Mental health training for community paediatricians: survey and proposal

Questionnaire Survey of BACCH Members to Ascertain Perceived Training Needs in Child Mental Health

Rachel Atkinson, Max Davie

Introduction

The work of Community Paediatricians has a large and increasing behavioural/ mental health component, involving both joint work and liaison with CAMHS, and work within community health services, education and social care aimed at promoting and safeguarding the emotional and mental well-being of children and young people. As a result, Community Paediatricians frequently voice a need for greater understanding of children’s mental health. Informally, this has been found to include requirements for better understanding of the relationship between emotional and developmental processes, ways of working with families around behaviour, as well as specific therapeutic methods and ways of working in specialist CAMHS.

The aim of this survey was to develop this informal understanding into a more rigorous analysis of the training needs of Community Paediatricians in this area, with a view to developing training materials and courses, jointly between BACCH and BPMHG.

Methods

A survey was designed using Survey Monkey, and sent via the BACCH electronic mailing list to all members in August 2013. The survey questions are shown in the Appendix. A ranking scoring analysis was applied to questions requiring respondents to rank their opinions. A higher score indicates that a particular response was given a higher number of top rankings in composite.

Results

64 responses were received, out of a BACCH emailing list of 1089

60 of 64 respondents (93.75%) said they would value training in child mental health. The answers given by respondents to the questions asked are shown below.

1.“How often are Child Mental Health skills and knowledge involved in the management of the children you see?”

Most people felt they need skills in mental health for every, or most children seen.

Answer givenNumberPercentageEvery time I see a child  3554.69Every one or two days  1929.69Once or twice a week57.81Once or twice a month  34.69Total62100

2.“If training was offered by BACCH/ PMHA what form would you prefer?”

Respondents ranked answers by preference. Average ranking was fairly even, though a blended model of training was the most popular, with E-Learning second.

Answer givenRanking composite scoreBlended model2.9E-learning2.59Series of one day events2.33Single course over several days2.21

3.“How far would you be prepared to go for this training?”

Most respondents were happy to travel for training, within reason.

Answer givenNumberPercentageAnywhere in the UK (within reason)  2539.06Within my deanery  3148.44Within my local area.  812.50Total64100.00

4.“What in your view would be the main purposes of training in Child and Adolescent Mental Health for Community Paediatricians?”

Respondents felt that skills would enable better practice rather than better referral.

Answer GivenAverage rankingTo Give clarity to our analysis2.98For a holistic approach2.94To enable Paediatricians to help with behavioural problems 2.52To enable better referral to CAMHS1.58

5.“Please indicate which topics within Child and Adolescent Mental Health are of most interest to you”

Answers were ranked by preference, and two groups of answers clearly emerged. The skills relating to everyday practice formed a more highly ranked group, with high ranking scores (6 to 8), and the other group comprised specific therapeutic skills, was less in demand, with lower scores (3 to 4). In the table below the shaded answers in the top part of the table below represent the popular interests. This seems to reflect a desire among respondents to improve everyday Paediatric practice by improving skills and understanding.

Answer GivenComposite Ranking ScoreGaining skills to help families who are struggling with their children’s behaviour7.84Understanding Attachment, its relationship with neurodevelopment and its consequences7.24Gaining skills in engaging with children to get their views and perspective6.70Gain skills in detecting disorders and disturbances of mood, intervening and referring appropriately6.30Gaining skills to promote and safeguard good mental health in all children and young people6.09Helping children and young people with long-term conditions to safeguard their mental health4.86Understanding the nature and management of Conduct Disorders, and their relationship to development4.74The appropriate use of psychopharmacology in community paediatrics.4.51Understanding Family Therapy and its use3.67Understanding Cognitive Behavioural Therapy and its use3.33

6. Characteristics of Respondents

How long had they been in their current post? The answers varied between 1 and 27 years

And how senior or junior were the respondents? They were a mainly senior and experienced group.

What group of doctor?Number (percentage)ST 6 to 82 (3.23%)Staff Grade Doctor  3 (4.84%)Associate Specialist16 (25.81%)Consultant41 (66.13%)

Conclusions

The conclusions of this survey need to be treated with some caution, as the response rate was relatively low, but on the other hand they accord with our own informal discussions with colleagues. The important conclusions are these:

1. Community Paediatricians as a group, would value training in Child and Adolescent Mental health.

2. This training would help them do a better and more satisfying assessment and management of the children seen on a daily basis.

