“No Harm Done”

https://charliewaller.org/mental-health-resources/managing-difficult-feelings/help-for-young-people-worried-about-self-harm

The Charlie Waller Trust, Young Minds & Royal College of Psychiatrists produced a range of mental health resources around Self Harm in 2016, including some fantastic videos to raise awareness and bring hope to those suffering. These resources were under the banner of “No Harm Done: Things Can Change”. We are now looking to update the information alongside these videos. Please take a moment to view the pages and send any feedback here, particularly if you are a young person or carer for whom this is directly relevant.

Thank you.

“A Revolution in Mindset” – Addressing the youth mental health crisis after the pandemic – Reform Policy Report 2022

“The aftermath of the pandemic provides an opportunity for the Government to reshape its approach to supporting young people’s mental health. The last two years have shone a much-needed spotlight on the shortcomings of current provision and a broad consensus exists to put young people’s wellbeing at the heart of the pandemic recovery.”

The Report makes 10 key recommendations which are well worth reading.

Mental Health in Asylum Seekers & Refugees

The Royal College of Psychiatrists have produced a new resource of information, guidance and professional support regarding the mental health of asylum seekers and refugees:

https://www.rcpsych.ac.uk/international/humanitarian-resources/asylum-seeker-and-refugee-mental-health

The advice is endorsed by the Academy of Medical Royal Colleges and will be of most use to those working in primary care, and schools.

“Medically Unexplained Symptoms” – A response to accusations of ‘gaslighting’

It’s been upsetting this week to have been accused on Twitter of “gaslighting” children and families.

I’m keen to clarify my position on Medically Unexplained Symptoms (MUS), an area in which I have clinical interest.

A thread follows.

  1. Everyone is familiar with the idea that life stressors can cause physical signs/symptoms (for example, we feel nauseous when nervous, our heart races when we are scared, we cry when we are sad, we might even collapse when in shock…). These are normal daily physiological responses.
  2. “MUS” is a rather outdated term. This field encompasses persistent physical symptoms for which there is no clear ‘biological’ cause (according to current medical understanding).
  3. Some years ago I wrote some guidelines on MUS, intended to help doctors, in particular paediatricians and GPs, to navigate this field, which is poorly taught in medical training.
  4. MUS are extremely common. There are a wide range of symptoms encompassed here, from persistent pain, functional weakness, non-epileptic attacks. Essentially any aspect of the body that can have a “functional” problem. Any clinician working with children, or adults for that matter, will be aware of these presentations.
  5. The majority of such symptoms are actually time-limited and will pass. Watchful waiting can be entirely appropriate.
  6. Some of the children with MUS – perhaps 4% – will go on to be diagnosed with physical pathology (where infection, inflammation etc are the causative factors).
  7. Therefore, all children must have full holistic assessments, including thorough investigation of biological causes. Some but not all will need blood tests, brain imagining, even Lumbar Punctures or EEGs.
  8. Also essential is an understanding of the psychosocial situation (school, home, peer relations). Is the child under particular stress? For example, exam pressures, parental separation, bullying.
  9. We also need to assess the influence of parental anxiety. It is normal to feel anxious when your child has distressing symptoms. Sometimes however the anxiety can be a perpetuating factor.
  10. Many children with persistent physical symptoms have sensory hypersensitivities, and consideration needs to be made for neurodevelopmental disorders such as Autism, which can be contributory factors. The concept of Interoception is little understood, but key.
  11. I have never met a child I have considered to be fabricating (making up) symptoms. Symptoms like pain are very real and distressing for all.
  12. It is very rare that a parent/carer will actively induce illness in a child, but it DOES happen and doctors need to be alert to this. RCPCH now favours the term “Perplexing Symptoms” as a framework to consider possible safeguarding issues. They have excellent clinical guidelines on investigating and managing these scenarios. Fabricated Induced Illness / Munchausens by Proxy are uncommon conclusions and tend to be overreported in the literature.
  13. It is never the case that a child with MUS “simply” needs psychological therapy. In fact, few do. They need a sophisticated discussion with a paediatrician who understands the body/mind connection. Time is needed to understand the health beliefs and what will work best to help the child function best and enjoy life.
  14. The majority of children and young people do not need referrals to CAMHS (which is a specific service set up to treat mental illness). Some children’s physical symptoms will cause persistent low mood or anxiety. It is important to offer treatment if these meet clinical significance, whether or not they are secondary, rather than primary phenomena.
  15. CAMHS services are under huge strain. It is in no-one’s interest to attempt to categorise problems as being ‘psychiatric’ when they patently are not. I am not seeking additional work!
  16. Turning to specific diagnoses, there are MANY biological conditions which can present with an array of physical symptoms, from mild to severe in nature. These include, but are not limited to: Hypermobility Syndromes, PANS/PANDAS, POTS, CFS/ME, Lyme Disease, LongCOVID. All of these disorders must be considered carefully as differential diagnoses.
  17. There are consensus guidelines for the management of these conditions. Doctors must work to these or their practice can be called into question. Guidelines will evolve as we understand more about these illnesses. Patient groups are right to demand more trials and studies where we have a lack of evidence.
  18. There are undoubtedly additional medical disorders which we currently have insufficient understanding of, and will come to light in the future.
  19. Additional tests must be entered into with caution. Over-investigation happens and can be a cause of iatrogenic harm. Some children will go on to develop a belief that there is something wrong with the substance of their body.
  20. I am not an expert in paediatrics. So I rely on paediatricians to tell me when physical investigations have come to an end. This is usually the point that I become involved, as a liaison psychiatrist.
  21. I have treated many young people with MUS. Many recover swiftly with a sensitive approach which considers body and mind, simultaneously.
  22. Many other terms used to describe MUS are clumsy – eg “Psychosomatic” which tends to be interpreted to mean that a psychological problem is the cause of the difficulty. My presence in the consulting room is not equivalent to my paediatric colleague thinking that symptoms are “in the child’s head” (whatever that might be thought to mean).
  23. Even now, medical schools teach in a Descartian, dichotomous fashion which separates body and mind. We need better, more accepted language to describe these complexities, and we need a new societal dialogue.
  24. We also need more research, which involves young people and carers at every stage. We need to work collaboratively.

