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So our next speaker is doctor reaching mitral who's a consultant, child and adolescent psychiatrist working at Westminster cams. She's got a special interest in neuro developmental disorders, medical education, digital innovations for mental health services, mental health of refugee minors and clinicians. Well, being Doctor Mitchell will be talking about why it's important for pediatricians of the future, aware of the current landscape of Children's mental health, how they may work with mental health services and hopes for exciting developments on how we may prevent and manage Children's mental health disorders in the future. Yeah, take it away. Thank you so much. Thank you for that introduction. Yeah. Pleased to be with you all. Um, well done for attending on a Saturday. Um, so I'll be talking about child and, uh, the less than mental health and issues relevant in 2022. So I think you just covered the the agenda. So I'll skip through that, So Yeah, First of all, uh, hopefully you're not asking this, uh, you know, am I in the right place? But why? I talk on mental health. So this is the kind of tagline of Royal College of Psychiatrists. No health without mental health. Um, you will encounter mental health presentations. Um, acutely on your pediatric wards. Obviously, it varies depending on a number of factors. Um, but this, you know, it can range from 10 to, I'm sure, 100% of maybe acute presentations for Children so really important to have working knowledge of of current disorders. So just to say, obviously, we've got a lot of common territory as child psychiatrists and pediatricians with both, uh, both need a developmental approach. We're thinking about what? What's appropriate presentation, Whether that be, uh, weight or milestones or behavior. Um, so we're both thinking along those lines, we've both got an opportunity to think about the child's life style will often be a asked about. Okay, Doctor, when when is when is a good bedtime for my six year old giving advice about diet, exercise, screen time. You really influencing how these young people are going to be, you know, living their lives? Um, we both need to be on alert for safeguarding concerns. You all have your Children safeguarding mandatory training. I'm sure, um and then lots of opportunities for for fun and creativity. So when I have my medical students in my clinic? Um, definitely. I think a lot of the feedback is Oh, I didn't realize Doctor Mitchell how long you spend kind of engaging at the beginning, making the person feel like he's getting getting to know them What they're interests and strengths are not just the pathology. Um, it's incredibly rewarding. And we are We are adult role models for these young people. It's a current landscape of Children's mental health. Unless you've been living under a rock or just avoiding, uh, what's going on in the news, which I wouldn't I wouldn't blame before there's an unprecedented, well being crisis. Children, young adults and and adults. Uh, so just some data from from this year, Um uh, 1.54 million people in contact mental health services by the end of January. Obviously, some disorders are increasing more than others. Um, and, uh, for month, 400,000 Children a month being treated for mental health problems. So you might be asking why? Um might be some quite obvious, uh, reasons. Obviously, we know the impact of cove ID on all of us. Isolation, disruption to education, opportunities to socialize and develop skills. Obviously in the developing mind that would influence, uh, acquiring these skills milestones, etcetera had a profound effect. Um, impact of lives online, Um, touch on that a bit bit more later. Other evolutionary theories, um, kind of manage adaptation to novel environments. We're not. We don't maybe don't have the same opportunities to socialize, etcetera. And and it's possible there's more awareness of mental health issues. So that's another reason people are presenting a lot more. So this is just a guardian earlier this year. So it's just reflecting. You know, services can't keep up at the moment with the increase in presentations and such for some disorders. Um, long waiting. This especially for eating disorders, a number of other services as well. Um, so we're really, radically having to rethink about how we're addressing addressing certain disorders and thinking about prevention. Okay, so what's currently on offer for our Children? So this is obviously applying to to public sector. Um, I'm not a huge fan of this term, but, you know, we do talk about postcode lottery. So depending on where where you live, it's important to find out locally how your your mental health services are are set up So typically and definitely where I work. Covering the bar of Westminster in London. Uh, it's a tiered system. Um, so, uh, as listed here. So Tier one's primary care and then increasing in, uh, severity of the disorder and presentation. Tier two is maybe more targeted. But maybe not a multidisciplinary team. So, uh, not not psychiatrist, for example. That may be a child, will wellbeing practitioner in school school counselors. Things like that. Uh, Tier three is, uh, community campus clinic where I work. And then Tier four would be inpatient or a specialist clinic. There's actually tier 3.5, which is kind of outreach service as well. Um, but there's more evidence being built and developments for a different type of framework which covers beyond the typical 18 years old after 25 years. Um, and that's, uh, thrive framework. Um, that's not necessarily based on severity and diagnosis, but