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Okay. Okay. Good evening, everyone on. Welcome to the second in our pediatric Siris. Uh, thank you for joining us this evening Over on metal. Um, is my absolute pleasure toe introduce this evening, Doctor Helen Armstrong, who is a pediatric consultant in neuro disability. And she joins us last week for our safeguarding talk on this week will be teaching us all about mental health in pediatrics on how to approach it as a junior doctor. So over to you, Doctor Anstrom. Thank you, James. So, um, so I'm gonna be talking about mental health and pediatrics. So just a little bit about May. I've been a pediatric consultant. Cold. They'll on her to feel foundation trust. First four years. I'm the designated medical officer. The cold, though, and Kirk lease for Send. I teach on G. I see a P. A lesson and less. I've been an instructor on the Yorkshire here on Humber Step program, which is their specialist, um, education in pediatrics program for longer than I've been a consultant. I used to be the trustee on Holiday Leader River Children's Charity, where we took away disabled Children. I am the Provera. Fine left. Yeah, I really shouldn't type things when it's late. But my dream reptile is one of these beautiful comedians you can kind of see low in this cream, which I held in in a shock. However they are. Devers need to mix them twice a day, so I haven't got one yet. But do you, however, have four snakes in the Geico, and I am a tough mudder enthusiast? The same thing? He asked. I'm enthusiastic for the first mile. Onda less enthusiastic by mile 10. I absolutely love a good gig. I've got some studies on die recently in the last year become a surfer and skateboarder Say, You know, I I try and be done with the kids. But let's be honest. I am not so down with the kids I would love to be. And so let's crack. Um So what? We're gonna say this, that this is just a little bit about our sponsors who are helping keep mine a bleep. A zoo? Uh, good. A service, you guys is It can be So what to expect from our session. So I'm gonna talk to you a little bit about the size of a problem. Then we're gonna talk a little bit about some common presentations a little bit about what you want to be thinking about. Any history. MM, quickly going over what you already know about the mini mental state exam Took a little better management talk about my favorite problems. The problems of social care of the problems that comes, go through a few cases, have a Q and A, which, uh, James gonna, uh, hopefully find if I find any questions for me on their talking about some useful resource is say, yeah, sorry to interrupt. If if anyone does have any questions, just stick them on the Facebook event on. I will pass him over to Dr Armstrong at the end. Okay, Saab, say, essentially, as we will know, look down on Do Cave. It been pretty rubbish for everybody on child. Mental health was a problem before that, however. What we are seeing, though, is daily admissions for self harm. Be that coming through any three GPS or just directly to the pediatric assessment unit. That doesn't always mean that would stay in, but they all need some form of mental health assessment. Sorry, we are seeing a double to quadruple level in admission for Children and eating disorders on This includes younger Children so used to be predominately a problem off teenage young ladies. However, we are seeing Children down to the ages of eight on. We are seeing an increased prevalence in boys. That doesn't mean that we're not seeing the case, and girls were absolutely are. But suddenly it just means it's expanding in a lesions we also see suddenly a breakdown emplacements for fostered an adopted Children. Essentially, whenever anything gets tricky in life, it gets the most tricky for those already really vulnerable. And sometimes, suddenly you'll see these Children for one to a better word being dumped on the ward until social care can. There can help us sort out that situation, which is really breaks out full consent. There's an increased presentation to clinic with more outpatient presentations of mental health such as headache, a non specific abdominal pain and also I was seeing at least a doubling of school absenteeism now that now the scale of which will vary from child to child. But school absenteeism is it's just a really early sign that something might not be quite right. Visit. We need to be talking about it, which is one of the reasons why this is there session that we're doing is partly serious. Just to give you some facts and figures, essentially the HS. See, I see. In 2004 said 10% of Children age 5 16 had a clinically diagnosed mental health disorder. 6% had a conduct disorder. 4% had a nimmo. Chinna Lysol. 2% had a hyperkinetic disorder. You think things like 80 80 on less than 1% of things such as autism ticks with eating disorders. However, that 1% let's be honest, has rocketed. Autism is about 45% on eating disorders. Probably a similar number. So we're gonna rock threesome, common presentations. Now, let's be honest. I apologize for my terrible, too afraid, and we're gonna do this one a time. Onda. I am not a woman that makes lots of power point sides. So we're gonna do a lot of talking around it. So if while we're going through, you got a specific question about that element that we're going through the time. Just pop it over on Facebook in James will pass it on over to make so we're gonna start with the heavy. It is we can start with self home. Let's be honest, I if if your medical school student, I'm sure you've seen some on replacement if you're a junior doctor, I can guarantee that you have seen someone that has self owned. It is the most common presentation that we see keep leak. And now usually this will be cutting. It's the most common thing, Um, but sometimes it can be bruising, burning and pulling out head. I am pulling off nails. Suddenly there's a There's a whole range. The most common we see is cutting. And it's a country we usually fairly superficial. Usually these young people present through an any department. So it's really common that you guys are gonna be. Firstly, let's see them, and the key things for you to do is think to yourself a couple of things. Number one. How about is it obviously? Is it deep? Is it fairly superficial? It's fairly superficial. You completely clean up, find out exactly what the trigger was if they if they can even tell you because sometimes they won't be over 80 on. Think to yourself what level off mental health intervention is required here because the answer is always some but the amount of very say if, um, personal self harm. It's very superficial there with the care, whether it's a decent human being. And by that I mean, they're gonna actually keep an eye on them over the next 24 hours and and you speak Teo, your psychiatric liaison team or the cameras liaison team, and you have a bit of a chat with them, and they often have, at least at least in cold gel. They have a chat with the family over the phone, and if they say their kids go, but that may be sufficient, so it may not take any longer than you were stunned today, any clocking an intervention. But yet you still have that extra little layer of them of kind of mental health, uh, glittering on it for once of a better walker. Um, so so you were like, actually is on team always an excellent point of cool? Suddenly, sometimes is deeper. I have seen young people that have required assessment bye plastic surgeons for either, either because it's usually accidental. Let's be on it. They accidentally cut a nerve or they've accidentally gotten much deeper than they intended because the blade or whatever instrument that using a shocker than they thought it was gonna be. And and when we come into the cases, I will take you through a case when I was a registrar. The term we will, we'll pick out a. We go through that case, the interesting things that can happen, perhaps them red flags on perhaps them. Top tips on how not to get yourself in a tricky situation. Let me want to intend to labor days. That's really the other most common presentation you're going to see on an assessment in in Viet six. Let's be honest. The most common hitter is paracetamol, but that can sometimes be combined with salicylates and plus minus alcohol plus minus diazepam plus minus. Whatever they can get their whole hands on the cocoa demos and of the thing that often you'll see. Obviously, your key questions heart. How many when over what timeframe? Because if it's staggered, you're gonna be thinking to yourself, I want I want to get out My, uh, Publix Practical pretty quick. Um, well, you're in a social sustain public street scope and you wanna be thinking about every four hours down the line from when we took these medications? Can I take the Bloods yet in any which is really helpful for us on the ward? Or do I need to refer them up to pediatrics and give them the time at which those Bloods will need to be taken? Because, let's be honest as a pediatrician on a busy in it, it's really helpful if you guys on the front line, or even if you're clocking for May on the pediatric unit, say to me, Oh, Helen, this child will need blood that they're not due until nine PM And even if that's not on your shift, that means that can go up on the board so that we all know that when that time hits, they can be taken off. Say that as quick as possible. We're gonna have an answer about whether that child used to stay in or have extra medication. So these Children, in intentional overdose is always need a cooling off period. You will. I. I don't believe there's a come service in the country that will just hopefully let me go home and say they usually end up staying overnight, regardless of what time they come in during the day on, regardless of whether they are medically fit. So that's you the question you ask yourself. Are they medically fit for home? And by that I mean, is there paracetamol level less than the normal gram? Um, if you had to give them, um, and I still assisting you are following your current local guidelines. I say that because we did have a wonderful national guidelines that essentially run a bag over four hours, know, run a bag over in our then every four hours, then over 16 hours, and it's changed recently. There's a wonderful new norm, a gram that runs it much shorter on base, and the gastroenterology colleagues that I have in in leads and across the country on also days within an e have kind of work together to sort out a new protocol that only takes about 12 hours on isn't seem to have any negative effects on liver function or on your clotting factors. So please, please, please, I would urge you just to check what your local department is doing. They may be on the old old preschool, they may be on the new one. Let's be honest, we're all kind of slowly shifting on. As we will know within the interest. These things changed variable rate. So the key thing for your hepatitis C is whatever your protocol is. When you get to near the end of the protocols, they don't wait to the end of your school. Don't wait till the end of bags 16 or bag 12, which, whichever it is at about an hour before take your love them because, let's be honest, a clotting and your LFT is they're gonna take a least loud to combat. And if you haven't got that result, you're gonna be writing up another bag on. That's gonna be annoying for you or what? It's gonna be even more annoying for your nursing colleagues who will look at you like you weren't prepared. So 1 to 2 hours before plum to take those bloods, because then you're gonna have that result back, Brady. For when that bag ends on, you can say to yourself, What's my eye on our kids? Let's be honest. That's your top hitter on. Then you look your left a Z on, but if your eye and I was okay, the LFTs are okay, then you're pretty safe to stop that medication. It's at that point you are medically fit on. Only when you are medically fit. Well, most comes. Teams come and assess that patient suddenly, depending on how good a mood slush, how busy your comes colleagues are will depend on whether, and they will accept a phone call to guesstimated that time at which someone will be medically fit on, then a follow up call when they're ready, or whether they won't even take any details from you until that child's medically fit on. Suddenly, that will vary from region two region on from colleague to colleague on an individual day, but those that there's just little nuggets to be aware off. When you're when you're thinking about your intentional a good ices, it's also we're thinking about. Sometimes they will be weird and wonderful. If the presentation you see is old, well, come on to that and again in one of the cases, just have to think to yourself, could could there be some over medication or brooks of abuse involved? Think to yourself whether you want to do a urinary tox screen on. Just think about kind of perhaps adding in an extra question or two that might cover that in the history. But we'll go through that when we come to the cases. So moving onto eating disorders. I'm sad to say that it is becoming more and more part of my daily life. And let's be honest. When I became a consultant for years ago, I may be sore one every six months. Now I'm seeing 1 to 2 Children as an inpatient on my water week on. They are long term patients because, sadly, the ones that hit the ward other ones that are wonderful community comes team have not managed to keep in the community. So these will be the Children. That's be a miser are horrendous. These are the Children that will look skinny little. These are the Children that really need. Tier four comes beds that do not have access to them because of either capacity within the crunch country oh, capacity within the local system or we're still capacity within social care. So you was a local pediatric team. I kind of thrown into the deep end of looking after these patients on it is tricky, say, First of all, the acknowledging that yourself and you're nursing colleagues, your senior clinician colleagues will find these cases difficult because they are not our bread and butter on. They are not our PS two resistance of knowledge, you know, show us all the bronchial it ic boom thought it. So it's a child with anorexia. We'll panic because although