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eight to eat. Lovely to meet meeting. So we Yeah, just the recording. Ok, lovely to meet you all. Um, and I'm here to hopefully introduce you into how to do a child psychiatry interview. And what factors to consider when you've got a child presenting with mental health problems. Um, and how to formulate, um, the issues in the context of their family. Um, Okay, So the idea of this session is to define what is meant by systemic thinking to discuss how the family, um, well, influence mental health problems. Um, describe how parental mental illness and divorce might have an impact and for any particular case, help you to understand how to list ideological factors that may contribute either to a disorder or two resilient factors. Um, and organize these in terms of the child, the family and their environment, and then predisposing, precipitating a protective and perpetuating factors. So all the peas, um, and using the examples explain how contributing factors can be targeted by intervention and to outline the principles of family therapy. And when it's indicated, um, can everyone hear me? Is there any problems hearing me? Austin, can you hear me? The audio is fine. OK, great. Thank you. Okay. So So the idea is to minimize what contributes to a young person presenting and to enhance what they have within themselves and within their families, system and circumstances to allow for protective factors to work their best. Therefore, you need to know what these are. Okay, So many factors could be contributing to mental health disorder, and it's useful to think of it in a systematic way. So, um, that means, um in an ordered way within how it affects the individual and those in their environment and then systematically, um, in a rational way. So think about to what degree? So systematic thinking. So a good grid for you when you see a young person. And actually, this is really good for any psychiatry patient, which, by the way, for child psychiatry the majority will present to their GPS. And 90% of this work is done by GPS. So, um, I think it's difficult to avoid being involved in some way. Um, no matter what area of medicine you land up in may be old age, you would probably never end up having to think too much about young people. But even in the old age, you would need to be thinking about what is contributing to their circumstances. So we use the four p's and we think about what what happened before they presented that made them at risk. Be it genetic bit personality bit, um, family circumstances. Then we want to know why have they presented today or whenever it is that they presented what is keeping it going. So why have they continue to have a problem way beyond when the precipitating factor make might have begun like, let's say, the loss of a family relative. Why is there still a problem two years later? And what sort of things are helping them and making them resilient? I think this is really important that we often forget this. So I think if we think of things in terms of an onion ring, um, then we can think about the young person in the middle there, family around them, uh, the circumstances of that family, um, in their immediate sense. So the parents, working or not working the school situation and their peers, and then we want to know about their local community. So, um, do they have a faith. Is the faith a supportive factor or not? A supportive factor? And it's interesting when I've seen young people who've been very psychotic. Often the flavor of their psychosis is related to do these factors. So very religious person might be worried about being punished by God because of something that they've done. So the hallucinations may come most in that way, so they definitely flavor their circumstances. Obviously, war is going to have a huge impact. And, um, the national system. Okay, so, um, this kind of gives it to you more detail. I can't actually overemphasized bullying. Bullying is a real big problem for young people. And I guess some of you here today may have experienced it. Um, and that definitely has a big effect on their mental health as well. As, um, sexuality can also have quite a big impact. Okay. And these might be the protective factors. So once again, um, you know, having a resilient personality. So when I was working on the wards with young people who had had terrible things happen to them, let's say they've been the consequence of a fire or something. Um, if they had come from a family that's very supportive where everyone gathers around. Um, that really can help, um, and a lot to be said for these sort of community supports. And then, of course, there's national charities and law and policy that can have a beneficial and not so beneficial. So, uh, evaluate all these factors that might be contributing and therefore potential targets of interventions. The different psychiatric disorders have different ideological risk factors. Um, though there is overlap. So whatever the disorder, um, these different factors may overlap. So God forbid, you know, child abuse leads to just about every kind of mental health disorder, whereas there may be other factors that might be more specific. Let's say a trauma is more likely to lead to PTSD, for instance, and not all factors will be operating for any one particular case. Therefore, you need to check which ones okay, and then it's also important to understand what it means to the family. So, for instance, when I was working at one of our big teaching hospitals here in England, um uh, they there was sort of exorcism kind of thing that would happen in, uh, places of worship. As a result, of, uh, means of helping get rid of evil spirits. Um, so I did have a young person who was in quite a lot of difficulty, shall we say, And I did invite the healer in, um, and as long as he didn't, you know, put hands upon this young person and