Substance using adolescents: Dickon Bevington talk

Hard to work with people who don’t want to work with you. Stressful and worrying

Recommended Michael Ungar and John Weisz

Quality of service more important than number of services. Vulnerable young people can feel overwhelmed by numbers of contacts

Alternative model of multi modal worker supported by others. This support needs strong structure

Team structure helped by aggregation of marginal gains.

Networking complexity
Family system, social ecology, local service ecology, political context

Negative feedback about professionals is a way of help seeking, but corrosive to local joint working.
Respect for local practice and expertise

Mentalising is a framework for bringing perspectives together. It’s a process of wondering, reflecting on what current needs are.

Csibra and Gergely: epistemic trust
There needs to be formation of a bond by understanding the particular situation of the person in front of you.  Then teaching, persuasion can occur.

Mentalising is born in attachment.
Therapeutically, you need to ‘get’ the person before you can make progress.
The job of a therapist is to show ‘I’m changing my mind about you not I’m trying to change you’

When contacting someone, important to mark the task. Mentalising had to start with us.
Never in a set balance, constant movement around tensions.

Consider levels of dis agreement, explanation, intervention, responsibility

If this summary tantalises you, Dickon’s slides are in our Member’s area

 

Michelle Koh: psychosocial impact of life limiting illness in adolescence

Michelle presented three cases of palliative care in adolescence.

Makes point that direct anxiety about death, suffering, direct molecular effects, and family dynamic issues all contribute to difficulties.

E.g. in DMD cognitive development shows unusual cognitive and social skills

Family refusal to talk about feelings exacerbates difficulties.

Useful for clinician to put death out there as a concept, and see the response.

Families very concerned about physical reality of death. Professionals need to engage with this.

You can control symptoms and pain but not suffering.

Some families desperate for death to happen at home, for others need to be in a hospital. Key is respect for views.

Long term illness can rob the child of a peer group.

Story of a bright, willful boy who got fed up with dialysis. Team resources this, boy signed own care plan. Rapid deterioration but manages to make it to 18th birthday and buy a round of drinks!

Paradoxically uplifting story demonstrates primacy of respect for patient self definition.

Children’s journeys through grief, with Jacqui Stedmon

Attachment serves add a biological basis for all forms of grief.

4% of children lose parent before 18

Interventions need to be carefully targeted, but evidence base is poor.

The assumption that bereavement is bad has hampered progress; many children are very resilient. 2/3 do well after loss of a parent.

Bereavement a potent trigger to attachment system. (See slides)

The stages of grief narrative remains dominant, but isn’t the whole truth. More useful is an oscillation between loss orientated and restoration orientated activities.

Continuing bonds model (Silverman) rejects the idea that the end point of grief is to break the bonds with the dead person. Accommodates children’s grief in an uncritical and helpful way.

Meaning making a important part of the cognitive work of grief. A punctuation (saying goodbye) can be helpful.

Lack of evidence but experience suggests that children have a distinct individual path through grief

Trauma can interfere with grief process as person revisits traumatic memories. Triggers can be quite trivial.

Details matter in making sense.

Viewing the body can be helpful if the child chooses. Choices need to be given in a neutral way.

Peer groups can be prepared to deal with a bereaved child.

Two broad types of complicated grief in children
Traumatic and delayed or inhibited

Seems to be quite a bit of somatisation after inhibited grief, all aberrant behaviors can be linked to grief.

Assessment and understanding should include consideration of family relationships.

Disenfranchised grief, not accepted by others or self, can come out in physical symptoms.

Slides will be posted shortly. 

Virtual hospice with Bettina Harms and Becky Hepworth

Isle of Wight team.
No physical hospice available on the island. Often isolated from the mainland. Ferry required, which is expensive, and not always available.
People want to be with families, not remote.
Aim was to provide the care of a hospice without the building.

Brings existing services together with additional resources

Without the service respite access was poor.
Lack of counselling support after death
Lack of clear choice of place of death

Feeling of all services serving own population important driver for brining them together. Passion of local people invested in their own populations.  Pilot by existing hospice not successful as too far, so local services joined forces.

Commitment to home care. Training from mainstream hospice. Additional resources for children’s community nursing including respite. Support from adult services, third sector.

Physical room found in adult hospice, as a fall back, and actually used for after death care, requiring considerable negotiation and training, but now improving confidence.

Family voices important, guiding principle of service.