there's some great Marcy patent guidelines say, for those of you who making that Will, notes Marty Pan, absolutely wonderful guidelines that you work from, However, even with the wonderful marzipan guidelines you and I are not pediatric dieticians on. Typically, these cases do not come in on a Monday or a Tuesday during working hours. He coming on a Friday afternoon at four PM and you'll be clocking him at five PM and you'll be making a diet plan. It's 67 PM and you'll be thinking, Why am I making a diet plan? I'm not a dietician, and you'll be thinking to yourself how many calories are required in the day. I don't really know on you'll be having a little questions to herself about Do I need to do the feeding bloods on The answer for the ones that come in is almost certainly yes, I'm ah, on well again, we'll go through a case study where work through these issues. But those are the things I won't need to be thinking about because they're in reality, the things that everyone finds tough. My top ticks are always be on the same page with your colleagues on. By the time you make a consistent plan, put it in your notes. We use EPL or been cold out. I make sure that if I make a plan for a young person with an eating disorder, it is stamped like a red mark across the notes in massive letters, so that when my colleagues come the next day, they do the same thing because the thing that Children with mental health disorders, particularly eating disorders, find trickiest on the ward is a lack of consistency. And I know this from wonderful and terrifying feedback from actual patients. Um, because the worst thing for someone that is essentially controlling their life by controlling their food because it's the only thing they feel they can control isn't helped at all by a system that is caring but changes his mind now, of course, we all know that there's some flexibility on We all know that there are things that change that we can't control but for the things we can control, such as how much they need to eat in a day. If you know that that young person is gonna have to have a breakfast on, then pick a piece of fruit for snack. Don't change that plum unless you've got a dietician that's coming and changed it for you. And then you go in and you update that young person on what that changes so that you're all on the same page. The best thing I did for my last comes patient was laminate her a copy of her diet plan. I put it on the wall And how are you so that every day, you know, only did I remember only did she remember? But the wonderful gene you doctors doing award around could see it at a gloves. So if they weren't sure, they have an eyeball view of it as they walked in. Because I I'm a visual learner. It was color coded. So every different point was a different color. So that way, also, you kind of your eye gets drawn to those different points as opposed to like a sea of block. My other top tip for those with eating disorders is they want to exercise a little time. And even when you've got someone that has great insight on the young lady I looked after most recently had great insight, she described as. I don't think I can get over the voices telling me to exercise. I don't think I can fight against them hard enough to no exercise. So you need to think of things they can do instead, things that could not keep high their time. Because to be honest, it is rough being in hospital when you are well, well, when I say well, I kind of with a with a physical disorder. It is even worse when you're on well with a mental health disorder, especially in cave did where you can't really leave your room and wonder the grounds and one to the ward. So you're essentially trapped in a cell for a week, two weeks a month. It's horrendous. You need to think of how you're gonna make that better for that in person. And let's be honest with top tip is ask them because things aren't gonna work the same for every child Fishing lady looked coloring, so I printed out some coloring for her to do. And I said to her, You color this for meal, Put it on my wall in my office. Eso I printed out coloring I liked. So I now have a steampunk apple on my office wall that this young lady colored for May on when I go in in the morning, if she hadn't finished it, she would show me what stage he was up to, and we discussed the interesting color palette she'd used on. So not only does it give you something too active as a method of reporting icebreaking at the start of your wardrobe, give them an excellent distraction, but that would be different for everybody. She will say, like playing. She was like playing shots, um, odd gain or games. But like shots, um, games. I hadn't seen board games and your PSA like puzzles, so she didn't fill this massive puzzle across the whole a table she had in her room on Then, when I wanted to examine her. She dropped with or push the table out of the way when the zillion piece puzzle wasn't required. So just ask. It's a great rule of thumb for almost everything in medicine, but it's particularly good rule of thumb. If you're thinking of activities, help you school, and I just go back with the Children that you're working with with eating disorders. Do you get a reasonable amount of compliance with your diet plans and on if you're distractions and new kind of activities, so that the honest answer is variable? Um, sedition lady who had great insight on her good days she would smash her diet plan. She would be absolutely distractible. But yet she would still have ah, screaming fit for about an hour before breakfast because she knew breakfast was coming. She knew that involved calories, even though we were picking the low calorie, low fat options. And I remember for this young lady I had the carbs and cows book for for the diabetic, trying to help her pick from the hospital menu the lowest fat options that gave her the calorie content. The dieticians recommended per day to help her pick food that would fit the calorie requirement we needed but would be in within her sphere of acceptability. The other extreme is young people who completely are not with you. Now, um, then you're in a tricky situation of all the parents with you or not. If the parents are with you, that's the kind of situation you're in, where you're thinking about nasogastric tube feeding. However challenging my eyes on you sometimes use the bridles, nasogastric tubes, which could be very challenging for the child on and first stuff. We had a young lady that again would scream and kick off of the nurses every time that engine to was accessed on that would be approximately 34 times a day. Which is awful for that young person is awful for the nurses. So it's really important to think about kids because we put in loads of support for the family. Really need to think about looking after ourselves on looking after each other is a team, and even if that's just a the end of the day or during the day, I quit checking, going. You're right. I know that's a tricky patient, so anything I can do to make it better, and the answer might be no. But it might be that that person just needs quick hug. Um, sometimes that makes life a whole lot better. Sometimes it might be. You know what? Do you mind just coming in with me to do this next feed change on the work of five minutes for you as a junior doctor will make the life of that nurse a million times better. So very bluesy. Answer on on a case case basis. Okay, thank you. Know, really, really helpful school absenteeism. I think this is probably the most tricky thing like face, because it can be really difficult to get to the bottom of it. Being a mental health disorder, so school absentees and will not always be a mental health disorder is number one. But let's be honest. It's that the top of my list of reasons why most Children absent from school other than the ones that deliberately paying, playing true and etcetera, etcetera on some of the ones deliberately playing true. And maybe you're young people that have a t h d. May have autism, but be very high functioning, really struggle to interact within those lessons so it's still worth having only differential list. If you see a child say this is more likely to be in a community place than on a GP practice and or for those medical students when you were out with community nursing colleagues and or school nurse and colleagues. Um, or even if you have relative friends that are teachers and they say to you, Oh, I got this kid that's never in my class Um, maybe it's worth saying to them gently, Have you ever thought that Why? And it might be that that you're wonderful teaching colleague has really thought about why they are on it like a carb on it. It is just a really tough situation. But it might be that that child has presented with constipation that they are off school for weeks at a time with manageable constipation on. In reality, they hate school. Be that because they're being bullied, be that because they they're IQ is not that at the level which they find stunned. Did learning pathways straightforward? It's worth thinking about Onda my top tip in those scenarios because let's be on a school up. Since he is intense to present as an outpatient problem rather than a key problem. Have a chapter with the school welfare officer is usually the best person. But in my experience, I've also interactive had teachers, pastoral workers, Um, have a little indie t have a little school MDT have a discussion with those people, get it from both sides because let's be honest, school are gonna have a lot of information that you don't have and you're gonna have a lot of medical detail. You can feed back that they won't know on between. You can come to a plan. The best thing to do is have a little discussion on, you know, in the in the world of teams and zoom, have a little soon meeting with those people. First on, then have the parents and the child in. And hopefully what you wanted to do is bring them along for the ride. Say that you is the medical professional, suggest that they're medical problem. May have an element off same it', a shin or functional issues on that. That doesn't mean that they're constipation isn't really because, let's be honest is they're just not managing it very well because of everything else is going up or they're having unrealistically expectations. Such a Z. Nobody needs a sick note when they have constipation, um, for weeks on end, and nobody needs to be admitted to the ward just cause they are screaming because they won't take that medical. I say this because I have looked after such a patient on. She was very challenging on. During locked down, I heard not one people from her Chart zero admissions. She had zero challenges with schooling because she was being home schooled on family Enough, she went down to one fracture of medical. In the last month, I have had five emails from her school teacher because she has not been in school for anything other than one week. Apparently her constipation is getting less than on her GP is giving her a sick note to be off school for constipation, which I have suggested might need a professional conversation about the nature of the problem. So that's one of my own going cases at the moment. School absenteeism, tricky business. Constipation is not the only thing is we're going to talk about. There are lots of medical present, a shins that have a flavor of mental health that is worth thinking about, because when you're in your clinic, if you only deal with the physical side, you are not going to treat that child. They will keep coming back to your clinic until you address the other side on say, sometimes a two pronged approach is required. Sometimes a single problem approach that looks like a two pronged approach is required it. But we'll come on to that. Is there anything else anyone wanted to ask about? School absences in Jones? Perfect. No, nothing's coming through the one, in fact, So I'm going to take the next group is a bit of a batch because the themes are the same on. I know that most of you can take a reasonable headache history. I know that most of you can take a reasonable palpitation and collapse history on a reasonable abdominal pain. History on what the theme is here is somatization in on mental health with a physical presentation. So essentially they will present to clinic in the way that anyone else with a headache or abdominal pain will. On your job as usual, is to be chief Detective, um, figure out what the trigger factors are associated with that case. Um, so typically, in a headache history, you might be listening and thinking his child sounds pretty anxious about, like not just not just about the headache and anxiety is a factor that's always gonna make headache. Where because they're they're anxious about the headache. They're anxious about that. It could be a brain tumor. The ranks is because they're from family member died of a brain tumor. The anxious they're gonna die. And if you don't address, even if it's not at a comes level mental health a lament to that you were gonna fundamentally ms treating half of that child problem because giving them some pills out if in or send, um, my mind has gone blank for all the drugs I used propranolol to to manage their headache with a migraine isn't gonna make an ounce of difference if you don't control their anxiety associated with it or explore their anxiety around it. Now for different Children, that might, um, being different forms because some for some young people cognitive behavioral therapy, great for some, just talking about their worries with a parent care. A trusted friend, you as a doctor might be enough for Somebody might need some medication, because if they are so anxious, you need to bring that down. And not to say that they can even clear their head enough to start processing. Which is why, for those Children propranolol mint drug, you know only help with the headache, but you also help with the anxiety that low dose propranolol kind of 10 to 20 mg, depending on the size of the child, obviously is an absolute gem for helping a two pronged approach course. You need to be thinking about all your other heart. It is such a delay. Have asthma. Don't give them beat. The book is. Are they on any other medications? But just think out of the box a little bit. When it comes to those presentations, I would say