we were present, um, so as to be alongside their cultural beliefs that obviously do no harm. So, um, some Children, the following clip have mental health problems. Um, this is probably before most of your time. It's called shameless. And, um, it indicates what we might consider a dysfunctional system. Um, so this system is not working very well. Um, and it was actually a comedy, though one could, depending on your perspective, whether you consider this a comedy or not. But this is a good way to illustrate, without having to show you families that obviously I can't share with you because of confidentiality. So I'd like you to think all of you and I will ask you what you think are the contributing factors in this example. Um, for the individual family and environment that has led to their difficulties or could lead to difficulties Okay, now nobody's saying the chats with the state as the Garden of Eden. At least I don't think they are. But it's been a good home to us, to me. Thank Calendar and my kids, who I'm proud of because every single one of them reminds me a little of no, no. They can all think for themselves, which they've means. Thankful. Fiona, who's big help? Massive lip, Who's a bit of a gob shite. Which is why nobody called in Philip here a lot like his mom, which is handy for the others because she's disappear into thin air and good luck to her. Cal. We don't let him grow his air. One. It stands on him that makes him look like Sawyer to Nick's Love him. Debit Temp. I God, Salt Angel. You have to check. Your chain should go miles out of the way to do him a favor. Roughly a little rock and roller. Want to be a star? No. Once you've got the fits under control, you know we sleaze things might need 2.5 decent community space. You need wide open spaces wherever one of those men or enabling you know fantastic name. Kevin. Veronica Lungey Anything? Well, no. Anything for all of them to a man. Know, first and foremost, one of the most vital necessities in this line is they know how to throw a pack school. Okay. Can people shout out what they think Our family factors that will It will influence the child's mental health in a young person living in these circumstances. Maybe maybe, uh, alcohol abuse or drug abuse. Lovely. What? What kind of thing do you think that could lead to? It can lead to charge Children, alcohol abuse and drug abuse. And also too, like some psychological disorders connected to that as well. Brilliant. OK, great. Have you Would you like to guess what kind of psychological disorders it could lead to? And I appreciate this is a guess. That's fine. Uh, I don't know. Maybe addiction. Is it psychological addiction? Yeah. You could call that. Yep. That is, there's psychological and physical addiction. So it's both Yep. Good. Um, okay. Anyone else can from this this setting, think of what you'd be concerned about. Maybe some forms of depression. Yeah, Yeah, Anything in the circumstances, though, that you would would think would be a bad influence on young people living in this environment. Uh, maybe issues connected to anxiety. Okay. Yeah, Yeah. The future might be uncertain. Yeah. Anything else? Was anything disturbed about this environment that you noticed? Well, it looks like it's not really welcoming for Children. Yeah. Okay. What? What would you say? Yeah, um, and it's, um I see the lack of care. Yeah. Yep. So lack of care. Um, okay. Good. Um, one could call it criminality. Would you say, Would you be concerned about criminality in this situation? You know, because of arson? Yeah. Arson. Getting into trouble with the law. Unemployment neglects probably. Yep. So you need to think of all these factors, and they will have an influence both on the ability of the parents to be able to care. Um, there's likely to be kids not attending school. Um, you know, so I haven't got the protective factors of school. Um, there may be poverty, so there may be issues around. Um, good nutrition. Yep. There could be pregnant moms who might be using drugs or alcohol that has a huge impact on the unborn foetus. All right. Thinking about hazards around them Yeah. Okay. So when we're thinking about biological processes, we need to think of genes. So genetic factors and really all of psychiatric disorders, even anorexia nervosa have been shown to have an influence on, uh, the genes and influence on the illnesses. Anxiety is probably the highest. Um, um autism, psychosis, Um, bipolar disorder for instances, very genetic. So you need to always ask about a family history in the family. Um, and a d h d. I would say Invariably, there'll be someone in the family pretty close family who've got a d h d. Even if it hasn't been diagnosed. Um, and then exposure to hazards like we just saw, such as alcohol and drugs. Um, the availability of things by which they can harm themselves. Obviously, that would have an impact in the suicidal young person. Um, and then there's psychological processes. So we're thinking biologic, biological, psychological and social for each domain. So at the moment when the family domain and we've just gone through biological, now we're going through psychological. So things that alcohol and drug use have both genetic causes. But also, if it's around them and there's availability that would we would consider that a psychological process that wouldn't really get too worked up about where they fit in as long as you don't forget these factors. So the law, um, and boundaries will have an influence on whether a young person is breaking it. The law, whether the kid is attending school or not, Does anyone know the difference between truancy and school refusal? Can you shout out if you know the difference between truancy and school refusal? Yeah, and the person who's raised their house on hand, I'm not sure. Just shout out. Well, perhaps, uh, currency is something about even the lesson to school and still refusing it