Trauma, the Autonomic Nervous System, and Symptomatic Responses in Children

I have just finished reading Dr Suzanne O’Sullivan’s excellent book “The Sleeping Beauties“, which I really recommend: https://www.waterstones.com/book/the-sleeping-beauties/suzanne-osullivan/9781529010572 . O’Sullivan is a neurologist with a particular interest in Functional Disorders (where the patients presentation isn’t objectively caused by biological disease eg. an infection, a lesion, or insult to the substance of the body). One of the phenomena she describes is children with the brilliantly named“uppgivenhetssyndrom“.

Enhancing this no-end is the short Netflix Documentary “Life Overtakes Me”:

Known in English as “Resignation Syndrome“, this is a profound and serious presentation in asylum seeking children in Sweden (very topical at present with Ukraine’s war against Russia and the horrendous trauma repercussions of this). They stop talking, eating, and even moving – as if they are in a deep state of sleep.

Finally, we can learn a lot more as clinicians by looking at the biological theories behind these withdrawn, catatonic-type states. Here is a very good paper by Kasia Koslowska et al – “Asylum-seeking children in shutdown: Neurobiological models

https://journals.sagepub.com/doi/full/10.1177/25161032211036162

The Polyvagal Theory in particular is something we should be teaching medical students and trainees.

Talking To Children and Young People about the War in Ukraine

I have been thinking a lot about the ripple effects of a war in Europe, on the psychological safety of us all. Children and Young People perhaps more than others will be vulnerable to feeling anxious, confused and upset. Graphic and disturbing updates are only a click away online.

I asked some colleagues about resources available in this regard. Particular thanks goes to Ryan Lowe, Clinical Director of “The Therapeutic Consultants” who has compiled a list.

