Transcript for
Supporting child mental health in general practice

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Sophie Guy [00:00:08] You’re with Sophie Guy, and today I’m speaking with Sara Whitburn about how GPs can support families and children in regards to child social and emotional wellbeing. Sarah is a GP in private practice in Melbourne who has a strong interest in women’s and children’s health. She is also a lactation consultant and has an interest in the early use of parenting.

[00:00:28] Sara, thank you very much for coming in today to talk with me. Really appreciate it. I wonder if you could just start by telling us a bit about your background and how you came to be interested in child mental health.

Sara Whitburn [00:00:39] Sure. So I knew I wanted to be a general practitioner when I was still training, and so I made sure that I did do a children’s term while I was in the hospital, and obviously that was heavily focussed on the physical but mental health always is part of our general health. So that’s probably the first time I got an inkling about the idea of both looking after mental and physical health for children. And then when I went into general practice, I was really interested in women’s and children’s health. And over time that led to an interest in early childhood, probably came around about the same time I had my own children and just found out how, how much of a struggle it can sometimes be to be a new mum with breastfeeding and sleeping, but also the wider picture of children and realised that this was something as a family doctor and a family person that was really important and I wanted to work in more.

Sophie Guy [00:01:37] How, how has your sort of training or expertise in that area developed?

Sara Whitburn [00:01:41] So I think I have done a lot more training in what I call parenting or even family dynamics. And I haven’t gone off and done a course, but obviously I try and stay up to date with resources that are available for families. I obviously make sure I read articles about child health and child mental health, and I’m very aware in my own practice trying to listen at the same time as I might be dealing with the acute problem. What else is going on for this family? What else is going on for that child? And I think I ask a lot more questions just about that child and that family and the people that are there and try and be a bit more focussed on that now.

Sophie Guy [00:02:21] Okay. So does that mean that I’m kind of jumping straight into the nuts and bolts of the realities, I suppose, of general practice, but does that mean that you, do practice in a slightly different way, do you think? Because to do that kind of work, it sounds like you would need to spend more time and perhaps have more consults with families?

Sara Whitburn [00:02:39] Yes, I think I do practice differently and these things do take more time. Sometimes it’s more about, though, realising you might only get little snippets each time, and that’s where the continuity of general practice and being in a community and opening yourself up to that you are there to see this family through a journey is really important because you may not have the time or the family may not be ready, but I think it’s a simple questions about, “how are you? And tell me about school?” And maybe just asking, “where are you off to now?” And just little snippets that might only be a minute or two, but you’re getting a picture of what’s going on, maybe just opening up doors for communications. So I think it’s the idea of being open to that and being holistic and thinking about the whole person and the whole family. Sometimes you do have to just file it away for the next time, but I think it’s thinking about the broader picture a little bit more.

Sophie Guy [00:03:35] And what are you looking out for when you’re faced with a parent or and you say, you know, that might come in with the acute stuff, but you’re looking for a bigger picture. What sort of things capture your attention in relation to child social and emotional wellbeing?

Sara Whitburn [00:03:47] I mean, I think the first thing is just how are the parents and the child interacting in the room? Does mum look flat? If mum looks flat? I might even just go, “how are you doing?” Or, “you seem a bit down today. How have things been going on?” I’ll be looking for, we know that if breastfeeding is a struggle that can be hard on mum and hard on the whole family, I might be asking about sleep. I might be asking about changes in the family structure. It’s not uncommon to find out that they might have been a change. You know, mum or dad might have changed who they’re living with or things might be difficult at school and just sort of trying to look for those things as, as we go through. I’ll definitely be looking at the child’s behaviour in my room and I always have toys. They tend to end up all over the clinic room, but it’s good to have toys and good to just see what the child’s interested in. That can give you a little idea. I mean, if if a child’s not sort of engaging or not playing with the toys or seems to be distant, so little, little cues like that, little clues.

Sophie Guy [00:04:48] And is this sort of way of practising, is that something that was taught? Was, did it come through in your training or is it something that you’ve sort of, it’s evolved for you?

