Transcript for
A GP’s role in supporting the family
Narrator (VO) (00:02):
Welcome to the Emerging Minds Families Podcast.
Alicia Ranford (Host) (00:05):
Hi, I’m Alicia Ranford and you’re listening to an Emerging Minds Families podcast. When it comes to the health of children and families, GPs are often the first port of call for parents seeking advice and treatment for their child’s health concerns. GPs are really well-equipped to address a wide range of issues that can affect children from common elements such as colds and flu to the more complex conditions like, say, asthma and diabetes. In addition to treating these physical health concerns, GPs can also provide important support to families dealing with mental health challenges. Children and young people can experience a wide range of mental health difficulties and GPs are often the first healthcare professionals to not only identify these but provide crucial support when it’s needed most. But it can be hard for parents to know when it’s time to seek support and feel confident in doing so. Today, I’m talking to Dr. Andrew Leech who has over 12 years experience as a general practitioner or GP, and he has a special interest in child mental health and wellbeing. Welcome, Andrew. It’s great to speak with you today. Andrew, you deal with such a wide range of issues within families. Why, in particular, do you think it’s really important for parents to be conscious of the mental health of their children?
Andrew Leech (Guest) (01:18):
Thanks for having me, Alicia. It’s great to be back working with the Emerging Minds podcast. I think families have a really important role in monitoring their children’s lives and mental wellbeing and from the outset, the history and the presentation and the way families present is so important that what they present with and how they talk about their lives is so important to us as GPs. I think the biggest overview of how children’s lives are going and we need to take that on board and be good at listening to that information. So the perspective they provide us through the challenges they’re going through, through the difficulties, the ups and the downs, and there’s certainly so much going on day-to-day in each family’s lives that it’s so important that they are conscious and aware of how their children are going over that time and that if they are concerned, they come and seek help.
Alicia Ranford (Host) (02:06):
Absolutely, and as a mother of two myself, I know that it can be sometimes hard to know what to look for. I guess that leads into my next question, which is what can a parent look out for in their children to even start thinking that perhaps they need some extra support in regards to mental health?
Andrew Leech (Guest) (02:24):
It’s not always easy. It’s not always clear cut. I think children are so broad in how they present that it may not be obvious, and the first thing to point out is that we all experience differences in our mental health day-to-day. I try and normalise mental health with children and families so that they are aware of that it’s okay to feel worried, anxious, fearful, angry, sad. These are normal emotions and help them to realise that there’s nothing wrong with them. They are okay to feel those things and to express those things. What I’ve found with children is it’s difficult because they don’t always know how to express those emotions, so they might change in the way they behave. Certainly have families come in worried about big behaviours, big impulsive emotions, anger, tantrums, meltdowns over a long period of time where it’s really challenging the whole family, the parents, and the siblings. That might be a child that’s internalising how they’re feeling and what’s going on for them.
(03:20):
And that’s certainly true for the younger kids who really struggle to know what’s going on and might have trouble saying the right things about how they’re feeling or even understanding how they’re feeling. Other presentations we see might be physical symptoms. Children, certainly, when they internalise their emotions, can develop other nervous system presentations, headaches, tummy aches, go off their food, having trouble with their sleep. So it’s not always clear cut for parents. It might not be obvious that there is a mental health difficulty going on with their child. They might just think this is normal child behaviour and sometimes it is normal child behaviour. So we have to distinguish between what is a mental health condition and what is actually just a tough time or a developmentally normal symptom. And then I guess as they get older and more aware of their emotions and they come in a little bit to see us or they talk to a psychologist, they are able to verbalise more about what worries and fears they might be having, particularly moving into the higher primary school years and into the adolescent years.
(04:15):
Then it’s a lot easier to pluck out those emotions of what’s going on for them and what might be triggering off an anxiety or a worry. It depends across the lifespan of that child what might be going on and hard to figure out if there’s a mental health problem, but I guess for families listening, if they’re ever worried, it’s good to get help and if they ever think, it’s never too silly to come and get help and I’d like to think that GPs are good at picking out the normal from the things that might need more support.
Alicia Ranford (Host) (04:38):
What would you say to a parent who wasn’t sure how to start that conversation with you as a GP about mental health with their family?
