence. I want to understand what's the meaning of this behavior. Particularly I'll be curious, what is missing in Aaron's life? The construct of fantasies around, perhaps to some extent, the missing father, the absent father, the peripheral father. And how often, these days with Blender family arrangement and high divorce rate and domestic violence, the role of man has been further eroded. The man of fathers, the role of fathers has been further eroded. So how much is though the construct in his head around his father? What does he think about that? The idea of, is my father all bad? Or is there something good about him? I would want to know that. I want to make it explicit so that you can again play with it. How much is the shame, the embarrassment, to know that your father is in and out of jail? But particularly I'm also very curious about, too particular area. I'm curious about from the attachment lens. It's not uncommon. A lot of conduct is all come from very disorganized attachment or the trauma lens. And also the family development. Particularly when we talk about family development, I'm very curious about the syndicate events in the family history. So particularly what are the experiences of parents from their own parenting, experience from their own parents? You know, it's so often that as you can appreciate, you apply Bowen's theory Anxiety can be transmitted across generations. And then when you come to talk about treatment, David Cockhill have identified multisystemic therapy as evidence-based. I'm not sure about Melbourne. Here in Sydney, there are pockets of multisystemic therapy available. However, they are only referred by child protection or family and community services. They are highly labor-intensive. They are very structured. They are on call, close to on call 24-7. They don't finish work until 10 or 11 o'clock. They can attend to a lot of crisis, which is very important. I am involved in a modified form of multisystemic therapy when I make a commitment to a child with conduct disorder. I will involve the youth police lesson officer. I'm not sure about other states, but here in Sydney, I have a youth police lesson officer in Carson Hill. I will invite him to join me for therapy. He has been very helpful and he come and join me for therapy. And the youth police lesson officer is a different kind of breed of police. They provide a much more psycho-educational approach to some of these conduct disorder kids. They come here, they're not harsh on them. They're both psycho-educational involved. In the past, I've been involved in community conferencing, which is an exceptionally powerful way of dealing with some of these delinquent kids or while heading towards JJ services. At the same time too, I've been working with school system now for some 30 years. I particularly take on a very collaborative approach about how to work with school systems because I want to identify resources and mobilize resources. So for example, I would like to mobilize resources from the church, from the youth group, particularly from PCYC who have boxing days for young people. So I'm very keen on all those areas of cooperation. I work very closely with a lot of psychiatrists. I can appreciate Dr. Cockhill mentioned about the use of a typical anti-psychotic is minimal. However, used in the context of consistent therapy with health professionals, it can have a small place because a lot of these kids are very, can be quite dangerous and in fact very, very violent. As you can appreciate, Aaron has reached a point where he's holding a knife to the mother. So you cannot be not too unpredictable. But at the same time, having to appreciate the context of a severe side effect from great gain is a big problem. So I would think about that. So when you look at multi-systemic therapy, you identify what are the benefits. First of all, it's a home-based service. The clients don't have to come to you. You actually go to the client. So that actually provides the opportunity to facilitate and enhance your therapeutic arrangement. Second, it's very ecologically based. You get to see the home environment. You get to see how they live and that will help you to design your intervention much more appropriately to what you can see that is real. For in some respects, it's very structural. You can see a re-enactment happening in front of you. And the way multi-systemic therapy works is that because of the intensity of the program and it's about three to six months duration, it is very... You can have a very timely fashion to responsive devices. Goes to, as I said before, on call 24-7, they're very intensive. And because you're conducting therapy in a client's home, you can generalize and change much more easily. But other things that I would... Work is that I would work with subsystems. I would work with Aaron himself. I would work with a parent for co-parenting strategies and ideas. I would look at the family therapy as a treatment modality. More importantly, I would look at reparative practice. How can I help Aaron to own up to his mistakes? How would I help Aaron to... I should begin to recognize that what he has done wrong. Particularly when I get involved with school system and they're suspended, they're aggressive, and they hurt somebody, I would be doing a lot of this work with Aaron about how he can make up what is done. So all in all, I think that would