Just, uh, the fact that the person, uh, shoutout she or he doesn't want to attend school. So if you Hytrin, you just try to hide the fact that you apply insurance. In fact, if you refuse to go to school, you just, uh, say directly. Yeah, I didn't quite hear the end, but you From what I hear, you've got it exactly right. A current person will leave home but not turn up in school or leave school once they've arrived. So the parents often don't know, and a school refuse ER, which is generally an anxiety problem. The child won't even leave home, so the parents know that the kids are not turning up at school insurance. The kids, uh, it's often a sort of behavioral conduct disorder kind of thing. They tend not to be anxious. Um, it's more. I wouldn't like to use the word delinquent because delinquent is basically when you break the law, but it's more like of a conduct, So a disordered behavior. Um, okay, other person's eating disorder. So if a young person sees their mothers constantly on diets for instances, they're more likely to think about darting, Um, or if they get negative remarks, um, about their shape, that can influence, um, an eating disorder. So we'd consider that psychological process. Um, and then the attachment's so poor. Early attachment may influence the child's self esteem, which can lead onto a whole load of disorders. And attachment is basically how the young person attaches to the caregiver. So it's the relationship of the young person to the carer. Bonding is the other way around. It's the relationship of the parent to the child, So it's how how the parent bonds to the child, you need both in place. Obviously, um, and attachment really kind of becomes to the four from around nine months. So that's why when you send your child off to nursery, um, and it's after nine months, it could take them a while to settle, because that's when they get anxiety, stranger anxiety. Whereas if you send them off before nine months, as my neighbor did, I found out just today she sent her kid off 8.5 months, and she's had no problems settling the child down. I'm not saying that's good or bad, because attachment is there so that your parents, you know, to stop your parents wandering off. Basically, you need your parents close to you. Um, okay, and then psychological processes. Number three would be expense of parenting. So whether there's discord, abused, parental illness, loss over protection or under protection, those kind of things and then we've got parental Mental illness obviously has an impact, but it's good to know that most as long as you've, uh, the parents, you can have a psychiatric disorder and still be a great, great parent. So really, it's it's important to think of the impact on the child, and the main questions to think about is as winner cop would say it. Are you a good enough parent? So no one's going to be perfect, whatever that means. And let's face it, you have to change your parenting styles depending on your child. But are you good enough and responsive? And, um, or are you putting your child at risks in the extreme like neglect or danger? Are symptoms distressing for the child? And how is the relationship between parents and child and someone called Irvin Yalom? Um, did this, uh, this brilliant, um, study where he looked at? You know how many attachments they actually need? A young person. He followed people up over decades, and he found that, actually, you don't need lots of attachment figures. And the attachment figure actually doesn't have to be the mother. It can be the father. It can be a sibling. It can be a teacher. It can be a very close friend. So, you know, don't think it has to be the mother. And what support resilience has a child to cope? Um, all right, so the following clip is a study that was done by one of my colleagues, Um, and he interviewed Children about what it was like to live with a parent who has mental health problems. And I think this video demonstrates very well what it's like. So I want you to look at this, and I will ask you questions afterwards. So please look and look and think, right? What do you think he would have seen? I don't know. I think it's very strange, actually. Mental honest, because I think somehow, even though it's not, you know, I mean, it's certainly not within. You can't control. It's certainly not controllable. I think that if you have Children somehow, you control it to a greater extent around your Children. Do you remember when she went into hospital? Kind of. So we're very worried about. Yeah. What did you think would happen to her in the hospital? She might deal with the worst. Uh where, sir? Then what would happen? You haven't me to. Maybe so. Ricky was worried that hospital might make his mother worse and he might catch it. The illness. His mother, Kate, showed how most parents will struggle to protect their Children from the effects of their mental illness. But as you will hear from some other young people, they do not always manage this. Ricky was only six, but Matthew, as well as Shane and Sabrina, the next young people you will meet. I've lived through these and other worries for much of their childhood. When a child visits on award award is not always a very calm place. Someone could be thrown a major wobbler, you know, and for a child to come into that sort of atmosphere, it's not good for him. The nurses don't deal with them properly, either. They don't explain what the parents seem for. So the child's coming to award where they're saying, Oh my God, what's going on here? There's all these crazy people running around, screaming and shouting. You know hell's going on, does math, you know when you're about to get Yeah, I mean, does you know who to ring like, Well, I've given this numbers. You have? Yeah, and has he had permission from you to ring up when I was sure about because I don't get your section because it doesn't matter. It's a