Key skills in engaging children during a child mental health assessment
Narrator [00:00:02] Welcome to the Emerging Minds’ podcast.
Sophie Guy [00:00:08] This episode is one of a four part series that sits alongside the Emerging Minds’ e-learning course ‘A GP framework for child mental health assessment (5-12 years). The course looks at engagement skills, formulation, phases of a child mental health assessment, and the ongoing management of a child with mental health difficulties.
Today’s episode features Aaron Chambers, a Brisbane-based GP who has a passion for family practice, including paediatrics, and is also a GP Liaison Officer for Children’s Health Queensland. He joins the podcast series today to talk about engagement and the key skills involved in conducting a child mental health assessment.
Sophie Guy [00:00:48] Hi Aaron, and welcome to the Emerging Minds’ podcast. It’s great to have you on.
Dr Aaron Chambers [00:00:52] Thank you.
Sophie Guy [00:00:53] We’re here today to talk about the unique relationship within the health system that GPs have with families and what engagement with children and their parents looks like within this ongoing relationship. And a phrase that gets used is to ‘walk with the family over time’. And Aaron, I’m wondering if you could tell me, what does this mean for a GP to walk with a family over time?
Dr Aaron Chambers [00:01:16] So I guess in our community, I think it’s a fancy term, but it seems really simple, actually, when you’ve been a GP in a community for a long time. And I guess to me, it’s that continuity where you’ll see a woman through pregnancy. You’ll see what’s going on with her and her partner. You’ll see the child get born and look after them from those early days and then watch and learn with that family as they grow over time. And I guess you also evolve as a person yourself and build up a lot of your own life experience and wisdom that you can glean from looking after lots of family going through their journeys. So I guess that’s what I would take from that phrase, is that it’s all about that lifelong continuity. That is part of being a GP embedded in local community. [Uh huh] At GrowLife Medical, we’ve really taken that to the extent to say this is the core purpose for general practice, is really creating that relationship early on in life is so, so important. Not only for the family, but also for the clinician. You know, it’s a really enjoyable journey as a clinician where you develop that relationship and continuity. So patient, family, community is the way we think about it. So think about the individual in front of you looking at what’s going on in their physical health and mental health and supporting that. But it’s much more important to think, particularly in children where where they’re intimately related to a family context, to think about what’s going on for that family. Has dad lost their job? Is mum having postnatal depression? And think about what the interaction with the siblings are. And I think that’s where you suddenly start to get a better understanding for what’s going on for that child. You’ll see patterns of behaviour repeated in siblings or from the parents and even the next generation up, grandparents. If you’re lucky enough to have a tri-generational family to look after, then often you can see threads of common themes running through families.
Dr Aaron Chambers [00:03:02] And then, even more importantly, I’m sure you’re aware of all the evidence around social health and its impact upon not only mental health and physical health now, but also on longevity and mortality. And we’ve taken the view that general practice has gone a bit missing in this area. I think back to when I was a kid and I had a GP who was really actively involved in local community. There were only two GPs in our suburb and everyone knew who went to which GP and those GP actively were involved in the school board or at fetes and that sort of thing. And they acted as spokespeople on what was really important for the health of that local community. And I still believe that’s relevant now because the world, whilst it’s become much more global, that also means that whole type of local context is even more important. And people are searching for connection and continuity, and something deeply personal, like their relationship with a general practitioner, I think requires that local connection. So, for example, how we enact that in our community is we go to the local fetes and we’ll have a stand and we sponsor the local school fetes. We go and run handwashing clinics in the local kindergarten. Some of our doctors will go and speak at a Rotary Club dinner about heart disease. And it’s those small interactions with our local community, including being present on social media, I think that’s increasingly important, and talking about okay, here’s a population health issue. Covid right now, is so important from that point of view. Having those conversations and being present at a community level, I think is where suddenly it creates a deeper relationship and a better understanding both from the community, what the practice is about, and also from the clinicians about, okay, this child goes to that school and that probably means that things about what’s going on for them and they really understand the subtle differences. It’s like an ultra local version of culture, I guess.
Sophie Guy [00:04:58] Yeah, that’s interesting. Are there other GP or general practices that you know are, kind of have a similar ethos?