be my part of the contribution. I will welcome any questions. Thank you. Wonderful. Thank you very much indeed, David. And we'll move on now to the conversation, the discussion between the panel. The violence in this case is just so apparent as you read the case study that's occurring in the home. We touched very briefly on the involvement of the police in such a situation when people are holding knives to other people's throats. It's pretty inevitable that the police will be involved. David Hong mentioned it. I unfairly asked Georgie for input on police involvement, and she really works with preschoolers. But do any of our panel have further thoughts about appropriate engagement with the police and judicial system with people like Aaron and his family? Yeah, I think I would want to comment on that, Steve. Dave Cockhill here. I mean, obviously safety first, and actually that's something that's really, really important for us. There's a lot of violence. There's violence between multiple of the contributors to this story. And we need first, before anything else, to actually make people safe and make sure people safe. The police getting involved can be really controversial. Is it good? Is it bad? Actually, it can be both. And it really depends on the style of policing. I was really impressed to hear David Hong say about having a community policeman, youth policeman, that he could actually call on to be part of the treatment team. And really that's what we would all like. We would like these systems to come together, whether it's the justice system, the welfare system, the health system, the education system to be working together. I think that there are lots of difficulties for police because they have multiple roles and multiple stresses. And they often work under suboptimal conditions, but very much getting them involved as part of the community and as part of the community of practice, the health community, both in keeping people safe, but also then looking at the ways that they can actually step in to provide some of the positive support that George is talking about. Okay, great, thanks for your mention, David. Anything further from any other panelists about that? Yeah, Andrew, I'll say something, Steve. Yeah, I think like the other speakers, I'm really big on trying to de-escalate these situations and it's already heightened emotions with everybody involved. And involving the police where it's appropriate is a good thing for GP needs to do that if they think it's appropriate, but working really hard to try and help to de-escalate any of that risk that is emerging and trying to create a more positive flow of events, I guess, instead of heading towards something that could end up being quite negative in the treatment. I often also leave parents with a safety check. This does get to this point, these are the contact numbers you will need and to have them handy and don't be afraid to use those. But I think that's very similar to what the other speakers said. Involving them in a positive way possible and using them where appropriate, but really trying hard to keep the treatment flowing and hopefully not stepping back into charges and things like that, which he probably doesn't need at the moment when he's trying to get better. Absolutely, so Andrew, also while I've got you, what about involving other organisations like Headspace, if you had much involvement with Headspace in managing children like Aaron? Yeah, I think Headspace would be a really appropriate referral for a GP. They work closely in this space. The problem in some states, including where I am in Western Australia, there is quite a long wait time to get into Headspace, anywhere from six to eight to 10 weeks. And so that delay means that we're going to have to do something in between while we're waiting to try and engage Aaron and keep him active in the health system. I also use child adolescent mental health service, CAHMS, which can also be a good step to get advice when you're not sure what to do. And I think there was also a question around some of the other supports that you could involve that are free and easy to access. The Parenting Program Triple P is really good. Evidence-based, positive parenting support for mum and also the Circle of Security. So I use both of those or refer to both of those. They are online and they have webinars as well. So I find them really useful in this sort of situation. Okay, great. Thanks for that. It's interesting watching the chat room that people are commenting on the different involvement of organisations, such as Headspace, but also the police in the area picking up on Sarah Wells, they're saying, we're lucky enough to have an early intervention police team that coordinates well with schools, families in the health system here in Hobart for these young people at risk. So what about schools? Does anybody have any thoughts about what sort of advice or support or involvement there can be for schoolteachers who are trying to support Aaron? One of the things I do a lot when I go to schools is that I want to go there and I take on a much more coordinating role. I ask for a meeting generally because I've been seeing the child and I will say something to the principal, the deputy principal, we have a common client here. Can we have a case conference? How can I be helpful? I think I went down position when I go to the school. Partly