more of a holistic approach. Um, so there's obviously advantages to that kind of approach as well. Um, also one offer, you know, in social care. So there may often be a family therapist in the in the Children's services. It may not be, um, pathology as such. So if there's a case of child protection or abuse in the family, the Children being witnessed a domestic violence, maybe that's something the social care would be better addressing. Uh, and then, thankfully, in this country, we got a lot of third sector support. A lot of charities, mental health charities. Mind your mind, uh, national autistics. I see. Um, so often we can sign post to to those as well. Um, so within, within the sub as a subspecialty within child psychiatry. Um, you may or may not be aware of pediatric liaison services again, depending on where you're working different availability of this. But they locally happy to happy to say that we've got pediatric liaison team and they would be addressing things like mental health to leave our physical health disorders. Um, supporting management of chronic disorders. Think about medically unexplained symptoms have just put a few examples of possible case studies. So, yeah, you could imagine why. You know, tragic car accident, A 30 year old girl needing, uh, double, uh, bilateral knee amputations, life changing injuries. So you can you can understand why they need mental health support as well. Um Same for? For for the next 17 year old boy. This was a suicide attempt. Survived, but life changing injuries. Um, so you mentioned the medically unexplained symptoms. So, um, someone may present with seizures. Uh, there's nothing found organically. E g is not showing anything, but actually, you're sensing in the background, there's there's stress. Is is it's not non epileptic seizure. Is this a psychosomatic presentation? Uh, just actually. Earlier this week, my colleague discussed with me boy presenting with psychotic symptoms. Um, suddenly, um, no family history. And it actually was found positive for Lyme disease that the psychotic symptoms were resolved after treating with antibiotics. Um, so this is really, uh, lots of interesting case studies, um, as well. So worth finding out locally what? What might be available. And this is kind of interface between pediatricians and child psychiatry. Very interesting presentations. Okay. In terms of what? Who decide what's what's commissioned, who used to be called commissioners now that it's changed Integrated care board. I CB there's others also government initiative. So around 2018, there's a green paper issued by governmental paper saying look, actually need more provisions in schools to prevent, uh, mental health disorders developing. Um, and I'll see, uh, funding given towards that. Um, Also locally, it may may differ in terms of what What's decided. It should be based on demographics and what the needs of the population. But for example, locally, uh, camps do a lot of our autism assessments, other boroughs, even neighboring boroughs with in London, um, the pediatric team will be will be doing the autism assessment. So, um, really varies. Um, so, yeah, similar to other NHS services. So it's important to think about access to services, so refer referring. So referrals can come from a number of, uh, sources, self referrals, GP school, social care and obviously yourselves. Um, so it is important to be aware of thresholds. Um, you know, self referrals. I just put this apologies, maybe the overuse of cartoons here, But, um, you know, some some parents can readily pathologize or you can go right up to the other end of, uh, Spectrum, where there may be some denial or lack of knowledge about this actually is a mental health presentation. Um, so we have different different practices, pressures to diagnose, obviously differences in different thresholds for NHS versus private care pros and cons to both. Um, so there's, uh, also barriers to access, and that can be individual. Uh, so again, uh, important to think about your your local population? Uh, a lot of us are working quite ethnically diverse populations. So thinking about okay, do do this popular Do this community to this family, understand mental health? Um, what their views on that, um, and then other barriers. Unfortunately, systemically, we have mentioned that a long waiting this, uh, lack of lack of services available some bureaucratic, clunky systems. We're working through some inefficient working. Um, so yeah, important to to consider that to consider this locally as well. Where you'll be working. Okay, so for yourselves, what What's the role of the pediatrician in, uh, in mental health? Um, so, as I said earlier, you'll be you'll be coming across these presentations whether it be in the community or acute services, and you would you would have a duty to assess screen at this stage thinking about safeguarding knowing who your local cams team are. Um, even from very early on, if the child is in the NICU, you know what, what later on, just being sensitive to. Actually, that was a time maybe the child had been away from parents, uh, leading to problems with attachment, etcetera. So just having a an awareness of impact of early childhood events Um, you'll also often be making referrals to camps from pediatric ent. Um, absolute bugbear of using this term. It's easily. It's easily done. Maybe it's unfair to they don't use it at all, but do qualify. What do you mean when you say medically cleared, um, often be it can be ambiguous and helpful. Confusing. Um, please consider ourselves as your your colleagues, Not not a separate team. Um, and sometimes