exactly the same about non specific abdominal pain. Non specific abdominal pain is the most common out present presentation in pediatrics because it has so many different causes. You have your constipation's. You've got your recurring UTI, so you've got your safeguarding. You've got your mental health difficulties. You've got your somatization. You've got your bullying Oh, you've got your genuine and irritable bowel or your, um, inflammatory bowel disease is on you. Is the doctor need to pull that part? That's what makes pediatrics really interesting. You you need to think to yourself what these key things that I'm going to tell me whether it's one of the other And what are those factors from my history that are gonna put me in that direction On what I would say with things like nonspecific other specific abdominal pain is think yourself what key investigations do you need today to tell yourself it's know any of the big hits is like off difficult, like silk rains. So, you know, a nice little stool card Protection is gonna take you a long way, and and maybe you want to test their firewood, especially if they're quite thin, very anxious and on, maybe to see the X cream. But I have to leave you on those three. You don't really need to do a massive full book out with my son. Look pale, pale. You don't really need to check the role of teas, and this they look yellow because the key thing is working, waking hard and small. No doing every test under the sun. You gonna do better? Few patient. You're gonna do better for the NHS, and you're gonna be the kind of doctor that I went away with. So once you've got to the fact that there is a mental health element, you then need her need to package that to address that with the young person on, depending on how old they are. Depends on how you go about doing that. For a very young person to kind of 45 year old Open, say something like, You know what? When I feel really rubbing, Sure, the anxious my tummy feels feels like it's got butterflies. Sometimes that means my tummy really hurts and it hits. His body is when I'm pulling and that that that is a real pain. But it's because my brain is poorly and I don't feel very happy. It's not because my tummy's really poorly. So how about we think about a way to make your brain feel a bit better? And then I think you tell me you feel better for an older child on gets Be honest, you're gonna gauge this upon response in the interact interact aeration. That's not really work interaction you've had with that child safe are because you might be able to have a very in depth conversation with an eight year old. Or you may have to have a very low level conversation with the 12 13 year old. That's all going to depend on their learning ability on the interaction and insight you've had from them so far. To guide that, because you might be able to have a conversation that goes, Look, we both know that sometimes we can't fully explain how we're feeling on sometimes those feelings that expressed in physical symptoms, and we need to address those physical symptoms that are being brought on by things that we find difficult to talk about. Say, you tell me whether you think talking to someone from say comes is gonna give you is gonna give you a hand whether you think, actually, just coming and talking to me, he's gonna be enough whether you think we need some medicine to take the edge off the pain while we went free these things, whether actually you think you know what, I know what's going on here. Doctor Armstrong, you give me the resource is to go and look after it myself. But I will. Well, we'll check in on each other in about 23 months, and that is the essence of collaborative care. Um, now, of course, you need to search a certain level of of good interaction with the child to be able to have that level of discussion on. But as I said, that will depend on the ability of the child. But working somewhere from the from the telling the child What's going on all the way up, Having that really lovely collaborative discussion about how you gonna manage it is the spectrum that you want to be thinking along. If you're dealing with a younger child, of course you're gonna have a printout conversation with the parent as well. Tell the child was going on. I always do my best to speak more to a child in clinic than the parent, even when the parent does that beautiful thing of looking at the child that looks really anxious. Do you want me to tell the doctor the story? And they're like, um and then it's absolutely fine to clean all the information from the parent, and I usually throw in a little line of that's great. You can let me tell me the story, but you think there's anything she's not told me or anything she's got wrong. You just dump it on hatefully That gives a young person in a freedom that if there is something that their parents missed out, you've been open enough with them that they will add in those little nuggets because they will probably be the Gemzar that actually taking the longest distance towards was getting, um, and these are things that gonna build that trust in your port so that that child opens up to you to really get to the new security of what's going on from. So I'd say the same go for palpitations and collapse. Of course, you need to be thinking about cardiology. Things safer. Those ones always get any CJ. Always check the BP and be thinking about if there's any red flags that make you think about the need for echo or 24 hour tapes. But also, I think to yourself, is that young person eating breakfast? Are you eating a tool? Is there anything to sort of? Hey, is that bullying going on in school? because, let's be honest, I've had many a conversation with teenage girls that go along the lines of I had a collapse after lunch while after, after, um, lunch break at school, I say to them, Did you eat lunch? They said I had an apple and I said, That's not lunch. That's a snack and they'll say Yes. But I get called fat at school and I feel pressured to look like all the other young people. Onda A look at Facebook or instagram structure and I don't look like them. Um, Then I said, Essentially, go Look, I'm in the beautiful position that I'm a very short, curvy pediatrician, and I can empathize with many people that I often face them. Look, you need to realize that you are beautiful as you, but you need to think that not just really, and so we need to get to a place where you're gonna believe that and ignore the people that tell you otherwise. And there's some beautiful ups that can help you with that. When we come to resource that I'm gonna tell you about some of my favorites. Is there any questions about common presentations before perfect so history taking Let's be on. It's time for you guys to do some thinking. And I have to be fair puts, um, helpful hints of, uh, psychiatric specific things on the left for you to look at a later date. I'm not gonna go through them or not gonna insult your intelligence by reading to you. And but if you think about all those key So theatric things from a psychiatric placements. Oh, from medical school when he did your psychiatric block. You know you want to be thinking about how does that child look? How is that child speaking to make what feeling? Um, I getting about their mood and affect What does their ideas and thoughts about the situation seem to be? Do they have any insight on what is their level of commission? Because all of those things are gonna impact on how you investigate how you manage the way you take it. So what I want you to do is have just two minutes thinking about what the key things you want from the history. Well, better still. How you gonna kick off that history? You know what? Nice open question you're gonna use. What kind of questions you can use to gently take that history down the path where you do. Well, Not very much talking on you. Let that patient take you through their story. So I'm gonna give you two minutes. I'm going to let James kind of man man in the Facebook so that we can get a bit of feedback on that in a couple of minutes. And that gives me a chance to not speak for kind of 6200 and 20 seconds while you guys do a beautiful Yes, I'm having looking the chat on metal metal is well, so if people would rather post there, if that's easier, I think it's alongside the video. Um, I can relate any comments. Just fresh. Okay. So, uh, the question is kind of how are we gonna open? Ah, history and how we're going to try and get the young personal child toe open up about their mental health and get them to do most of the talking. Um, to someone, someone in the chest was just asked to go over What exactly? The question was again. Perfect. That is exactly the question. So let me give you some top tips. While you're thinking just to kind of prove those ideas, think to yourself what nice phrases can use t move a history along that doesn't involve you asking any extra questions. Really? What kind of questions are gonna be a good opener That's gonna essentially let you delve into the heart of the problem. Mm. Without putting to narrow band on what's going on. And then once you've got that bulk of that history what? Keep probing questions? Do you want to ask to really nail things down? Case we've got one person has responded saying, Can you tell me a bit about what has brought you here today? Yeah, That's a nice question. I like that. That's a good one. Yeah. Nice open broad. You got any other bright ideas? Otherwise, I'm gonna give you my list. Okay. Um, I always quite like to just tell me a bit about what's been going on with you recently. I like that. That's a nice one. Sometimes it goes wrong. I'm not gonna like you. You know, You get a detailed what they had for breakfast, and then we did a lot of lessons in school cause they normally get interrogated by mom or dad when they come home. But for the most part again, it's nice. No, but even if you do, you get that. You can use that to your advantage. That's quite nice icebreaker on. Then you can say, Oh, thank you so much for telling me that. Now tell me a little bit about why you're seeing me. No, absolutely. I like that. That's very quick. Thinking only comes from years of experience on of sometimes getting it wrong. Um, and that's the beauty of these Webinars, you know, sharing, sharing our our life experiences and top tips. Because, let's be honest, I'd say the step teaching program I teach on I do challenging communications scenarios on Do, um, essentially, we have actors that work with RSD one and S t three pediatricians, And every time I get little nuggets from from those wonderful junior doctor, be like that's a great phrase. I'm going to steal that on. I just add it to my armory, um, on a new maternal share mind against That's a great way for them. So someone else to sound that they, uh, they often find the child's parent just shoots often basically tells them everything. Um, but then I think they bring it back to the point of your same. They tried. Acknowledge what the parents said. You know, you can't just ignore them, but they then say Okay, you know, let's address the child. And so you know what's been happening lately, which is really a nice approach, or it might be this. So you're quite right. There are lots of parents that are so worried about their child that they essentially want to offload on you on. The most important thing to do is let them, because if you don't, that's gonna be more of a hindrance. Tea when you get to the stage where you want to ask more probing questions because sometimes these wonderful, anxious parents just a so glad that they're seeing a doctor, that they just need to tell you everything in their life and then on, then you can get okay, Thanks for telling me. Well, that how about he told me specifically about this, and then you can. Then you can start to direct him a little bit because we've all been in those situations where you have a 15 minute see of information where you don't really get those little nuggets that we really want to kind of dig down into the situation. But do you give you a beautiful overview of what that family situation is? Um, do you give you a really nice idea of what that support network might be like a foot foot, for better or for worse? So, as James said, Really nice tightness and things like Tell me why you come see me today. So in clinic, that's my favorite, because I often get GP letters that will tell me one thing, and the patient thinks a completely different thing. Sometimes they think they're coming to see a pediatric surgeon, So I am not. So it's best to address. You know, we'll talk about ideas, concerned expectations in medical school, on die. I I think that you should not be, uh, by the stage when you are on actual doctor saying that loud books do be thinking it in your brain on thinking of a way that you can find out those things because they are important to to what you do. So I want to know why they think they're there, because then I can say Okay, that's great. So why I think you're here? Is this my plan is to do X y and that Is that okay? And so say, for instance, a child that's coming headache. So they're GPS told me they've got a headache and I'll say to the young, personal the A parent. So tell me why you think you've come see me today and they'll say, Oh, come see with headache But we've also got five other problems on That's a good point to say. Okay, so your GP is referred you to me with headache. We've got time to talk about the headache today. If we have any extra time we can. We can touch on those other things. But think to me now, be having you think about what one of those are. The problems is the chief thing that's worrying you, because then you're managing the expectation that you cannot cover 20 problems in the 20 minutes lot. But when you come to his address, the thing that's bothering the most and that might not be the thing that come to see you, which isn't always a tricky business in medicine, is a whole pediatrics know different patients will come to see you with what you think is one thing on what they think is another. And it may it will be the same thing. Maybe that the I am leg that has just fallen off is a worth problem than their headache, which is now settled on. Do you may have the opportunity if you have the skill fat to do so to address that problem and say