Bereavement with Su Laurent and Tracy Dowling

Tracy talked about the process of preparing for death, the questions (what will he look like? Will he need an ambulance?) that she asked, and the planning and listening from the team. Vital meeting in her kitchen.
Trivial things matter in this situation. Planning for details of different contingencies, including an ambulance directive for which hospital he was to be taken to. Importance of ongoing relationships and things being done by familiar people.
Impact, both positive and negative, on younger brother. Planning and discussion with siblings.
Importance of fitting language to the audience. A lot of people prefer direct language e.g. dead rather than lost or in heaven.
Advanced care planning is key, and is not death planning.
Death takes its time, often far longer than any of us expect. Weekends are especially tough during these last days. Doing things for ‘piece of mind’-we need to ask whose piece of mind?
Importance of medicine leaving the room, dropping off the trappings of medical care.
After death.
Bereavement hurts, physically and the exhaustion is worse than the exhaustion of over work experienced during dying. Often the complete withdrawal of care is devastating.
Numbers and anniversaries are important and become a way of counting and marking bereavement.
People say things to add positivity. E.g. back to work, have another baby, it’s a blessing. Language of moving on can be unhelpful. People also avoid the bereaved. Talking about the child as a person is valuable.
Bereavement team’s role: mainly to get parents together. Hearing the stories of others can give you examples of what not to do, as well as what to do.
Differences in how people are treated depending on how child died. Unexpected death in some ways better, but often complex feelings of guilt. Every bereavement is different and heading each other’s stories is valuable.

The epidemic of self harm in young people

The BBC  have obtained figures that suggest a rise of 20% in one year alone in the admission of young people to hospital following an episode of self harm. The PMHA did a survey last year that supports the idea of a rapid rise in these admissions,  suggesting that this finding is genuine. So why are more young people self harming,  and what can be done about it?
It’s impossible to generalise about why young people self harm. Some feel that the physical pain of cutting is preferable to the psychological state that they find themselves in, others use taking an overdose as a way to tell people how hopeless or angry they feel. The thing that seems to unite people who self harm is a psychological state that they find so unbeatable that they feel, even for a short time, like they would prefer the pain and/or risk of harm of a self harm episode to their current situation.
So an increase in self harm means an increase in the number of young people in these situations, at least to some extent. What has changed?
Well, when asked, for instance by Young Minds, young people talk about pressure. Pressure from school, to behave, to succeed or to conform. Pressure from peers to be a certain way in order to be popular. Pressure from the media to have a certain body, clothes or sexual habits. They talk about feeling isolated, including in their own families. And when they want to talk to someone , there is often no one to talk to. Any attempt to improve the situation needs to start from this perspective.

So, here’s our wish list

  • Young people can educate themselves about self harm at selfharm.co.uk, and look out for their peers.
  • Parents can talk to their children about mental health, feelings, and pressure, and make time in the day when no-one is staring at a screen, to give a chance for conversation. It’s often easier to bring up issues while doing something else, which may be one reason why shared activities as a family are associated with better wellbeing all round. Young Minds have an parent helpline, which can help if you’re worried.
  • Schools are under huge pressure. But they can act as great detectors of early problems, as well as providing counselling and other services.
  • Health services need to reach out to education and to parents, provide support and training, and respond promptly when young people get into difficulty.
  • Government needs to fund mental health adequately, and commit (all parties) to implement the forthcoming mental health taskforce recommendations.

We hope that things have got as bad as they are going to for young people’s mental health. Only by concerted effort by everyone listed above can even this rather meagre hope be realised.

CAMHS: the health select committee speaks

The House of Commons Health Select committee has produced a report on CAMHS.

The  Press notice provides a neat summary.

Hilary Cass has responded on behalf of the RCPCH:

“For too long policy makers have failed to tackle the crisis in child and adolescent mental health– so much so that it is now becoming a hidden epidemic.

“If a child with a physical illness is forced to travel hundreds of miles for a bed, if funding for hospital services are severely cut or if there is huge variation in the provision of care for children with a physical condition – it is deemed a national scandal. And yet we continue to see budget cuts and increases in waiting times for CAMH services, and increasing numbers of children and young people being held on adult mental health wards and high numbers still held in police cells.

“Today’s report paints a picture of a service in crisis, but provides some real solutions to transform the landscape.

“We fully support the emphasis on early intervention; children and young people with mental health problems can become adults with mental health problems. All professionals working with children and young people need to be better equipped to recognise and act on the signs of mental ill health in children and young people , with more care delivered outside the hospital setting.