Sara Whitburn [00:04:57] I don’t think it’s come through my training where there’s been a distinct class or a distinct course. I think it is watching other GPs who have an interest, I think, you know, as a registrar, obviously having your supervisor, if they’ve got any interest in child mental health or a colleague who’s got child mental health, it’s always good to see how they practice. It’s also good to be, to see how you practice, to see how things are going. So I think in registrar time, it’s really important to sort of see and mimic and role model those kind of things. And then it’s just I think if you’ve got an interest trying to learn more and it can be as simple as finding out what’s the local maternal child health nurse resources. Raising children website is one that is told to all parents and is really useful as a GP as well. You know what’s available, you know what’s available in the middle of the night when mum and dad is struggling. And through that, I’ve also jumped onto other online resources, which can be both a learning tool for me, for my practice, but for parents as well. So I’m thinking the Breastfeeding Association website. I’m thinking Royal Children’s Hospital here in Melbourne. But, you know, using your local children services, even some of the pediatrics websites. That’s the beauty of the internet now. But I also think that through general practice, through our own college, that there might be articles or there’s courses. So it’s, it’s saying, I’m really enjoying this. I’d like to learn a bit a little bit more, but also talking with parents and just asking about their experiences. And then I think that then grows and develops. And over time you start to feel more comfortable. And then over time, you might focus more on that. But I think even in when you’re starting out, just thinking about the family nature of what we do is GPs and that we get to see children, babies, adults, that this is our sphere and we can even just get to know those patients a little bit more.

Sophie Guy [00:06:52] Mm. Yeah. That brings me to the statistics that I sort of flagged with you before we met, which I think are really interesting that have come out this year. And one was the Health of the Nation report, which shows that eighty-eight percent of Australians see a GP at least once a year and eighty-four percent see a GP multiple times. And then also some work that was done in South Australia recently where they let the university into the Department of Child Protection to look through the records systematically and found that one in four children with twenty-five percent of children is the subject of a notification. And they’re not just small things, they’re really kind of notifications that warrant investigation. It sort of shows, I suppose, the unique position that general practice and primary care is in perhaps to intervene early. And I just wonder what you, how you feel about that and what you see as the role and the opportunities for general practice.

Sara Whitburn [00:07:46] Well, I think first, statistics say that we are part of the community and we are the family doctor in that idea of family practice. And so, therefore, I’m not surprised that we’re seeing people regularly and that people see us for at least one thing. Now, they may be coming for something completely different to what we might be talking about, but as I sort of alluded to in my previous answers, they don’t just come with that sore throat or that rash. You know, they are a child who has interest and that they’re part of the family. And I think we have the interactions, so that’s really important. But I think it also goes to a lot of topics that can be challenging, but need to be asked about. And I think the statistic you’re talking about with the one in four, I think we can bring that out to domestic violence and child mental health and other things that are often uncomfortable to talk about. That, it’s also about GPs asking the questions and having a question to ask that they feel comfortable with that might just be opening the door. You know, I think I know myself, it is a challenging area and it’s always something that you think about before you ask. But it may be as simple as just saying, “what’s happening at home?” And knowing to ask at least a question to be able to at least start the dialogue. And I think that that’s where those two statistics interplay. We are seeing people and we need to ask the questions.

Sophie Guy [00:09:15] So you gave one example, are there any other examples that you have with the kind of questions you might use to open up those conversations?

Sara Whitburn [00:09:21] So I might do a really broad question like that, but sometimes that might be a bit too broad or people might not feel comfortable talking. But I really like that idea of normalising the question, and I will often say, I always ask how things are at home because I’d like to know how you’re doing. Some people don’t feel safe at home and they find it hard to talk about. But it is a question that I ask everyone. And if you wanted to talk about it, we could. Or I might just say, “sometimes when people are feeling flat or down, they might be worried about hurting or harming themselves or others. Has that ever happened to you?” So making the question really normal. Not saying, “I’m asking you because of you”, but I ask everybody and this is the place to talk about it. So I find those questions really helpful. Sometimes it may just be, ” can you tell me more about that?” Or, you know, “you are free to tell me about that. Maybe this isn’t the time, but the door is always open.” And I think that’s the other strategy is to always have that little opening in the door, that little link, or, “I’d like to see you again. Do you feel comfortable making another appointment” or, “why don’t we make an appointment and see if you don’t need it? You can always cancel”, but just giving those little links because it may be that we’re not ready to talk about it. It also means you don’t. I know when I first started out these these topics are so overwhelming. They’re so important, but they are challenging. And it may be that you don’t feel comfortable really going into high detail, but you’re really happy to open a very, you know, ask a very open, broad question to at least get the dialogue going. And these little questions might be easier when you’re first starting out to try out.

[MUSIC]

Narrator [00:11:04] You’re listening to an Emerging Minds podcast.

Sophie Guy [00:11:09] What would you suggest or do you have any tips for GPs who perhaps don’t feel very confident asking these kind of questions?