And right, I started to the GP going well, patient, excess legged fault Nothing that was distressing them. But we talked about how they could get a new leg. The headache. Whoever is completely settled, I'm discharging the back to you. Okay. Century eccentric ways to me of the conversation along When you are talking about the the bulk of the history, I find things like things that acknowledge that you're listening, but that you want to help them move forward to the key. Say thank you for telling me that I can imagine, say and only be yourself is my other top tip. If you're not the kind of person that would be like thank you for telling me that. I imagine that was a really awful situation. Can you tell me how that made you feel? If that's not you, is a person. Don't don't don't Don't be that because I've told you to be you will find your way on your way will be an equally good because it will be you need to you and therefore will be much more genuine and therefore the patient will respond much better. And But that is one of my ways. And I have different ways, depending on a different page, different patients. So the way I talked to my Children with autism in my clinic, it's very different. The way I talk to young people have come in with her father say, my child with autism, I usually say to me, I usually say things like So how do you see the situation? You tell me what you think about it on, because the way they see the world is different to the way I see the world. Let's be honest. I secretly love the way of the autistic Children. See the world, or at least my high function is because sometimes I see the world that way but can't say out loud, and they get, say out loud. It's brilliant and they want to talk to me about stoles on the fact that the fact that our fate is amazing well, don't put her down and flak and tell me all about how great your favor is, but I need to occasionally tell them about sleep because something when you're when you're when you're not excited about everything. Sleeping, sometimes tricky. But by letting them have five minutes to talk to you about your feeder, you can then have a five, a two minute conversation about melatonin so so much like everything in life. It's all about trade off and then other ways to me of the conversation for these things, like Okay, so you told me that you were feeling really down recently how long that's been going on for. So so there's little detail questions that you acknowledge that you've heard what they fed on IV listened on the evil follow up question the same with things like, So you tell me you've been cutting. How long have you been doing that? For? What kind of things tend to trigger off episodes? How do you feel after you've done it? Do you actually feel better. Sometimes they get, they'll say things like feeling recent. Sometimes I'll say no. And then you can say things that like, Well, then we need to find you a better coach mechanism because this obvious isn't working for you. We've ended up in hospital for the 2nd, 3rd, 4th time. Let's let's together find a better way because the thing that upsets me diced about Children's mental health is the way professionals deal with it. Um, I have seen a zillion professionals be beautiful, Have some lovely conversations. I've seen two new doctors do a better consultation. I could do the second child, but I've also seen, oh, the worst conversations where essentially, people have not acknowledged that that young person has feelings, that they see them out. A cases in this is this is X, and they've self harmed because they self home, they've done it to themselves. Why am I bothering? They're taking up my time. When there are Children with diabetes that need three, these Children need to just and your care. An empathy will take you so far with vision people. There is a reason why I accidentally get pet patients and or have patients that I worry about for a long time on the world. Um, please don't Don't be me. Don't get highly involved with every case the, um, but also don't have a heart stone. I cannot imagine most of you on here. D Most people who instant pediatrics are wonderful, warmhearted, giving people that just want to make child's life better. But we all have days when we've been on a 12 hour shape. We are not kids on. We just want to go home. And then a challenging clocking like this comes in on you feel emotionally drained so you aren't emotionally ready. Tough. The best version of this conversation you could on it is just worth us being emotionally intelligent to recognize that within ourselves on. So it might be that you take a perfunctory history, so you get the key details. You get the key information. But do you think to yourself Either myself or colleague needs to go back later, have a proper interactive talk with this young person, one that's actually going to be able to move forward on management? Does that make them perfect enough about history taking ah, brief word about the mini mental status test mint. I don't do them all the time in pediatrics. You know, there's some advantages and disadvantages I'm not going to read through to you that you can look at when you watch the video back. Or just you know, as you have a Zyman bill on words, you can read them on the slide. And but if when you meet young person, you're struck by the fact that they're GCS does not appear to be 15, ask yourself these questions and then potentially ask them these questions because if you've got a young person that, for whatever reason isn't able to interact with you on appropriate level, you may not be able. Teo, get that level of discussion about mental health that you want to today. But you might need to address there alcoholism, all their use it, marijuana or other drugs that have weird names that I always think that's, um, you want Yeah, when you when you called drug seems like Smurf and stupid things. I don't understand. I will go. I'll have to talk. Face talked face will tell me what to do. Talk space is your friend, my friends. For a while things and you know there's always someone lovely and the poison service you can phone up and go is again. We'll talk about you will come to the case off. Why go is 12 13. GCS is 12. Why we think they've taken bubble bubble gum. How do I make that better? Well, what do I need to do to monitor them until they're GCS is bigger on, say they'll be occasional Children will do this for. And let's be honest, I I sometimes do do this for young people that present to me with additional needs or send concerns because it gives me a really quick idea of roughly weather act. And you don't necessarily need to do the whole thing because you're not necessarily using it for the exact same reason. You wouldn't say another with dementia, but is giving you a nice idea about if if a child can't remember three objects, then there is the memory difficulty. If a child doesn't have the attention to be able to count down backwards, that might point you in one direction. Where is if they have a flight of ideas? Pressured speech? Can't name objects, feeing then to be on his childhood strokes happen on. They may well be a differential for a child that presents with what looks like a mental health difficulty. Actually, when you kneel down to it, they've got a really subtle right sided facial weakness on the power in their hand is four plus not fired, and you probably need to scan him. So these are all things that are gonna point you in a direction. So my other top tip in life is we came a Z discussed last week and safeguarding was try not to tunnel vision. I know we all do it. I know we all do it, but try and think yourself. Hang on. Let's look at all the horses. But be aware for that zebra because once in a blue moon, that will be a separate. And if you've got a low your ears pinned but and you're I use in your radar white, you won't miss. That's ever when it comes along. Management. My top tip is mental health is not gonna be fixed by using permission alone. Mental health is personal, and it is something that you only really take hold off when you is a patient, Take hold of it. And I can say that someone who suffered with a bout of anxiety a year into becoming consultant because being consulted his heart. And so some of the APs at the end I views myself and all. Brilliant. I'm really make a difference. I'm so I am well aware that you need to be ready to fix yourself before anyone else is going to be able to fix it. But there are things that you can do to encourage coaching to talk, encourage them to stay in contact with friends on their support network, encourage listening between family, encourage routine, encourage thinking well of themselves and others because, let's be honest, who's our biggest critic? Also, we won't know that said, because let's be honest. Medics out there were also, like perfectionists, most of us, and we all think to ourselves a well. We only got 70% on that text. Everyone else got 80% and then reality hits and you go. Actually, some studies pretty amazing, but I passed on. This is medical school should probably be pretty proud of myself. I'm not suggesting that you go to the polar opposite become a narcissist. But I am suggesting that you're a little kind of yourselves a time, and he's said, Focus on controllable tasks and I it says handwashing. I think that can maybe beyond helpful. For those with a tendency to OCD Go, focus some things you can achieve. I would suggest that for any child you see with the mental health difficulty of any kind of suggest making goals a little bit, let you make a PDP things like today. I want to make sure I do the washing up. That might be the only test they do that day. But if they have been in the whole of depression and they finally get to the stage where they can achieve a task and do it well, you should be proud of that. And you know what you'll find over a week or two weeks. You can add onto that task risk so that they're doing the washing up. They're picking out the ring clothes. They're actually having a shower every day, and you're getting that child nearer nearer. It's going back to school because let's be honest, Little steps is the way forward. Those of us who think out there that you can certainly go from being really poorly with the mental health disorder to being fine are misguided. What we really know is that is positive little steps on acknowledging that for two steps forward, there might be one step that, but that that's all right. And as I've seen across my Facebook pages recently across my friend's recently knowledge in this okay to not be okay and they're talking about that is all right. Actually, once you start to talk about it, you will realize that 50% of your consultant colleagues have also have a lot of anxiety at some point. Because being a consultant, hold on so that when you have a good report with your colleagues and you can actually say to each other, you look like you're not having a good day today. You're right on. Did you then feel comfortable enough to go now? I'm know. Okay, on they say to you, get off the ward for 10 minutes, get have a coffee, and you go and sit in your office for 10 minutes. They have a coffee and a biscuit on you feel a million times better ready to go here. That would again, Other said. Being self aware is really important. Having coping mechanisms and support networks is really important, because if you don't do it for you, how can you possibly encouraging person say. As I said, confidentiality was safeguarding limits. So when you were talking to a young person, it might be that they're totally some super private things on. That doesn't mean a safeguarding level, necessarily, but it might mean they're telling you the ins and outs of their relationships. It might mean that they're telling you about the really tough situation. They have a parent. It might be that they're disclosing things about domestic violence within the household, even if it's not aimed at. You know that, then. So as James Wise, he said last week, Whenever you have a conversation, you say to them, Look, this is all confidential, But if there's anything that makes me think that you're being her, well, that someone else is going to get her, I will have to tell someone emotion, people pretty good and say they know that you will keep what you can keep confidential, confidential, but then at the end, I would encourage a to also add on the caveat for mental health. Look, it's really important for our team to be able to look after you Well, that most of us have an ally idea of what's going on. How much of this you happy feet there. So although in reality you're going to write the majority of it down in your notes, what you can do is save a junior doctor face. I'm getting it going. So on the notes, it says that you were going out with a 17 year old boy. He touched you inappropriately on that young person. Never wants to talk about that ever again. And you've already shut down that consultation by just walking in the room where it if you know that that child has had a very awkward relationship, there's got some safeguard and concerns, but they're being dealt with. What you can instead say to that person is I know that you've been through a really rough time, and I know that you've had a really tough relationship. How you doing today and then you can wear calm your wardrobe in your day to day tasks. You're not ruined any relationships, and you're not very many barriers and you'll say you're not very good, actually trust. So it's all about the fine lines of what you can do when you can't. And if in doubt, always ask you seniors always or ask a colleague because there will be a rich wealth of experience between Listen, I know it sounds simple, but let's be honest. Sometimes we're not very good at it. We listen for what we want to hear. We listen for those trigger words like Melena on and things like that. So for mental health, I want you to listen to much more subtle trigger words such a Z when a child mentions that they haven't been doing the normal activities that they love. Oh, when you ask, is there anything they're looking forward to? And they say No. Or when you say, Do you enjoy school? They're like silent will often be in case there's no answer. Um, that's the time where it is to say, Yeah, school is pretty tricky, isn't it? Tell me what's bothering