“Sometimes the healthiest wheel is the squeaky wheel: Why children and young people come to the attention of health services, and the meanings made of this”

Psychiatrists and psychologists recognise that a child’s behaviour, when unusual, troubling or troublesome, is often a reflection of a disturbance in the system around them. This is an unconscious process. The function of that behaviour can be to draw the attention of professionals to that which is (or should be) concerning: abuse or neglect, parental mental illness, bullying and so on.

Such behaviours, especially when involving repeated attendance in crisis, for example sequential overdoses or self-harm, are commonly mislabelled as “attention seeking”. This has perjorative connotations and is both dismissive and unhelpful. I prefer “care seeking” when the child is appealing for emotional support or containment and “change seeking” where the necessity is for something to alter, a practical difference to make the life of the young person and their family safer, and more tolerable.

Rather than representing illness, these behaviours are often understandable responses to distressing life events, or future uncertainties. Medicalising them through diagnosis-seeking can be dangerous.

Analogously, children are commonly referred to paediatric departments with physical symptoms which cannot be explained medically. That is to say, organic pathology has been ruled out; there is no biological illness to explain the symptoms described. And yet the symptoms are experienced just as keenly as those with a physical causation: chronic tummy pains or headaches, debilitating fatigue, loss of vision, sensation or motor control.  In comparison to the child harming themselves or causing disruption, these are known as ‘internalising’ as opposed to ‘externalising’ symptoms. Again, medicalization must be avoided.

Fundamentally, a child may lack the emotional maturity and linguistic sophistication to give words to their predicament. In such situations it is their actions or their body that ‘does the talking’ on their behalf. There is clearly a problem to be addressed, but a belief that the answer lies in diagnoses, medical investigations and interventions is fallacious.

Take, for example, the 11 year old girl who has developed unexplained weakness in her legs, and ‘drop attacks’ (episodes in which she suddenly falls to the floor, apparently unconscious). These appear only to happen at school. An admission to the paediatric ward involves a wide range of investigations, scans and tests, which are expensive and invasive. Epilepsy and other brain disorders are ruled out. On the 5th day, our patient is introduced to a child psychiatrist. He spends time with the girl, with her mother, and later with them both, together. He learns that the symptoms began shortly after the death of her maternal grandmother, who had been ill for some years with dementia, and was living in the family home. Her father left some years ago, following domestic violence, which she witnessed.  He was never prosecuted. Since grandmother’s death, Mum has been tearful and withdrawn, lacking in purpose now her caring responsibilities have come to an end. Mum admits to feeling suicidal, and her daughter nods silently, apparently unable to speak.

It is not the girl who is traumatised or unwell, but the mother, who is bereaved.

An intervention is made by the psychiatrist to link Mum with an adult mental health team. She also meets with a social worker who gives advice about the financial difficulties the family are in. In a few short weeks, our patient is back in school, walking normally and feeling relieved to have ‘recovered’.

How do we understand what occurred? The child psychiatrist’s job here, in conjunction with the paediatric team, was to understand the drivers of these very real physical experiences. He applied the so-called ‘Bio-Psycho-Social Model’ to see the young person in the context of their environment.

Such cases are universal in healthcare, but often overlooked. When a family experiences a major change, it is not uncommon for the youngest members to be the ‘vehicle’ of expression – the so called “Identified Patient”. Families are finely balanced systems. If one mechanical aspect is failing, other elements may take on additional strain and burden, practical or psychological.

The psychiatrist here is like a mechanic, and the ‘squeaky wheel’ is the problem which is brought to his/her attention. Importantly and commonly, the vehicle itself may not need new parts fitting, but it does need realignment. In our particular case, the girl was suddenly the bearer of additional ‘weight’ (the responsibility for worrying about her mother’s state of mind). In truth, her symptoms helped save her mother – it could be seen as rather heroic, had it been intentional.

