The future of child and adolescent psychiatry - a medical student’s perspective
Special note from the editors: This is the third blog of our new series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.
As a medical student soon to be beginning my clinical years of study, the world is still very much my oyster in terms of choosing a career path. I am certain, however, that my passion for child mental health will influence my journey in some shape or form.
I have worked with many children and young people with mental health difficulties in my part-time job, both before and during medical school. What has really struck me when working with these children and their families is their vastly different experiences of getting support from child and adolescent mental health services (CAMHS).
Some families have had relatively straightforward interactions with CAMHS, whereas others felt that they couldn’t get appropriate support with their child’s condition and had no choice but to turn to private services. Equalising disparities in accessing and experiencing help from CAMHS is something I really feel strongly about; children with mental health difficulties should not face a postcode lottery when they need help.
Having recently been appointed as one of the Royal College of Psychiatrists’ ‘Psych Stars’ for this academic year, I am keen to take full advantage of the mentorship, learning and funding opportunities offered by this scheme in order to further explore a career in child and adolescent psychiatry.
For now, as a potential child and adolescent psychiatrist of the future, I share my thoughts on what I believe child and adolescent mental health and service provision will look like in the years to come.
Children and the coronavirus — a match made in hell?
At present, there is one thing on every healthcare professional’s mind: the coronavirus pandemic. In addition to the physical symptoms, which are still not fully understood, there is emerging evidence describing COVID-related neuropsychiatric symptoms. This means that people are experiencing new symptoms of a mental health disorder as a result of the brain being infected with the virus.
In children, it appears that encephalitis (inflammation of the brain) and seizures can occur as a result of being infected with the coronavirus. Although COVID-encephalitis cases seem to be rare, encephalitis can cause serious damage to the brain, resulting in complications such as personality and behavioural changes.
This draws parallels with a similar group of pathologies, Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS). PANDAS is suspected when children suddenly develop obsessive-compulsive disorder (OCD) or tic disorder following a streptococcal infection (a type of bacterial infection) such as scarlet fever.
It is not yet known whether encephalitis related to coronavirus could trigger an autoimmune attack on the brain, and replicate symptoms of PANDAS. Concern has also been expressed that coronavirus infection in children with pre-existing PANDAS could severely worsen tics and symptoms of OCD.
The complexity of these issues is further confounded by the fact that there is debate within the scientific and medical community as to whether PANDAS actually exists. PANDAS onset, symptoms, and their responses to treatment can be extremely varied, and so some clinicians are uncomfortable with accepting PANDAS as a formal diagnosis. This could prevent some children from getting the help they need.
It is therefore critical that investigating coronavirus-related neuropsychiatric conditions in children becomes a research priority, especially when planning for future service provision. Child and adolescent psychiatrists should be upskilled in accordance with the outcomes of this research, in preparation for a potential influx of new neuropsychiatric presentations in children following the pandemic.
As well as the physiological effects of the coronavirus, the accompanying lockdown has thrown the psychological wellbeing of children and young people wildly off balance.
Closure of schools has meant that routine has been disrupted, and children have been isolated from their peers and teachers. Loneliness and social isolation have been shown to negatively impact children’s mental health, with the correlation between duration of loneliness and worse outcomes being particularly alarming, given the nature of the lockdown.
For some children, school is also unfortunately their only escape from unstable home environments. Decreased contact with teachers and support services during the pandemic means it is much more difficult to monitor the wellbeing of children, especially those who have already been identified to be at risk.
Lockdown will also have put a strain on relationships within families that weren’t previously at risk. It is unfortunately very likely that some children will have suffered abuse during the lockdown, and it is therefore imperative that these children are identified and supported as soon as possible.
The Royal College of Psychiatrists recently expressed concern regarding widespread and inappropriate media coverage of people gaining weight during the lockdown. Such reports have led to young people with eating disorders relapsing and rapidly losing weight, and presenting to hospital having become very unwell as a result.
Recent initiatives to combat obesity are hot in conversation at the moment, but have also been argued to be a potential risk to young people’s relationships with food. Eating disorder support charities such as BeatED have criticised proposed actions such as presenting calorie counts on menus, as it could harm people suffering from eating disorders by encouraging them to eat less.