you about school. Take any concerns seriously. There will be some young people with mental health problems that will fabricate. We have to acknowledge that because it does happen or will not fabricate, but we'll be hallucinating. You know, my favorite young person, God bless them with on Dyken Say this with just because we caused it is when you give them midazolam for procedure to sedate them on. Then they seize fighters on the walls. Or, better still, that they access ephedrine on double down the corridor. Oh, on my favorite clocking from my ST three placement in a little when the child had got onto the counter. I've got hold of the open bottle of laundry. Me on was genuinely drum a three year old drunk. It's the best thing you've ever seen under. Worse because that is a safe guarding issue, obviously. But the tiny bit of you that consistent find life hilarious After you've done the key things you need to do, goes. That child was swaying like a drunk. Amazing on they had think to get a stool to get up onto the counter to get the open lung. Breathe on, then, when I'm going to drink the whole thing, excessive medication is needed. Now. You don't need to be an expert in that as a junior doctor, so please don't think I'm saying to you, Ah, this child means SSR eyes knew that is a senior decision. Bucks. It is really helpful. If you've done an excellent blocking to go, this seems a bit more than normal or a bit more than the average a record specialist comes is gonna be needed on the Actually, some medicine might be needed because then you're going to start to have that discussion with a child. You can say to them, Look, I see that the level of your low mood is quite about on Do that. Actually, talking alone might not be enough. Now I need to talk to my my senior colleagues. You deal with. I'm childless in mental health, but it might be that they think some medicines a good idea. And if that's the case, that I want you to know that we will walk through that process with you. As we said, excessive specialist comes as needed. Consider the mental health liaison team. That's more for when you're in a any you've got a situation where you think in discharge on. You need to have a discussion. Consider whether addiction or alcohol services required because, let's be honest, however much We like to think that Children don't need that stuff. Teenagers are teenagers and suddenly, sometimes even younger than that. If you're in an awful situation, sometimes alcohol or drugs. Is there any way out for these young people? They feel like this on we. I am not qualified to get them off alcohol. I am not qualified Teo to help them not take marijuana every day, or we're still heroin or, you know, the hard core drugs. But there are fantastic addiction services out there on across the country. There are child and adolescent specific services if you need them, and you can always ask you adult colleagues for direction to those services. If you don't know well, you comes colleagues. They often have kind of sign pace for those two liaise with social care Now that's not not always needed. But if you've got a looked after child or you've got a child that's been in a safe guarding situation, be that they were found in the middle of the park on their own with a GCS of three. As we will come to um, or whether they were beaten up and you want today, was that an adult. Was that a child? Was that again? You should have also should on Most importantly is we said, give them resource is for selfcare say the problem. Social care you don't see this side is fairly bank because essentially, in my head, I think it's It's like a spider diagram on. When I was doing this slide, I didn't have the time. Or the mental resource is to make us find a diagram. So what we're going to do is do a virtual spider diagram. So the problem of social care is several fold. How'd we more time? Because I am aware that I talk for England. Um, I would let you pull together some elements of the spider diagram. So what you're seeing at home, it may be that you think of things we can add on. So please do Roy on, um, the white board or right on Facebook ideas that you have about what might be issues with interacting the social care in the scenario. Because what I will do at the end of this session is I will make it into a spider diagram from the things that we talked about on any other ideas that you bring in because let's be honest collaborations the best way to work. And so the chief things that heavy hitters in my book is there ain't enough of them. So there isn't enough social care Carries a Z in. There is no shot of social workers. They are time pressured on. Do they often don't have specialists? This specialist training required for very subspecies sick elements of mental health care. So lack of training, lack of resource, lack of physical humans, lack of appropriate beds, Luck of time, Yeah, lack of knowledge, the challenges of pulling together four or five humans in the same room of the same time. All the same Zuma the same time. The problem of seniority, what you really wanted a really complex case is a manager. What you get is someone that's just out of university. And you know what? It's okay to say? Is the medic. Can I please speed your monitor? Because But it's important to acknowledge that that lovely person you spoken to his not plugged. They are not someone that you can walk all over. They just don't know enough. And it is all right to go. Thank you you've been really helpful and really polite. But I know I need speech your manager about this because I know that otherwise all you're going to do when we finish having this chart is found them anyway. And I'd rather just skip that step. And even if that wonderful social worker is going to be managing that case after you've had that initial discussion with the manager, you've sent them in a better stead where they don't feel out of the debt where they don't feel uncomfortable, where they don't know the questions to ask you, they're gonna make a difference, whereas they manage will. So there's the main problems I can think off. I'm sure they're a lot of others, Um, which we will collaborate together at the end. So the problem of comes as be honest, similar spider diagram. Ah, the problem of comes number one. It's been eroded over time. It's been Tier one comes has moved into schools on school. Nurses are fantastic, but they are not comes practitioners. Um, so we are trusting and not just trusting because you know what I trust our school nurses. We are giving the responsibility on the onerous nous off picking up low level comes problems to our school nurses who already covering several schools and I overworked, underpaid you too much. Like many people in the Jets. It is unfair, in my opinion, that we do that now. It is what happens, and Subway is a system that for the majority of the country kind of works. But we also know that lots of Children's look through that because of this on, because it is tricky to get into Tier two or teeth. Tier three comes despite the fact that you can self refer, and despite the fact that there was such a level of need out there on, that is one of the problems. The level of need, the level of need is high, and he is getting higher than it ever was. Pre pre lock down on Precose did are we need to acknowledge that comes now very much. Take the worst of the worst of cases on the actually is GPS any stuff and pediatricians you're going to be seeing more and more Tier two and Tier three or keep three cases that you're going to be managing. What do you want to or not? you're gonna be managing on day, you're gonna be taking advice from the comes professionals. So there are two or three cases that I run entirely myself. But well, okay, on occasion, when I come into a challenge or come into a bit of er not really short to do here, we'll phone apart. Wonderful comes consultants, or comes nurses and get a look. I need a bit of advice on this. What can I do? Next on It will be the work of 2030 minutes. Instead of the work of for 5 10 hours. That comes practitioner. They were managing that child themselves. So we all went in the service a bit. A bit like that. We need to get behind our GP colleagues when they're being bashed in the media. We would need to get behind our cameras colleagues When, Let's be honest, I have days one might comes. I hate you. All I want to do is refer this child to you on all they need to do to get home. It's for you to come and see them. Why did it take you 12 hours? And but we need to remember that individual comes practitioners or not, they're twiddling their thumbs going. I can't be asked to go and see this child with an overdose on that. What they're actually trying to do is trying to manage so many Children. I'm trying to do the best for so many people that they can't be the best that they wouldn't pay. They can't deliver the service that they had ideally deliver in an ideal world on, we just need to be a bit mindful of that. And, you know, I say that to myself. A much is to all of you, because, as I said, there were days when in the heart of winter, when there's 40 Children on the board and flow is awful and it's a consultant, you're in charge of discharging or doing wardrobes. Kind of 23 times a day to discharge. When you've got a cancer patient has been there for four weeks and you think in. Come on, come on, pull your finger out and that we re perhaps need to Teo, give yourself 32nd Think. Hang on, Helen. Is there a reason why this might be? But we also need to be good advocates if the has been a delay. We absolutely need to champion for the child, but that's not all right. Um, but we just need to do that in a in a kind of professional manner. Say we for our long term patients and cold cell. Have a great system where the matron consultant, that comes consultant or nurse on the name dinners. That child has an MD tea, usually on teens once a day for a long time. Patients. That means we can have a five minute, 10 minute check in of where our progress is. So that way we can feed that back to the family. And so that be We all know what we're doing because if we don't talk to each other, that's where we all for that say is the main problems with comes. Sure, there are others like yes, what? We don't have a tick service. You think, Oh, what ticks is Definitely it comes disorder. Let's be honest on neurological colleagues of finding new and exciting ways of using drugs that I use for A for Children with spasticity for ticks. Um, that I am learning about every day and go Oh, you'd like me to use, um um, trihexyphenidyl. Or you'd like me to use some clots, um, and quantity for these Children. I feel a bit uncomfortable about that, but okay, let's walk through that process together and learn. And so sometimes the medicine in. And to be honest, as you become more senior, you will realize that there is a little bit of focus focus, that is, that is based on fact. Um, but hocus pocus comes with going Okay, so we're moving into using this drug in a new field. We've seen some evidence that it might help, but for this patient, we're going to have to do a little bit of tweaking. Let's tweak with hand holding that might be. You have being handled by another consult. That's done it before. But maybe you holding the hand of another consultant because you've done it three times and they've never done it. And that is the beauty of having colleagues. My top tip in life, aside from just mental health in in in Children, is when you decide forever area of medicine, you separately, and eventually pick the place. You weren't based on your colleagues, not on your specialty, because the people around you that you have is your backup or you have is your extra brain. Because that's what I see some of my consultant exiles, my spare brains, and we'll found you in good stead. So I know the time. Not good at cardiology. I could read any C G. But if you give me a 24 hour tape, I look at it, smile it it and read the summary on the front home on. But I can't really interrogate that data well, whereas I will walk it down the corridor to my colleague Khalil, who is our cardiology need locally. Oh, can you just read through this and just make sure there's nothing I really need to worry about on it? For him, it's a motor work of moments. You will do it in two minutes and you're like, Yeah, it's fine. But he will come to me having a child with, um cardiomyopathy and say this time, really, we call him, and I have no idea why I've done a CK, and it's normal. Can you see them in your new a disability clinic? And I'll be like, Yep, that's that because none of us are in island and none of us know everything. Um, the biggest revelation from when I take a went from being a registered being a consultant is consultants are very knowledgeable. That is true that nobody knows everything. I genuinely thing that especially as a junior doctor, I believed that consultants knew everything because they seemed to because they seem to always be calm in a crisis on they seem to always have unanswered award round. And some of that is because they've got years of experience. Um, some of that is because they've got team of 10 to 15 colleagues behind them that when they go for a coffee break the gay guys, I've got a really tough case on the ward, really not sure what's going on. I've done X y and said, Can you think of the investigations to do? Next on, you'll have a 3 to 4 people level interaction where you'll make a new list together and you'll come back to the ward and say to the junior doctor is okay with that GI X, Y and Z test. They've poured, you know, dots like how those do they think of that? That's because six brains work on it. together. So So there is some wonderful magic and jiggery pokery that happens behind the scenes that that perhaps you don't waste you all over the moment is a junior. But that really does happen. Consultants are are not infallible. Consultants are not all knowing they are experienced, but they Absolutely if they know what they're doing. Share cases with colleagues because you get to get the best outcome for the patient that way. Sorry. I digress. So okay, studies say none of these written down because I want to walk. You treat them slowly on Big N I. I am terrible. Terrible. I very much him. Um I'm the kind of person that when I'm teaching