Training for paediatricians for mental health crisis care: Claire Miller guest post

I often wonder about how much time paediatric trainees spend on learning and rehearsing the steps of all the various APLS algorithms. Indeed,  we are encouraged to do so as the curriculum and assessment process that we go through during our training has a strong focus on physical health. We are then further armed for the frontline with various medical calculator applications on our phones that can ease us through calculations in difficult moments. What can we have in our minds and pockets to help us when children and young people present to a/e with unmet mental health needs? Maybe the attached handouts on mental state examination and risk assessment would be a start. They are assimilated from information contained in a fabulous free resource called MindEd. Have a look and see if it helps….

Mental state examination

MindEd E learning references

Risk

New courses from HCUK

Mental Health Support for Asylum Seekers and Refugees Providing Emotional First Aid for Refugees, Second Annual Conference

Monday 22 May 2017
De Vere Conference Centre, London

A Joint Conference Healthcare Conferences UK & The Tavistock and Portman NHS Foundation Trust

This important and timely conference will support delegates to better understand and meet the needs of asylum seekers and refugees. Through national updates, practical case studies and extended interactive masterclasses the conference will look at developing local services and responses, developing early access to psychological first aid, delivering psychosocial support to refugees. The conference also includes interactive sessions drawing on theory from psychotherapy (eg the effects of counter transference), narrative and systemic family approaches, community and liberation practices, working with asylum seekers and refugees who have experienced trauma, and therapeutic care of unaccompanied young people seeking asylum.

For further information and to book your place visit

http://www.healthcareconferencesuk.co.uk/mental-health-support-for-asylum-seekers-and-refugees or emailkerry@hc-uk.org.uk

Follow the conference on Twitter #RefugeeMentalHealth

 

 

MASTERCLASSES

 

Safeguarding Children: Level 3 Mandatory Safeguarding Training in Accordance with the Intercollegiate Guidelines

Monday 12 June 2017
De Vere, West One, London

The course is interactive and aims to highlight the key principles of safeguarding children and young people, with a view to embedding best practice in safeguarding in accordance with the core UK legislative framework and guidance. Healthcare and allied professionals requiring level 3 mandatory safeguarding children and young adults training and those professionals requiring an insight into safeguarding principles and best practice. Certificates for this training counts as the 3 yearly safeguarding children training in accordance with Intercollegiate guidelines.

For further information and to book your place visit

http://www.healthcareconferencesuk.co.uk/safeguarding-children-and-young-adults-level-3-safeguarding-training or email hanisha@hc-uk.org.uk

EXCELLENT psychopharmacology child module that will sell out

The November 2017 Child and Adolescent Module will be held on Thursday 16 and Friday 17 November at the County Hotel in Newcastle.  A programme for the meeting is below. It begins at 10am on Thursday 16 November and ends at 3.50pm on Friday 17 November.

 

The Child Module is extremely popular and always over-subscribed.  Places are limited and you are encouraged to book early if you wish to attend. The meeting is not bookable at the BAP website but you are welcome to forward this email to colleagues if you wish.

 

The registration fee is £390. Accommodation is also available for Thursday 16 November at the County Hotel at a cost of £75 B&B if required.  If you book accommodation via the credit/debit card form, you will not be charged for the accommodation at this stage but will pay on departure from the hotel.  Those booking via invoice request will have the accommodation charge added to the invoice.

 

Bookings may be made in two ways:

 

With a credit/debit card via this link: https://www.bap.org.uk/childNov2017card

 

By requesting an invoice via this link: https://www.bap.org.uk/childNov2017invoice

Please note that we will not invoice individual delegates – only finance offices

 

When the meeting is full the above links will be disabled.

Excellent-looking conference on mind/body problems in Paediatrics

This looks great:  https://www.acamh.org/events/2017/02/just-faking-it-exploring-issues-mind-and-body-underlying-somatising-disorders

Just Faking It?: Exploring issues of the mind and body underlying somatising disorders
Friday 3 February 2017
Hilton Southampton, Bracken Place, Chilworth, SO16 3RB

Somatic symptoms can be distressing and have a negative impact on day-to-day life. When the amount of distress that is experienced and the degree to which functioning is affected seem disproportionate or when no medical explanation for these symptoms can be found, management and treatment of these difficulties becomes infinitely more complex.