I want to earn some brownie points from them that I'm there to support the teachers. Uncommon before I go, I will survey all the teachers. I ask for a round robin survey, particularly I'm interested in the behaviours. So I ask them to be very objective in describing the behaviours of the young people. How much of the behaviours I would want to know is how much of the behaviours are more ADHD behaviours, how much of the behaviours are more ODD behaviours and how much of the behaviours potentially might be learning difficulties because every one of them requires a different management plan. It's also not uncommon that I'm organised a meeting at lunchtime with all the teachers after I have that kind of information and I want to hear from them, I want to draw them together so that they can support each other about the plans that they have worked because I would by then have put together a summary of all the observations that they have put together for me and how much is the ADHD behaviours and then I would also be talking to the pediatrician about how much maybe the child is said not at optimum level of management when you talk about stimulant medication because one of the research on ADHD was what are the competency standards required to work with ADHD and they have identified five areas and those competency standards of having to appreciate the neurobiological perspective of ADHD to appreciate the medication and education aspects of ADHD to appreciate the parenting, the experiences of other diagnosis the co-morbidity so it's very important then as a clinician that when you're working with this particular very challenging, very complex client load you have to work out due to the ADHD first or anxiety because anxiety can mask ADHD symptoms the same as depression can mask ADHD symptoms I'm very curious about where you talk that's why I work very closely with the child psychiatrists because we work off each other and we provide much more comprehensive care so in terms of school system, lastly I want to identify the resources in the school particularly I want to interview the child and ask him, tell me all about your teachers tell me all about what subject you like what subject you don't like, what subject you hate because that gives me some valid information that we might be on the right track to identify learning difficulties, for example so I like to do that So just before Dave Cokke or Pitch is in we're really interested in these school meetings David, who would be the essential members of that meeting who would have to be in the room for it to be a success in general terms? Every school is different but if I want authority if I want to go in with some authority I would ask for a deputy principal to be present for very obvious reasons I want authority I want, and then I go in, I want to advocate for the child so the most common people that go with the year coordinator generally the school counsellor and the deputy principal if I ask for them otherwise if I don't want to pull in the heavy duty people I don't need the authority then I would just have to generally the school counsellor and the year advisor not uncommon a lot of times, by the time that the young people come to me things is very difficult between home and school the school blame the parents of parents from the school and because I have mediation training I'm a trained mediator I can use my mediation skill in a good way for example, I will focus on the needs of the child rather than the two parties that are disputing I think on a very kind of like grey area half the time when I go to school I try to find line between advocating for the student and the parents and advocating for the teachers in the school so I try to find line but I find that in 30 years of working in schools and I do a lot of training on systems and ABHD so it's been a pleasure really and I have not find too many schools that will not allow me to go there a very small percentage will not be party to this OK, thanks for that we might actually hear from Georgie first of all then I'm not sure if you had something to add as well but Georgie Fleming on involving the schools yeah, I was thinking of two things in the context of involving schools number one, being the importance of providing teachers with psychoeducation what we know from the literature and from clinical practice is that teachers although they're often assessed to identify that these sorts of problems are a problem they don't feel adequately trained to manage them in the classroom or really even understand how they develop or how they maintain so I think from a clinical psychologist's perspective doing a lot of psychoeducation provision in order to upskill teachers in understanding the various types of presentations of conduct disorders as well as how best to manage those presentations specifically in a tailored way in the classroom environment and the second thing I wanted to talk about as well was the importance of a sense of school bondedness that a family has with their child's school and I'm thinking in particular around the parent-teacher relationship and how important it is as a team member in a case like Aaron's to facilitate this relationship and allow Aaron's mum to feel linked in with the school and feel supported by the school because I think that's a huge barrier to kind of coordinating the multidisciplinary team is if