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?
In answering these questions, I will present my view, but I’m keen to hear from BACCH members, especially where this article will be posted at pmha-uk.org.
What do we mean by mental health?
This is a topic which could take up the whole article, to very little benefit, so I’ll use ’emotional and behavioral aspects of clinical presentations’ as a rough definition, to distinguish mental health from work on vulnerability, public health and neurodisability. The focus is therefore on clinical presentations, although training and service organisation underpin this work also.
What aspects of mental health ought to be the business of community paediatrics?
There are two categories of CYP where we might come across mental health problems: those in whom the presentation itself suggests that a paediatrician is the best person to assess, and those whom we are seeing for another reason, and who present ‘incidentally’ with mental health problems. These categories need to be approached slightly differently.
So which presentations are we best placed to assess? That obviously depends on the particular skills of individual clinicians, but on the basis that there has been a centralised training curriculum for more than a decade, we can make some generalisations.
Developmental assessment is at the core of our work, and so any child presenting with behaviour suggestive of a neurodevelopmental problem would in theory benefit from a paediatric assessment, aiming to interpret the behaviour in the child’s developmental and psychosocial context. However, given that pretty much any behavior could indicate an underlying neurodevelopmental problem, it is necessary to develop some exclusions.
One could exclude on the basis of diagnoses, for example assessing for ASD and not ADHD, but as presentations and differentials of all the developmental conditions are so intimately intertwined, that seems an arbitrary and inefficient way to run a local health economy.
It is better, but not unproblematic, to exclude particular presentations. The table below has some suggestions where paediatric assessment is probably not the first option.
- Difficulties in only one context (e.g. Home only)
- Secondary school initial presentations
- Anxiety in the absence of Asd indicators
- Behavior problems in pre nursery children, In the abscence of specific neurodevelopmental markers.
- School refusal
- Behavioral sleep or toileting problems as a primary presentation.
- Academic difficulties alone.
There is of course another population of vulnerable CYP, who are seen by community paeds either on a statutory basis (e.g. LAC), or as part of safeguarding work. There is a unique form of complexity to these cases, which can both take them beyond the remit of paediatrics, and arguably makes them unsuitable for a medically-led model of mental health care. I would propose the following scope for these CYP.
- Biopsychosocial formulation and explanation to carers and YP.
- Identification of mental health disorders requiring specialist CAMHS
- Specific and basic problem-solving around, for instance, sleep, feeding, specific behaviors.
- Advocacy for the individual and also for vulnerable CYP locally and nationally.
Of course, there are grey areas where there are genuine uncertainties regarding our role.
- Adolescents, or rather people whose developmental age is in the adolescent range, present particular challenges for assessment, and arguably their mental health needs are best served by a combination of youth work and specialist CAMHS in most cases.
- Vulnerable CYP who do not meet CAMHS threshold present a particular challenge. Resources are thin on the ground, and imaginative and flexible multi agency work, incorporating the third sector, is probably the best way to make progress.
- Enuresis and Soiling are conditions with medical, developmental and psychosocial aspects, which are therefore well suited to community paediatrics, preferably in concert with nursing colleagues. Provision varies, however, across the country. Access to CAMHS for these children can be particularly difficult when required.
For a lot of the scenarios that we have been exploring, if they were exam questions, the answer might, among other things, be ‘refer CAMHS’, and there is still a feeling that all children with emotional or behavioral difficulties need to be ‘under CAMHS’. However, even if specialist CAMHS had not been cut drastically in the context of rising demand, this would be wrong.
In fact there are two senses of CAMHS, which I have seen confused even at the highest levels. One is a specialist service, usually very small, and increasingly having to concentrate on self harm, eating disorders and psychosis. The other is a system, usually informal, of local agencies who aim to help CYP with emotional and behavioral problems. And for such a system to work effectively, community paediatrics has a big role to play.
How can paediatricians who are practicing in this area ensure they can make a difference, and be safe?
It’s hard within the confines of a single article to give comprehensive information on this. The CCH curriculum is a good guide to what is required, and PMHA members can access the RCPCH mastercourse chapter on emotions and behavior on our website. A brief guide is offered below.