Not everyone is critical of such efforts, others argue that these actions are important for many.
Referrals to CAMHS have also decreased considerably during the pandemic, meaning children and young people might not be accessing the help they need. Identifying and supporting those who have slipped between the cracks during the pandemic should be absolutely paramount.
It is likely that children and young people will be reeling from the effects of lockdown for quite some time when things return to ‘normal’, so picking up the pieces will be a key role for child and adolescent psychiatrists in the near future.
But there are positive lessons from the pandemic
It’s not all bad news, though.
Entirely to the contrary, there are children and families who have thrived during the lockdown, proving that there are lessons to be learned from the positive experiences as well as the negative ones.
Enforced infection control strategies such as social distancing and travel restrictions have assisted a drastic improvement in health for children with immunodeficiencies. This reduced contact with the ‘outside world’ has meant less opportunity for contracting infections, meaning that these children are spending more time in good health.
This has in turn boosted mental wellbeing within this group, which could mean that there is scope for mental health professionals to advocate for alternative learning arrangements for some young people (e.g., more learning from home where appropriate) in order to promote their physical health, and in turn, their mental health.
With a large proportion of the working population furloughed or working from home due to the pandemic, parents and caregivers are also spending considerably more time at home with their children. This has been a lifeline for some children with conditions such as autism or learning disabilities.
Some parents have had more time to dedicate to helping their children with learning and activities to support their development, which in many cases is helping these children progress considerably. Reaching these educational and socioemotional milestones is bound to have a positive impact on the mental health of not only the children themselves, but their parents too.
This again shows that child and adolescent psychiatrists could play a role in ensuring that these children receive appropriate support within school, but also with their wider development.
This could be done in many ways such as 1:1 support with learning, a modified school day, and increased parental support with activities where possible.
The negative impact of social media on the mental health of children and young people is already widely documented and has been explored in an earlier InSPIre the Mind blog. Whilst it is easy to criticise social media, lockdown has allowed us to see the potential benefits of the interconnectedness it brings.
Social media platforms of all kinds have allowed young people to keep in touch with each other and their families during the lockdown, thus easing loneliness in otherwise incredibly isolating circumstances.
Young people are being kinder to each other on social media, with anecdotal reports of less cyberbullying. It is disappointing that it has taken a pandemic to drive this change, but encouraging nonetheless to see that young people are viewing life through a different lens.
The merits of technology have also been harnessed and used in service delivery. Running appointments over the telephone or via video call software has proven to be, in some cases, acceptable alternatives to face-to-face appointments during the pandemic.
The flexibility and improved accessibility afforded by these methods could mean that virtual appointments are here to stay, especially for people who have conditions that make leaving their homes difficult, or for those who have to travel a significant distance. Despite these benefits, many people will still prefer face-to-face appointments and so these should still form a large part of service delivery where possible.
Moving forward from the coronavirus pandemic will inevitably form a major part of the future of child and adolescent psychiatry, with meticulous planning needed in order to ensure that service provision meets the changing needs of children and young people.
The realities of resourcing CAMHS
When considering the future of child and adolescent mental health services, it is important to not only consider the population that needs serving, but also the resources available to provide this service.
CAMHS is chronically underfunded, and psychiatry training posts across the board are undersubscribed.
There’s an old adage in medicine that ‘prevention is better than a cure’, which is absolutely true, until you realise you physically do not have the resources to provide preventative services. CAMHS funding has decreased by almost £50 million since 2010, and currently only comprises 6.7% of all mental health spending.
This has led CAMHS to take a largely reactive approach to child mental health crises and treat them as they occur, rather than being proactive and able to prevent these crises to begin with. This means that children and young people with severe mental health difficulties are understandably prioritised, but it leaves hordes of young people with emerging mental health difficulties without the help they need.
It would be naive to think that the ‘magic funding fairy’ will solve all of the problems faced by CAMHS, but more funding would certainly go a long way in helping to turn current service provision on its head and put the emphasis on prevention.
