Feeling on the edge-, a leaflet by the Royal College of Psychiatrists, is a great leaflet to have available in Emergency departments.
Feeling on the edge-, a leaflet by the Royal College of Psychiatrists, is a great leaflet to have available in Emergency departments.
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
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
6) a new study day
We want to do a study day on mental health for community paeds trainees. Current ideas for content include
Role of OT
Explanation of psychotherapy for children
How to give behavioural advice
Let me know what you think
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.
Doctors reading this may have switched off a bit. This is standard medical history stuff. You can wake up now.
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.
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
|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:
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.
PMHA research, as well as countless conversations with colleagues, has revealed that a growing proportion of community paediatrics is now concerned with managing emotional and behavioral presentations. People worry that they are ill prepared for the complexity of cases coming through, and by the withdrawal of CAMHS under financial pressure from areas where they used to be active. It is a testament to the dedication and humanity of paediatricians that they have not shirked the challenge, but serious questions still need to be answered:
It was a great privilege to be invited to speak at the Paediatric Mental Health Association winter meeting in January on the topic of communication with adolescents. Not only was it great to get the opportunity to share some key messages from young people who use CAMHS services – but it was also very interesting to hear from paediatricians who work with young people on the difficulties they may face when trying to communicate with adolescents.
A number of those present raised the issue of developing a rapport with young people, getting them to understand their mental health and the importance of maintaing it. Interestingly, these were similar to the issues which young people have raised during previous discussions on communication – they often raise the issues of rapport, and of not having a full understanding of what is going on with them and why their treatment is important.
The key messages which I feel most important to share following our discussion are:
Ask the young person how they would like to be addressed: don’t assume name on record. Asking them what they would like to be called shows a respect for their identity that will help establish trust and rapport.
Often first name terms is best for communication: doctors may be concerned that this will distort their relationship, or will seem unprofessional – but young people are more likely to respond to someone they view as on their own level. However, if this doesn’t feel natural to you don’t force it, as a young person will know if you’re pretending to be something you’re not!
Focus on the young persons needs/desires: ask what they want to get out of a treatment or a session, or even what they want in general – this may give a insight into what is troubling them. It can also give a positive place to start at, and allows the physician to work backwards from the young person’s goal.
Don’t assume that because a young person has dealt with a traumatic event or long term physical health problem that they are going to be able to deal with a new, smaller problem. Sometimes a young person is walking a fine line with their mental health, and something seemingly insignificant can tip them in the wrong direction.
It can be difficult to talk about yourself to a complete stranger: sometimes it might be best to ask a young person about their friends, ‘Do any of your friends take drugs/self harm/tell you they feel down?’ etc etc. The young person may then talk about their ‘friend’ as a method of talking about themselves.
Don’t try too hard to emulate youth language etc, as it can actually be more alienating to a young person. Acting like yourself and being relaxed in your role makes a young person more likely to open up and feel comfortable.
Know when to use the family: while parents being present can make a young person more limited in talking, they can also be a useful supportive aid in a consultation, especially with a professional they don’t know. It is important the young person gets a chance to speak to their doctor alone, but do ask if they’d like a relative or friend to be there, even for first session.
Ask about physical manifestations: a young person may not know what ‘anxiety’ feels like, so ask specifically ‘has your heart ever felt like it was going very fast and you didn’t know why?’ Or ‘have you ever found it hard to breathe all of a sudden’.
Always give them the last word – every single consultation needs to end with the questions: ‘Do you understand everything?’ and ‘Do you have anything you would like to ask?’
Once again I can’t thank Max Davie and the rest of the PMHA team enough for inviting me to come and join your meeting, and to all those in attendance for being so welcoming and engaged in all aspects of the discussion. I hope that you all found it as useful as I did, and that you continue to use and share these messages from young people in your practice every day.
This post is intended to summarise the discussion at the PMHA workshop, held on the 3rd September at the BACCH ASM. We hope that it will promote discussion and the sharing of resources and ideas.
Increasingly, community paediatric services are presented with children in whom neurodevelopmental problems, usually presenting as SEN, have come to light in the primary school period. Given that there are 1.5million children in England with SEN, and a shrinking pool of NHS resources, there are challenging questions around which children need assessment by a paediatrician, and what form this assessment should take.
Nice looking resource from mencap