different question, but he knows I'm not very well at the moment. you know, being very protective. He, like, goes Oh, I don't want to know and is too upset in or whatever, but I feel he does need to know. Now he's got to understand why his mom keeps getting sick. I was just talking to your mom, and she was telling me about the time when she was in hospital. And, you know, when she was made to go in compulsorily and she do you remember what she was like in that? Very depressed? She said she was a bit more than depressed. I don't remember what she just did. You don't remember? We don't want to remember. Just don't remember. Okay, Anything I remember when she tried rescue and frozen chicken, something roughly was Harry the police that off They didn't arrest. Then he just tried to come home. They didn't measure. It did arrest me, did they? Yeah. I told you that she was made to go to hospital at Yeah, now. She wanted to see you. Even though she was in the hospital. Mhm. And the hospital people thought she shouldn't see you because it might be bad for a boy of your age. I suppose you were letting them to come up and see his mum in that state. But do you think they were right to say it's best for Matthew? Not to see if mom and she's very upset? No, that's wrong, Actually, could seeing me could have cheered up a little bit. I got to take them to a private room or something. But no, I didn't. I'm angry now. So Matthew was worried about his mother's illness and find it difficult to think about. He was worried about the hospital and wants a safe place, a private room where he could see her. And even though matches wish to see his mother in hospital, was to make her feel better. It still may help him to feel better, as it may make him less worried about her, who looks after her at home. Mama. Well, my mom looks after us, and we'll look after my mom when you were growing up, Did you think that it was normal? What was happening two months? Stone? Uh, you always told him something wrong. What did you think is wrong? Just the way he shouted. It's not normal. Sometimes I do like sometimes she talks a lot, and that doesn't make sense sometimes. So it's not normal. And you can just tell in her physical appearance that she doesn't look correct. She doesn't look. Sometimes she goes darker. She doesn't sleep in the night. And in that she's awake. She's going out. She does like things you wouldn't normally do. It's weird. Did it used to scare you? No. It did. Because, like, I remember once, um, I was home on my own with her when she was ill because my sister had to go somewhere, and I was really scared I was, because normally I was sleep with her on her bed with her. But just you want Sabrina? Uh, while spring bring the headroom because, like, I can't leave her, and I don't sleep on that. So I would normally sleep well, but sorry. Why can't you leave? Because Because I don't want to feel alone. That's why you've got to sleep with Mom. Because you don't owe me or Sabrina. One of you has got to sleep. Yeah, and she woke up in the night. She, like, was waking me up and was going out. I was really scared. And she called ambulance and stuff like that. Sabrina, She needs older sisters. 16. Why? She described what she saw happening to their mother. Sabrina adds more about the effects on herself and on her own life. Like I don't fit in. I do feel that cause, like, a lot of my friends that I get along well with I don't, you know, older people. I don't I do feel that. But that that was was always there because of what was like, yeah, before. So even like when you came here tonight, you thought you'd fit in better with the adults. That with the kids? Yeah. Is there anything good about your mom's illness that's been good for you in any way? Sound bad to say? But I think it's made me I think, Really, um a better person. Like I look at life and appreciate I appreciate now my mom as well, I I appreciate my mom and I've had to grow up more. What? I think that makes me sensible. Really? I don't know. Probably does look good of it. Would you know what to look for? I mean, supposing she was about to become ill again, Would you know what to look for. That would kind of be a sign that would make you say, Hey, I better call the doctor or something. She always talking to massage her head. She was talking to massage head whenever she's doing ill. So if she asked her to massage ahead using that's a sign. That's a sign. Did you miss not fitting in with other kids? Yeah, I do. I did. You ever try to change it? Yeah. Yeah. I find it's funny because, like when? Yeah, well, I when I when I tried to fit in with my other you act like a child. Absolute child. It's just two different. You feel too silly or yeah, I just go through. It acts so silly. Yeah, it's like two different people. Is it that you can't act silly because it seems so silly? Or that you would you do act silly and then you don't like it? No, it's not that I don't. Well, maybe I don't have the opportunity to until this project. Really? I didn't. I felt different from everyone else. Even like when I'm going through things like this. Even not necessarily necessarily that my friends project meal I just felt away from people they need, like social activities like this and also like continent. But we that that's something that I didn't want well, but I think it's better when to prevent it. But I was when at the time I kept inside me crying and move like that. What you did feel really societal. Okay, I think that's quite a powerful, um, video of what it's like to live with an adult with mental health problems. Um, can I just have a couple of comments from you guys as to what struck you about this? What you learned from having watched this Anyone Can I show you? Maybe I would want to say that First of all, we have to consider what our patient and their Children want themselves. Because, for example, that little boy he