Dr Jane Gilmour Welcome to “Inside the Teen  Brain.” This ACAMH series will leave you   inspired by best practice and armed with tips  to transform your work. I’m Dr Jane Gilmour,   and I have a special interest in the teenage  brain. From puberty to about the age of 25,   the brain is in a unique state, with core drives  including identity, novelty, risk, peers, respect,   autonomy, and intense emotions. In each episode,  we explore one of these developmental drives   and answer three big questions, what’s the  background? So what? And now what? Today,   we peer inside the teen brain to explore autonomy.  This episode is called “A State of Independence.” Now, the first big question, what does the  literature tell us? To be fulfilled as an adult,   we must develop autonomy, at least according  to Ryan and Deci’s Self-Determination Theory.   The independence brief is wide, covering  emotion, cognition and behaviour. Previously,   the literature simply defined autonomy  as a loss of close parental ties,   but more recently, it’s been considered  a process of evolving relationships with   connected but equivalent roles. In  geopolitics, conflict often precedes   a declaration of independence, and  so it goes in the teenage brain. The push for independence is marked in the  early teenage years with reported and observed   increases in familial conflict. But conflict  is not necessarily negative where it occurs   in families that support the development  of autonomy in principle, for example,   giving choices, respecting ideas. That healthy  debate supports psychosocial adjustment.   Puberty leaves the brain marinated in pubertal  hormones. Testosterone impacts neural circuits   in males and females and results in a heightened  sensitivity to status. Crone and Dahl’s review   note that this explains the need to be regarded  as equivalent to adults in the social hierarchy. What we regard as high status is context specific.  For example, in general, Tibetan Monks aspire to   be courteous, and Ron Dahl described adolescent  trainee Monks competing quite ruthlessly with   one another, each striving to be the most  polite. The environment also shapes the way   autonomy develops. For example, longitudinal  data show adults’ perception of their peers’   independence will predict expectations  of their own freedoms and boundaries. Strong evidence indicates young people respond  best when they’re addressed in a respectful tone,   contribute to their community, and develop  intrinsic motivation, which in essence means   I’m doing this ‘cause I want to and not because  you told me to. Based on these three operating   principles, evidence from Yeager, Dweck, and many  others, show that to connect with young people,   it ain’t so much what you do as the way  that you do it. We know healthy eating,   fitness, smoking, bullying, education  and crime interventions are more likely   to be successful if they’re delivered to young  people using a respectful, consultative manner. So now we turn to our second big question, and  ask so what? We’re very lucky to have Bella Plows,   a 19-year-old maths student with experience  of CAMHS, who now advocates for young service   users. This episode is a valuable chance  to consult with a young person. So, Bella,   I want to hear your thoughts about how we can  deliver best practice in CAMHS services. So   welcome to our episode. I’m going to ask you some  questions and I’m really interested to hear what   your thoughts are. My first question is, what was  the most positive part of your CAMHS experience? Isabella Plows I think I was –  I’ve been in CAMHS for seven years,   but there was lots of ups and downs and  I really tried to cling onto the ups. Dr Jane Gilmour Hmmm hmm. Isabella Plows I think one of the biggest,  kind of, good things about CAMHS was that I   felt cared for. Like, no matter what was  going on around me in school or at home,   like, CAMHS was the place and the  people who would look after me. Like,   I think the fact that I have a Caseworker, like,  I know that I’ve got that person to rely on,   and the Care Co-ordination who – they’ll talk  to all the different services. I think that   that’s really invaluable because it can be really  confusing as a service user as to who to speak   to. So yeah, just having that – just knowing that  there’s, like, one person there was really good. Dr Jane Gilmour So you – yeah, I mean, you  talked about that one person and, you know,   having a very, sort of, practical support  in terms of, you know, translating all the   different services and perhaps the vocabulary  and so on. Was there anything about that person   in particular that helped? In other words, you  know, the context of your relationship? Or was   it the practical support that they offered,  do you think, that was the most valuable? Isabella Plows Well, so a certain Caseworker  comes to mind, and she spent quite a long time,   kind of, at the start of our sessions building  up a relationship, learning about me, you know,   who I am, like, what my childhood was  like, who my family are, and just,   like, really showing that she cared about me. Dr Jane Gilmour Hmmm hmm. Isabella Plows I think one of the ways that she  showed that she, kind of, understood me was she   adapted to her style of working, and she was very  visual and we’d write things down, and so, like,   for example, at the start we created a timeline  of, like, my childhood, but like, she used, like,   this big paper and colourful pens. But when she  used the different coloured pens, she always asked   me, “Bella, what colour would suit this?” Like,  and it wasn’t her leading it, she facilitated   me leading the sessions and I thought that  really empowered me and that really helped me. Dr Jane Gilmour I mean, that’s such – so  articulately described. So the idea that she was,   sort of, a mouthpiece for you, but it was  driven by you, is really interesting, and it   