3. Training should focus not on specific paediatric diagnoses, but on generic mental health skills.

4. The training should focus on improving skills for everyday assessments, not so much on learning new techniques such as Cognitive Behavioural Therapy

5. A blended model of learning, combining e-learning, study days and tutoring, is preferred.

6. Although many people are prepared to travel far for this training, there is a strong preference for local availability.

So what do we intend to do about this?

In a joint venture between BACCH, the PMHA and the RCPCH, we plan to deliver as close to the training that BACCH members want as we possibly can. We need to start small: partly due to resource constraints, and partly because we need to learn from every step.

In mental health work the need to back up relevant knowledge with well-honed skills and reflective, considered attitudes. Our model reflects the fact that simple didactic study days cannot fulfil this function.

The proposed model is as follows:

September-December 2014: Delegates sign up for training, and commit to complete 4-6 e-learning modules from MindEd and the Healthy Child Programme (precise details tbc). Anyone working in community paeds is welcome, from ST4 to clinical director.

January 2015: Delegates spend time thinking about the mental health aspects of their work and prepare an anonymised case to discuss with the group

February 2015: the study day: How to manage emotions and behaviour in community practice, is held at the RCPCH. The day will be practice-based, with Q&A expert sessions interspersed with case-based small group workshops.

We propose to run the workshops on:

Helping families to understand and influence children’s behaviour

Advanced skills in engaging with families, children and young people

Detecting disturbances of mood in children and young people

And expert Q&As on:

1. Understanding attachment in the context of psychological development.

2. Promoting and safeguarding mental health in children and young people

Ongoing support: certificates will be issued at the end of the study day, but those who wish to will be invited to join the PMHA Google+ group, for further facilitated discussion.

What happens then will depend on you!

We want to know what YOU think of our proposed model, and whether you think our survey is representative of the true training need in Community Paediatrics. Have we missed out a crucial workshop we MUST have in February? Email maxdavie@gmail.com or leave a comment under this article at pmha-uk.org. We look forward to hearing from you.

Appendix: Questionnaire

Please take the time to answer these questions and give us your view:

1. Would you value extra training in current methods and knowledge in treating and preventing problems with children’s/family’s mental and emotional health?

Tick one:

Yes

No

2. In your view how often are Child Mental Health skills and knowledge involved in the management of the children you see?

Tick one:

Every one or two days

Once or twice a week

Once or twice a month

Other, plase specify……………………..

3. If training was offerred by BACCH/ BPMHG what form would you prefer

Please rank by preference

A series of one day events spread over a six to nine month period,

A single course over several days

An e-learning module/series of modules

A ‘blended learning’ model of e-learning combined with study days and tutoring.

Other: Please specify……………………………………………

4. How far would you be prepared to go for this training (tick one)

Anywhere in the UK (within reason)

Within my deanery

Within my local area.

5. What in your view woud be the main purposes of training in Child and Adolescent Mental Health for Community Paediatricians?

Please rank by preference

To help give clarity in the initial assessment of complex cases to inform a clear management plan

To enable paediatricians to work with families encountering problems with behaviour, feeding, sleep, toileting, physical symptoms etc.

To enable Community Paediatricians to refer to specialist CAMHS more appropriately

Other, please specify……………………………………………………………….

6.Please indicate which topics within Child and Adolescent Mental Health are of most interest to you:

Please rank by preference

Gaining skills to help families who are struggling with their children’s behaviour

Gaining skills to promote and safeguard good mental health in all children and young people.

Gain skills in detecting disorders and disturbances of mood, intervening and referring appropriately

Understanding Attachment, its relationship with neurodevelopment and its consequences

Understanding Family Therapy and its use

Understanding Cognitive Behavioural Therapy and its use

Understanding the nature and management of Conduct Disorders, and their relationship to development

Helping children and young people with long-term conditions to safeguard their mental health

The appropriate use of psychopharmacology in community paediatrics.

Other, please specify……………………………..

7. If you have any comments or ideas on Mental health training for Community Pediatricians please write them here:

………………………………………………………………………………………………….

…………………………………………………………………………………………………..

………………………………………………………………………………………………….

ADHD study days: George Still Forum

The George Still Forum have released details of their twin ADHD days in September, one covering the nuts and blots on the 18th, and a masterclass on the 19th on more advanced aspects.