wanted to see his mom even though health workers they was unsure. If it's right, that's a beautiful remark. Absolutely beautiful remark, because we assume that coming on to, um, an adult inpatient unit would be very traumatizing. But if done well for him, that would be reassuring, because I guess he worries. Yeah, and then I don't know if you noticed that one of them said, boy, I'd catch it. So, you know, also education of the young person that you can't catch mental health problems by being around people who've got it. It's not like covid, for instance. Great. Thank you. That's so. But But also, maybe sometimes it's better to isolate the caregiver from the child. Okay, So the other from the other hand point of view? Yeah. What? Because you think it's too frightening for them? Yeah. It can be a very disturbing factor for the Children's, uh, psychology. Yeah, that's true. But the question the question is whether you take them away every time they become unwell. It is quite a delicate balance, isn't it? Knowing when to intervene? You know, it's not a static process, I guess. You know, as you could. I mean, in in, in, in the clip friends. And she was quite well, even though she said she wasn't actually that well, but she didn't appear psychotic, did she? Yeah. Yeah. Okay. Thank you. That's very helpful. Thank you. Okay. Okay. Um and then we've also got to think of So we used to do parenting groups. I'm sure they still do parenting groups. But I used to be involved in parenting groups, um, for kids who had a d, h. D or behavioral problems. And, um, we took the mood the parents mood pre the parenting group and after the parenting group, and we did nothing to manage their mood. It was purely to help them cope with having a child with a D h D or ASD autistic spectrum or whatever. Um, and we noticed that their depression improved just by getting support of the group, um, in, you know, giving tips how to parent kids with behavioral problems so it can be a chicken and the egg where Mum's depression can lead to problems. But also the kids problems can lead to depression. Okay, another thing we need to think about is expressed emotion, so things like bipolar disorder and even things like anorexia are influenced by expressed emotion. So things like over emotional involvement or high level of criticism and little warmth, um, can trigger relapses in young people with schizophrenia or bipolar disorder. Um and um, high levels of criticism can lead to depression and a young person with low levels of warmth linking to anorexia these are trends, Okay? So don't don't. None of these things are definite, you know, in a particular circumstance. Okay? Other social pressures, pressures will be things like adversity such as unemployment, financial problems, isolation, migration, war, um, and cultural influences. Um, such as, um extended family, for instance. I had a young person had an eating disorder and we had to involve the maternal grandma who was living with them because every decision that was made in that family was made by the maternal grandmother. So, you know, depending on the culture, there would be different people who have different influences, and it's very important to involve them in conversations around how to help a young person and their family. So knowing who's got the authority in this family, I guess in some families, the child may have the authority, which, of course, is not great. And you want to bring it back to the parents having authority. Okay, Another factor, But not really by no means, um, always an issue marriage and divorce. So we now have a situation in the UK with 2.9 million, um, divorces and, uh, sorry, 2.9 million, um, families operating as in a lone parent situation. So it's around 15% of the population are in families with a single parent. So the risk may include, um, these ones that I'm showing you but may not. But these are the things you need to think about. Um, but you should also remember that if you're in a very warring situation with parents who are not getting on and it's very unpleasant, they are better off separated. So problems seen post divorce, maybe by B mediated by sub optimal parenting of disorganization. Um, change in print, child relationship. So the, uh, let's say one of the Children may become a care of the mother or the father to kind of jolly them along? Um, it might have financial implications. One of the parents might become unwell. Um, and the actual divorce process may have an impact. Um, And then, uh, individual family and environment really operation in in isolations, so they all affect each other. So, uh, this isn't really operating like this in a circle, but more like this with, for instance, parent ill drinking, causing lack of discipline or boundaries. Um, that kind of affect the child self esteem, which might need the child to drinking alcohol, which might need to conduct disorder. Um, you know, and so forth. Um, conduct of problems may cause the parents to lose their job because they've got some lights. Then take charge of the child or whatever. Um, okay, So this is how we do it in practice. So we when we have a case, we think about the child we think about the family. We think about the environment. And when we see when we see families, when I get medical students to see the families, I asked them to put something in each one of these boxes. Um, And just to get into the habit of that to all, always think about individual family and environment. And when you, as medical students see young people or even people with psychiatric problems further up, uh, you know, it's an older age. It is helpful to think about these things because your interventions are also going to be along the lines of these factors. Um, I don't know. It's Yeah, 43. So I don't think we've got time for a vignette, but yeah, so I won't go into this. Um Okay. So family therapy, um, is a presenting problem, which