Covering a wide range of topics, this conference explores key issues in our understanding and management of young people with somatisation disorders.

This conference is suitable for those working with children and young people in primary care, education, social care and youth-based services as well as those working in both physical and mental health.

Content covered during the day includes:

·       A look back at the concept of hysteria, its changing meaning and its fit in modern day psychiatry;

·       An exploration of the complex issues encountered when navigating the interfaces between somatisation and safeguarding;

·       An overview of the evidence base for treating functional symptoms as well as the skills needed for engaging young people with assessment and treatment of these;

·      Examination of non-attendance at school and how this is understood;

Principles of parenting- what you need to know

There is a vast market in courses/ books/websites to help parents who are struggling with their children’s behaviour. Fortunately, they are all founded on the same core principles, which are summarised below. What one is essentially doing is implementing new habits, forming new structures of reward and consequences to make the organisation (family) run more smoothly and improving interpersonal relationships. (It is a process that should be familiar to anyone working in the NHS, who will also understand its difficulty!)

Positivity

In order for behavioural management to be effective, it needs to be based on a ‘good enough’ relationship. At some level, the child needs to care about the parent’s feelings, and also feel good about themselves, to cope with the changes the parent wants.

Promoting the emotional security of the relationship through shared activities is useful, so any shared activity is worthwhile, but play is paramount for younger children. Play led by the child for a short (10 minute) period is advised, but any play where the adult attention is on the child is useful.

‘Catching them being good’ and noticing when they have made small positive steps is a powerful tool.

Targeted praise: vague, general praise (aren’t you a good boy) has been shown to be worse than none at all, whereas specific praise (I like how you did X) is beneficial.

Responsivity 

Much attention is focused on children’s screen time, but it is perhaps more important that parents limit the time they are unavailable to their children due to phone conversations, Facebook etc. Unlike most household tasks, these cannot be combined with conversation with the child. Parents must learn to distinguish between listening to the child respectfully and granting the child’s every wish, as learning to tolerate a degree of frustration is an important step in emotional development. .

Structure

A routine is important for children to feel safe and reassure them that the adults are in control. This can be very mundane, like a list of tasks involved in getting ready in the morning, or fun, like a weekly film night.

There need to be rules, binding upon the adults and children. These need to be simple, unambiguous, and (initially) few, perhaps 2 or 3. These rules should specifically target unwanted behaviours (eg don’t hit, rather than be good). Patterns of behaviour take a long time and much effort to change, using positive and negative encouragement and the power of habit, so sometimes it is more productive to target only one behaviour at a time to start off with.

Planning for situations does not require strategic genius. Parents know the situations where children have trouble, so before they enter a supermarket, for example, it is useful to stop, and calmly tell the child what is expected, what is not allowed, and what the consequences of positive and negative behaviour will be.

Consistency

None of the above will have any effect unless parents are consistent, in several ways:

* consistency over time.

* consistency across all parents and carers

* consistency across settings and contexts.

Rules cannot be dependeant on parents’ moods or energy levels. Occasional rule lapses act as ‘intermittent reinforcement’, shown to be the single most powerful way to ensure that the behaviour that is being targeted continues with a vengeance.

Patience

This is perhaps the most important element, yet often overlooked by parenting manuals selling a quick fix. Behavioural management works, but takes time, and there is often an ‘extinction burst’ of increased unwelcome behaviour before things start to improve, as the child reacts against the new boundaries. Parents need to be prepared for this.

As well as patience across weeks, parents need patience across hours, to be able to abandon a shopping trip, wait out a tantrum, or stay calm in the face of sibling conflict when shouting would, in the short term, be quicker.

5 minute tips on sleep

Please read our introductory post before reading this

As always, you need to know

a) generic advice

b) a formulation that tells you why this child has problems now.

You can then adapt the former according to the latter.