CIRCULAR

Programme 18 September 2014

Programme 19 Sept 14 (2)

Booking form 2014

Contact gsfcoordinator@hotmail.co.uk for more details

Neurodevelopmental disorders- what to look out for

By max Davie: PMHA convenor

This is a version of the talk I gave last week to the Primary care and pubic health conference at the NEC Birmingham. The main purpose of this post is to reinforce some of the messages in that talk to delegates, and help with signposting to other resources. It may also be of interest to other professionals curious about these conditions.

Professionals and parents are increasingly aware that children are being diagnosed with developmental disorders, but it’s not always clear what these are, or how to spot them. My aim is to help with this.

The term neurodevelopmental disorders is often confusingly defined. For me this is a group of inter-related patterns of abnormal neurodevelopment, which show themselves in characteristic patterns of behaviour, and lead to functional impairment in the child. Put another way, these are just patterns of dysfunction that more or less cluster around certain diagnostic terms.

This piece is not about the causative pathways that lead to these conditions, nor about the anatomical, physiological or genetic correlates, but about spotting and differentiating these patterns, in order to inform intervention.

I’ll try to cover ASD, ADHD, DCD, and a few other topics. Basically, when I run out of energy, I’ll stop.

There are a few universal points about these conditions that are with making. 1) They are multifactorial. Anyone who tells you that these problems are entirely biological or entirely psychosocial is just flat wrong.

I’m going to blog about this in detail soon, but broadly. these diagnoses consist in variance from the norm in development, and impairment of function as a result. The developmental variance is mainly biological, but its functional impact is intimately entwined with the child’s psychosocial environment. So we can support those who point out the biological correlates for these conditions, while remembering that in the real world it is mainly psychosocial improvement that makes the difference

2) They are spectrum disorders. What I mean by this is that the developmental variance causing these disorders  lie on a spectrum, stretching from the Neurotypical range outwards. Therefore, there is no ‘clear blue water’ between children with these conditions, and children with what are often called ‘traits’. Attempts to make a hard distinction, for instance at 2 standard deviations, are inherently arbitrary. So how do we decide? The diagram below might give some guidance, although it’s important to emphasise that it’s only a conceptual framework, not a study result.

We can plot a normal distribution curve of children’s function at a given developmental age (a concept to which we will return). Now, as we know, the world is designed for Neuro-typical brains. As the child departs from this norm, difficulties (shown by the red line) are at first pretty modest ( section a), then the difficulties escalate rapidly as the child’s compensatory strategies break down (section b) and then things level out, because these children have other, relatively spared areas of development (section c). The important thing is that the shape and position of this ‘difficulties curve’ depends on the child’s environment and, crucially, the responses of adults to their behaviour. This will become important when planning intervention, because very often ‘shifting the curve’ is all you can hope for. So what does this framework mean for diagnosis? Broadly, I would say children in section a should not get a diagnosis, those in section c should, and for those in section b it should be a decision based on the usefulness of the diagnosis for this child. So it’s crucial not only to detect developmental differences, but also to work out how much trouble is being caused by these differences.

3) These conditions are co morbid. When you have difficulties in one neurodevelopmental area, you are quite likely to have difficulties in other closely related areas. These are two ways to approach this: one is to look at categories, and then a ‘rule’ of quarters emerges. Roughly, one in four children with a given neurodevelopmental disorder have any other given diagnosis. Roughly. The other way of thinking about it is like a trampoline. When you land on a trampoline, you press down on one area, but other nearby areas are often also pushed down, only not quite as much. It’s the same with development- children with a language problem often have some sub-diagnosis social communication difficulties, for instance.

4)  These conditions are diagnosed by observation and opinion

What we are trying to do is look at patterns of behavior and abstract from our observations a picture of the child’s neurocognitive profile. This is a process vulnerable to bias and error of various kinds, and we should work hard to correct for these factors (as I’ve covered previously for ADHD). One way to do this is by triangulating several views, for example from teacher, parent and paediatrician.

5) These diagnoses are a tool

When making a diagnosis, I am not making a statement about the world, but expressing the view that this diagnosis is likely to benefit this child. This is counter-intuitive but important.