Sara Whitburn [00:11:17] I think you’ve got to remember that, yes, we work in our clinics, in our room by ourselves, but we’re not alone. Even solo practitioners. I think it’s all about networking and I think it’s all about resources. It’s calling a friend. So if not in your own practice, a lot of us now are working group practices because that does help us bounce ideas off and have shared care and shared responsibility. So it may be as simple as talking to a colleague. A lot of the children’s hospitals will have teams or groups who are experienced in child mental health or child protection if you think that that’s also part of the care that’s needed. And they often will have telephone numbers. I think paediatricians, you may be in a town where you’ve got one pediatrician, but it’s worth networking and getting to know them. So I think it’s all about, you aren’t on your own and that it is okay to ask other people and that even if you ring to notify, sometimes you’re just talking things through. It is our job to at least bring it up. It’s not our job to investigate. I think that’s the other thing. It’s about just getting things out into the open. And finally, you know, I think there are lots of good resources. This is an area that’s really important. So I know the college at times will do, will have a statement, guidelines, they’ll have journal articles. The Department of Health will have information and things like that. So I think it’s about, what are my written resources? Who are my call of friends, making sure that you’re not on your own in the, in the larger sense.

Sophie Guy [00:12:51] Is part of that also giving yourself permission or it’s okay if it doesn’t go well sometimes?

Sara Whitburn [00:12:58] Yeah, I think so. We’re not perfect. Nobody’s perfect. And you don’t have to have the perfect question or the perfect referral. But what is helpful is to say, “but I can start this going and I can get help if I need to.” And I think even when you have a consult that may not have gone well, I think it’s having the confidence to actually say that a lot of things is about, “oh, I feel uncomfortable. I don’t want to say that.” And I’ve had consults where I think I’m managing it well and I can see the body language of the person in front of me shutting down. And I might even say, “I think I’ve upset you. I didn’t mean to upset you. Have I said something wrong? Can we talk about it”, if that doesn’t work I’d say, “look, I’ve really upset you, but I think this is really important. Perhaps you’d like to see one of my colleagues. Maybe they’d have a, a way that you would find more comfortable or maybe it’s just that we’re not the right fit for each other.” So I think it’s having confidence that it’s okay if things have to swap or change. It’s not about you, it might just be what’s the next step and where’s the next way to go? And and knowing that everybody has bad days and that it may just be that you need to reassess or get a friend in. And as you said, people come back. People keep coming to general practice. So I think it’s just taking a step back and and thinking about how can we manage this in the bigger picture. And it’s always okay to go talk it through with a friend.

Sophie Guy [00:14:29] Mm hmm. I think generally in sort of mental health, we often don’t respond until there’s a clear problem. You know, perhaps the parents come in with saying, “I think my child’s got X ADHD” or something. But of course, you know, there’s, we’re wanting particularly within Emerging Minds, I’m sure within general practice as well. You know, it’s very much about public health and wanting to intervene more early. How well do you think that’s going in general practice in terms of child social and emotional wellbeing or mental health? Are GPs having those conversations sort of early in the piece where they can perhaps see that things might not go so well down the line?

Sara Whitburn [00:15:09] I think it would be good if we could. I think that there are some barriers that can make it challenging in day to day practice. General practice is still a small business with time and financial constraints, and that’s always gonna be pushing up against longer consults or deeper consults. So I think that’s always a little bit of a push and pull. As I sort of said, I hope it’s more about putting little hooks in and then using perhaps repeat appointments and been thinking about, “okay, you’ve come in crisis. This is really getting on top of you. What do we need to do to get you through the next day or what do we need to get you through for the next week?” And then saying, “and once things have stabilised, then thinking about maybe having a longer appointment to really delve into details.” I think, you know, say mums come in with a child whose behaviours have got so challenging. We don’t have a diagnosis. Everybody, the child’s frustrated, mums’ frustrated. It may be, “okay, what’s the first thing we can do to make this easier? Is it that you want a referral so that you feel that something’s in place and so you get that done? And so now would you like to come back and talk about how we’re going to manage this or how are we gonna get you through until you get to the next appointment?” So I think it’s about bite-sized pieces and trying to just be open to these things and knowing that we do have the, we do have the ability that if we have a crisis, then we need to see people over time, we can try to arrange that, and trying not to do it all at once. But once again, it comes back to being happy to have it discussed, having a safe place. And if perhaps a doctor isn’t feeling comfortable to do that, sort of, you know, think about what I can manage this first acute crisis, but perhaps I’m not the right person or I don’t feel comfortable or it’s not my area of expertise. Then talking about, “who can we get you to see to make you feel more comfortable?” And so I think everyone should be asking the questions, but perhaps if people are more interested in child mental health, they then allow themselves to practise in a way where they’ve got longer appointments. And I know that’s what I’ve done. The trade-off might be that I don’t see as many people or I don’t feel as much, but because I’ve decided this is the area I want to do this, I’ve structured things in that way.

Sophie Guy [00:17:38] Is there anything in particular about this sort of what we’re talking about that you want that I haven’t sort of asked you?