if you don't involve the family, the child, uh, in that in that decision and they just medically cleared, you know, they may feel validated or they should have come to a candy or being shifted over to another team. So just thinking about this kind of language and implications of that Okay, I I realize I have packed a lot a lot in, but I'm glad you'll be getting these slides, so I'm just going to skip through, um, this one, But please have a read. So just give me examples of why and why early detection and intervention is important. Um, again with this one, you know, this is all the concepts. You You would, of course, be familiar with prevention. Better cure would just be more specific about that. So here. I've just spoken about a a study, You know, how far back can you we actually prevent? Actually, prenatal period. We're finding, uh, there's a study showing that, actually, uh, mothers with with a higher being my, um uh, show the offspring had a higher prevalence of problems with cognition and behavior regulation. So obviously, there's clinical implications for targeted preventative strategies. Um, aimed at reducing the MRI. Obviously ethical, um, implications of this And you think, think about doing the sensitively. But this is an example of You know why we need to be thinking very early on. Okay, So, um, implications and hopes for the future. Um, you know, we're hearing about these these higher rates of of disorders, um, changes in ways of working, et cetera. So our online, uh, life is changing. We need you need to adapt. So obviously, the pandemic has kind of propelled a lot of implementation of a lot of these things um uh, even Precose Did you know, we're thinking about our referrals Will be online. Even the data that we may need, uh, pre assessment. Getting that online, having a system where your parents can do a questionnaire, you can get feedback from schools. Uh, when we see the child in person, the family kind of already got a lot of background data. So this baseline data, uh, you may be thinking. Okay. What What is that in a child? Psychiatry. So obviously, just like, uh, in surgery, you may have your pre surgery. Uh, X ray. Um, obviously, we need some baseline data. Okay. This is this is how they're presenting at the beginning. Uh, we do an intervention, and then we find out it's been successful. Um, also, you know, implications for interventions. Um uh, and development of pharmacogenetics testing. So, for example, prescribing a PhD medication, Um, not readily available in NHS yet, but soon to come. Hopefully, um, I have had patients come with privately done pharmacogenomic testing. So they find out which, uh, genetic test test done to find out which a PhD medications they will be, uh, will be more successful for them and maybe others, which they may have adverse effects based on certain proteins they may have means they can't not metabolize a certain drug number of factors. So that's really helpful. Making individualized. Um, calling this precision medicine is really, really exciting developments. Um, so other other changes coming, um, and already being implemented. So online appointments? Um, of course, we want to see them in the room at some point, and hopefully initially, But then certain reviews, even uh then doing therapy online has proven to be successful. Also, you know, they're developing more of evidence based for technology assisted therapies. Uh, more so for the for the lower, less severe presentations. Um, where? It's kind of self guided. CBT technology assisted CBT. Um and then also we're thinking about a digital prescription. So whilst I maybe, uh, we have this bio psycho psycho social approach. If you've heard of that term where we're thinking about what? Our intervention socially, biologically, maybe with medication, uh, psychologically. But a digital prescription may be advising on the AP. So if you've heard of certain apps that can move trackers, um, com, um, meditation about various things. So it may be that you also say Okay, I would recommend this. Um, And just as you would do with the medication, you say Okay, this is you need to be familiar with these apps and say, Okay, this is the This is what I'm hoping these are the benefits. Maybe the down, some of them obviously subscription. So this is also coming, and a lot of us are doing that already is a kind of sin posting, as we all do have smart phones. Having recommendations for for an app can be really helpful. Okay. Just to, um I guess a little promotion. This is a charity I'm involved with. Called called Best for You is on is on line. Um, it's registered that charity, but does have grants from various NHS trust, and it's in a pilot phase, But on here, there's on on the website. There's a lot of digital support in terms of, um, information for parents, Children, even professionals about certain disorders. We're trying to have blogs which are topical. So recently, um, we had a blog about talking to Children about the Ukraine war. Um, so kind of things that are going on with addressing them, as as we go along. Um, and also information. This is local to, uh, north northwest London. Um, so also information about local services. Uh, it will be later on linked to a day service. An inpatient unit as well. So at the moment, it's a pilot phase. It may be rolled out more, more, uh, nationally. So it's really, really exciting thing to be involved with. They've also got their own twitter and, you know, doing a lot of social media information as well. Okay, so, uh, in the last time we touched on, okay, Our life being online Globalization, social media, Yeah. Pros and cons of