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In focus: How can GPs support children's mental health?

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In Australia, around one in seven children (13.6%) aged 4-11 experience a mental health disorder (Lawrence et al., 2015). Of these children, 26% meet the criteria for specialist support; yet only 5.7% access specialist services (Guy, Furber, Leach, & Segal, 2016). This means that many children are missing out on the appropriate and timely support needed to prevent concerns from developing into more serious disorders (National Scientific Council on the Developing Child, 2012; The Royal Australian and New Zealand College of Psychiatrists, 2010).

Australian children visit their general practitioner (GP) more than any other health professional (Lawrence et al., 2015; Warren, Quinn & Daraganova, 2020). GPs also often see the same family for many years, enabling them to build a strong, trusting relationship with both children and their parents. When it comes to anxiety, depression and other mental health concerns, many children initially show only mild symptoms, which can be missed or misunderstood by the people around them. General practitioners are in a unique position to notice and intervene early at signs of mental health concerns, and to promote positive mental health for infants and children.

Family GP consults present the ideal opportunity for these interventions, but most doctors are pressed for time, and some may lack confidence in identifying and addressing mental health concerns in children (particularly infants and toddlers). Talking with parents about the issues they’re facing, and how they may be impacting on their children’s health and wellbeing, can also feel overwhelming, particularly in the aftermath of a natural disaster or community trauma (also known as ‘collective trauma’).

However, supporting children’s mental health doesn’t need to be difficult or time-consuming. Many of the skills general practitioners use every day can be applied to support children’s mental health, through identification, prevention and early intervention strategies. The following resources have been created to help increase your confidence in this space.

Many of the skills GPs use every day can be applied to support children’s mental health.

Talking with parents about adversity

Parents play a critical role in ensuring their child receives adequate mental health support. They decide when and where to seek help for their children, and provide permission for any interventions to occur (Heflinger & Hinshaw, 2010; Sayal et al, 2010).

While every parent wants the best for their child, some may lack awareness and understanding of child mental health, and may not even realise their child is experiencing mental health difficulties. Some parents may not know which support services exist or how to access them; while others may be battling feelings of shame, blame and stigma around their child’s difficulties (Anderson et al, 2017; Dempster et al, 2015; Reardon et al, 2017), particularly in situations involving parental substance use or family and domestic violence. For these and other reasons, many parents may not express their concerns with a GP unless invited to do so. The PERCS Conversation Guide ‘opens the door’ to these conversations.

The guide is an evidence-informed psychosocial discussion tool, created specifically for GPs. It supports collaborative, respectful conversations with parents around the impact of adult health issues and family adversities on children’s daily lives.

The guide is semi-structured and includes example questions to help you explore five important domains in a child’s life:

  • Parent-child relationship
  • Emotions and behaviours
  • Routines
  • Communication and meaning-making
  • Support networks

These questions are designed to help doctors unpack the effects of adverse childhood experiences (ACEs) – such as parental health problems, substance use issues, FDV, and natural disasters and traumatic events – on the child’s wellbeing, in the limited consultation time they have available. The guide is also designed to help practitioners recognise parents’ strengths and hopes for their family, and identify opportunities to support and improve children’s mental and physical health, resilience and wellbeing.

In the following video (1 minute 13 seconds), Dr Sonja Morgan shows how asking a single, open-ended question at every contact appointment can make a big difference to parental and infant mental health.

Many parents may not express their concerns with a GP unless invited to do so.

Diagnosing mental health difficulties

Intervention strategies can make a difference at any age, but prevention and health promotion in the early years (from conception to five years of age) is particularly important for lifelong health and wellbeing (Warren, 2018). Most general practitioners are familiar with conducting adult mental health assessments, but many are less sure what to look for or how to formulate a diagnosis and management plan for infants and children.

To help, we’ve created two free e-learning courses on conducting child mental health assessments with infants and young children (0–5 years) and 5–12 year-olds. These courses focus on the identification, assessment, care-planning and support required for infants and children at risk of experiencing mental health difficulties.

Each course includes the Emerging Minds Mental Health Consultation Guide, which is built around four distinct phases of a mental health assessment:

  • Connect: Engage with the infant or child; listen to the family’s needs; and prioritise what’s important for further exploration.
  • Explore: Gather a history; discuss strengths and vulnerabilities with the parent (and child, where possible); note what you see; and formulate an understanding of the child’s developmental, relational and biological needs.
  • Plan: Establish a management plan with the family, considering referral pathways for the child and family and outlining clear goals; and provide targeted education focused on the child and family’s needs.
  • Collaborate: Work with the team around the child – including the family, childcare/school, and other supports and services – to ensure there’s a consistent and coordinated approach to intervention.

The courses also focus on the importance of including biopsychosocial formulation as part of assessment. Using a biopsychosocial approach ensures you have a holistic picture of the child’s and family’s biological, psychological and social factors.