on on G I c o r a p l s. I like to talk you through case studies and get you to shout back out. So that may know I know what a webinar. It's very difficult for you to shout back out So that May s O if you could shout back ounces on Facebook and I will just fill in the gaps where I would hear your voice is for today and then that's what we'll do. I'm only going to take you through two or three cases for the for the benefit of time. However, when you get the feedback for this session or the question and answer if there was a specific type of case that you are interested in or worried about, please ask because I can think of a case for almost all the things that we've covered. Say Case number one young lady off 13 presents with a three month history of weight loss. She used to be a dancer on a gymnast. She's now skeletal. She was been referred by the comes team for query anorexia nervosa on heavy am I is 60. You are the junior doctor on the admission gene it, and you need to clark her come up with an investigation plan on initial management plan. I want you to just have two minutes to think about what those would be. So my top tips are Think about what key things you're gonna be worried about. Think about what problems are severely low. B m. I give she think about the problems that having not eaten for a long time gives you and how you gonna check out with any of those need management? Keep going. I guess As a current junior doctor, I can have a slight stab of this. Well, we're getting some input. Um, so we were previously talking about starting nice and opens kind of what's been going on recently, Um, explore any pressures that are school or from dancing and gymnastics, both of which least historically can have some pressures on. Kind of wait on Desai's, um, once kind of got a good history thinking kind of investigations. A medical school. We always have to spit up into the bedside bloods image it lovely. Um, so at the bedside, we're going to start with, uh, I think I would want a blood glucose. So I'm also play with my dog at the same time to stop her from whining. Um, well, what I want to do, I would like a height and weight, so I can I mean, we've got being I You already told me that. Well, I don't want that because, you know, I want to have a look at it. Um, kind of a Also be looking at as well as daily weights. Kind of fluid and food intake out. Take on thinking about some bloods. Definitely want to get you. And he's particularly if we're gonna be changing this person's diet, thinking about refleeting syndrome with things like that. So as well as those, um, these were going to want a bone profile to look at the phosphorus calcium. Um, again, I think. Let me have a quick look. Got someone is saying that they would do a c excrete. That seems like something quite sensible. Very well, I could do that. Yeah, that would be Yeah. And I think that that's really good point. We'll see to be thinking about some of the organic causes, so, yes. See, accidentally be one of thumb. Um, I did. I got in some cheeky TFT is a swell for that reason. Tease your shorts and acting test. I don't know. He would get another X You with medicines, but so I'd probably know. So So a short acting great idea. But we'll follow your second line testing me. You want to be looking at expectations on looking at your feature on clinical examination before, before perhaps doing that test? It wasn't immediate. No, that makes perfect sense. Um, and I will finish with, uh some sort of skeletal survey to see kind of bone density there. Thank So that's more of an exam on. So then I think a practical one. I can think of one child. I've done a dexa wrong for eating disorders on. They had extremely severe demineralization bone on their bone age. So if your growth so so, of course, with things like anorexia, you often see very skin Children. But hopefully you don't see very short Children. If you see thin album short, then you want to be doing a wrist X ray traditionally left to look for bone age to see whether it's appropriate to their their chronological age, because that's gonna make you think about we were endocrinology tests. So be thinking about things like your hormone profiles your your, um, your testosterones your prolactin. Yeah, um 17 OHP. He's on all the kind of things that I sometimes check with my endocrinology endocrinology colleague for the full list, because there's always one I met on DHEAs, which I could never remember the full name off. But it's okay because you can find that that's just based on that. So, yes, I do. Please be thinking about your potential organic causes because they are those episodes that occasionally sneak in her to trouble you on, uh, my particular favorite on that account with a child I saw in Bradford. So it was a young lady who, of course, with wearing a hit job who was very anxious. He was very touchy. Called it, um who was very thin, Whose B. M I was was perhaps 19 or so. So not terrible, but but not good. Um, and I I came on for the night shift on was 100 over by my my day junior doctor colleague that the that I needed to decide what blood when he did and finish the work up. Anyway, I went in and I was like, Why is this kid so tachycardia? She's not accepting on D. I had a look at her neck and she had a massive goiter that had been hidden by her his job. And I was like, we might need to do some TFT is only my friend. I'm friendly enough That walked the cause. Um, on my colleagues were astounded, but this's not like I I I'm a practical, simple person. I like simple things that is why I'm a pediatrician and I I like talking simple words. I I don't like long words, which is why I find orthopedic letters challenging to interpret it times. Because I I work in a world why I work with feed. It's a lot. And I sit in my clinic going Oh, is this quivering like the other one? And I just want to say the foot is turning inwards because that is what I see on that is what parents understand because we use a lot in when it's a beautiful language. But we don't need to use it to confuse our colleagues or a patient. Um, so yes. Um, but in this particular case, this young lady and had come with a potential diagnosis, one of wrecks here on. But we did indeed to do all of those tests except shoots that that have been mentioned. Andre all came back as normal. Other than her left her electrolytes, which was slightly out. She has massively dehydrated. Her urea was approximately 20 initially on, say, for the first night, we did actually need to fluid resuscitate her and not not in terms of fluid. Bolus says per se um, but we did give her a liter or so over the 1st 24 hours of her stay with us, and before we started giving her more food as well. Um, on be to add to your list of things like magnesium and zinc. So you're thinking about your trace elements that are really gonna make a difference to potentially remembering potentials that, you know, magnesium is one of those things that I forget effects remembering potentials until it affects member in potential. Um, and then you're like, Oh, gosh, magnesium. Yeah, I remember that. If that it stabilizes the membrane, if you don't have enough things, go about, um, on, Then then say to yourself, What is the level of a for once a veteran cooperation? I have vision, person. Oh, my brain skipped a step. We all forgot that we always need to check BP on. We always need to do any. See GI on a child with anorexia because they will often have A with me is secondary to the electrolyte abnormalities. So a baseline EKG and a baseline BP is very helpful. Baseline BP is helpful because I'm sure many of you will be aware many of them have blood pressures in their boots because they are either dehydrated or have been living off so little reserves that their body essentially goes into seven. Shut down on only does essential tasks on so their systolic BP may only be 90 which, depending on the age of the child, can be quite terrifying and on their heart rate may well be 40 normally on. So you will have to think about setting your alarm that it's differently, otherwise, necessarily be very distressed on. We'll call your register all multiple times overnight because their heart rate is 37. Like they're asleep. All they not yes, from their heart rate's only an average of 44 when they're awake. Yes, don't worry about them unless they're blue or their oxygen saturations are. We'll just give him a little poke. If you feel very worried, Um, and then management management for things like anorexia. As we said, look at the marzipan guidelines. Fantastic. Uh, try and get a specialist dietician to see was possible. Ideally, had comes specific dietician, but in reality we know those take a week or so. So get your local dietician seems possible if you can't do that, make a sensible plum. And by that I mean, if if what you're talking someone, you get a rough feel that they have been consuming about 200 calories a day. Don't came for what they need to be going for, which is, like 1500 implicitly sensible, like 500. And then you can build up over a few days. Because, of course, refleeting is a real thing. We need to be mindful of that. And also stomach's gonna have shrunk down to the size of a pain ups. Um, and if you try and give it more than slightly more than peanut sized amount of food, they're just gonna vomit, and that's going to create an even worse cycle for them. So you need to introduce things slowly, so it may be that you give a high calorie concentrate small volume for a few days until you Kenbrell go up to more normal food. So it may be that you essentially say to them for a couple of days you've got a license to eat cake. I want you to eat cake and a small portion of cake and that will be your food for the day. And then in three days time, we'll work up to chicken. So that case number one, is there any burning questions that have arisen from that that have come on any brilliant? It's a case number. Tea. 11 year old girl found unconscious in the park GCS of three came in viral, um, with the parents and was found by the any team to say This child, GCS is three. Can we bring them up to the ward? And of course, they weren't no nobody. With a GCS of three, you should be on the ward immediately. So the register I went down to assess them, confirmed that they're GCS was not three, but was in fact, no. Because, of course, if your D says is really three, you're not protecting your airway, and you probably need the anesthetic team, whereas if you're Jesus is nine, you're probably snoring, and you may or may not need a good L Airway, which is what this young lady did, and your then sitting on the waiting game of what is this child going to wake up and what textual I do in the meantime, so that's what that's. That's my chief question today when you have a child, he's been found unconscious in the park on their own with a G CSF somewhere between three and nine. Who, When you get the water to them on the ward, you put them in HD you because that GCS is nine and is maintaining their own with with is maintaining and tolerating it. Good Alaway. What investigations are you going to do on what thoughts they're gonna be going through your head in terms of what other organizations you're gonna need to involve. I'll give you 30 seconds to a minute type of thing. So I guess having a quick think from my perspective, uh, things that could cause someone's kind of pass out in the park, It could be a cardiac cause something like a fit a seizure. Um, given the nature of this talk that we're doing, it could be ingestion, deliberate ingestion of a toxic substance. So it could be an overdose. Um, similar. It could be alcohol or accidental overdose of an illegal drug. Um, what other things were also gonna want to look at their blood glucose and think Could this be something like hypoglycemia? Um, and there were things I think that we can kind of then used to look or investigations and history. Assuming this person wakes up, um, on one of Ah, you was currently san s e g BP. Yeah, absolutely. Definitely getting. Okay. So for this year, lady, we did all those things. So they're great suggestions. We also did a urine tox screen when we managed to get a urine off this young lady. Um, on that urine, tox screen showed marijuana. We also recognize that she smell of alcohol. Um, and when she woke up, we had a very interesting conversation that went along the lines of Who were you with? She was with young people older than her. So she was 17 year olds that she knew. So she said she went out with friends. Um, then not necessarily on the immediate time you have that conversation, but you need to be thinking about Are those appropriate relationships? Is there any safeguarding concerns there? Is there any parenting safeguarding concerns in terms of either? The parents worried that they're hanging around with a bad crowd form of a better word. All lack of parental supervision. That means that going out and joining such groups on often need often. Suddenly, it's a combination of those two fractures, like someone in the trials holiday. Exactly the same thing. So so burning team. Why I was a child on their own in the park. That's such a young age of that sort of time. Um, someone else's even wanted out, You know where they could have been assaulted. Could there be something else going on? Rate thoughts, guys. Great thoughts? Because, let's be honest, I've seen cases that would fit with all of those things you mentioned. Thankfully, Listen, lady have not been assaulted. Should have any bruises or injuries. Um, other other than the knock to ahead where sheet conked over. And thankfully, that was fairly superficial. Um, she admitted that she'd been drinking so most of the day with these with these other young people. And but it wasn't until I said to her. So your urine toxicology has shown that that's the marijuana. Yeah. Did you smoke anything on D? Um, as long as you're fairly open, most young people and let some some young people will come up, but make sure people like Yeah, actually, I did. Um, That then leads you into a nice conversation of things that that is that something regular that you do. Is this the first time you've had this kind of reaction? I am on that. Then leads you down the path of Is this marijuana? Its own Has someone joke to my wallet? So you're looking at a worse