What is mental health?

There is no settled definition of mental health, which is at times frustrating. When a referral to a child and adolescent mental health service (CAMHS) is turned down because the person does not have a mental health problem, then an understandably narrow definition may be in use, based around a set of diagnoses considered suitable for that service. This is understandable since CAMHS in the UK has experienced significant cuts since 2010. When a governmental strategy on mental health emerges, it usually aims to encompass all aspects of children's well-being into the concept and runs the risk of being impossible to apply to the messy real world. For this article, we will steer a middle path and use mental health to mean the emotional and behavioural aspects of paediatric presentations. This might mean an obviously emotional presentation like self-harm, the physical manifestation of emotional distress such as somatisation, the emotional fallout of physical illness such as diabetes or, more usually, a complex mixture of these dynamics.

Are mental health problems common?

Of the 8 million children and young people in the UK, an estimated 850 000 have mental health disorders.1 A further 850 000 have mental health difficulties that do not meet diagnostic thresholds. The proportion of children with mental health problems is higher in children presenting to healthcare, as demonstrated in table 1.

The situation in children with disabilities and developmental conditions is complex and is covered in the article ‘Community paediatrics and mental health: left holding the baby?’ available at the Paediatric Mental Health Association (PMHA) website.5 Note that this description of the presence of mental health issues is not to imply that they cause the physical manifestations, but to emphasise that mental health is a significant part of the experience of paediatric patients.

Do mental health issues matter?

• Suicide is the second most common cause of death in adolescents, both male and female.6

• More than 50% of adult mental illness is apparent by age 15.7

• Mental illness is the single biggest cause of morbidity in adults.8

• Good emotional health in childhood is a stronger predictor of high adult life satisfaction than any other factor, including wealth, education and physical health.9

So yes, child mental health matters. It matters a great deal in the long run. Many of these conditions are treatable, especially in their earlier stages.10

Is mental health part of paediatricians’ business?

Mental health work scares people. Most paediatricians did not choose their careers to handle complex emotional and family dynamic issues, and yet as the burden of morbidity shifts from life-threatening acute disorders to chronic conditions, many without clear biological pathology, paediatricians are increasingly having to tackle mental health issues.

The number of child psychiatrists in the UK is, given the prevalence of issues, woefully inadequate—about 1 for every 1400 children with a mental health disorder. Paediatric psychologists are, save a few specialist centres, similarly rare. But even if there were adequate numbers of mental health specialists, paediatricians would still need to address mental health issues. As an exemplar, consider recurrent abdominal pain, which is, as in table 1, associated with mental health issues in around 80% of children and young people. Clearly, paediatricians should not therefore stop seeing abdominal pain. However, to see children with abdominal pain, and lack the skills to identify and address mental health aspects would represent suboptimal care.

There is an argument that the paediatrician's role is to rule out physical causes and then pass onto mental health (figures 1 and 2). But as well as delaying the process of addressing the anxiety, this creates a very unhelpful dynamic, as caricatured below.

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Figure 1

The paediatrician's role is to rule out physical causes and then pass onto mental health. But as well as delaying the process of addressing the anxiety, this creates a very unhelpful dynamic, as caricatured above.

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Figure 2

The paediatrician's role - how much better would this be?

The paediatrician's interest has waned, the family feel fobbed off (figure 1) and there is now a huge and unnecessary barrier to get over in order to engage with CAMHS.

How much better would figure 2 be?

Where emotional and behavioural factors are not thought to be contributory to the original pathology, they can still have a great impact on quality of life, adherence to therapy and overall outcomes. This is true both in the conditions one might think of in this context, like diabetes, but also asthma, constipation and epilepsy.

So if we aspire to provide excellent care for children, we cannot entirely delegate care of their mental health to other professionals.

What can paediatricians do about mental health issues?

Mental health work is demanding of professional time and can become very complex, very quickly. While accepting the importance of the paediatric role, paediatricians need to be realistic about what we can achieve as non-specialists.

Here are a few ideas of what can be done.

A role in advocacy

This can take place at several geographical and organisational levels, and in several directions.

At all levels, we need to emphasise:

• the importance of mental health in child health;

• the importance of mental health services that address the needs of children with long-term and developmental conditions;

• the need to integrate services and break down professional barriers.

In the UK, the Royal College had been increasingly active over the last few years, in concert with the PMHA. But in an increasingly decentralised National Health Service, children with mental health problems need people on the ground in localities putting their case.