figures with, you know, what we know about  the best way to connect with young people,   about giving them a sense of agency and  advocacy. So I’m really interested to hear that. One of the things that we know is that lots  of time is spent on waiting lists, and lots   of young people and families are on waiting  lists for a long time. Have you got any ideas   about what sort of support was useful or would  be useful while families are on waiting lists? Isabella Plows Yeah, so I think one of the  most important things about when you’re on a   waiting list is knowing where you are on that  waiting list. I think a lot of the time you   kind of feel forgotten about. It’s like you’ve  ticked that box, I’m on the waiting list, great,   but actually, like, having maybe a call every  six weeks or something like that, with somebody,   just to be able to say, “Okay, we’ve not forgotten  about you, you’re still on our list, and you know,   we’re hoping to get to you as soon as possible.”  So I think that regular contact about updating is   really important, but also the regular contact  to be able to have that safe space to talk and,   like, just because you’re on the list now to go  – to get help, doesn’t mean that your problems   are just going to disappear. So I think still  having that ability to speak to someone, even   though it’s only – you know, it doesn’t have to  be a long phone call, but it’s really important. And I think also seeing what there is around  in the community as, like, that can, kind of,   fill that void of CAMHS from a – in the meantime.  Like social prescribing, and you know, is there   any arts clubs around? You know, just something  to help them in the meantime. And then also still   having access to the, like, materials, like DBT  skills or still having access to what they might   be able to learn in therapy. Because, like, for  me, whilst I was waiting, I was going on websites   and like, looking at different, like, CBT kind of  things, just so that I wasn’t just deteriorating,   I was – I had something to focus on and I  could still be learning whilst I waited. Dr Jane Gilmour I mean you – that’s such  a proactive and smart idea. It’s almost   like pre-reading for a course. So you were  investigating some of the skills that you might   be using in therapy. Was that your idea or was  that something that the service suggested to you? Isabella Plows It was my idea, because I’m quite  an inquisitive person and I need to know exactly   what’s going on and what’s going to happen. And  so, having all that time to wait, kind of, allowed   me to explore, “Ooh, they do this,” or “They do  this,” like, and actually, I started to – once I   got to the service then I was, like, “Oh, this  is what I need,” because I’d already, kind of,   checked out everything. But yeah, a bit – it was –  me and my family, kind of, worked together on it. Dr Jane Gilmour I mean, that really makes  me think that something services could do   would be to provide a list of good websites  and appropriate material, because the web,   you know, the internet is an amazing place,  but it has an amazing amount of, you know,   inaccurate and information that might  not be helpful. So one thing might be   useful for families is to have a  sort of suggested reading list,   a suggested place to look and think about some  material before – you know, before coming to   the service and hit the ground running. So I  think that’s, you know, that’s a brilliant idea. And your, you know, your idea of engaging in what  the community can offer is also really important,   and we know that peer support is very useful. It  has validated benefits. So it’s also about finding   out what’s in the community and that one of the  things that we, you know, we do know is around the   country community support is very patchy, not  everybody has the same experience. But again,   services could potentially let families know  about those while they’re on the waiting list. Bella, I think you’re going  to have to get involved in   some political or professional  planning as you become older,   because you’ve got some ideas that I think  need to be rolled out in a more specific way. Isabella Plows I have so many ideas, but I   don’t know where to turn and  tell them and get them done. Dr Jane Gilmour Well, this is number one,  this is step number one, and you know,   we’re hoping that this is – you know, it  is an opportunity for somebody who’s had   the experience and, you know, will have some  really interesting ideas to share, and that   can perhaps be explored in a more, you know, a  systematic way across the different services. So I’ve got – I want to ask again some – for  more of your ideas, and I want to ask you,   if we were – sort of, had a professional  in mind who was trying to engage a young   person in services, perhaps they were  a bit cautious, they weren’t sure if   they wanted to come to the service, what  advice could you give that professional? Isabella Plows I think one of the  key things is be patient. You know,   you can’t rush the young person. The more you  push them, the more they’ll push back. So I think   they’ll engage when they’re able to engage,  but there’s obviously things that you can do   in the meantime to help them engage. I think  one of the most important things that I found   to relieve my anxieties around going to  services was, like, getting information   about who I’m going to be seeing. Let me see  a photo, let me see a description of your job,   what you do. Like, I want to know your  hobbies, like, because if I know who I’m   going to go and see it just – it takes away one  more barrier of, “Oh my God, who is this person?” I think one of the ways that professionals could  help as well is talk to them about how you can   help. Like, talk to them about what your intention  is, like, what do you see sessions looking like,   and show them that actually, like,  these are my ideas as a professional,   but it’s going to be led by you. Reassure  them that it’s – they’re there – well,   the child or young person is there to get better,  and that’s all the professional wants, is to help   them. So I think just reassuring them that the  young person’s interest is what’s at heart. I think as well, like, if they’re cautious about   coming into the building, you know,  can the professional go to their home,   go to a place of safety like school? If the young  person doesn’t want to speak about how they feel,   is there alternative methods of communication?  