Western health systems must evolve to become more sophisticated in their understanding of the interplay of the physical, the psychological and the social. This involves challenging received wisdom, better educating future generations of clinicians, but also altering societal discourse about what illness truly is.  
The role of Paediatric Mental Health Liaison teams 03 March 2016 Rory J P Conn   
BJPsych eletter in response to paper by Ford et al “Needs and fears of young people presenting at accident and emergency department following an act of self-harm

“I would like to thank the authors for producing the most significant (and accessible) paper that I have enjoyed since beginning my higher training in Child and Adolescent Psychiatry. This is an essential ethnographic account of the inner mental states, characteristically undisclosed, of young people presenting in crisis to acute medical settings. I plan to share the paper widely amongst colleagues in Emergency Medicine and Paediatrics, but it also makes for vital reading for other health professionals (paramedics, social workers and police) who will come into contact with this patient group in their respective, essential, lines of work.

The paper hints that the patients it describes are merely the tip of the iceberg. Most under 18s who deliberately self-harm do so in isolation and do not seek medical attention, precisely because of the degree of stigma and misunderstanding to which they can be exposed when they present to hospital.

Although deliberate self-harm is often impulsive, invariably there are significant and longstanding problems in the young person and his or her family. The instinctive “flight to health” under the circumstances described in this paper can be powerful, and young people may hide or minimise their distress in an attempt (conscious or otherwise) to leave the hospital. Some presentations (eg boxer’s fractures in boys) are easily missed as self-harm events, because the young person in question will choose not to volunteer the context of the presentation.

What the paper does not directly address is the strategic means through which we can improve the experience of care for these young people. Some argue that the acute hospital is not an appropriate setting to care for young people in psychological distress, but often they will need medical attention (bloods, stitches, scans etc) and they should be considered as much “Paediatric” as “Psychiatric” patients – their needs are no less deserving.

Admission to a paediatric ward (recommended by NICE guidelines but often not followed) is an entirely appropriate intervention, irrespective of immediate “medical” need. This demonstrates that the act is being taken seriously, that professionals recognise the severity of the symptoms and that the patient is being thought about, rather than ‘disposed’ of. Frequently, it is only the next day, in the safety of the paediatric environment (following consultations with family members and any already involved professionals) when the full social circumstances are made apparent, and disclosures are commonly made.

Dedicated Paediatric Mental Health Liaison (PMHL) teams, co-located with paediatrics in the acute setting, are sadly few and far between. Where they exist, they can provide a gold standard in integrated physical and mental healthcare, with rapid response times to A&E, including out-of-hours, when most such patients present. Assessments can be afforded sufficient time, and aside from quantifying risk, can be therapeutic events, making the child’s prospective contact with community CAMHS a more approachable idea.

With the input of PMHL teams, admission to Tier 4 inpatient psychiatric services is rarely needed. Many patients are successfully assessed and managed on the paediatric ward for 24-48 hours, avoiding the need for a higher level of psychiatric care. These are therefore early intervention and cost saving interventions for the wider healthcare system. In addition to the assessment and management of deliberate self-harm, PMHL teams perform a range of diverse roles in children of all ages from the neonate to older teens, including management of the psychological sequelae of chronic illness in children, medically unexplained symptoms, life-limiting illnesses, bereavement and perinatal mental health. The bulk of work in PMHL is in fact with such non-emergency cases.

Liaison teams also help staff from allied disciplines to develop a more sophisticated understanding of such complex cases, by assisting in systemic reflection – often known as “work discussion”, or “psychosocial meetings”. The presence of a PMHL team is psychologically containing for paediatric colleagues as well as the patients. Such teams build confidence as well as resilience.

Too often, children and adolescents presenting with self-harm to hospitals without PMHL teams are left to wait for many hours to be assessed (a torturous and emotionally compounding experience, given the cognitive state they are often in as described so vividly in the paper). They may be reviewed by general adult psychiatrists who will perhaps lack the clinical acumen and confidence of a specialist in the field.

The rates of child and adolescent self-harm presentations to hospital are increasing year upon year. As promised new funding finds its way to the frontline of CAMHS services, it is to be hoped that a good amount of it is invested in Paediatric Mental Health Liaison Services which are a key intervention for this group of distressed and desperate young people.” 

Published by Dr Rory Conn

I am a Child Psychiatrist working in Devon, UK.

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