Andrew Leech (Guest) (04:45):
Yeah, it’s a really good point because lots of parents come in and talk in code to me because they don’t want their child to know what they’re talking about and that’s tricky. So we are sometimes talking in sign language and code and spelling words out and I think it’s good to write things down. If you’ve got a concern, write down a list of the things and that’s always helpful. Day to day, what challenges are you faced by and what’s the school been saying? What have the teachers been saying? What does dad say? Get the whole family approach and come in, even for a separate appointment just on your own as a parent to start off with, and then we can have that really open conversation, all the ins and outs of what they might be worried about and it might end there. It might just be, “Okay, look, let’s just observe for another term and see how things go and try these things and let’s come back and reevaluate.”
(05:31):
But if you are with your child, again, I love to normalise emotions and if it helps to come in and talk about what’s been going on with a child present, it can actually be very empowering to that child to say, “Look, I hear you, I can tell it’s been a tough time for you. We all go through these tough times. This one sounds like it’s been really challenging. What do you think would help and how can I help you to work through this? And would you like to talk to me about it or would you like to draw about it? Would you like to write things down? Would you like to colour how you’re feeling?” There’s different ways to communicate with children about emotions, but it’s still good to have that conversation. Even with a six-year-old, a five-year-old, it’s still good to have those discussions so that they feel listened to as well.
Alicia Ranford (Host) (06:09):
And how great to start normalising conversations about mental health at such a young age.
Andrew Leech (Guest) (06:14):
Yeah, it is, and I think that’s probably where health professionals might get a little bit lost, is what do we say to children and what do we say to parents around mental health when it is such a highly prevalent issue that’s coming in our doors at the moment? How do we start that conversation and how do we involve the child? I still struggle with this. I think health professionals find it really hard to work out that dynamic between the parent and the child and what to say and what not to say and help that child feel included but not feel like there’s something wrong and something that they now need to be fixed.
Alicia Ranford (Host) (06:45):
I’ve heard you talk about that sometimes that might be watch and wait or let’s try a few things at home and see how that progresses, but what else as a GP can you do to support a family where perhaps the child is experiencing some more significant mental health difficulties?
Andrew Leech (Guest) (07:03):
Family presents with more severe persistent pervasive symptoms with their child, so this is really impacting school, this is really impacting their home life, this has been going for quite a long time. It’s not just something that’s been happening over a few days, it’s actually been their whole livelihood is being affected. We might start to think about a mental health disorder and start to work through the system and navigate the system to help that family reach care that they need. I think the first step always starts with the GP, a GP that cares and listens and takes on board what’s been going on for them. I see us at the centre of the cogwheel. We send people to different care providers and we expect them to come back to us and have feedback from those care providers so that we can continue to work through these issues with the family without losing them.
(07:50):
That’s how I see the GP’s role. We firstly need to be good at listening, empathising with what’s going on. It’s a difficult time. We may not have all the answers immediately. We might not be able to fix this immediately. As I said, it doesn’t need to be fixed. We just need to help support them so that they can have tips, strategies, tools, and work through the problems that have been presented. Treatment might include a referral onto a psychologist, which might involve some family therapy. It might involve some child base therapy, which you can arrange depending on the age. It depends on what the therapy might be, or an occupational therapist. I find them really good for the younger kids, especially the ones with the mental health skills and background, can be great for dealing with some of those tricky social skills and challenges with emotional regulation. Or a social worker or even just might be a simple thing referring to a tutor who can help with some learning difficulties that might help their mental health as well.
(08:43):
Referring to your clinic nurse to have a bit more of a chat and a bit more of debrief. That’s what we do here now. We’re starting to involve the nurse a little bit more. So it’s just getting some help so that you don’t feel so isolated just with the GP, you’ve got a few people now on your side that are teaming up with you. Involvement of the school’s really important and I’ve started to now email the school teacher and start to create a bit of a loop there so that the teacher can start to communicate with us as well. Obviously, that’s with the parent’s permission, but good to have that input as well into this child’s mental health. And then through to ongoing coordination of care. If it isn’t going well, then it might be a paediatrician or a child psychiatrist, which, in the state that I’m in, WA, it’s very, very hard to get help from because they’re all really got capacity. The child development services as well locally, the mental health services, the child adolescent mental health services, they’re really busy. So it’s not always going to be a quick thing to get into those services, but if there is a more severe mental health disorder at hands, that might be where the GP refers to.
Alicia Ranford (Host) (09:43):
I’m wondering also whether part of your job is a bit detective-like, so looking at perhaps what’s going on in the wider life for the child perhaps at home or in other circumstances to see if that’s impacting their mental health in some way.