Diagnose and manage developmental conditions
This is the core function of community paediatricians. As the population had changed, and awareness of the spectrum of more subtle neurodevelopmental conditions has become widespread, so the range of conditions has expanded to include higher functioning ASD, ADHD, DCD, APD, sensory modulation, and so on. There had therefore been a spread towards the neurodevelopmental aspects of CAMHS work. Forming robust multi agency for these individual conditions is important, and has covered elsewhere. My point is that, in order to avoid diagnostic confusion, duplication, and fragmentation, the first step must be a holistic, Biopsychosocial developmental assessment. Community paediatricians are the best people to do this.
Know what is available locally, and support engagement
While urging paediatricians to embrace mental health work, I’m not asking you to do it all. It’s vital that you know what is available to support parents locally, both from CAMHS but also from the local authority and voluntary sector. Parenting advice given in clinic, while useful for specific problems, is no substitute for engagement in an 8 week parenting group. We should explain the evidence for these interventions, and our limitations in supporting parenting. Equally, the voluntary sector has a growing role in family support, and should be supported.
TOP TIP: when referring the parent of a child with additional needs to parenting, emphasise that they have a specialist job as a parent, and this is the specialist training they need and deserve.
Having completed your Biopsychosocial assessment, which spans from pregnancy to the irritations of the latest supermarket trip, and from the biological insult of prematurity to the often toxic nature of family relationships, you are in an excellent, I would argue unique, position to tell a story which explains, without excusing or condemning, the behavioural and emotional presentation. It can be extremely helpful to make the telling of this story the conclusion of the initial assessment, leaving diagnosis aside until subsequent visits, so that questions about whether the child has X or Y do not predominate.
The kind of story that emerges can often be helpfully expressed on a 4p grid
Here is an example of a typical presentation:
Jared, 6, has been referred by his school for ‘consistently choosing to disrupt lessons despite clear instructions from the head teacher’.
Table 4. Jared’s 4p framework.
|Predisposing||Paternal history of criminality||Poverty, teenage mum|
|Precipitating||Emerging SEN||Awareness of falling behind at school|
|Perpetuating||Impulsive response to stress||Negative attribution||Harsh, critical parenting|
|Protective||Good social skills||Some positive relationships||Mother enrolling in college|
The advantage of these stories, or formulations as mental health specialists like to call them, is that helpful, simple interventions often fall out by the application of common sense (a particularly strong suit for paediatricians!):
In Jared’s case
- Encourage mother to combine college with some parent training.
- Arrange for Jared to have an assessment of his SEN.
- Talk to his mother about involving others in the family who get on well with Jared.
The process of explaining behaviour, in a way that avoids blame and stigma for anyone involved, while suggesting practical ways forward, is an extremely powerful one and, especially after a comprehensive assessment, can be a powerful moment of understanding for families.
TOP TIP: actively challenge anyone thinking that a pattern of behaviour has a single cause, be it ADHD, prematurity, attachment or neglect. Behaviour does not work like that.
Identify conditions requiring specialist mental health intervention
In response to often devastating cuts, specialist CAMHS teams have understandably confined themselves to children and young people with identifiable mental health conditions that they alone can adequately handle. The conditions that seem universally to be accepted by CAMHS are self-harm, psychosis, eating disorders and severe anxiety/depression. Coverage is not consistent however and it is welcome that the RCPsych has recently produced “When to see a child and adolescent psychiatrist” .
Producing an effective referral to CAMHS requires two things: symptoms mapping to a particular disorder, and resulting impairment. For mood disorders, the former will usually begin to emerge from a good quality paediatric assessment, for instance with avoidant and/or repetitive behaviour or agitation in particular contexts, and can be supplemented by a variety of useful and accessible questionnaires, including SCARED, RCADS, and MFQ (links at PMHA website).
The second element, impairment will also emerge from your assessment. It is worth, when summing up to families and mentioning mood problems, asking “what things can they not do because of their anxiety?” for instance.