this again. I'm sure there's nothing new for for Children. What is it we need to think about? What is the impact of, uh, social media? And they're online lives? Yeah. They may be better informed. There's greater opportunities for education having these global connections. Um, there's downsides to that as well. We see Children, uh, that they've with their gaining their their friends and have a community across the world. But there's there's dangerous for that as well, which is a vulnerable group. So thinking about the risks of, uh, this as well, Um Yeah, the risks of a bit of being online. A lot more cyberbullying, um, is a lot harder to, you know, switch your phone off and, um, cut off from all of this. Uh, And then although a lot of apps platforms are attempting to have parental controls, I think, you know, we all know that it's often limited effectiveness. Obviously, Children can find a way around it. So thinking about how the impact of that as well. Okay, so this is very exciting. This is going to be coming for all of us. It's already, uh, already here, um, artificial intelligence. So there may be a time, you know, a therapy sessions is recorded. There may be a machine learning where the software may pick up certain words or tone and therapy session and then guided guides the therapist to say, Actually, this was a This was the theme. This needs to be addressed. Um, so it's kind of monitoring the progress. You're altering treatment where necessary. Um, and also, you know, use of of wearable. So I'm sure many of you have, um, Apple watch is I have this, uh, ordering. So it's kind of tracking heart rate sleep. Um, you know, there has been times where I've had a, you know, stressful meeting, or, you know, uh, and I can see my heart rate go up when I When I when I look at the data later that day. So, you know, using these in a healthy way. Obviously, you can People can get addicted, and it's, uh, verging on, uh, pathological. But, you know, using this, um it may be a time where you know, it tracks your your mood and then advises you obviously dangers to that as well. If you're fans of Black Mirror series, you know, I think I'm sure there's a series where you can pick up someone's mood and then they play a song that maybe, you know, uplift you. So kind of not wanting to get into this, uh, monitoring mode. Um, too much better balance. And it's exciting. What's happening? Hi, Doctor. Just sorry to interrupt. Just say this just four minutes left. Okay? That's great. Thank you so much. Um, okay. So I can't do a talk about mental health without reflection, considering our own mental health and wellbeing. Um, so, yeah, thinking about prevention, like we do with our Children thinking about healthy psychological, uh, coping strategies. Um, how are you preparing for stressful times ahead. How are you? Uh, reacting. When? When? Times are tough. Can you deal with this angst? Anxiety later. Uh, humor, Uh, use of humor, sublimation challenge, challenging negative energies. Uh, maybe give an example there. Boxing, Uh, where you need to find what works for you yourself. Altruism. Another healthy coping strategy When times are tough. Also important to be where of burn out, important to know where you can get you can get support. Okay, So maybe my most important slide. Have you just discovered a career in actually child adolescent psychiatrist for you? So I said earlier, lots of things in in common. Very rewarding career. Lots of a similar skills and attributes so rapidly evolving, uh, vacation career path, lots of variety. Lifelong learning. It's incredibly in demand. Um, and the lifestyle choice, you know, there may be times we can give a lot can be done online. You can work remotely as a you know, digital nomads still providing care effectively. Uh, there's a lot, a lot on offer. Uh, so this is just lifted from the College of Psychiatrist website. If you are unaware of the training path, so hopefully some of you are are considering, um, psychiatry as well. Just some references from the studies I mentioned. And, um, any happy to, uh, take any questions? That was really interesting. Thank you so much. If anyone's got any questions, they can pop them in the we chat box. And if you're okay to stay for only five minutes until the next talk, that would be ideal if you can answer. Sure. My pleasure. Thank you. Okay. No, No questions. Thank you. Thank you for your, uh, gratitude. Okay. Do you work with Children with? Oh, really? Good. Really good. Really Good question. Um, there is actually a gaming disorders clinic has just been set up within our trust. Uh, was actually involved in advising on that, um, number of addiction. Same as, uh in adults as well. But yeah, addressing is often the root cause of people being addicted. Whether it's substance, misuse, gaming, etcetera, you will find an underlying you know what they're substituting for. So in this early stage will be taking again holistic approach. And what is the impact of this gaming or addiction? Um, so there's not There's not specialist services apart from this gaming disorder clinic. Um, is it the national? It's in? It's pilot phase. Um, but I don't You know, I don't personally, but I most manage Children with neuro developmental disorder. So HD autism learning disabilities who are prone to, you know, gaming disorders or addictions online. But I think we all come across it. Yeah, that's great. Thank you so much for your help. And for a wonderful talk this morning. I'm here now just to present our next speaker, which will be on a career in academic pediatrics with Doctor M. R. Alexander. So she's a pediatric STD.