There are some generic links to begin with, then some specific to the current Ukraine conflict.

Information produced previously about war and international violence

How and when to talk to children about war, according to a parenting expert (Independent):

https://www.independent.co.uk/life-style/children-war-talk-russia-ukraine-b2023695.htm

How to cope with traumatic news – an illustrated guide (ABC News, Australia):

https://www.abc.net.au/news/2014-12-23/illustrated-guide-coping-traumatic-news/5985104

Talking with Children About War and Violence in the World (Family Education, US):

https://www.familyeducation.com/life/wars/talking-children-about-war-violence-world

Tips for parents and caregivers on media coverage of traumatic events (The National Child Traumatic Stress Network, US):

https://www.nctsn.org/resources/tips-parents-and-caregivers-media-coverage-traumatic-events

An article in the Independent on talking to children about Ukraine: 

https://www.independent.co.uk/life-style/health-and-families/ukraine-invasion-how-to-explain-kids-b2025587.html?r=39325

We should not hide from children what is happening in Ukraine (Schools Week/Children’s Commissioner):

How to talk to children about what’s happening in Ukraine and World War Three anxiety (Metro):

Help for families to talk to pupils about Russia’s invasion of Ukraine and how to help them avoid misinformation (Department for Education)

NASOGASTRIC FEEDING UNDER RESTRAINT IN PAEDIATRICS

Sadly, the numbers of Children and Young People presenting with a picture of severe, restrictive intake has increased exponentially in the last 2 years. This is undoubtedly a consequence of the pandemic. Young people have had to tolerate a high degree of uncertainty, a lack of structure, a loss of normal support functions. They have been without many normal peer interactions. Some have been increasing exposed to emotionally damaging home environments.

In seeking ‘control’/containment/certainty, a small subgroup of young people have turned to managing their intake in a way which has become pathological. Many of these would not meet criteria for a “typical” Eating Disorder (anorexia nervosa). Rather than body dysmorphia and a fear of fatness, per se, they have become obsessional about the need regulate their bodies. Many have had unhelpful relationships with social media accounts promoting weight loss or dieting. A smaller subgroup speak of the “need” to be, or appear, unwell.

A clinical challenge for CAMHS and paediatrics has been the management of the physical health risks of these young people. Some become so compromised (bradycardia, hypotension, weakness) that they need inpatient care. We know from the evidence that specific “Eating Disorder” unit admissions tend to be very lengthy and involve being a long way from home. The evidence that such admissions are beneficial is poor. Most young people are best managed close to home, with short, planned admissions to paediatrics, supported by a close collaborative network of mental and physical health professionals.

Inevitably, some of these young people are so unwell that they may need feeding against their own wishes – via nasogastric tube. In a smaller number of cases, the resistance to this intervention may be so high as to necessitate clinical holding or even restraint, to protect the life of the child. Such an intervention is not entered into lightly. There are significant ethical and practical considerations to be made. Not least, what legal frameworks can and should be used to facilitate feeding.

Published today, a good paper by Sarah Fuller and colleagues sets out some of the challenges:

https://www.cambridge.org/core/journals/bjpsych-bulletin/article/nasogastric-tube-feeding-under-physical-restraint-on-paediatric-wards-ethical-legal-and-practical-considerations-regarding-this-lifesaving-intervention/86FECE4DA94B4E7B3A9B0F9903664ECD

Most acute trusts are finding that their paediatric wards are increasingly having to manage these complex situations. All hospitals should have a lead for Young People’s Mental Health (as per NCEPOD and RCHCH guidance). There is a drive to skill up paediatric staff across the board.

In Summary: The pandemic has brought a wave of distress for many young people, some of whom require intensive and at times restrictive care for their recovery. We appear to be encountering a novel clinical presentation, in some. NHS England recognises the urgency to adapt clinical environments to attend to these often rather desperate young people.

It is hoped that the ‘resolution’ of the pandemic may help us return to pre-COVID levels of referrals, but many of us on the frontline are not so sure. The ripples of the pandemic will be felt for some time.