Dr Aaron Chambers [00:05:05] Not many, and I think, say, for example, we also have run parents groups to help look at that that social determinant of maternal mental health. I think state governments do run them. But I also think that state based health system doesn’t understand community at that the ultra local level, like general practice does. I’m sure there are practices out there who are really foresighted and visionary and don’t put the almighty dollar first. And I think that’s gonna be really important over the coming years. You know, we’re facing, I hate to say it, but unprecedented economic downturn in the wake of covid. And I think we’re going to see much more mental health fallout, as we’re already seeing with teenagers and school aged children, I think presenting in numbers that I’ve never seen before with distress be it school performance or or behavioural issues. You know, that’s that’s what we’re seeing.
Sophie Guy [00:05:55] Is that right? And you have sort of noticed that over the last few months?
Dr Aaron Chambers [00:05:58] Oh, definitely. Especially the last month or two. Yeah.
Sophie Guy [00:06:00] OK. That’s interesting. So why is engagement so important when supporting children with their mental health?
Dr Aaron Chambers [00:06:09] So I think children are really good readers of character, and they always, just like the Circle of Security model, where you look at that hand model that they have where the child kind of goes out and explores on a limb and then has a problem and then comes back to safety. They’re acutely aware of danger when it faces them and they’ll retreat to safety in in their parent typically. And that can make I think sometimes it very difficult. You know, you can think of the child that comes into your office and he’ll be cowering next to their parent and really not want to engage. And it’s hard to to draw out an understanding of what that child is feeling without them having a sense of safety. And so my view is that that doesn’t start when they come into your office presenting with a behavioural concern or a mental health concern. It actually starts when they’ve come with a cold and you’ve examined them and you’ve built trust. Or they’ve come and they’ve scraped their knee and you managed to do it gently, and they build a sense of confidence that this doctor’s here to look after me. Even through their vaccinations, you know, making it fun, blowing bubbles, having toys that they can play with and making it an experience when they come to the practice. That means that when they do present later on, you can trust that you’ve built enough of a relationship with that family and with that child, that they’ll feel pretty comfortable to come into your office and talk about what’s going on. And I think they’re some of the most rewarding consultations. So I guess that’s that engaging piece. For a GP, it’s not about trying to force them within one or two consultations. It actually extends back in time. And it’s about the way you treat that family with every single interaction.
Sophie Guy [00:07:43] And then to take it to a more specific example, like you gave that example of a child that’s very timid and staying very close to their parent. In that kind of moment, what would you think about in terms of how would you go and engage a child that.
Dr Aaron Chambers [00:07:55] Let’s say it’s a new, new relationship, I’ll usually then turn to the parent. So if the child really doesn’t want to talk to me, I’ll usually talk to the parent and just make it a pleasant conversation. And even specifically indicate to the parent and say, you know, that’s alright. They’re obviously feeling nervous. How about we have a chat and we can figure out what’s going on, and I’m sure they’ll come and join the conversation when they’re ready. And kids are smart. They pick up on those things and then they know that they’re there listening and they say, oh what’s this guy doing? You know, is he being nice to my Mum? And it tends to work, you know, I think kids do really open up when you show that you’re genuinely interested in what they’re thinking and what their world is. And there are lots of little tricks and techniques you can use to do that. I’ll fold a paper crane and kind of get their interest and just let that child kind of see what I’m doing and get interested in it. And then suddenly you’ve got a little gift for them. And there even subtler things, like often a parent will reach out to try and grab the gift. But I think it’s really important that you keep that interaction with the child and let the child receive it from you. Because I think they pick up on subtle hints like that to understand that actually it’s okay for them to broker a direct relationship with the doctor rather than broker it through their parents. Because that’s where you can really get breakthroughs and they’ll start to open up and talk about whatever it is that’s bothering the. And when it works well, I’ve seen some kids say stuff in the clinic quite openly with their parent there that they’ve actually never opened up and mentioned to a parent, like they’re being bullied or that there’s something that’s really scaring them when they go to school.
Sophie Guy [00:09:23] This interview is part of a series to sit alongside the GP mental health skills training course and a core principle of that course is this idea of being child-centred and family focused. So I wondered if you could just talk to me about what it means to you to take a child-centred and family focused approach when supporting children’s mental health needs?
Dr Aaron Chambers [00:09:44] So I think I referred to that a little bit in in talking about how we think about the patient, the family, and the community context of what’s going on for our our patients. One very foundational thing is just thinking about the environment in your practice. Is it conducive to children coming in and feeling like this is a place that actually meets their needs? Do you have a place where they can go and draw or colour? Do you have toys in the corner of your office that are more than just a token effort? The books that you’ve got for kids to read with their parents, really engaging and enjoyable? Or are they kind of torn and disused and unkempt? I think that’s a really important factor. Because once kids come in and they enjoy coming to the practice and there’s stuff to play with, I think adults we can learn so much from kids where you get to play with them and it’s one of the best things about looking after lots of young children and families, is getting to just play during your consultation. [Mm hmm.].
