Children with ADHD ‘learn better when fidgeting’ http://www.medicalnewstoday.com/articles/292671.php
‘ 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!
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.
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:
- 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.
This open access review http://m.adc.bmj.com/content/100/4/308.full looks at trials of mental health intervention for children in physical illness.
Physical illness is, as PMHA members will know, a risk factor for mental health problems, with around 20% having diagnosable conditions, and many more suffering broader mental health problems.
The trouble is that there are almost no trials done in physical illness. In part this is understandable- liaison mental health services are small and under-resourced, the population is highly variable, and the symptoms are affected by complex factors which discourage the application of a single treatment modality.
However there are good reasons, precisely because of this complexity, for thinking that treatment may need to be adapted to this group. Without more trials, though, we will never know.
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:
- What should be the scope of mental health work undertaken in community paediatrics?
- How can paediatricians who are practicing in this area ensure they can make a difference, and be safe?
- How do we ensure that specialist CAMHS remain engaged where they are required?
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.
Important to build resilience in yourselves before you can do so in others. This can decrease stigma in others if you do it openly.
Resilience is the ability to cope with adversity. Not toughness, stiff upper lip. It’s good mental well-being and resourcefulness.
Analogy of a tree in a hurricane is useful, bends not breaks.
Resilience is not a dichotomy, have it or not. Small degrees of improvement, slowly build.
Personal resilience built by respect, care
Suicidal thoughts quite common, but no-one talks about it. Taking about it will not make someone want to do it, but particular methods may be copied.
Identification of suicide risk currently very poor.
Self harm connected to suicide, although not invariably. Often an expression of distress which is temporarily relieved.
Adolescents are vulnerable to taking ‘small things’ as massive issues.
Resilience associated with optimism, self-esteem, gratitude, emotional awareness, flexibility, problem solving ability, self regulation.
One thing better is worth doing. External motivators e.g. pledges, social pressures, can help.
Gadget free time.
Mindfulness application in families needs to include self compassion. Your inner voice needs to be kind as much as possible.
Suicide prevention requires: awareness, compassion, skills, governance.
Professionals need to lose their fear of suicidal people. Need consistent assessment framework applied across professions.For pediatricians, awareness, triage, co- create, effectively refer, common language are key.
Human factor errors important. E.g. good assessment leads to poor documentation.
Suicidal thoughts can be classified into passive, active, dangerous and dangerous and imminent.
Talking through scenario can be beneficial.
Connecting with People is a not-for-profit organisation formed to develop and deliver training packages for a range of sectors, including healthcare, social care, statutory bodies and communities.Our modular training includes bite-size suicide awareness and prevention courses and we have also developed resources and training for young people, professionals and the wider community
Portsmouth currently biggest port for trafficking into UK. Needs coordinated national response.
Human trafficking has several elements
Movement, control, purpose.
Last year 1746 cases referred to national agency.
Sexual exploitation most prevalent form
22% of total are children, 40% sexually exploited
60% of children go missing after care. Only one centre for trafficked children exists. Placement depends on individual needs.
Estimate 10000 victims in the UK
Some examples: Vietnamese children in cannabis plantations
Arrested and treated as criminals not victims
Trafficking may be external (cross border) or internal
Sexual exploitation a common purpose
Not an immigration issue, an organised crime issue.
Parents cannot consent to trafficking or exploitation
Different to people smuggling
Multiple forms of exploitation. Forced labor, sexual, domestic service
Multiple means of control including use of drugs, deception, debt bondage, removal of documents
Very hard to detect.
Modern slavery helpline open to all: 08000121700
Modern Slavery is closer than you think:
Indicators: any sign of abuse
Rarely leaving house
Lots of chores
A&e attendance with workplace injuries
Unusually long hours
No identity documents
STI, prevented from being seen alone
Prepared story of origin
Multi agency response required. Need for reception centres, mental health input.
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.
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 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.