How paediatric trainees can attain mental health competences in everyday practice

Paediatrics has taken baby steps towards embracing mental health as an integral part of practice. One area where there has been progress is the incorporation of mental health into curricula. This is great, but the problem is that no-one had thought through how to achieve these time-consuming skills in the maelstrom of training.

We held a workshop last week to examine this question at the BACCH national trainee day. We had a highly engaged group who came up with a ton of suggestions. Here’s a summary with some pointers.

We put aside the curriculum document, which is a little vague in its wording, and instead talked about what would useful in practice:

1) mental state examination- how to do it, and interpret it.

Advice: this is an area where a quite common sense exercise has been made unnecessarily mysterious. The idea is simply to record the appearance, manner and pattern of communication employed by the person in front of you. In this sense, great novelists are masters of the mental state exam. There are few great novelists working in paediatrics, though, so an acronym helps you to remember some of the important aspects.
A- Appearance and Behaviour
S- Speech
E- Emotion [mood and affect]
P- Perception [Hallucination and illusion]
T- Thought content and process
I- Insight and Judgement
C- Cognition (how information is processed)

2) tools to assess mood problems

Low mood and especially, anxiety are extremely common in community paediatric clinic, and can generally be elicited by features of the standard history and a few selected questions, as below.
Anxiety: history of avoidant behaviors, agitation in certain situations and specifically voiced fears
Always ask: is she a worrier?
Low mood: history of loss of previous interests, lack of enthusiasm, withdrawal e.g. into computer games
Always ask: do you ever feel like you’re worthless?
There are now two questions: how do I decide which children require specialist assessment, and what do I do with those that don’t, or those that are awaiting CAMHS input?
The first question I’d probably best answered by pointing to some useful, freely available questionnaires that can be given to families to fill out. RCADS covered anxiety and depression, as does the mood and feelings questionnaire.
Managing mental health difficulties before or instead of CAMHS assessment is difficult. We have written the 5 minute tips series to help you, but essentially you need to work with the family to produce a story about why the symptoms are happening, and use that story to tease out areas of resilience and protective factors, which you can then use to improve the situation. You will also need to incorporate some standard advice, as lain out here for anxiety, and here for depression.

3) Involving local CAMHS in your training
It’s important to remember that CAMHS teams are small, and beleaguered. Also, there are increasing pressures on community paediatric teams to increase productivity. Training in mental health, across different teams/ trusts, is obviously harder to attain.
On the other hand, there are some essential experiences that ought to be possible:
Attend a CAMHS referral meeting, and learn how many referrals they get, and how many other options there are for emotional and behavioural problems other than CAMHS.
Observe a few CAMHS assessments, just to see how the approach differs from community paeds
Discuss some of your cases with a psychiatrist, not in order that they take them on, but to see another perspective.
Joint clinics can be great: my personal experience is that this works best with non-doctors who work in CAMHS- they value your medical experience while you will learn from their approach and skills. If they want you to see for a clinical reason (possible ASD, genetics) you can also ching it as a referral to your own service, so your bosses will be happy (and it’s a good model of care).

4) accessing e-learning
There is a ton of e-learning relevant to the mental health aspects of community at Mind Ed. The core curriculum is a useful introduction, the specialist CAMHS section pushes you on, and for the overlap between mental health and community, there are some Healthy Child Programme sessions that can be accessed via Mind Ed.
Finally, there is even a paediatric learning path if you log in!

5) supporting parents to deal with behavioral problems
Coming soon..

6) a new study day
We want to do a study day on mental health for community paeds trainees. Current ideas for content include
Medication workshop
Role of OT
Explanation of psychotherapy for children
How to give behavioural advice

Let me know what you think

5 minute tips for anxiety in children and young people

This post allows you to give brief advice if it send that a child has problems with anxiety. It should be read after you have gone through our introductory post, and is intended for non specialists working in health services.

When to think of anxiety
Excessive anxiety is common in childhood, but is particularly common in chronic or recurrent pain (up to 80%) and in developmental conditions, especially autistic spectrum disorders.