For suspected psychosis and eating disorders, early discussion with a CAMHS duty professional is the best advice to give.
TOP TIP: visual hallucinations are relatively common in autism (at least they are reported as hallucinations) but are very rarely part of a psychotic presentation. The same is true of hearing voices, as long as these are not threatening to the person.
Yes, you’re good, but you cannot achieve lasting change across the family’s responses and the child’s behaviour like a parenting course can. However, you can help the family to solve particular difficulties, especially in sleep, feeding and toileting.
Using your assessment and formulation, you can identify perpetuating factors behind the behaviour in question, and intervene. An example regarding sleep is given below.
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’.
Such problem solving must of course incorporate the standard advice for these difficulties, for instance:
- sleep hygiene: set bedtime, screen-free period, soothing routine, dark and quiet room, parent gradually withdrawn if present, minimise changes after child has settled.
- mealtimes: as a family, around a table, with no TV, no shouting, no forcing of food, but equally no snacks or alternatives to what is offered
- toileting: encouraging, calm approach, reward for small progress, attention to physical barriers/ fears
Further information on this can be found in the downloadable document Pathways to problems
TOP TIP: If you’re trailing melatonin for a child, and it starts to become less effective, a ‘drug holiday’ can be a really effective way to get the therapeutic effect back.
Educate yourself and your colleagues
Mental health skills often seem mysterious and arcane- specialists have been guilty in the past of encouraging the idea that only the chosen few can possibly understand the intricacies of the human mind… Fortunately this is changing. MindEd, a suite of e-learning written by specialists for a general audience, is an excellent starting point, and there is a paediatric learning path which may be of interest. For those wanting to extend themselves the ‘specialist CAMHS module’ is very accessible and relevant to paediatric practice. Other websites such as Mental Elf are accessible and always informative, and the RCPCH’s own Healthy Child Programme has a heavy mental health slant.
But e-learning alone is not enough, which is why the RCPCH has begun a course in emotional and behavioural problems in community paediatrics. This first ran in London in March- if you are interested in running one locally contact firstname.lastname@example.org.
More than formal courses, what will increase the confidence and competence of paediatricians is the fostering of supportive local networks based on the sharing of knowledge and understanding.
TOP TIP: join twitter, and check out the PMHA mental health research list!
Maintain local networks
At a national level, the Department of Health CYP mental health taskforce has recently reported: one of the stated aims of the report is to open up CAMHS from being a service to being a system. Paediatrics are envisaged as very much a part of this, particularly in community.How this will affect local arrangements and relationships remains to be seen. It is important, however, that such networks should not be a bi-polar relationship between paeds and psychaitry, but a network of all concerned parties, including schools, social care, educational psychology and children’s centres.
One of the disturbing trends we have noted through our research is a reduction in the amount of liaison and joint work between paediatrics and CAMHS, at precisely the point at which they should be increasing to support the additional complexity of paediatric caseloads. This brings us to our final question.
TOP TIP: meet your local psychiatrist for coffee. Take cake.
How do we ensure that specialist CAMHS remain engaged where they are required?
CAMHS feel beleaguered, with cuts of up to 40% and shrinking local authority support. When paediatricians increase their mental health role over time the temptation to breathe a sigh of relief and let us get on with it must be enormous.
But although safe mental health care does not need to be within specialist CAMHS, we do need access to their support where necessary.
The remarks above about identifying CYP needing specialist input may help in terms of referral, but more broadly, easy access to consultation, effective information sharing, and care pathways which reduce duplication and uncertainty will be required for a functioning local system. Hopefully the taskforce report will provide the structure for this, but only strong local professional relationships will maintain these systems. Hence the cake.
It is in the best interests of children and young people that paediatricians have a substantial role in mental health. Our skills are well-suited to this work, and it is challenging but incredibly rewarding when done in a well-supported local environment.
I hope this article has acted to stimulate curiosity, and demystify an area that will only become more important in community paediatrics in the future.
Mental Elf: http://www.thementalelf.net
Youth in mind (information, links): www.youthinmind.info
Young minds (charity): www.youngminds.org.uk