Andrew Leech (Guest) (09:59):
That’s a really important point that the GP has the broad holistic lens of that family’s world and quite often, I’ll already know that child and I’ll already know the parents, the siblings, the grandparents, and even their child’s friends who might also be coming to see me. Obviously, we’ve got confidentiality here, but I already have that broad lens about this whole family and their dynamics and what might else be challenging them in their lives. So that’s the beauty of being a GP. You get to know them over time. Quite often, these kids that are coming at seven, eight, nine, I’ve seen them since they were born and that’s just amazing. You’ve been able to really work with them over a long period of time. Such an incredible privilege as a GP, but the other thing about being a GP is we can think holistically about the other causes of mental health difficulties.
(10:49):
It’s not always clear cut. As we said, children aren’t always great at communicating what might be going on for them. So we might need to think broadly and ask different types of questions, communicate differently with different children and also potentially look at other causes such as neurodevelopmental concerns like ADHD and autism, medical causes such as poor sleep, sleep apnea, thyroid, iron deficiency. We might need to do blood tests. We need to really hone in on all the possible issues that could be going on. And I love starting with those basics: sleep, diet, exercise, social life, screen time, just those little basics, that might be where we start until we work through with the other things.
Alicia Ranford (Host) (11:30):
There would be many parents who haven’t heard or don’t fully understand what a mental health care plan is and in particular, the benefits of implementing one. When we talk about mental health and wellbeing, can you talk us through how a mental health care plan can benefit a family?
Andrew Leech (Guest) (11:48):
The mental health care plan is a document that the GP will type up that lists the issues and concerns that might be presented by the child and family and the goals that we’re trying to achieve to help them through these concerns. Goals often are things like supporting social skills and connecting with friendships, helping with emotional regulation and anxiety, dealing with anger outbursts, helping the parents to parent challenging behaviours. There’s some classic goals that I use in my mental health care plans through to figuring out is there a diagnosis at all? Are we dealing with a mental health disorder or a neurodevelopmental disorder? Do we need further help? So the mental health plan lists things out. It’s a requirement for Medicare to complete a mental health plan if we are going to seek some funding for psychology, OT, or a social worker. The mental health plan is not compulsory for referrals to psychologists so you don’t have to have one.
(12:47):
But it does often help families, especially those struggling financially or who feel like this is going to be a bit more of a longer term thing, we need those extra sessions, it can be a really good starting point to get that funding. It’s important to note that Medicare requires a diagnosis for a mental health plan to be put through. I give parents a heads-up on this because I will have to write something on the plan and if they’re going to read it, they might get a bit shocked to see, “Oh, the doctor’s written anxiety disorder. That’s not what we thought was going on,” but it might be an anxiety disorder still being figured out. So I word it carefully so that we get the Medicare funding, but I also let parents know this is very fluid and can change.
(13:27):
This might be how things are presenting at the moment, but the psychologist might write back and say, “That’s actually not anxiety. I think it’s actually something else.” So these are not locked in stone. These are just terms we use and I try not to label things. I try to use terms so that we can get that support for Medicare. The rebate doesn’t always cover the whole cost either. There’s usually a gap and it’s up to the family to call up the psychologist and find out what that gap might be. The funding is up for up to 10 sessions per calendar year. It used to be 20 during COVID. Unfortunately, that’s now being reduced back to 10.
Alicia Ranford (Host) (13:58):
But still lovely that families can have access to some funding if they need it.
Andrew Leech (Guest) (14:03):
Yeah, it’s really important to do. And the other thing is that it connects me to the psychologist, so that then allows me to start the ball rolling with that first referral and then psychologists will write back after six sessions to give us feedback on how things are going. Usually, at that point, it’s a really good touch base point for the family to come in with the child, and then we open up the further four sessions.
Alicia Ranford (Host) (14:25):
And Andrew, is there a minimum age range for a mental health care plan?
Andrew Leech (Guest) (14:30):
There’s no minimum age range, which might sound a bit controversial for some GPs that might be listening because how do you diagnose a mental health condition in a newborn? But I have occasionally had to do mental health plans on really young kids that are having a hard time maybe connecting with their mum or connecting with their family or having a really difficult time with sleep and settling and it potentially could be mental health related. There’s such a wide range of ways that mental health presents, even in newborn children. So there is no age range set by Medicare for a mental health care plan. Some parents might find they go to a GP who’s a little bit resistant about doing a mental health plan on a young child and that’s okay because every GP is at different levels of their understanding of how these work. And so it might mean you have to seek out someone else who might be able to help you if you’re really struggling to get what you need with that referral, or just start with the psychologist and then if it looks like it is going to need longer term management, come back and get the referral.