safeguarding issue than you thought. Because then you begin to think, Do I need to involve the police as well? A Z social care on The great thing about safeguarding in pediatrics is often you'll have a three way conversation anyway. So the police safeguarding unit will will be on your kind of little MBT. I space out the moment. Let let's be honest, most of our mg t s of I teens or zoom or whatever platform, uh, secure that we're using. And on the lovely you safeguarding policeman will go. This family are not known. There's no role for us here, but in this case, they said, actually, we have been worried that there's been some tainted marijuana happening in Huddersfield. Um come, you get an extended tox screen and then you'll be off to the lab and ask, um because let's be honest, a young person who, with alcohol on marijuana, doesn't wake up after 12 hours cause it was 24 hours before this young person wake up. I gave her a shot of kept track soon in the end, just in case it was many jobs, um, pulled off. PCR is just in Case it with meningitis. Um, because it is pretty rare to see a young person's come in with, even even with a fairly significant drug overdose of a recreational drug that doesn't wake up until 24 hours post the event. Um, so this was very much one of the cases that I just got back off to the consultant corridor. And you guys, this child's not waking up. I don't know why I've I've I've sent of bloods for explains edge on there like you said, the urine toxin. But yes, I've sent a urine tox, so I need to speak to talk base. And I did actually speak to talk space, and once we got the extended urine toxicology back and said to them, Look, you come across any cases where marijuana is caused this level of problem on. Then you find out because talks days know so much more than you do that. Actually, there is, um, newer synthetic batches of marijuana being brought out that are much more concentrated on a much more dangerous, um, can cause significantly more side effects than their previous counterparts. Never like, Oh, I feel richer and knowledge, but no better in protecting this child. So is that any questions about that case? Fantastic. So let's move on to our final case for now, which is, um, essentially a sanitization or or medical presentation. So I saw a young man off 12 that presented with recurrent vomiting and headache. So he came into my clinic, looked pale as a pale thing, as in white as a sheet. He was an anxious young man. Um, but but great interaction. Great. Pretty great insights. He acknowledged that he he's he suffers with anxiety. Um, on we had to discuss together an investigation of management plan. What do you think your investigation of management plan would be fishing? So you're saying he had some some vomiting, current vomiting so daily morning vomiting every morning, every morning. Also, every lunchtime cut on. But the first one is probably a good, accurate timescale. Diarrhea, you know, Is this happening on weekdays or days when certain activities, perhaps ah, going to be happening at school or on the weekends with P Sports Drama Club, Whatever, whatever the impressive having a particular difficulty with or, you know, maybe going to either mom or Dad If you know their parents separated over the weekend and again, it could be just weekends that I have this, that there's a little great. And once you got to the bottom of that, is there any Is there any kind of red flags for medical conditions that you want to be ruling out from what I've told you? So in our chat, we've had some suggestions to do your knees on some list of blood sugar is, well, teas. Um, yes. I, uh I guess kind of you having the blood sugar is definitely an informed one. I think that's definitely a essentially kind of your red flag. Abdominal pain Could be someone in, and I think this'll child was pale. Pale thing is, and I have very rarely seen. Seen a child walked to the mission room. What else you gonna be want to be doing? I'm hoping that your brains are wearing even thinking, Helen, I'm gonna be doing a full blood count and a blood filled. Um, because I did, um, on that you might also want to check the ferritin level. Um, you know, dig down a little bit into whether they drink shed loads of milk. So he's the wrong age to be my typical patient with severe iron deficiency anemia. But let's be honest. I see it a lot. They tend to be the toddlers that have a diet. Often 90% milk on day, 5% food, Um's their parents Didn't efforts eaters and you say to them, Have you tried giving them less mill? So they're not full of the time, like, but they crime, like Children do cry. You have to put up with that. You need to introduce foods. Thumb. It is good for them. It's has minerals and vitamins on devolved them, not being iron deficiency anemic. So we did that his his red cells were down with him, and he did need a lift with vial. Suddenly, that was not the thing that made him think you get, um, you'll be glad to know that he had a completely normal blood film. Didn't have any hideously Kenya or things like that. Which, let's be honest, I have sadly seen one case that presented, not so dissimilar, they had, like pain no more than abdominal pain. Um, you can occasionally see brain tumors presenting this way sadly, often the ones that got Max, because by the time it gets the point where you were super pale, that is, that is the anemia of chronic disease. Um, and your red cells, usually in your boots. By that point on, you're in need of transfusion on sometimes platelets. Another useful nice things that hemotologist give you. Um and so there are lots of potential medical diagnosis there. I looked into gastritis and ignition ransom PPI, see if it helped with his vomiting but actually won't really helped with ah hearty dose of propranolol helping his migraines. It helped with his abdominal migraines, which were actually what was triggering the abdominal pain and vomiting. And when he had a particularly bad episodes, we also gave him some um on dansetron to help reduce the vomiting, say that it wouldn't become a vicious cycle of being worried that he was going to vomit. So kind of vomiting up in any way, Um, in a brick period of two years. He knows the pink is child. I look after he now does sports. They now go on family holidays. They weren't going anywhere, that the quality of life was horrendous for the whole family. Because of this young moms challenges. Um, and I also got him support by a low level comes on. But the difference between the young mountain that looked to his feet that was pale as a pale thing that let his mom do 90% of the talking on the young man that now tells me about his favorite football team. When we agree that I'll see him in a year just to make sure he's all right before discharging him is beautiful on That is why medicine is excellent. When you're getting it right, you get to see people much less often. Get to talk about some things more than you talk about their diagnosis. It's and that's what most of us are aiming for is actually the time when you can. When you can wave to your regular statics and go any admissions? Are you remembering to take your Proventil inhaler? Have you had any oral steroids this year? How often you using your blue inhaler? Let's do a quick peak flow. Let's have a quick listen to your chest. How's school going on? Then you have a nice just about their their their current recreational activities home that where you learn more about them. It makes the consult consultation so much more enjoyable for you as a practitioner on also, it makes it much richer experience for that patient. Any questions about kind of what I'm going to call generic so materialization presentations? It doesn't look like it. I think everyone's just quite happy to have the answer. I think it was quite a uh yeah, there are lots of lots of different suggestions or very sensible ones. Yeah, I wanted to know, but it wasn't the it This young man could have been any of those medical conditions that that many of you suggest it on. That is why your surgical save will never be a problem on will always be in essential Torti, regardless of how seen you becoming medicine. But as I said before. The key thing is thinking of those key test. They're going to rule out those heavy hitters v eight. So essentially this young man, I don't think I did a lefty's on I did. TFT is to see the X screen a full blood count on do a film because his headaches were so bad. We also did the MRI, um, headaches or one of those things where you have two options, and it's very much one that you need to discuss with the family and the young person, because you could either watchfully weight. I'm not scam. All those that really anxious will have a really significant family history of of on collectible problems. It is best to reassure them and reassure. You need just scan early, but then don't scan again, even if the headache changes. Unless there's focal neurology associate It all were. You do a bit of a flex. Um, let's be honest, flexes where I often sit. We say, Look, I don't know what she's come today, However, I want you to keep Headache diary for me for the next two weeks. If things change, I mean, she phoned my secretary on Then I will request that MRI scan if it's necessary. So then they're not waiting 34 months to see you again. Let's be honest. That is the average weight time, however much I've loved these, um, these patients in two weeks or a month or two months time and I give my secretary is the open door for those patients to come back because it's a two minute job for me to request the MRI on E p. R. On a two minute job for me to write a sentence, saying this child's headaches have not improved or got worse. Therefore, as discussed in the consultation, an MRI will be requested on. It just means that that level of trust between you and that family is just maintained. You are no accidentally because, let's be honest, was deliberately make patients wait for things you know accidentally make him wait twice a long for tests. Um, and yet you're not ordering tests unnecessarily. It is a fine balance. We will get it wrong. Let's be honest. I get it wrong. Um, well, we're not in frequency suddenly, but I try and learn from those incidents and take them forward. Say that the next time I see a similar case, I don't do the same. So Q and a time? Is there any burning questions? You wonderful people have a lot of mental health and Children that I might be able to answer. There are some things, obviously, I'm not a camera pediatrician seen lots of Children, mental health difficulties. But if there is questions I can answer, I do have an excellent friend who is a counts pediatrician who I haven't. The end of text message that I can always text your textual questions to on get you answers within the next couple of days. Okay, No burning questions. Air coming in at the moment. But by all means, if anything does up over the next day or two, I will pass it on by a milk itself. So my key takeaways, see, What can you do with the junior doctor? You can listen. You cannot judge because let's be honest, we do it all the time with our friends. We think, ah, they're new girlfriends off. Oh, Onda. Some of us may keep that to ourselves. Some of us are terrible humans. And tell them, And if you're protecting your friend fading. But when it comes to your patients, don't judge thumb, be open, take any safeguard and consent. Seriously, as we mentioned last week, you do not need to be there, counselor, So only offer constructive advice and activities on that might be for destruction or as a way to move them forward. You were not accounts practitioner. Unless you become a comes practitioner, Um, please work within your limits as you would for anything else with the medicine. Key thing you can do for that child has helped them to take control of their own situation. Give them back some of the power so that they do not need to seek power in inappropriate coping mechanism such as self harming, such as taking Overdose is such as developing an eating disorder on be the sign post that is also your biggest role sign post to use for resources on which nights his of a mine. There are wonderful things on practitioner health. There are wonderful things just on the instant in general, I literally googled mental health in Children under this wonderful 10 ways, parents consult fort, they're Children, build positive mental health habits came up, so I'm full enough. None of it's rocket science. It's things like Help them problem. Solve efficiently. Talk to them, let them get some exercise and, since leak, feed them, encourage them to think positively about themselves. Praise them. When they do well, try and work together. If they are having a meltdown, give them cuddles, not shouting all. If they need a minute, encourage them to breathe deeply and encourage them. Number 10 is essentially what we said is the most useful thing you could do. Encourage them to develop autonomy because autonomy is the thing that is going to make the biggest difference in mental health condition. With that in mind, we've got our youthful resources on the right now. Some of them I have looked at some of them. I have just taken from the top 10 tips of comes in various different regions. I like how some different comes. He was different. One. The ones I find the most helpful at the top because I've either used them myself. Um, because they are just wonderful services. So the summer is was developed from somewhere down cells. I want to say Bath, I might be wrong. Heard might be Bristol someone that begins with a B, I think, Um, but it's an out. You can easily go on your phone. It's free. All the content is free on my favorite thing. That it did is that you could explode. Your worries. See, right now I was wearing You be at school. Mine was clinic wrote down clinic, and you press it and it explodes in front of you or it's visually really beautiful. Exploded. Your worries is fantastic. Suddenly having looked on the summer recently, having not needed it for 23 years can't explode or worries anymore, or I couldn't find the easily. What you now do is you can float your worries away, put them on a boat and send them off. That's interesting. You seen them, uh, worry monsters. A little stuffed toys with really love Worry Month is I have given a worry monster