Dr Aaron Chambers [00:10:39] And then I think utilising the skills of the team around you, including the practice nurses, if you’re lucky enough to have a child psychologist in your practice, like we do. Really just using the ideas that come out even from your receptionist. We’ve got some of our receptionists are university students and bring a great deal in just ideas into how we can make the place fun and engaging. I think one of the best ones I’ve seen is, we’ve got a little area that’s kind of, it’s a bit of a nook that the kids sit in and they draw and they started to do the drawings and one of the researchers said, hey, how about we just get some blue tac and we’ll put that up on the wall. And this wall started growing. And then what we noticed over time was, actually there were starting to be little conversations happen between kids, between visits. And so they’d write on there and say, you know, Dear Sophia or whoever it was, hope you’re feeling better soon. And then there’d be a note come from another child saying, yeah I’m much better. There’s beautiful things like that that make children feel like they’re part of a community. That classic, it takes a village to raise a child.
Dr Aaron Chambers [00:11:37] So that’s what I think we mean by engagement. And it goes all the way from the receptionist being really competent and comfortable welcoming children and being happy that they’re there. And making sure the environment is family friendly and child-centred in having stuff that kids enjoy. Allowing them to play, and even things like just having a baby change tray. You know, making sure that all that’s sorted out. Making sure your office is friendly and is comfortable for children and that they’re free to play and are safe to do so. So it’s not too clinical. And then it comes down to your rapport and your ability to build a relationship with the parent and the child, remembering that you’ve got two patients in the room.
Sophie Guy [00:12:17] Mm hmm. Yeah. What do you do in situations where, for example, perhaps the parent is sort of dominating the space and you’re wanting to put your focus onto the child as well and hear from them? How do you approach that?
Dr Aaron Chambers [00:12:31] I think one has to remember, and as a parent myself, I know if there’s something going on for my child that where they’re having difficulty with something or they’re worried, you feel that deeply as a parent and actually your own insecurities and nervousness and things will come out. And I think it’s important to acknowledge that parents in coming with their child facing a mental health issue or a behavioural issue, are probably nervous and upset themselves. And sometimes you can’t address that in one one visit. And you certainly can’t, if you’re busy and you know you’ve got a huge afternoon in front of you and you’re already running late, I think breaking it down can be so important. And perhaps using that opportunity to suggest some information gathering. Or just laying it open and saying, look, doesn’t look like we’re getting a whole lot of information from your child or it doesn’t look like we’re really proceeding today, how about we book a few appointments? And even if they’re just about coming in and having a good time and playing, but really consciously saying that’s what we’re doing in order so that at some point in time they’ll feel comfortable to tell a story.
Sophie Guy [00:13:35] Okay, great. What do you think are some challenges that GPs might find in this area of engagement and having a child focus and family focus?
Dr Aaron Chambers [00:13:48] I think the time pressures of general practice. I know there’s a lot of financial pressure in general practice at the moment, and that can really get in the way of providing good care because it is so difficult right now. And a lot of the initiatives that I think are very well-meaning sometimes don’t recognise the lack of remuneration in general practice for really doing a good job. So I think that’s a huge challenge that we can’t pretend isn’t there. And I think federal government needs to address that adequately by by putting in place rebates that appropriately remunerate spending time with patients, which is often the bit that is required. Sometimes you can pull a bit of Lego out of a child’s nose and it’ll take you five minutes. And that’s remunerated infinitely more than spending half an hour really talking in depth about a complicated problem that’s facing a family that probably has far, far more impact in their life. [Mmm wow]. And I think that’s really difficult. How do we fix that? I think it really needs policy and Medicare setting change.
Dr Aaron Chambers [00:14:48] So that challenge is there. It’s not insurmountable, you know. Thinking about how you deliver health care and making sure you appropriately use Medicare to do that. So using things like mental health care items, I think is really important. Sometimes, depending on the practice you’re in, if you’re not lucky enough to be a practice owner or don’t have much control over your practice environment, then that sometimes may be out of your control as a consulting GP. But I think that then means if this is work that’s important to you, making sure you advocate for the that the environment in your practice is appropriate, or going and finding a practice where it really does fit what is required for parents and families. And I think one that we don’t often appreciate is cultural barriers where they aren’t necessarily, you know, there’s obvious cultural barriers. Families from a refugee background. I mean, we’re all aware of those sort of cultural barriers. Perhaps if you’re from a non-Aboriginal Torres Strait Islander background and your patient is, that may be a cultural barrier. But there are other more subtle cultural barriers. I think sometimes, obviously, as doctors, we’re relatively well remunerated and of higher socioeconomic status. I think sometimes it’s very hard to appreciate the difficulty that someone who is really struggling every day goes through where you’re not from that background. And I think it’s really important to keep one’s eyes open to that. And then there are even further subtleties. Families who are of prior generations might have come as refugees. So like really thinking about what is the background of your patient. What biases and positive aspects and negative life aspects do they bring to the table that make them uniquely who they are? And how do you think about that.