Ok, now onto the conditions themselves (with apologies to purists)

ASD The best way to think about ASD is to think about people whose only difference from the rest of the population is their autisticness, that is, people with aspergers. There is nothing wrong with these minds, they can do genuinely wonderful things, but what they lack is the ability to connect facts and create rules of thumb, or guesses, to navigate through life. Put another way, they are weak at inductive reasoning, that is reasoning that takes what is observable and makes predictions and models about the world  This is most obvious when they are encountering the most complex and unpredictable objects we ever meet: other people. How do they present? Sorry, yes, that was my brief. Children with more serious difficulties present earlier, so I’ll split the observations you might make into those of younger children (broadly, pre school) and older kids (primary school). Adolescents are tricky, at least in this context, so I’ll leave them out. Social communication This is that part of communication that isn’t to do with the transfer of information, or alternatively, that part of communication that doesn’t go into an email.

Younger children Look at the picture below: this boy I’d looking s straight at the camera, and his facial expression suggests expectation. Meanwhile his finger points to something to which he wants to direct your attention  (a process called joint attention). He pretty much sums up what is lacking in severe ASD.

Older children Here the problem is easiest to see in conversation. When we converse, we need to fit what we say to our partner in several ways. We need to produce content that is relevant, partly to their interests, but also to the context of what has been said. We need to frame what we say in a way that takes into account their state of knowledge, and we need to adopt a style of speech and non verbal communication which suits their expectations. Thinking about it that way, it’s rather amazing that any conversations work at all!

Social interaction It’s really important here to pause and make a point. People with ASD are not automata; they feel emotion, very deeply, and they do care about people. It’s just that connecting with people is hard, and the failures are often so painful that the child withdraws into his or her own world. That is, broadly, the pattern that you see in younger, more severely affected children. They often play alone, using toys as objects rather than representations of things, and sometimes use adults as physical tools to get what they want. In older children the presentation is often more like a social awkwardness, as below. Group activities, involving as they do infinite variables of interaction and communication, are often intolerably hard. Attempts to make friends in the ‘normal’ way are often frustrated, so friendships are often based narrowly on a shared interest, at least initially.

Rigidity/ repetitive behaviour I’ve said that children with ASD find it hard to make inductions (or guesses) about the world, and when you encounter something, or more terrifyingly someone, new, induction is necessary to guess the sorts of behavior and responses that are required. So we shouldn’t be surprised that children with ASD show a strong preference for the known. So for younger children, everything must be ‘just so’, and transitions to new activities are feared and therefore resisted. At this point, it’s common to hear about particular short clips of tv being watched over and over, as part of this search for sameness. For older children, there is a more subtle, internal ordering. There is often an interest in concrete, defined facts, such at bus timetables, and for ordered leisure activities and worlds such as minecraft. The habits that are developed as a way to insulate the person from too much change are often unusual, and can add to the child’s social isolation.

ADHD Here is as important to be clear about what ADHD isn’t as what it is. The best analogy I can think of is that children with ADHD have brains that are too fizzy. If you think of bubbles as emotions, impulses, and thoughts, then children with ADHD just experience these more intensely, and in a far less ‘filtered’way. For most people, these ‘bubbles’ are filtered out subconsciously, and only the relevant ones (mostly) come into your mental inbox. By contrast, living with ADHD is described as ‘living in a constant shower of post-it notes‘. So children find it hard to concentrate among all this internal noise, they act on some of these impulses (especially if emotionally or cognitively overloaded), and because they, like all of us, are not passive receivers of emotions and sensory experience, they spend a lot of their time in a hyper-aroused state, which is one important reason for their hyperactivity.

So ADHD isn’t anger or defiance, though children with ADHD do get angry, and frustrated, by years of getting into trouble without often knowing why. It isn’t learning difficulties, although a lot do have specific learning disabilities such as dyslexia. It isn’t laziness, though children do give up at school after a few years of not having their difficulties supported.

How does it present? This table can be helpful; the symptoms on the right are often present in children with ADHD, but do not usefully differentiate these children.