“It is absolutely crucial that the prevalence study of child and adolescent mental health is conducted regularly and extended to under 5’s with better evidence collected on the mental health of children and young people from ethnic minorities. The current variation in services for children and young people with mental health needs is unacceptable and far too few paediatric departments have sufficient and timely paediatric liaison services.

“Adolescence is considered a risk period for serious mental health disorders, substance misuse, and risk-taking behaviours. We welcome the report’s focus on transition to adult mental health services and plans to review progress in this crucial area again in 2015.

“There is a clear message to the next Government: get to grips with the CAMHs crisis or put the mental health of thousands of children, young people and adults at risk.”

Max Davie, PMHA convenor, gives his personal view here

We in the PMHA are committed to support RCPCH and other bodies to continue to campaign for change, as well as engaging with the DH CAMHS task force (which Max attended yesterday).

If you are reading this as a non-member, please consider joining to help our work to continue (and other benefits to you!)

PMHA at the party conferences

Max Davie, PMHA convenor, reflects on the party conferences:

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For the past few weeks, I’ve been roaming the country with the RCPCH public affairs team. We’ve been talking about children and young people’s mental health at fringe meetings at the three major party conferences, along with colleagues from the RC Psych and the charity Young Minds. I’ve been able to talk to people from around the country about the problems with CAMHS, and discuss some possible solutions. For the benefit of PMHA members, here are some thematic reflections on the problems:

  • There isn’t enough money in the system

While there had been no concerted attempt to cut CAMHS, the brute reality of NHS and local authority funding has led to unprecedented reductions in budgets, by up to 40% in 4 years. This is in part due a lack of clear tariffs and targets, because in the NHS “money follows targets”. An understandable retreat by local authorities into their ‘core business’ has compounded matters.

  • We think of CAMHS services, when we should be thinking about a local CAMHS system.

Services have, in response to cuts, raised the drawbridge to referrals, and shrunk their scope. Paradoxically, once children are in services, there are perverse incentives to pass then to ever more expensive echelons of the system. Meanwhile, other children and young people are lost between services as they don’t ‘fit’ anywhere. Only by re-imagining CAMHS as a comprehensive system, supported by specialists and incorporating education, health, social care and the charitable sector, can we maximise our resources.

  • Early intervention needs more priority

More lucrative specialist services have been prioritised by cash-strapped mental health trusts, but parenting programmes and universal mental health education for children are low cost, effective interventions which need political priority.

  •  Professional cultures need to be more collaborative and inclusive

There is a pervasive myth that mental health can only be done by specialist CAMHS. This is encouraged by lack of engagement by many CAMHS services with the wider system. This leads not only to poor integration, but also another lost opportunity for early intervention outside of specialist CAMHS.

  •  Parity of esteem needs to be more than just a phrase

Many of my first points can be encapsulated in this: parity was enshrined in the health and social care act, and yet mental health continues to be a poor relation of physical health. Recent policy announcements, especially by the liberal democrats, are welcome, but a robust plan is required to embed parity across the NHS.

  •  No CAMHS system will serve children and young people unless it listens to these young people

The best speech I heard at our meetings was by Lisa Murphy, from the RCPCH youth panel, who talked passionately about the need for a responsive system which listened and respected young people as individuals. How we achieve this while embedding robust commissioning and manage a continuing squeeze on finances is the challenge of the next five years.

 It was fascinating to visit the conferences, with their bustle, intrigue and hubbub of chat and speeches. Mental health had never been higher up the political agenda, and we hope that we have played a small part in keeping this vital issue somewhat at the forefront of politicians’ minds.

 

Sluggish Cognitive Tempo: the next big thing in diagnosis?

This blog ://www.slate.com/articles/health_and_science/medical_examiner/2014/09/sluggish_cognitive_tempo_is_it_a_disease_independent_of_adhd_and_can_drugs.single.html is very good, and recommended.
Briefly, sluggish cognitive tempo is a terribly-named new conception of children who have poor concentration, not due to the ‘fizziness’ of the ADHD brain, but due to slow processing in the absence of other learning disabilities. The slate article rejects SCT partly on the basis that it’s just an exaggeration of normality, but PMHA members will know that this argument could apply to whole swathes of the diagnostic textbook, from ADHD to hypertension.
So should we be looking at diagnosing this condition in our clinics? At present, it’s very hard to be clear, as the evidence base is tiny for usefulness of this concept, and it is likely to be mainly treated with educational intervention.
But we would be interested in your thoughts…