the philosophy is that presenting problem arises for from, and or is maintained by the nature of the family. Relationships and beliefs rather be located in one individual. So we don't say when we're working with families that it's all Gregory's fault. For instance, we try and we, we we we think of problems, Um, as what's contributing to the problem within the family. And we try not to let locate the issue in the one individual, but we kind of try and share out the blame, so to speak. The contributing factors, um and the aim is to improve the way the family functions by creating new understanding of relationships and communication. Um, and there's different kinds of schools with which you would work with. So a structural approach would be where I was saying that you've got a perent ified child. So where the charges parenting one of the parents would be to get the parents back in charge and the child to not have the responsibility of looking after the parents. That's if he's depressed. Um, so, um, you try and, you know, have the hierarchies back to where they should be. A system approach is, um, is thinking about how one person's beliefs and feelings might have an impact on the other. Um, and we we ask them what we call circular questions. So instead of saying to Bob, how are you feeling now? We might ask the mother, How do you think Bob is feeling now? And that enables Bob to hear what he thinks his mother thinks, but also ask to get an idea of what Bob is thinking via the mother. So you get two pieces of information, and then you might ask the child whether they've got the mom has got it right or not or whether you know it needs more fine tune in the way that she's discussed it, Um, and then family There people have the family's in front of the mirror with sometimes the whole team behind. So when we were teaching medical students, we have the medical students sitting behind the mirror and then the the clinician will be in front of the mirror, and, um, it's a bit like a forensic situation where you've got the police interviewing. You got the people behind the mirror, commenting and I used to bring them in. So I used to bring them into the room and, um, ask, um you know when when you when you don't have problems with, uh, staffing levels, ask them what they thought would be helpful for the family so that views are shared, if that makes sense. So when you were in a liaison situation, So when I was working on the wards with the pediatricians, I sometimes would have the pediatrician join me and we do it together. And if I was doing most of the interview, I would still say to to the pediatrician, I'd asked them to get involved and, you know, what were you thinking? And how do you think? Um, something would be helpful. So it's basically involving all the parties in conversations. So these these this kind of therapy is useful for whether relationship issues, obviously, where there is high expressed emotions, lots of criticism, lots of very hard, highly charged situations or poor poor emotionality, you know, from the from the other point of view. And, um, it's been shown to be helpful, So nice guidelines is basically guidelines that is published by authorities. Um, so let's say, on depression you'd get, you know, a number of senior leaders in treatment of depression, and they'd look through all the evidence of depression. And they would discover that the way to treat childhood depression is a combination of CBT family therapy. Um, and medic and medication. Um, and they've actually said that you should have for young people unless they're severely depressed. You should try some therapy first. But they've also demonstrated that that CBT and medication are both useful. Um, and actually, the most uses the combination. Um, eating disorders. Absolutely. Family therapy is the main line of treatment for family therapy for 18 disorders. Sorry. Okay, so targeting environmental factors, Um, so you might want to, you know, if you've got a case of school refusal, you really should involve the school because unless they're involved, if there's bullying or educational issues like dyslexia, that's not been diagnosed, you really are not going to be able to target this without getting involved in the school social services if there's child protection issues and then other community organizations. Okay, so this is to see whether you've been paying attention. So which family factors may contribute to psychopathology and a child. So what we're gonna do, we're gonna do this in the chat where everyone writes in the chat? What they think So, um, what factors may contribute to a psychopathology. So modeling of behavior. So is that true or false? Can you put this in the chat? True? Yeah. True unemployment. Okay, so someone said unemployment is false. Any other, Any other ideas? Someone else has said false. Okay, unemployment does contribute towards psychopathology in a child, so unemployment of a parent will contribute. Um, expressed emotion, so that's, you know, critical parenting. Um, lack of warmth. Yeah. True good. Parental mental illness. Brilliant, Loud and strong. True. And then genetic factors. You should all get this correct. Brilliant. Yep. That's true, too. Ok, great. Um, I did have a vignette, so I don't know. Do you want I don't know, Sharon still on the call, but I don't know. Do you Do you guys want to just ask me lots of questions, or do you want a vignette which would involve a role play? So I'm wondering how we do a roleplay. So I'd probably have someone who's got a good connection. Um, could do one of the parts in the role play. And I'm happy to be the doctor of the world playing. We need someone else to be the mother. So we could do that. Or you could just ask me lots of questions. Whatever people think would be helpful. We haven't had any haven't had. Uh, Doctor Taylor, we haven't had any questions in the chats. Okay, so, um, anyone