Dr Aaron Chambers [00:16:21] And then the final challenge that we face, and I think this is one we’re trying to embed into the way we practice, is thinking about adverse childhood experiences. So both for the child and for the parent. And for anyone who hasn’t gone out and watch those two very informative documentaries on adverse childhood experiences. There are two excellent documentaries that can be found online that are really worthwhile watching. So one is called ‘Resilience’ and the other is called ‘Paper Tigers’. And both are documentaries about adverse childhood experiences and the impact they has upon children, the parents, and the community around them, and how we can start to think about this and how we can address it in our community. So I think that one is very much worthwhile thinking about because some of the most difficult consultations I’ve had and ones that potentially haven’t ended so well, I can think of where there was a question that I once learnt from someone who is much more experienced to me in dealing with complicated presentations from families. And they had suggested how about you ask the parent, what did you learn from your parents about being a parent? And on the surface, it sounds like quite an innocuous question. But this particular presentation, there was an odd interaction that I was witnessing between the mum and the child, and we were about four or five consultations in and I hadn’t been getting very far. And after seeking advice from this respected clinician, I asked that question and said, what did you learn from your parent about being a parent yourself? And the parent got very angry with me and ask me, what’s the relevance of that? And actually, I never saw that individual again as a patient.
Dr Aaron Chambers [00:18:09] But I think it told me that perhaps there was some very deep trauma there in the background for that individual. The fact that they reacted in such a strong manner to such a relatively benign question, I think told me a lot. And hopefully that might for that individual mean that they, over time, are then able to address whatever it is that they’re holding with them, with the next clinician that they see in the chain. You know, I’m sure they have caught up with another GP and a perhaps paediatrician or a psychologist in order to deal with whatever’s going on there for them. But I think having an awareness around adverse childhood experiences both for how it colours the parents’ interaction with their child and how it affects that child’s upbringing is probably a big challenge that we need to start addressing as GPs.
Sophie Guy [00:18:54] Great. Thank you. So the final question I had and you’ve been talking around this anyway and giving some suggestions, but what advice and guidance can you provide to GPs that might help to overcome some of the challenges that you talked about about supporting family and children over time and this process of engagement?
Dr Aaron Chambers [00:19:13] One I haven’t mentioned already is thinking about how can you address the social determinants of health in your community. So I guess the way in our practice that we’ve we’ve started to address that is creating parents’ groups that are free. They’re non-medical. They’re purely there to create social connectedness and enable a peer support network for, for parents who live in that area. So that’s one concrete example of something you can do. I think peer support is really important and often provides different avenues for parents to address whatever’s going on for them than we do as clinicians. So thinking about how can you do that in your local community, I think is a good start. Think about how your practice caters for children, as I mentioned earlier. Think about the environment and how it makes it feel welcome and comfortable for that child to enter your clinic so that you can have that that relationship and that discussion.
Dr Aaron Chambers [00:20:07] I would say consciously stepping outside of your clinic, talk to the school in your local area, get to know the local guidance counsellor. Work consciously on creating your community of practice so you really intimately know the psychologists in your area, the services that are available, and that you have a relationship with the other clinicians and other transectoral providers so that they know that they can discuss with you a difficult circumstance. And that why you’re creating a really good environment within your geographic radius, that everyone is working in the same direction, not just for that one child, but for all children. And finally, probably just to enjoy yourself in that consultation. Make sure you’re open, playful. And usually the answers will come to you when combined with all the sort of stuff that people like Emerging Minds are creating those skills of really assessing exactly what’s going on. But from a how does walking through time with a family as a GP goes, I would say that’s the take I’ve got on it.
Sophie Guy [00:21:08] Okay, great. Well that’s been a really useful and interesting conversation. So thank you very much for your time, Aaron.
Dr Aaron Chambers [00:21:15] Thanks for asking me. Sophie.
Narrator [00:21:18] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.