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.