Sara Whitburn [00:17:44] I think it’s really important that we at least think about child mental health to be aware of what the level of child mental health is out there at the moment. I know that anxiety is quite high amongst children. You know, there’s a lot of people who are concerned about how their children are processing things and I mean, thinking about autism or ADHD. I think it’s just saying, this is not an area that you have to be scared of doing. It may be that you don’t want to or don’t feel comfortable or it’s not your area of expertise where you might do longer appointments, where you’re really focussing in on child mental health is a strong clinical interest. But I think it’s about, you know, do you think about this as every time you see a child who’s coming in for a sore throat or a broken arm, maybe not in that moment, but what is this? What is this child’s interests? What’s their child’s family? How are they doing day to day? How do they seem in their mood to you? How does mum and dad seem in their mood? And I think it’s about encouraging people that even those first things about learning about their family and learning about how they might be feeling in their mental health helps you practice for the whole care of that person. And and it’s not something that should be overwhelming or scary.

Sophie Guy [00:18:57] You talked a bit about Raising Children Network and information resources that you’ve obviously familiarised yourself with a lot. Are there any other particular tools, do you use any particular screening tools or anything like that as part of this work?

Sara Whitburn [00:19:12] I use HEADSS a lot, which is where you look at home education. The ‘A’ can be for alcohol and drugs or it can be for anxiety or you know, ‘S’ for sexuality. And so it can, you do have to adapt at per age, and it may not be as useful for the very young children, but I’ve used it for primary school children to sort of get a picture of what’s going on. I do use the PandaScore for mums with young babies because that gives me a sense of how mum’s mental health is, which might then give me a sense of what baby’s mental health is. I don’t particularly do screening, but there is screening for developmental concerns. I know that there are screening resources out there and I think that they can be really useful. I tend to just describe behaviour in the big areas like gross motor, fine motor, social and language and kind of be more descriptive. I haven’t sort of used depression, anxiety on children, I kind of tend to use the HEADSS to get a feature of what’s going on, but there’s there are scales like that available. So, so I use those. I mean, a lot of the resources I use is about supporting mental health in the home, so maybe I’m talking about resilience or parenting and looking at the, trying to support positive mental health or trying to support mental health in times when, which are really normal changes like changing school, friendship sort of challenges, because these are all really important, but these are things that maybe we can port in a more resilient way. And Raising Children is really good. I really find things that are coming from the Children’s Hospital, yes, useful. There’s a, one called I Cope, which is good for mums in the early stages of parenting. And a lot of books and parenting books and things like that, trying to find things that are supportive for parents and getting into a little bit more of what’s called bibliotherapy or try to, trying to have good evidence-based books that can help mum and dad or even children. Thinking of one could Stop ANTS which is about anxiety and intrusive thoughts, which is quite good for children. So, yeah, and it helps me too, I read these and I can think about it as a parent and I can think about it as someone supporting parents. And I have two children of my own and I can try it out on my children and see what they think. So I think I think resources are important. It’s that in the middle of the night or home from school, what are ways to support the families until they can come and get some help? And as you said, often come in crisis and need something to get them through that day or that week until we can start to perhaps put things in a bit of a slower pace.

Sophie Guy [00:21:56] So it sounds like you are working from kind of a resilience framework and are you sort of introducing these things also when things are going okay and there’s not the obvious signs that things are necessarily going wrong. Is that part of how you practice?

Sara Whitburn [00:22:10] I mean, I’m very lucky. I have slightly longer appointments and I’ve got a strong interest, so I’m probably asking kids all the questions that they just want to get out and get home. And I’m like, “what are you doing and what are you interested in and how are things?” [Mm hmm] But yeah, I think what would be lovely in general practice is to also think about, as you said, public health or I think of it as preventative or even supportive mental health, both for natural life changes. I don’t want to over medicalise what can be challenging situations, but can be overcome with support and resilience perhaps, or mindfulness. But yeah, I do talk about it. As you said, often I’m there when things are wobbly and hopefully we can get things back on track. But I do ask and if we’re talking about school, I say, “how’s school and what’s helping?” These are these little questions, I might only have my short appointment, “just to continue that idea of continuity. And I want to know about you and I want to know your whole health.” And but as I said, I’m very lucky that I can practice in a way where I might just have a little bit more time where I can throw these questions in. So maybe if people are interested in this area, it’s about that balance of time availability, but also doing the work that they feel is is enjoyable and helpful.

Sophie Guy [00:23:28] Well, I feel like we’ve asked the good range of questions and covered a good range of areas. So perhaps we’ll leave it there. Thank you so much, Sara, I really appreciate your time.

Sara Whitburn [00:23:38] You’re welcome.

Sophie Guy [00:23:39] It’s been an interesting conversation. Thank you.

Sara Whitburn [00:23:41] Thank you.

Narrator [00:23:43] Visit our website 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.