What are the key questions to ask
Worries: in quiet moments, does the child worry about going to school, harm coming to their family or themselves, any imaginary creatures or anticipated events
Avoidance: anything that the child doesn’t do, or doesn’t want to do
Sleep: difficulty settling, frequent waking, nightmares
Eating: restrictive patterns, poor appetite

Safety checks: (seek advice if these are happening)
Is the child harming themselves, or consider doing so?
Does the child feel worthless?

What advice can you give?

There are two main forms that therapy takes, both of which can be applied in a ‘low-voltage’ fashion in non-specialist settings.

Firstly, it is helpful to draw out the thoughts and beliefs that underlie the anxiety.  This is not so that the adult can dismiss them as silly or mistaken, but so the child can be helped to compare the harmful cognitions with their other beliefs and feelings (e.g. monsters aren’t real) which can then be used to challenge the anxiety. Equally, it’s important when a child is worried about a particular event to talk through what consequences may result, and again check that the child really thinks these consequences are likely, and plausible. In some cases, especially involving social situations, it may that the child’s fears are justified, in  which case negotiation with third parties (teachers, family) would be useful.

Secondly, some kind of graduated exposure is often helpful. Say the child is scared of going to the toilet alone. Going with a parent, but with the parent then standing in the doorway would be a good start, which the child could be rewarded for. Next time, they would need to tolerate the parent being in the hallway in order to earn a reward, and so on.

These techniques are explained further in resources

Resources

This fact sheet can be a useful start for parents . Simple-ways-to-help-children-with-fears-and-anxieties

Cathy cresswell’s article in the Archives of Disease in Childhood is very good, as is her book for parents

The Mind Ed portal has a lot of information on anxiety. It’s designed for professionals, but there is really no reason why a motivated parent can’t access it, especially

The worried child

Anxiety disorders

The session on school avoidance is excellent, and there are loads of generalisable tips in it

The next government must address CYP mental health as an emergency

This much shared article is brilliant, heart-breaking, and matches exactly the experience of PMHA members.

As we prepare to vote tomorrow, we just want to remind our members and friends of the importance of children’s mental health as a political issue, as well as a clinical one.

Quite apart from the moral imperative to help, we know that:

1) Mental health is the biggest cause of morbidity in adults,

2) Adult mental health starts in childhood. 50% have symptoms by 15

3) The biggest determinant of adult happiness is childhood emotional wellbeing

4) We can save £17bn by intervening early to prevent problems.

It’s a no-brainer, a scandal and if we don’t want to end up with a  generation of damaged people, we need action, not words, now.

Troubled teens – recognising and responding to the health needs of looked after young people | British Association for Adoption and Fostering

‘ Negotiating adolescence is a challenge for any young person but it is particularly difficult for looked after and adopted young people and care leavers, including those on remand. Although these vulnerable young people experience a wide range of health inequalities, and high levels of mental and emotional health difficulties, professionals may find it difficult to engage with them to address difficulties with school, relationships, sexual health, bullying, including through cyber-space, self-harming and other challenging behaviours, and to safeguard them from child sexual exploitation.
 
This fascinating conference will consider the evidence base and assist health, social care and education professionals to understand these issues and risks, and how to approach them. The themes of engagement, health promotion, building resilience and developing skills for the adult world, all of which are required to promote health in the broadest sense, are considered throughout the conference’