the parent in particular feels as if they're being made a pariah by the school staff which can often happen when we have this type of presentation of child so that would be my two points to add around school involvement. And I had loads of things to say but David and Georgie said most of them and I think that's one of the things that I really enjoy about being on these webinars that we get so much good collaborative work. One of the problems we have is it doesn't always work that way in reality and it is something that we've really got to work at. Particularly I think in Australia when one's working in a private practice maybe working on your own without colleagues around you without a multidisciplinary team around you the whole day then you really have to work hard to make sure that you do that joined up thinking. It's interesting David's a family therapist now but trained as a mental health nurse and from my clinic in Scotland where I was until I came here four years ago our clinic was if not run by nurses a lot of the forward front facing work was done and most of that mediation work between schools and families was a partnership with our mental health nurses. And I think that is something that you really come up against often in the clinic is that the family will be angry with the school the school will be angry with the family it's tempting at times to take sides but if you take sides no one's ever gonna win and I think David your discussion about mediation and being able to broker that relationship and the same that Georgie said is just such a huge thing not just between families and schools but between families and all the other agencies individuals within those families and all the other agencies that need to be involved. Thanks Dave and a number of presenters did talk about the genetic links with this particular disorder. We've also been considering though in the case the fact that Aaron's mother was known to be abusing alcohol during the pregnancy and other drugs as well as her father and stepfather. What about the maternal ingestion of alcohol during pregnancy? Do we think there could be some significant physical cause here? Well it's an important question although one that the answer won't change our treatment. So it is important in understanding what might have caused some of the difficulties and certainly those with FASD are at higher risk not just of ADHD not just of other neurodevelopmental disorders but also of oppositional disorder and conduct disorder later on. But the other part of the story is that interaction between genetics and the environment. So of course those with a condition like ADHD women with ADHD are more likely to misuse substances including alcohol, including smoking and also find it harder to quit. So there's a circular relationship often between the biological and the environmental factors and it's unfortunate because we can't turn back the clock to have addressed mum's alcohol use during pregnancy. But as I say, the important thing is that it may be important for us to do more assessments to fully understand the complexity of Aaron's issues, Aaron's difficulties, the other types of learning and intellectual difficulties and cognitive difficulties that may be there. But in the end, it's not going to change the treatment other than us to take into account those cognitive difficulties when working with him. Thanks Dave. So certainly interpreting those behaviors and I'm very mindful of the other Dave's comment about interpreting Aaron's violence as being a form of communication of his underlying stresses and traumas. Does anybody else have anything to mention at this stage? Maybe I think Andrew, you wanted to tell us something about the prevalence of conduct disorder. Yeah, there was a couple of questions about how prevalent it actually is and looking at some recent studies, it's sitting at around 2% of children, four to 17 year olds and more prevalent in males. So 2.5%, 2.5% were male and 1.6% female. So it's not the most common mental disorder in children. ADHD, anxiety disorders tend to take that, but it is prevalent enough to be thinking about and as I said in my slides that it often crosses over with other disorders as well. So to be considered in that diagnostic workup as we look at a child. And I think we're talking a bit about ages as well, what age is most common and Aaron sort of fits that bill. The need to late teenage years is when it really starts to present itself and the symptoms from looking at the DSM symptoms can develop from 13 or even less. So that's probably the main sort of finding I found from looking at the research. Thanks Andrew, there certainly were a lot of questions on that, does anybody have any thoughts? Yes, so. Just to come in, Steve, on that. I mean, as Georgie said, those with early onset conduct disorder and as Andrew said in his very first slide, conduct disorder is a serious diagnosis. You really have to transgress the rules to meet the criteria for conduct disorder. It's a word that's often thrown around quite glibly, but actually to meet the criteria for conduct disorder, you've got to be pretty serious. And those who meet it early on in life pre-teenage during primary school years certainly have a much higher risk of continuing problems into adult life. The one qualifier I would put on that is that there's some research come out over the last four or