want to be do roleplay? Oh, yeah. This is, by the way. God, this is a bit that I contributed to. So I've written the chapter on the matter form disorder. Um, and it's free. So there's no nothing not to like about this textbook. Um, and it's online, and it's updated, and no one gets any money for it. So, um, and it's global, So there may be someone from Ukraine who's written a chapter in it, but it is absolutely global. Um, and it's got a chapter on every disorder within child mental health. So you just put this into Google, and, um, you will get basically a free text book. I'm very happy to disseminate the slides. Um, anyone who Well, anyway, I'll send them to Sharon, and she can disseminate them. And, um, yeah, this is the This is the learning outcomes. So I could go onto the so I'd have two unshared there. Yeah, good. So unshared. And then I could go onto the vignette. Um, and but I'd need someone to role play the different, um, the different bits because I couldn't do it myself. All of them. So I don't know if people are interested in doing this. Um, it is a real patient, but because because you're recording this, I can't show you the real patient because I don't know who's going to end up seeing it. And out of respect for the family, consented for this good to go globally. Basically. So, um, I've kind of made it into I've got rid of anything that would identify this person. Um, I've made it into into a transcript with the dish with edited transcript. So, um, I can show it to you here. Can you Can you see it? The transcript. Wilson, can you sit? No. Okay. Right. The person who said no, because I can hear you so loud and strong. Can you roll Play one of the one of the parts in this land script? Yeah. Which part would you like to be? Do you want to be the clinician, the child or the therapist? I'm not going to give you the option of the mom because that's only about two lines. Uh, I'm gonna be a child, maybe beautiful. Um, does anyone want to be the therapist? Yes, sure. Lovely. Thank you. Be the therapist and I'll be the mom. How about that? Okay, So we've got a female teenager sitting on her bed with therapist, which is in the living room, And Mom is sitting in an armchair in the same room off to the side, and I'm going to ask you to formulate everyone to formulate what they think the problem is here. And what are the contributing factors? All right. So, child, can you kick off with the first line, child, and then the therapist do her bitch? Yeah, I had what I thought was, but flu for two weeks aches, pains and cold sword of thing. Very, very tired. And it just seemed to carry on from there. It's fatique Really? So that was the main thing. This fatigue. Yeah, it wasn't normal. You know, you can feel tired usually if you were done a lot, but this was really I was excessively tired. Uh, it wasn't something I was used to. I've noticed, for example, that you've got your bed down here. This is the living room. Uh, it's have got quite bad. Really. Uh, worst what we What were you able to do? Nothing. It's like some sort of paralysis. You literally I couldn't move my head. That was the worst point. I think she was worse in my point of view. I mean, she couldn't really even eat or drink without any help. Go to the toilet. It just was. She was completely bed written for three or four months. I found it hard to do basically any anything. Really. I just found the simplest tasks really tiring and exhausting. It was just generally had to do anything because it wasn't really letting me do it. I had range of symptoms, really. I had headaches and dizziness and nausea. Lots of things. Eight muscles enjoined pain and just, uh, you know, there were serial sort of catalog of symptoms. I was sleeping 23 hours today. Kind of thing. I felt I needed a bit sleep. It didn't really help. It wasn't refreshing. During the whole of 1999 I was getting out of recurrent infections with my, uh, obviously being away from school, there was a lot of work. It was my first year at G C S E. So there was a lot of work and being away. I was finding the sheer volume of work too much. You know, I was finding It's really hard to cope with. I didn't find it hard. There was just so much to do. I was fighting myself, getting behind behind with it, because there was so much before the tear. I had a friend, a very close friend who I was friends with for about 10 years. We were always together sort of thing. And then, um you know, all of sudden, she decided she wanted to be friends with someone else. She didn't really say anything. She just carried on as normal, and I didn't quite know what was going on. And I wasn't nice to lose someone you'd been close to for 10 years. She was my best friend for that time, and she just went off. Um, they must have been very difficult. Uh, you mean losing her really in effect then in during 1999 Didn't you lose your dad's uncle? Yeah, he died in about doing time. And it was hard because he was a connection to my dad's side, because obviously my dad's not from this country, and I have family in other countries and his connection to them and it's been a family, and I'm sort of kept away from them. And it was nice to have that sort of. We were sort of very close, and I and I had a good relationship. He was challenging for me and was a good person to talk to. My parents were obviously together, and then my dad went away and I got arranged marriage and then had a son. Your dad's from Ghana. Gotten it right. Um, he had a son, obviously my half brother and then I guess my mom and then started another relationship. And then I was there. And as far as I know that my brother and my and his mother don't know anything about me, right? So he's now living back with that original family. Yeah, he's always lived with them So you're in effect. Your kept a secret from his family. Yeah, except for my uncle. My dad's got a big, big family, and