A role in promotion of good mental health

There is enormous potential benefit to a group as influential as paediatricians giving consistent advice on mental health promotion. However, one needs to be careful that the advice is not coloured by personal experience or whatever media story is currently in the ascendency.

Evidenced and realistic recommendations to promote good mental health include:

• time together, sharing activities as a family

• regular exercise

• good quality and amount of sleep

• meals eaten together

• absence of bullying.10

Screen time for children is a contentious area. Current evidence suggests no causative link to poor outcomes, except that the child loses opportunities for other interactions and play. In the UK, the Royal College of Paediatrics and Child Health (RCPCH) recommends a limit of 2 h a day, which is probably a sensible compromise, and it is in any case important that parents remain in control of the ‘dose’ of screen time experienced.

Clinical approach

As the abdominal pain example describes, an approach that integrates mental health from the first encounter will avoid the unhelpful consequences of a purely physical approach that then fails, and subsequently introduces mental health to a distressed and disillusioned family. In some areas, for example, diabetes care, progress has been made, but elsewhere mental health issues are seen as a fall back when ‘proper’ pathology cannot be found.

Each area of practice will require a different approach, but the following are offered as examples:

• Routine enquiry about emotional or behavioural problems following the child's first seizure.

• Incorporating mental health into the assessment of any painful presentation.

• Routine provision of relaxation and breathing exercises to children with asthma.

• Routine information and empathic listening for adolescents with self-harm, from the moment they arrive in healthcare.

Detection and referral of mental health conditions

Data suggest that paediatricians only spot 25% of the mental health disorders in children2 presenting to them, so improved detection will be important. The best strategy varies by condition; sometimes, it is detection and referral on, and sometimes, it is ongoing provision of care.

Conditions that need to be detected and referred on include the following:

1. Eating disorders: should be suspected if weight loss is associated with abnormal patterns of eating and/or a distorted self-image. These conditions are easy to miss in chronic illness and in males.

2. Psychosis: rare before mid adolescence. Usually presents with auditory, not visual, hallucination, delusion and perplexity—the feeling that something is wrong but no knowing what.

For mood disorders, the paediatric role is different: the first priority is to ask about anxious or negative thoughts, avoidant or withdrawn behaviour, and problems eating or sleeping. As anxiety and low mood are at times a normal part of childhood, it is not always clear when these become a ‘disorder’. The Revised Child Anxiety and Depression Scale is a helpful questionnaire, available online, which can help. Creswell et al11 provides an excellent stepwise approach.

For behavioural disorders (oppositional defiant disorder, conduct disorder), the approach is different again as these are not considered mental health problems by many CAMHS, and so support is often sought via schools, local authorities and the charitable sector.

Finally, attention deficit hyperactivity disorder is increasingly a paediatric diagnosis and the local developmental paediatric service ought to be able to advise on possible cases.

Advice

It is important to recognise both the power and the limitation of paediatric advice. In problems like disorders of sleep, anxiety, feeding and toileting, helpful advice, backed up with good written material, is likely to be believed and perhaps acted upon. However, for more pervasive, complex problems, lasting change may only occur following, for example, a parenting course.

Specific advice is beyond the scope of this article but bear in mind the following:

• Be aware of generic advice, for example, on sleep. See the ‘5 minute tips’ series on the PMHA website (pmha-uk.org).

• Agree a story with parents that incorporates temperamental, biological and psychosocial factors to show how the child's difficulties were predisposed, precipitated and now being perpetuated. See document ‘Pathways to problems’ on the PMHA website.

• From that story, adjust and augment the generic advice to draw out protective factors that can be encouraged and developed within the family.

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 (http://www.minded.org.uk), a suite of e-learning written by specialists for a general audience, is an excellent starting point, and there is a paediatric learning path that 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 (http://www.thementalelf.net) are accessible and always informative, and the RCPCH's own Healthy Child Programme (http://www.rcpch.ac.uk/hcp) has a heavy mental health slant.

E-learning alone is not enough, which is why the RCPCH and PMHA are working together on a number of face-to-face courses in the mental health aspects of paediatrics. See http://www.rcpch.ac.uk for details.

Far more important than formal courses, however, is the fostering of supportive local networks based on the sharing of knowledge and understanding. These will increase the confidence and competence of paediatricians in this area.