five years that's looked at adolescent onset conduct disorder which we thought was much less likely to continue, much more likely to remit, but actually demonstrating that quite a significant portion of those who have an adolescent onset of conduct disorder don't remit and do continue to have problems. So whilst it's certainly true that the earlier the onset, the more likely it is to persist and the more serious it's likely to be, not all of those who develop conduct disorder in adolescents who didn't have it in childhood actually grow out of it as we thought they did. Okay, thanks for that. And David Hong, you've created some ripples with your mention of internet addiction. What more can you tell us about that and its connection to conduct disorder? One of the complicating factor of complexity of clinical presentation these days is that is how much is ADHD and internet addiction is a subset problem. And so as you can appreciate with internet addiction or what you call internet misuse and internet addiction is more commonly known is that the kid, first of all, they don't go to school, they punish their parents, especially if they're of Asian heritage, it's a very powerful way of punishing parents by not going to school. Because I work with a number of selective school here in Sydney where young adolescents with also with co-morbidity to ASD actually refuse to go to school because it's such a powerful weapon. And if they get to get into peer, then they get extremely aggressive. I do a lot of house visits in Sydney as part of my role. I like to offer a service where I go to the home and because parents have no power to bring the kid to therapy, especially with those extreme ones that lock themselves up and they end up with property damage and things like that. The other part about internet addiction, the complicates clinical presentation is the school refusal. The school refusal. So how often then there's severe anxiety and how they actually, internet was a way of coping initially and not becoming a huge problem. In the Asia Pacific market, you're talking about Korea, Japan, Singapore, Malaysia, you're talking about 15% and maybe up to 20% of young people addicted to internet. I think less so in the Western country. So it's actually an emerging big problem. And yet at the moment, really, we're not sure how to treat it properly. Number one, they can't get them to therapy. Number two, they get violent. And number three, they're not motivated. The parents are your customer. So I've done a lot of house visits with some of these challenges and I'm still baffled to what is the best approach at this point. I'd like to- It sounds like a great topic for another webinar, though. We're gonna get plenty on that one, I'm sure. Thank you all. Thank you very much for that. It's now time for us to move to the summing up and we'll go around the panel one by one. So Andrew, USGPs are now and overseas as family physicians. Let's hear about your thoughts now and where you stand as a family physician for this family and its problems. Yeah, I certainly didn't think I'd be seeing children with conduct disorder when I'd went through GP training and it's a more complex area than I imagined I'd be having to deal with. So I guess understanding that it can be very hard and can be very challenging and to accept that and that it might not get it right the first time but really helping to build up that team for Aaron so that you can all work together on this problem and also developing that therapeutic alliance with Aaron letting him know that you're worth, you're with him, you're on his side and you're trying to do what you can to help him and at least judgmental manner as you can respecting him as well. I think that's what I was trying to get across is that creating that real nurturing environment for Aaron so that you can work together at tackling this. Okay, well, thank you for that that it's certainly a challenge and I don't think we did prepare you for it in GP training, you're quite right. So let's now hear Dave, your thoughts in summing up. I think the first thing that comes to mind is safety, I've said it a few times but making sure that everyone's safety is ensured the best we can. Working in these kind of situations with these kind of cases has to be done as part of a team whether it's a formal team, a multidisciplinary team for example with a cam set within a cam setting or an informal team of professionals that make sure that they stay in touch and make sure that they collaborate, make sure that they're working together and not against each other. For me is the key to moving forward. Great, thanks for that. And Georgie, your sum up. Yeah, thanks Steve. So I think my biggest take home message is the importance of tailoring our treatment approach from McLean Sykes perspective, your intervention is the key and it must be individualized to the unique needs of each child of each family. In a case like Aaron's where we have this kind of intergenerational history potentially of trauma, there's been domestic violence, there's been interpartner violence and that's likely to have played a really important part in the clinical story and that's probably something your treatment is going to need to address in the context of your standard kind of behavior management approaches. So it's taking into account the story in order to develop a treatment plan and