In the following podcast excerpt (2 minutes 2 seconds), Dr Andrew Leech discusses how a biopsychosocial approach can help you to really understand what’s going on for a child.

Intervention strategies can make a difference at any age, but prevention and health promotion in the early years is particularly important for lifelong health and wellbeing.

Supporting children after a disaster

The relationships between general practitioners and families are never more valuable than in the aftermath of a bushfire, flood or other traumatic event. Many doctors in disaster-affected communities describe people arriving on their doorstep immediately after the event. As a trusted professional and member of the community, GPs can offer families a safe space to tell their story, be listened to, and be offered comfort and support.

It’s important to remember that children are resilient, and the majority will experience only minimal or short-lived distress following a traumatic event. However, some children may find their stress persists over time; while others may appear fine at first, only to display trauma responses weeks, months, or even years after the event. In the aftermath parents will need guidance, information and support to reassure and care for their children as effectively as possible. Regular consults can act as opportunities to check in with families as to how each member is recovering, and to provide referrals and resources to those needing extra support.

However, strategies for recovery following a community trauma event differ from individual trauma therapy approaches. In order to effectively support families’ recovery, GPs need to be professionally prepared themselves. The Community Trauma Toolkit and Supporting children and families in general practice after a natural disaster or community trauma e-learning course will help you to support families before, during and after a disaster. They cover the potential impacts of bushfires, floods and other collective traumas on children’s and parents’ mental health; signs to look out for; and strategies to help lessen these impacts and take care of your own wellbeing.

In the following video (1 minute), Dr Penny Burns discusses some of the long-term effects of disasters on families, and the importance of regular comprehensive reviews.

As a trusted professional and member of the community, GPs can offer families a safe space to tell their story, be listened to, and be offered comfort and support.

The doctor-patient relationship is one of the most important in an individual’s life. The strategies and resources shared here ask general practitioners to consider why and how they can best use this relationship, along with the broad range of skills and knowledge gained through their practice, to promote positive change when children and families are going through challenging times.

Resources

Emerging Minds has a range of free, RACGP-accredited e-learning courses, podcasts, toolkits and other resources specifically created for GPs. They’re divided below into shorter (one hour or less) and longer resources.

Podcast: Biopsychosocial formulation Podcast: Engaging children during a child mental health assessment Podcast: Taking a team approach to managing children’s mental health in general practice Podcast: Transferable skills and the role of GPs in child mental health assessment Fact sheets: Understanding child development Practice guide: PERCS Conversation Guide for GPs Practice guide: Supporting parents of 4-8-year-old children with mild to moderate anxiety Practice guide: Supporting parents of pre-teen children with mild to moderate anxiety Practice paper: What is infant mental health, why is it important, and how can it be supported? Short article: A GP’s guide to anxiety in children
Online course: Child mental health assessment (0-5 yrs) Online course: Child mental health assessment (5-12 yrs) Online course: Supporting families after a natural disaster or community trauma Online course: Supporting children’s resilience in general practice Community Trauma Toolkit ACEs and General Practice Toolkit

References

Anderson, J. K., Howarth, E., Vainre, M., Jones, P. B., & Humphrey, A. (2017). A scoping literature review of service-level barriers for access and engagement with mental health services for children and young people. Children and Youth Services Review, 77, 164–176.

Dempster, R., Winders Davis, D., Jones, V.F., Keating, A., & Wildman, B. (2015). The role of stigma in parental help-seeking for perceived child behavior problems in urban, low-income African American parents. Journal of Clinical Psychology in Medical Settings, 22, 265–278.

Gleason, M., Goldson, E., & Yogman, M. (2016). Addressing early childhood emotional and behavioral problems. Paediatrics, 138(6), e20163025.

Guy, S., Furber, G., Leach, M., & Segal, L. (2016). How many children in Australia are at risk of adult mental illness? Australian & New Zealand Journal of Psychiatry, 50(12), 1146-1160.

Lawrence, D., Johnson, S., Hafekost, J., Boterhoven de Haan, K., Sawyer, M., Ainley, J., & Zubrick, S. R. (2015). The mental health of children and adolescents: report on the second Australian child and adolescent survey of mental health and wellbeing. Canberra: Department of Health. Table 2.2: 12-month prevalence of mental disorders among 4–17-year-olds by sex and age group, p. 26.

Oh, E., Mathers, M., Hiscock, H., Wake, M., & Bayer, J. (2015). Professional help seeking for young children with mental health problems. Australian Journal of Psychology, 67, 187-195.

Warren, D. (2018). Children’s use of health care services (LSAC Annual Statistical Report 2017 chapter – October 2018). Melbourne: Australian Institute of Family Studies.

Warren, D., Quinn, B., & Daraganova, G. (2020). Health service use among children at risk of social-emotional problems: Opportunities for early intervention. Melbourne: Australian Institute of Family Studies (AIFS) and Emerging Minds.

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