to my two nieces and my nephew on my nephew became a worried monster, um, after Halloween, because they went to a terrifying circus. Well done, my sister and he became worried that monsters would come out of the mirrors at him on, but, um, my my sister and my brother in law. We're encouraging him that monsters aren't really, I think, to an extent that's a helpful. Because, of course, we all know that monsters are really they just happen to be people. Um, not necessarily the the thing off nightmares. So instead, I reminded Gene that they have a worry monster on that. What Miles should do is write down his worries and feed them to his worry monster, and that therefore, there was some good months is out there that can take away is where is on within 24 hours He was sleeping again. Go, go on CNN and the other things you can do in the summer. Ah, you can mindful mindfully color. Oh, it's hilarious. And I think coloring is a wonderful thing. When I was anxious again, I found great, great calming in those very complicated coloring designs and now, now deliberately designed for adults. Um, because there is something wonderful about neatness within lines. And, um, you know, that just plays up Teo. My slight stationary related OCD tendencies, and but they can be very helpful. But on the up you get to pick a serene picture, whichever you find most urin. So things like beaches is a picture of bees. Clearly, some people find be for a serene um, or some like beautiful mountain ranges or a snowy landscape on do it. It makes it all all misty for you. So it's all covered on what you congenitally do with your finger is gently uncover your wonderful picture of peace. I don't know if that significantly helps young people, but I found is an excellent distraction, if nothing else interesting. I just wanted to highlight someone has a question in the chat. Um, so they said that they are a PA student. Um, they come across this issue a couple times on placement. Um, where eventually a child has had a social worker at school bonded really well, seem really good improvement in their kind of behavior. Mental health? Um, they they moved to secondary school, lost contact with the previous social work, have been told there's a six month wait to get a new one. Little delays on essentially, they take a massive step back. Um, so the question we have said is what kind of would be a good course of action apart from, uh, talking therapies? Because again there was a very long way in the cases that, um absolutely, as we said the problems. As as we said, Our spider diagram with the problems with social care and the problems that comes Wait list is an absolute cracker. We all probably know from our own experiences of times when we felt not amazing for whatever reason, that what you don't need is someone saying In six months time someone will talk to you because in six months, but your friends, your family yourself, you will probably be better. I am on that that point it is useless. You need something to help on that day, which is why I remember the name of the app. Please write down Kuchera O T H. That is at least the Yorkshire in the Humber system that young people can can go on to on get immediate help on by immediate help. I mean, at least during the hours of nine AM till nine PM some one man's the chapped so that someone could get on and kind of essentially MSN Messenger, a trained, comes professional to give them some immediate advice. It's not a program with CBT. It is not kind of intense interaction, but it is enough to prevent them from self harming or prevent a crisis. Um, on what that that wonderful practitioner can do is then direct them to helpful Resource is so some of the other things I said on here some of them are talking things like child line and Samaritans. Headspace is wonderful. I would highly recommend it even if your head doesn't eat any space. If you think your mental health is perfectly perfect, still download headspace because there are a lot of ways gonna be days when, for whatever reason, you've had a really busy day. You've had an awful recess case. Even if you've managed it beautifully on your head is worrying like a cycling. And you've got another long day tomorrow and essentially you're up till two am like buzzing giving oh, a conflict at this case at my head headspace have some beautiful mindful meditation on. You know, I was very much one of these people. It was like mindfulness want. But on also meditation, that's for your GI bears. Um, hum on. Actually, it's beautiful and I've played it to my friend who had a break up. He was asleep within two minutes, and I have never got to the end of of a relax a shin session. It was in headspace before I'm asleep. So if you have any issues with sleep headspace or is brilliant, there is also some very specific focus things about depression, anxiety, other mental health difficulties. But I'd highly recommend it. It was the thing that once it's funny that nobody talks about mental health until you're talking about it. It was the thing that once I started talking about my anxiety to my colleagues, I found out that about 50% of them were using um, one of the beautiful things. It doesn't encourage five minutes of mindful meditation in your car when you get to work a day. If you are, someone is anxious or becomes anxious about clinic, and I really hope none of you ever do. But let's be honest. Suddenly, most of us, at some point in their lives, have a bout, however brief, of challenges with all mental health on anything that could make that better. Just just means you don't stay in that whole first long and and essentially it's thinking about the kind of weight of your body against your seat in the car thinking about your breathing, just being really aware of where you are in the moment, Um, it could be sometimes really challenging to be in the moment when you're when you're a doctor on your you've got, you know, 20 different things wanting you and 20 different directions. But I really encourage you to take even those 23 minutes day for you to ground yourself because we do a very difficult job. Onda are in situations where we go from run crisis to another, and even if you're not going from one crisis to another without intention, you take on the emotional baggage off the families you meet, even if you manage to put them away at the end of the day. And I know some fantastic colleagues. You do that way better than I did. Um, but you need for yourself a little tool kit off ways to manage that. And, you know, for May I play my rock music really loud, Um, or better still, nobody can be sad listening to the song Duck Tales, which is the theme to into a Wonderful eighties carting if you could be sad and listen to duck tales. You're a stronger side. First time I am because even when I have had a full out with my boyfriend and we have had a raging row, if I go in the car and put on duck tales, I cannot help that smile for you. It might be something different for you. It might be your Children for you. It might be a dog for you. It might be going to somewhere beautiful where you can see water running. I find surfing is a brilliant, um, care for my worries in that when you were out there with the waves, nothing else matters and find what works for you is my top tip. Um because it will be different and it will be different a different seasons of your life. But whatever it is, take that time even when you feel you have no time to be nice to yourself. On is the thing that people told me over and over again when I was in. Well, Onda still remind me when we're in the heart of winter room Oral tail tick? No. Is that we need to look after ourselves. We need to look after each other and we need to be kind of to ourselves because I still find myself even on my good days going. Oh, Helen, your, uh, your inbox has about 20 letters in it. Why you don't read them yet on. I'll remind myself that I've already addressed all my email inbox. I've already done the whole would round. It's only 10 AM on. I should probably give myself a break. Um, on the by the end of the day, I'll have read those letters and responded to them on that We're not a super model. Your local cams website or the local offer website from the CCG can be helpful. And then there was some brilliant things that I haven't tried but are highly recommended by comes units up and down the country, so worth it Sounds amazing. It zits. I think it was set up by a school. It's essentially trying to encourage Children that they are worthwhile. How awful that we have to encourage Children that they're worth while bucks. If it's the only place that's doing it well, please point in that direction. What's up close toe? What's that? But essentially doing that mind shift mood path. Mood track diaries all work on a similar idea. What kind of tracking? What your what your mood is or changing how you think about things. Because let's be honest. Mental health doesn't go away. We all have mental health challenges at times in the lives. That's how we deal with that. We'll think about that. We'll process it. That is different on Do the the way that I deal with the problems that still exist, that I have no control over. When when my patients turn up for clinic, even if they're 20 minutes later, I feel guilty and feel I have to see them anyway. That used to really upset me because I'm very organized on I like my clinic to run to time and get very upset if it doesn't mean to time friendly enough. When you change your thinking, anything I'm never gonna be able to control when they get here, just gonna have to see them when I see them on. If that 20 minutes late for their appointment on their appointments only 20 minutes long, I have fully within my right to say to them I will re appoint you or I'm fully within my right to say, Okay, you've got five minutes. We will go over the critical problem for today, and then I'll invite you back in a few months' time on when she shift you thinking suddenly you go from having more. He'll mountains to mountains the on even, Um, a little smiling mind. I just love the name. All haven't looked at it myself, but it sounds great calm. I have downloaded, but I've never tried mindful powers. Sounds great. Essentially, from from from from the, uh, picture looks like you're in trying to encourage your mind to be a superhero, which I think is brilliant and then even better for me, reminding Children that they sometimes need to take the time to listen to themselves. I just found this beautiful picture that just really in calculates the the encouragement of of what can help cultivate good habits that encouraging Children young people to do things that make them happy. Do you know what that will, as we said will be different for everyone that might be going for a walk with their dog. You know, we've all heard stories of when a dog being introduced to the family of an autistic child has led a child. Start speaking when they never did before. Um, or it might be that that child hates humans, as in, they are quite a socially isolated young person. My ex husband was quite a socially isolated, isolated person on much preferred the company of our reptiles and actual people. I'm actually giving him 10 minutes to hold the snakes with much better than trying to encourage him to go to the pump. So it is all about thinking about what that person he's gonna find beneficial for them unaccepted, that that will be different for all of us. But the encouraging them to do that wonderful thing that makes them happy is gonna put them in a positive track. So in summary, Children's mental health really matters. It impacts on every single elements of the rest of their lives and on every single element of their care. It affects our Children with comic disease. What I didn't touch on and what we could do. A whole of electron is about how killed in with chronic disease such as diabetes, celiac disease, asthma that severe Children with additional needs and cerebral palsy have a very interesting self worth or world view that is offered affected by their mental health on DNA. Not having psychological resource is or resource is to be able to give these young people means that fundamentally, you could be trying to manage their sugars with insulin all the like. But they will still have hypos or extreme high is because you haven't managed the fact that they don't want to inject in school. They're embarrassed. It comes into every area of your life personally under them work, and it is well worth giving five minutes to have a low Think about thank you very much for listening everybody. I would really appreciate your feedback. And obviously this is Ah, this is a new set of Webinars. I am very keen to improve if there's anything you want to know about that we didn't touch on, or if there's any of the format that you'd have preferred to be different. Please, do you tell me I will not take offensive long as it's constructive. Uh, um, please do give us a feast that we really, really appreciate it on. I really hope you enjoyed the session. If there are any questions, please. Do you send them in? Okay, thank you very much. That was really informative. Lots of interesting, different things. They're very much enjoyed the cases. You absolutely do get on, give us and pee. But we genuinely read it all on. We take into account when we make the next webinar. Um, just Well, we've got this up on the screen. Just want to touch on a couple of other things. Um, So first we were taking a break next week because there is a finance webinar from mind believe going on at same time. Um, so we're gonna have a week off, then return the week after. So keep your eye on Facebook, keeping on your emails, and we will let you know about the session that's coming in two weeks' time. I also just want to mention our new sponsor as well, which I think is CPD me, which is a website that provides you with lots and lots off at different webinars that count towards your portfolios. Whether that is for GMC or the nursing equivalents of the n N. C. I think, um, but through monthly, using the you are code we put up earlier in the Webinar, you can get 50% off, which is 8 lbs full year's access to a smelly webinars, as you can get your hands on on. So, please, by all means do check that out on Do give us a feedback on Do thank you very much for attending.