Couldn’t have put it better myself!
http://www.baaf.org.uk/node/7444

Introducing… 5 minute tips

Emotional and behavioral problems in children and young people are complex. Specialist assessments and treatments are time-consuming and increasingly hard to obtain. And yet the vast majority of children with children with these problems get nowhere near a psychologist or psychiatrist. They are looked after as best they can by teachers, doctors,  nurses,  family support workers, and above all parents. But the training of this informal workforce is inconsistent,  and often messages are mixed and contradictory.
We in the PMHA know that the system needs radical overhaul and investment,  which is why we’ve been involved in the future in mind report produced by the Department of Health.
But any system needs to be built on the foundation of everyone who works with families knowing the basics,  and being able to communicate consistent messages.
Our small contribution is 5 minute tips. We will produce a number of blog posts over the next few weeks to communicate important messages that you can transmit to families in a fairly short time (although we can’t guarantee the 5 minutes!).
This post,  though, is background for you to read first. Because in order to produce sharp advice,  You need to be able to understand the family’s story, and help them make sense of it. And yes, that part does take longer than 5 minutes!
These are complex problems, but it is a myth that you need to be a specialist to understand them.
What you do need to do is learn to think in a particular way. paediatricians like me are trained to think about symptoms and signs, find a cause, and apply a treatment; but these situations just aren’t like that, and you need to adopt approaches from other disciplines.
If you asked a historian why the first world war happened, and she simply said ‘Franz Ferdinand got shot’ then you might not think much of her skills. Instead we would expect her to tell a story, firstly outlining the predisposing factors which made 1914 so combustible, describing the chain of events which led to (precipitated) the declaration of war in September, and then explain the factors that perpetuated the conflict and made it so devastating. A good historian would range across economic, political and military aspects to really give the story explanatory power. In the same way, professionals need to create a story with families about how the child was predisposed to difficulties, how the difficulties were precipitated, and how they are being perpetuated. To generate a compelling story you need to range over biological aspects, psychology (that is the child’s own thoughts and emotions), and their social context and interactions, both within the family and outside. This sounds complex, but most of it falls out when you apply your curiosity and common sense to some of these questions.

  • What is the problem?
  • How does the problem affect the child and family?
  • Who is in the family? Are there other problems in the family?
  • Has the child themselves suffered any adversity?
  • How did the current difficulties start?
  • What else was happening at the time?

Doctors reading this may have switched off a bit. This is standard medical history stuff. You can wake up now.

  • Next ask: how do people respond to the problem?
  • What do you think about the problem? What does the child think?
  • What worries everyone most?
  • What are you doing about it already?
  • Are there any times when it gets better?

These deceptively simple questions, if pursued with follow up enquiries, will allow you to populate, either in your head or on paper, something that looks a bit like this.

Biological/ developmental Psychological Social
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors

You can then use the information you have to agree a story with the family about what is happening.
Why have I told you all this? Because out of this story will fall useful interventions, and adaptations to the generic advice that will be contained in the 5 minute tips. The problem with generic advice on its own is that it treats people as if one size fitted all, which of course it doesn’t. By combining your own on the ground understanding of this family’s predicament with the evidenced advice, you can make a huge difference to families, believe me.

Let’s take a short example of this process:

Ahmed, 4, has a tantrum every night at bedtime. His health visitor has advised his mother to shut the bedroom door and ignore him, but it’s not working. Table 4 shows her 4p framework.

Table 24. Use of 4p framework for Ahmed

Biological/ developmental Psychological Social
Predisposing Preterm birth Maternal anxiety
Precipitating Break-up of parents’ relationship Domestic violence
Perpetuating Screen use (TV) in bedroom up till bedtime Anxiety of mother Mother unavailable due to depression
Protective Healthy, good communicator Good relationship with mother during the day Family well-supported by grandparents

This leads to some simple, hopefully helpful interventions:

  • Stop screen time before bedtime
  • Mother to seek counselling/ treatment for depression.
  • Grandparents asked to help with domestic tasks so mother can spend time with Ahmed
  • Gradual withdrawal of mother from bedroom at bedtime, following good ‘wind-down’.

Please see our upcoming post on sleep problems for more details!

We hope that you can see that by adopting this narrative approach and combining it with generic advice (and a flexible approach to finding sources of support!) then you can achieve an awful lot for children and families.

Of course this approach won’t work for everyone, but it’s always a good starting point, from which other interventions and assessments can build.

Got it? Have a look at our anxiety post. More to come.