they're only about two who know about me. And, um, it's, uh I was a secret. I'm still so the only one that knew about her was actually the uncle that died. Yeah, he was the only connection to them. Gosh, so it must have been incredibly difficult when he died. Then she couldn't go to his funeral because obviously, we were all secrets. So that obviously didn't help because she just had she Just after that, she started to get really sick before you got on. Well, how would you describe yourself as a person? Mm. I guess I'd say I was fairly outgoing and active, you know, just a sort of optimistic and happy kind of think. I just say that I didn't let things bother me a lot. If you don't think about it, it can bother you. So right. So in terms of what Carla was saying about tending to keep her emotions inside and not really talk about them. Do you agree with that? Yeah. She wouldn't talk about them because obviously, they hurt to talk about it, so she just shut it out of her mind and she wouldn't discuss anything. So therefore, I assume that contributed to her getting sick. How are you at school? Did you like work or not? Particularly in your work. Oh, I like school. You know, I had I was going really well. I was quite ambitious about school, and I like to achieve and do well. And do you think you're quite similar to people who are different? In some ways, I think we're different. Very yes, definitely different. I would say She's highly strong, and she likes to express her feelings. And I don't close myself off sometimes. Right? This Mom. Worry about what? Yeah, that's a beautiful circular question. Yeah. Does Mom worry about what you do? Do you think that is a circular question? So you're asking mom to the perspective? Yeah, a lot. You know, she's very she does. She can get she panics and vote worse. So Brilliant. Well done, guys. That was loud and clear and brilliantly, brilliantly, um, read through. Thank you so much. Um, and I know the family. And you did you kind of depicted them. Very well. Um, do, uh, could people, um perhaps I'm going to go to the slide, which talks about this, but be helpful if people could, um, tell me what they think are factors here to, um this young person getting unwell. Firstly, does anyone want to guess what they think is wrong with this family? What child? Depression. Yep, yep. That could well have been some depression. Yep. Depression. I would definitely agree. Yeah. What else could be What? What? What do you think explains all the fatigue and not being able to get out bed and stuff like some sort of anxiety? Mhm. Anything else do you have? Do you have the concept of chronic fatigue? Emmy in Ukraine. Is that something you're familiar with? Not really. So a post viral, actually looking, I think. Yes, there is a chronic particular crane. Um, so post viral fatigue. So she probably had a post viral fatigue. Um, and absolutely. She could have got depressed. Secondary to that. But, you know, this physical health problem probably triggered it. And then she landed up, but and then she had all the factors. So does anyone want to identify some factors. So can anyone think of any predisposing either protective factors or predisposing factors? Mhm. Right. Okay, so this is what we would go on. Does someone want to say something? Like family Factors? We find out that about onco about, like, problems with mother and everything like that. So there were a lot of factors that affected this exam. She was a secret. The father wasn't living with the father that had another family. Then the uncle died. Um, they weren't allowed to go to the funeral because they weren't known about. Yeah, lovely. Anything else? I mean, these are all what? We've kind of put together these factors here. Did any of these ones in particular strike? Anyone here Maybe lost a friendship as well? Yes. Yes. And we all know how How awfully damaging that can be. Especially when you're an adolescent girl. When someone you and your abandoned. Okay, beautiful. Any any questions on this? I have a question about mother reinforcing her symptoms by bringing the bad. Uh good. Tell me, what's your question on the first floor? How is it working? How is it working? Why is that reinforcing? Yeah, Listen, I would totally agree. I think I mean, I'd be interested to think. What do you mean? Why is it reinforcing? Um, Because I think I agree with you. Tell me what you mean by why is that reinforcing? Uh, well, I mean, uh, it can be reinforcing because, uh, she's, uh, like that her child is staying in bed always. And Mom is okay with that, But I don't know, it could be adaptive. It could be the only way the child gets to go to bed. You know, that's that. It could be, Yeah. I mean, it's interesting, isn't it? Because if you know, if the child was paralyzed and the parents brought the bed downstairs, people would say that be making an adaption in the home so she can live a life. So, yes, that's questionable. Whether that's reinforcing or not, it would be my perspective on it. Yeah, so I think you highlight, um, when we interview, families were making judgments. Really, And it's not necessarily the, uh the truth were deciding with our lens and the way we view the world, what we think are factors and what are not factors. And at the end of the day, that's subjective, not objective. If you do a gene test, that's objective. Because it's telling you whether someone's got vulnerability to let's say, Huntington's career. But child psychiatry is not like doing a gene test, you know, chest of their genes. Genetics. Does that answer your question, Milena, I hope I've got your name. Yeah. Thank you. Yeah. Any other questions? Um, Sharon, if you're still on the on the call, Um, if we could not have the role play in the recording, that would be good. So if that can be edited out of the recording, because I'm not sure where you send where you send them according to, but okay.