Useful symptoms

Less useful

Always on the go/ won’t sit still

always having tantrums

doesn’t listen

doesn’t do as he’s told

Disorganized

defiant

gets into dangerous situations

gets into fights

can’t concentrate on dressing

can’t concentrate on homework

runs off in shops

runs away from home

can’t wait in queues

can’t wait his turn to speak (in younger kids)

distractible by meaningless noise (cars outside)

destructive of others’ property

When you have looked at the presenting symptoms, you then need to ask some more about the child’s ‘symptoms’. It’s tempting here to use the DSM criteria- I’d rather you used ASDA. This isn’t advertising, the point is that supermarkets are a nightmare for parents of children with ADHD: highly stimulating, crowded environments with long aisles to run down, tempting treats to grab,  and at the end a nice long queue! The broader point is that if you want to know about ADHD symptoms, it’s far more useful to talk about mundane everyday tasks than dramas. So I always ask about the following:

1. Getting ready for school

2. Walking to school (or taking the bus)

3. Supermarkets

4. Mealtimes around a table

5. Bedtime

If nothing falls out of this low-key narrative, you’re not dealing with ADHD.

One of the changes of emphasis when looking into possible ADHD is an increased wariness about over-diagnosis. I’ve covered how to avoid  this on my own blog, but broadly, parents who come with symptoms down the right side of our table and saying the child has ADHD are more likely to be fishing for a diagnosis, and these people will often wonder why on earth you’re interested in going on the bus, for example, because that is not where their problems are concentrated. It’s important, however, not to shame these families, who are just looking for a reason for their child’s behaviour, but to gently steer then away from neurodevelopmental towards more family dynamic explanations.

DCD (Developmental coordination disorder)

I call developmental coordination disorder the Ronseal disorder: it does exactly what it says on the tin. When coordination is significantly poor due a developmental process to cause functional impairment, dcd is present. There are complications, in that you need to ensure that the impairment doesn’t have another cause e.g. learning disability, but that’s mainly it. It generally presents with one or more of poor self care, frequent accidents, disorganization at school and aversion to sports. What’s interesting about DCD is what underlies it, because that will guide therapy, and give clues to other problems that ought to be anticipated. Broadly, DCD can be caused by one or more of: low muscle tone, causing a relatively pure motor presentation, sensory processing difficulties, of which more below, and difficulties with planning.

Executive function: a detour outside diagnostic boundaries

Executive function is best illustrated by a picture:

Broadly, it’s the process of getting things done, and children who struggle with this cognitive skill, however bright they may be, are likely to struggle with academic activities, and with organising themselves at home. Often difficulties with executive function are underpinned by a combination of problems with attention, memory and planning. I mention it here because an intriguing group of children who may previously have been classed as ADD (without the H) may turn it to be more usefully thought of as having executive dysfunction.

Sensory processing difficulties: vague but important.

Think for a minute about an intense physical sensation: if it makes you feel more comfortable, we can agree that I’m referring to eating chocolate. This sensation can have powerful effects on your emotional state, which if controlled and channeled can be profoundly positive for your emotional well-being. Then imagine that whether you experience this sensation is not under your control, but that of others, either knowingly, or unknowingly. Finally, imagine that this intense sensation can be touch, or noise, or flashing lights. If you have followed this thought experiment, you may be in a somewhat better position to understand children with sensory processing difficulties, who often self induce precisely the sensations that they find unbearably aversive when done ‘to’ them by others. These difficulties are most prominent in ASD, of course, but are also an important determinant of DCD, as difficulty processing touch and body position information makes motor coordination less accurate.

Things not to forget

When deciding if a child will benefit from a given diagnosis, one of the questions is always whether the features are excessive fir the developmental age. This is a slippery concept, and it might make more sense to talk about a language age, and a nonverbal cognitive age (for psychologists tutting at my lack of rigour, this equates to the age when the child’s performance would be on the 50th centile. So there). Basically, you can’t expect children to behave too much older than either of these. A child with the cognition of 6 year old in a classroom of 9 year olds will look like he has all of these neurodevelopmental conditions, at one time or another. The other, obvious point is that we shouldn’t be identifying these conditions unless we are reasonably confident that the child can see and hear. The latter problem particularly is easily missed, so testing should be considered at an early stage.

Take home messages

As I perhaps should have guessed, this has got way longer than I planned, so I need to keep this bit short:

1) You’re looking for patterns of behaviour, not particular ‘symptoms’. Each behaviour needs to be thought about in context.

2) Concentrate on the mundane, and amazing things will fall out.

3) Never take one person’s view as definitive. Even mine.

Thanks for sticking with me. More to come, also updates on twitter @paedMHassoc (science, policy) and @maxdavie (politics, anger, jokes, baking)