Alicia Ranford (Host) (15:27):
And that’s a great question. If you go to your GP and perhaps you are finding that they’re not providing for you what you would like, what advice would you have for someone to find the right GP for them?
Andrew Leech (Guest) (15:40):
I think looking onto the clinic’s website and seeing which GPs have an interest in children’s health. Most websites for clinics will list the GPS and list what their interests are. Some GPs have done extra training, which is called the Child Health diploma and you can get a clue there that they’re probably interested in children’s health if they’ve done that extra training. I think then once you get to the GP, you just need someone who’s good at listening and someone who’s able to spend some time just taking that information on board that you’re presenting with and whether or not they have the answer straight away, I don’t always have the answer straight away, they might send you away and have some thinking time. It’s just so helpful to have someone who feels on your side and is able to really connect with you and understand what’s going on for you. That’s the first step. And I think if you found that person, that’s a great start and the rest you can figure out together.
Alicia Ranford (Host) (16:29):
The together word is important because I know, for me, it was really important to feel like we were trying to find a solution together
Andrew Leech (Guest) (16:36):
And remembering that this sort of work takes more time, so book a long appointment. If you are coming in a short appointment, you can’t really do a huge amount in that short amount of time. They don’t like rushing it. So try and book a long appointment with your doctor so that they can give you that extra time and not be rushed.
Alicia Ranford (Host) (16:52):
Andrew, you’ve spoken already about different practitioners that you can help guide a family towards, such as a occupational therapist or a psychologist. How can a GP help parents and families with navigating the healthcare system? Because I know for many of our listeners today they might find it a tricky system to navigate sometimes.
Andrew Leech (Guest) (17:12):
It’s super tricky. GPs, you see, usually have an understanding of the local networks and who’s around them and that’s helpful. It’s a good starting point because then they can connect you with the right people. It’s also helpful if you come in with someone that you’ve heard that’s good or you’ve done some research, you’ve talked to other families going through similar struggles and you’ve been able to ring up and even get an appointment, that’s amazing. You are welcome to always bring in some people that you know of are good in these areas. So I guess a GP’s role is to navigate that system to connect you with the right people with a special interest, but then also to hold you over that time. Whilst you’re waiting to see the psychologist, you might have multiple appointments with your GP just to go through each little bit of what’s been hard for you.
(17:55):
I love doing that sort of work, the in between work. We have probably a 12 to 18 month wait to get into a paediatrician here, so the in between work is a lot. We spend probably, I’d say, every month or every school term catching up and touching base and chatting to the kids and figuring out if there’s anything else we need to do in the meantime while we’re waiting. How do we really support this family while they’re waiting? That’s a really tricky time. And then the feedback and the closing of the loop from the providers. Once they’ve seen the providers, the GP needs to chase up that feedback and follow up what’s going on and implement that plan. And if the plan’s not going well, what do we do next? We need to continue to evolve with that family.
Alicia Ranford (Host) (18:33):
And we’re talking today about children and their mental health and wellbeing. A child’s age can range from a newborn all the way up into being a teenager. Does your approach change depending on the age of the child?
Andrew Leech (Guest) (18:46):
Definitely changes. The newborn children obviously can’t talk. The younger they are, the less easy it is to get a history and the history comes from the family, the parents, and the behaviours of the child, the emotions that they’re presenting with. As they get a little bit older, again, it’s still looking at behaviour, it’s looking at physical symptoms like we talked about. It’s talking about their school progress and interactions with peers, but the next group up, the older primary children into the teenage children, I like to see them on their own because they can really give you a good history of how things are and it’s great if they can have a safe space to express those things. The adolescent age are faced with many challenges now and I’m well aware of them because I hear about them through my history.
(19:28):
And the GP’s role is changing. When I was at medical school, I never learned about Snapchat, Instagram, drugs, alcohol, transgender health, eating disorders. To be honest, these things are all encompassing, massive issues that are happening in adolescent children at the moment that we would have had no idea about 10 years ago. So those teenagers that are coming in, I think the GP needs to try and have a chat to them one-to-one and be very down to earth, non-judgmental, accepting, and understanding, but we have to help them with those tough periods of their life that they might be going through and that is an immediate impact on their mental health, those things I’ve just mentioned, that can really affect their mental health. So it does depend on the age and I think each age has their own unique set of concerns. The other thing is that just with mental health and ages, that there’s a lot of developmentally normal mental health symptoms at each age.
