Written evidence submitted by Dr Rory Conn (CYP0009)
The reality of modern day Paediatrics is that mental health problems are highly prevalent (RCPCH – State of Child Health – Insight into the state of child health in the UK). Now more than ever with the wide-ranging effects of the pandemic and lockdown, these young people need our help. Yes, we can and should advocate for better resourced mental health services, for crisis services that will avoid hospital admission where possible, but it is short-sighted to create an artificial divide between the physical and mental health of children and young people, choosing only to see and manage the part with which we are familiar.
Whilst CAMHS services are designed to assess and treat mental illness, there is a far larger group of young people (the bulk of the iceberg below its highly visible tip) who present with emotional difficulties in the absence of formal mental illness, in particular in the context of physical health problems. This includes the large numbers presenting with Medically Unexplained Symptoms, often a physical manifestation of anxiety, in the child or their caregiver, often both.
Sadly, few paediatric departments screen for mental distress, depression and anxiety, despite the fact that in chronic long term medical conditions these are likely to be common comorbidities. This is in part because paediatricians may not know what to do with the findings, few hospitals having sufficient provision of paediatric psychology to meet the large, and growing, needs of this overlooked group.
Those working at the interface of physical and mental health are clear that joint offers of support which combine body and mind produce better paediatric outcomes. That is: fewer unnecessary and intrusive investigations, shorter lengths of stay, better control of diabetes, asthma, gastrointestinal complaints, to name just a few. A good multiprofessional paediatric liaison ‘offer’ should also result in fewer serious incidents involving restraint and tranquilisation, plus improved staff wellbeing and satisfaction in work, with lower rates of burnout.
Of note are the growing numbers of young people presenting to the acute hospital setting with self-harm, self-poisoning, or restrictive eating in the absence of a typical eating disorder. These should be seen as young people in “PsychoSocial Crisis”. Invariably, the drivers for the distress are linked with deprivation, abuse, neglect, bullying, adverse childhood experiences. We need to understand these as safeguarding concerns, and respond to them in a co-ordinated fashion.
Repeat attenders are a common challenge to acute paediatric teams. Clumsily described by some as “attention seeking”, these are young people seeking care, and refuge. We must ask ourselves what it is that they are escaping from and act appropriately. Staff may fear generating a ward environment which is made “too welcoming” or comfortable. If a hospital bed is more attractive than the care received at home, what does this tell us about the quality, or absence, of care received from caregivers? Paediatricians can be consistently supported by child psychiatrists in understanding these issues, and in identifying the systemic problems which present in families. The intergenerational attachment difficulties and patterns of behaviour, in particular relating to health and help seeking.
Working to help children and their families can be immensely satisfying and rewarding, but highly stressful. The emotional responses that we all experience towards complex “CAMHS” patients must be recognised. Feelings of Irritation, Frustration, Confusion, Helplessness, Worry, Anger to name a few are common, understandable and natural. These are usually “projections” of the feelings in the patient themselves (or their family). Departments which prioritise regular, structured, reflective spaces in which to explore such feelings (such as a Balint group), function better.
Paediatric teams benefit from having psychiatry and psychology but also a social care presence embedded within the team. Fully integrated care systems are the vision of the future where organisational and funding barriers are overcome. In the meantime the best results are likely to be achieved if we as paediatricians reach out to mental health and social care colleagues, develop relationships, build bridges and are the driving force in securing funds to finance these joined up approaches within our own departments.
RCPCH have produced a position statement on the Role of Paediatricians in supporting children and young people’s Mental Health, available on the college website [Role of paediatricians in supporting children and young people's mental health - position statement | RCPCH]. Paediatricians, like any member of the children’s workforce, have a role in promoting good mental health in all their interactions with children and young people. There should be a clinical lead in all paediatric settings to ensure the mental health of children and young people is considered in departmental activity, but also the mental health of our workforce, which has been challenged during the last 9 months more than ever. A further description of what this mental health lead role may include is in draft. Improved training for all Paediatricians in promoting good mental health and recognising and supporting mental health problems is addressed through the updated Progress Curriculum and the new SPIN module in Mental Health. Paediatricians in managerial roles should also be focussing on improving the interface between paediatric and mental health services through liaison and integration to provide effective joined up services.
If we haven’t convinced you then listen to young peoples’ views through ‘RCPCH and Us’, the college’s forum for engaging with service users. The striking findings of a survey of young people around mental health are on the college website (Voice matters – RCPCH – State of Child Health) and part represented in the figure below. One young person said of mental health: ‘I think it’s equally important, it might even be more important than physical health’.
February 2021