More funding would hopefully also allow more local mental health beds to be secured, so children and young people won’t have to travel so far from home for specialist inpatient care.
Traditionally, psychiatry has been one of the least popular choices of medical specialty for trainees. This could be for a number of reasons, such as the perception that psychiatry ‘isn’t medical’, or the fact that our understanding of mental health has been historically poor when compared with physical health. Whilst perceptions are currently changing in the right direction, we still have a long way to go in order to raise the profile of a career in psychiatry and mental health.
Changing the psychiatry training pathway is showing great potential to attract more trainees to the profession. ‘Run-through’ posts allow trainees to spend the entirety of their psychiatry training in their subspeciality of choice (like child and adolescent psychiatry), rather than spending three years in core psychiatry training and then picking a subspecialty later on.
Applications to train in child and adolescent psychiatry through these newer run-through posts were significantly higher than applications to train via the traditional route in 2019. This could mean that increasing run through training places both for child and adolescent psychiatry and other psychiatric subspecialties could go some way in increasing recruitment.
Initiatives such as less-than-full-time (LTFT) training, or out-of-programme opportunities, are also making psychiatry a more desirable specialty.
LTFT training does what it says on the tin, and affords trainees greater flexibility with having children or other responsibilities outside of clinical work.
Out-of-programme opportunities allows trainees to take time out of training and pursue other interests such as research, working abroad, or teaching. These opportunities should be advertised more heavily to prospective trainees.
The Royal College of Psychiatrists’ ‘Choose Psychiatry’ campaign recently celebrated an incredible success, with 99.4% of core psychiatry training posts being filled for 2020 intake. As current PsychStars and future psychiatrists, we in turn need to engage with and inspire the next generation of budding psychiatrists in order to support them and attract them to the profession.
Into the unknown: child mental health research
Finally, a crucial part of planning for the future is evaluating what we know and where the gaps in our knowledge lie. Research in child psychiatry is rapidly developing as we continue to explore the complex interplay of neuroscience, psychology and sociology in shaping the mental health of young people.
Adverse childhood experiences (ACEs) and their strong correlation with poor mental health in later life is an area of research that has gained increasing traction since the 1990s. There are ten recognised ACEs and they are broadly categorised into abuse, neglect, and household dysfunction (see image below).
This previous InSPIre the Mind blog explores ACEs in more detail.
Whilst it is too late to prevent mental health problems in the now-adults that were studied in past research on ACEs, a better understanding of ACEs will allow for the development of preventative strategies to be implemented for children in the future.
Professionals like teachers, who have lots of contact with children, already have a role in safeguarding children, but they could be trained specifically in recognising and referring children that may be at risk of ACEs. Child and adolescent psychiatrists, with the help of other teams such as social services, can then provide an early and sustained intervention in order to mitigate effects of the ACEs and give the children the best possible chance of a ‘normal’ life.
The processes and criteria for diagnosing for mental health disorders in children need to be scrutinised and reviewed more regularly in order to ensure that diagnoses are made in a timely and appropriate manner. This will help children with mental health difficulties receive early intervention and support tailored to their needs, but also ensure that we are not pathologising what are essentially just variants of ‘normal’ childhood behaviour.
Child and adolescent psychiatrists will have a role in auditing services, so that the diagnostic processes are accurate and lead to good patient outcomes, rather than over-diagnosing children and potentially causing them harm as a result.
Despite their general effectiveness, more research into the use of mental-state altering (psychotropic) medications in children with mental health difficulties is also needed; they are often a last resort due to their side effect profiles. The issues surrounding these medications need to be further explored in order to support a change in the system, for example by developing new and hopefully safer medications for future use, or through more robust education for caregivers on the risk and benefits for their children.
Overall, the future of child and adolescent psychiatry looks to be very dynamic and rapidly evolving, and I am very much excited to be a part of it.
It is clear that mental health services will face many challenges in the years to come, especially in the wake of the coronavirus pandemic, but I am confident that the future of psychiatry lies in safe hands.
NOTE FROM THE EDITORS: If you enjoyed today’s blog by Emily, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion and the mind-body interaction.