intervene in a way that specifically addresses what's maintaining this presentation for this child and in the broader context for this family. So helping mom recognize her part to play and her family of origin stuff by linking her in with the appropriate services that she needs as well. Thanks Georgie. So clearly this is going on for a long time and Aaron's in his teens now but even as an infant, as a child the trauma and attachment issues going on then, it must be difficult to address those this far down the track. Definitely, although what we're seeing from the literature around attachment is that it's been seen as this really unchangeable thing but we're chipping away at potentially being able to shift patterns of attachment. In a 15 year old, I think the jury's still out and whether we can do that which my other take her message being we need to get in early with this sort of child. Like we've mentioned before, early onset kind of promises are the worst prognosis in a lot of cases and if we can intervene when this child is five, younger, four or three, we're gonna have a lot more traction to avoid this really entrenched, very serious trajectory of conduct problems when he's at the age where he is. Okay, and can you teach Aaron at this stage to recognize fear and discomfort in others and sadness? Yeah, the literature would suggest you can. Whether or not we're actually inducing empathy in this population, I think again, the research jury's still out but I think definitely chipping away at what we know are important risk factors and it's lack of emotional literacy. If we can remediate that and we can use something like a reward dominance approach where we reward better recognition, where we reward kind of prosociality then I think at least we can get him maybe into the normal range of functioning even if we're not remediating all of them or kind of biologically based or temperament based deficits. Okay, but you can at least give him some control over them which would be a wonderful outcome. Thanks for that. Now, what about you, David Hong? What are your final thoughts on Aaron in his case? Well, I think early intervention is really critical at the end of the day but at the same time, this kind of work with Aaron are extremely labor intensive. I think the self-care of the therapist is an important consideration as you can appreciate, you know. If you take on a case like that you could be getting quite regular phone calls and even though I'm in private practice I make it a point when I think on the case I make a commitment to the family that I could attend to that kind of requirements but I certainly would have to turn off the phone by 10 o'clock. So the clients know that and I am mobilised external services. So the other thing to recognise that you can't do it by yourself, you require team effort and you need to communicate it with the team. So I think on a very kind of coordinated case management role as well in the world. So I don't take on too many of these cases. If I do take one, I make a commitment. Okay, thank you very much indeed and thank you all, all our speakers for providing such a lot of information this evening. It's a very complex case obviously with no easy answers but I think you've covered the ground with a great aplomb and given us a lot more to think about. There's a few things that I want to just cover off on before we close up. The first is to ask you to please complete the exit survey. You can see the yellow icon there on your screens. So if you click on that and give us the feedback we need in order to continue and improve these webinars. So please do. This is actually the last webinar from MHPN for the year. Christmas is coming, the end of the year. The next one will be held in 2020. Some really important topics there working to support the mental health of children with an intellectual disability. Really important topic on the 13th of February. Heading into March then there's one from the DVA supporting the families of veterans understanding the impact of veterans mental health on their families, partners and children. So that's the second part webinar there. And finally the 23rd of March, the ones we're talking about now, really important topic responding to the needs of a person who presents with suicidality. And of course that can be a feature in the condition we've been discussing tonight. So jump on the website there and get your registrations in soon. So you'll be reminded in the new year when those webinars are coming around. A few things just to say before we close to remind you that MHPN supports engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with each other. Other mental health practitioners to share tips and resources as you've been doing tonight in the chat room. To build local referral pathways as well and to engage in CPD activities such as this. To learn more about joining your local network contact MHPN or find out in the news section of their website. And also if you want to put a mention in your exit survey MHPN will get back in touch with you about where to find local supports. But before I close I would very much like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present. So thank you everyone for your participation this evening and I wish you all a very enjoyable festive break and see you in the new year on the next MHPN webinar. So thank you and good evening.