(20:21):
So a child that might be struggling to sleep because they’re scared at nighttime can be very normal. A kindy child that’s having trouble being dropped at kindy who’s really clinging onto mum and crying and falling apart, that can be very normal. And quite often, I’ll just reassure and let’s give it some time and let’s do small steps, let’s go up the ladder slowly to try and let those big emotions settle. So quite often, children and even adolescents have quite normal ranges of emotions. And as we said at the start, it’s those extremes and when it’s impacting on life and learning and wellbeing, then that’s when we start to really need help.
Alicia Ranford (Host) (20:58):
Andrew, I know from the work that you’ve done with Emerging Minds previously, you have a strong belief about GPs walking alongside the whole family. Can you tell our listeners a bit more about that?
Andrew Leech (Guest) (21:10):
So the GP has that oversight of not just the person presenting, but what I think of as the invisible people in the room. The other sibling that might be at school at that time, the dad that might be at work or the mum that might be at work, the grandparents who look after the kids on the weekend, there’s invisible people that are influencing the mental health of the child that’s coming in and we have such a unique lens on those people. And so it is really important that your GP is thinking about those people or you mentioned them yourself to your GP. I love doing a family tree at the start, just so we know who is involved here, who’s living at home, who are the pets, who is important to you, who are your friends, because that is really what impacts our mental health and wellbeing, all those people.
(21:57):
And then understand how are things in that network, how are things going in that network? How are those connections going? Are there areas that are being more challenging for them? Sibling rivalry is really common, but that’s normal. But there’s families that I see that are really having a hard time with separation and some kids that come in with foster parents or even in child protection. There’s a lot of different levels of who is the invisible people in the room. And so just thinking really broadly and an understanding about what else is impacting on this child’s mental health, who else is there? And asking the child, “Who are you close to? Who your support people? And then who do you trust?” And that helps us as well to know that they’ve got someone out there looking out for them. Quite often, the GP will already know these people because they will be seeing them. So I would love getting back the parents for their own individual mental health assessment and review. If we can support the parents, then we can also support the child. Quite often, the parents will end up going to see a psychologist themselves just to get some parenting support and advice. And quite often, they’re exhausted, they’re overwhelmed, and they need that extra help. So just being really broad with who you’re dealing with.
Alicia Ranford (Host) (23:03):
And as a parent of two teenagers myself, I know that we have highs and lows in parenting moments, so it is great to know that a GP is there for us through all of those.
Andrew Leech (Guest) (23:12):
I’m a parent myself and it’s great to be a peer of myself because I can say, “I hear you. I also have had the same warning as you’ve had of fighting to try and get to school and arguing and trying to get your clothes and shoes on and have breakfast within an hour. And I hear you, I can totally relate to what you’re going through and it’s very normal.” Every family goes through challenges and I’m no exclusion to that. So I think it’s another great perspective I can bring to the discussion.
Alicia Ranford (Host) (23:40):
Andrew, it’s been really lovely to talk to you today. And I wonder if before we finish you could just give us a couple of take-home messages. If you wanted our listeners today to just remember a few key things, what would they be?
Andrew Leech (Guest) (23:51):
Just with mental health, remembering that there’s such a wide range of mental health that we all experience and our children experience and it’s never too early or too late to come in and talk about those things with your GP. Find a GP that you trust, that is able to listen to you. Book that longer appointment and allow that GP to help you through whatever challenges you might be having and hang in there. It might seem like it’s all encompassing and daunting. It does get better. Things do get better and it’s so cliche, but I always tell families this, that things will have a way of working out. One way or another, we will get through this. And I think if you can find someone that is able to work with you on that plan, then that’s such a great start.
Alicia Ranford (Host) (24:32):
Very wise words, Andrew. Thank you so much for joining us today.
Andrew Leech (Guest) (24:36):
Thank you very much for having me.
Narrator (VO) (24:41):
Visit our website at www.emergingminds.com.au/families for a wide range of free information and resources to help support child and family mental health. Emerging Minds leads the National Workforce Centre for Child Mental Health. The Centre is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.