Generic advice

Sleep schedule: Your child’s bedtime and waketime should be about the same time everyday. There should not be more than 1 hour’s difference in bedtime and waketime between school nights and non-school nights. Make your child’s bedtime early so that he can get enough sleep.
Bedtime routine: Your child should have a 20-minute to 30-minute bedtime routine that is the same every night. The routine should include calm activities, such as reading a book or talking about the day, with the last part occurring in the room where your child sleeps.
Bedroom: Your child’s bedroom should be comfortable, quiet, and dark. A nightlight is fine, as a completely dark room can be scary for some children. Your child will sleep better in a room that is cool (less than 75°F). Also, avoid using your child’s bedroom for “time out” or other punishment. You want your child to think of the bedroom as a good place, not a bad one.
Snack: Your child should not go to bed hungry. A light snack (such as milk and cookies) before bed is a good idea. Heavy meals within an hour or two of bedtime, however, may interfere with sleep.
Caffeine: Your child should avoid caffeine for at least 3 to 4 hours before bedtime, although it’s best to avoid it totally. Caffeine can be found in many types of soda, energy drinks, coffee, iced tea, and chocolate.
Evening activities: The hour before bed should be a quiet time. Your child should not get involved in high-energy activities, such as rough play or playing outside, or stimulating activities such as computer games.
Television: Keep the television set out of your child’s bedroom. Children can easily develop the bad habit of “needing” the television to fall asleep. It is also much more difficult to control your child’s television viewing if the set is in the bedroom. Keep all other electronic devices out of the bedroom too, such as computers, cell phones, and hand-held computer games.
Naps: Naps should be geared to your child’s age and developmental needs. However, very long naps or too many naps should be avoided, as too much daytime sleep can result in your child sleeping less at night.
Exercise: Your child should spend time outside every day and get daily exercise.

Sleep problems resistant to first-line advice

Most parents presenting with young children with sleep problems are frustrated by the child’s inability to settle to sleep alone, or by their frequent night wakings. We will not discuss infant sleep, but concentrate on the pre-school child.

Social factors: Historically and cross-culturally, it is highly unusual to expect young children to sleep alone. Nonetheless that is the UK norm, and it is acheivable for most families.

Psychological: Going to sleep alone is a form of separation, and like all separations must be prepared for. If the child is in an anxious or fearful state this will require very slow withdrawal of the protective adult. Usually, if the fear is external to the adult, e.g. of the dark, gradual withdrawal is effective, but where the fear is of the adult, or more commonly about the adult, e.g. in domestic violence, then more specialist work may be needed.

Sleep is also a habit, and habits form very strongly in pre-school children. If sleep is usually with an adult, or in the light, changes to this should be carefully applied one at a time. Likewise, if the physical situation (light, noise, presence of adult) is different between sleep onset and the (normal) awakenings that occur every 1-2 hours, then full arousal will often result.

There is an association between some forms of insecure attachment and sleep problems, and also maternal depression. The precise relationship is unclear, however, and probably varies from family to family.

Biological:sleep is a biological phenomenon, and is therefore affected by biological mechanisms. Chronic symptoms e.g. pain or GI symptoms may prevent sleep, but equally phenomena such as epileptic seizures can disrupt the diurnal rhythm. A far more common way to interfere with sleep initiation is to watch a back-lit screen close to bedtime. These appear to suppress endogenous melatonin secretion, and thus the psysiological ‘cue’ to sleep, and so should be avoided within an hour of bedtime.

Example case:

Louie, 4, has a tantrum every night at bedtime. His health visitor has advised mum to shut the bedroom door and ignore him, but it’s not working.

4p grid constructed as follows:

 

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

 

This leads to some simple, hopefully helpful interventions:

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

 

Sleep Scotland Paediatric Sleep Information Day

Date: 24th January 2017

Venue: Central Edinburgh

This is a one-day training course designed to provide an understanding of the causes of poor sleep in children and young people with additional needs, including an overview of sleep processes and the support that you can offer to families. Further info can be found at our website: http://www.sleepscotland.org/professionals/paediatric-sleep-study-day/ Contact:ailsa@sleepscotland.org