Can you write to each other? Can you draw? Can   you play with toys? But I think there’s lots  going on in that child or young person’s mind   and just taking the time to understand why  don’t you want to engage? And go from there,   but just trying to listen to the – to young  – to the young person is most important. Dr Jane Gilmour And that idea there about  demystifying what a session would look like,   what the building would look like, is a really  straightforward and simple idea, but it would be   very effective, particularly for people who  haven’t been in the CAMHS building before,   who have never been to a therapeutic session. And  so you are letting them, you know, process a lot   of the new information before they come into the  session. And it’s very easily done, it could be   sent out, you know, systematically, it could  be on the website, you know, there could be a   journey from the front door to the therapy room or  – you know, there could be lots of ways of letting   young people see what it would be like, maybe  even hearing the voice of the therapists on the   website and so on. It’s a really important idea,  and I can imagine particularly for young people   who are autistic that would be very valuable, but  for everybody, for everybody who is getting the   idea of a therapeutic session, you know, to settle  that idea, as it were. I think that’s really nice. I also like the idea of different ways of  communicating. It’s really important. It   doesn’t matter whether it’s verbally or it doesn’t  matter whether it’s, you know, it could be in lots   of different forms, drawing or, you know, by  any means necessary. I think that’s brilliant. What about if we turn this round a little bit  and say, well, what about what advice would you   give the young person themselves? What would you  tell them, if they were cautious about attending? Isabella Plows Well, I’d tell them, be brave, you  know, whatever you’re thinking, it can be solved,   CAMHS are there to help them. You don’t have to  say or do anything you don’t want to say or do,   and your CAMHS worker will listen to you and find  out what will make you the most comfortable. And   you know, if you want to bring in anything that  will make you feel better, like fidget toys,   that’s – you know, you’re more than welcome to.  I think the reason CAMHS are involved is because   things might not be going too well, and there’s  no harm in trying something new to try and make   things better. I just think, you know, things  can be difficult, but CAMHS are there to try   and help so, I would just close your eyes  and do it. Feel the fear and do it anyway. Dr Jane Gilmour And that’s brilliant. And you  know, I think – I wish we could bottle you, Bella,   and say this is, you know, this is something that  we could offer young people. Just hearing that   advice as somebody who’s been through the process  and has, you know, come out the other side doing   so well in life, that that is a wonderful piece  of advice. But hearing it from another young   person is much more valuable, we know from  – than hearing it from somebody that’s older   and perhaps a little bit less relatable.  So it’s really – yeah, that’s fantastic. Okay, so let’s think about what would you change  about CAMHS services? Now obviously different   CAMHS services are delivered in different ways,  but from your experience, what would you change? Isabella Plows I think it’s difficult really,  because you kind of just want to make – wave a   magic wand and, you know, change everything, but  the reality is that, you know, the services are   underfunded, understaffed, under resourced. But  there are little things that can be done, like   more structure. Like, I would go for appointments  week-after-week, and it would just be like, “Hi,”   we’d have a rant about the last week, and then I’d  go. But what I found, when I got given a 16-week,   like, this is the therapy that we’re going to do,  this is how it starts, this is how it ends. Like,   having that clear expectation of, “This is what’s  going to happen,” was really beneficial to me,   ‘cause I had clear goals, and I think, you  know, goals are something that is pushed   in CAMHS. You know, they, like, Caseworkers  know how essential they are because you’ve   always got to be working to something. But  I think sometimes they can be forgotten,   so just making sure that goals are always  set and there’s clear expectations. Dr Jane Gilmour Hmmm hmm. Isabella Plows I think because of the high  turnover of staff in CAMHS, there’s a lack of   continuity of care. So I think one of the things  that CAMHS needs to really focus on is looking   after their staff, because only when the staff are  happy and want to be there, is when they’re going   to provide the best care possible. And as a young  person accessing the service, I want to know that   I’m not wasting anyone’s time and I want to know  that, like, that that – the CAMHS worker wants   to be there. So I think – and – because then when  a CAMHS worker leaves then you’ve got to transfer   that caseload onto a new worker, and it’s just a  lot of disruption for children and young people. So – and one of the biggest things that I’d change  about CAMHS is I’d up the age to 25, because,   you know, the brain doesn’t stop developing when  you’re 18, you know, it’s still developing until,   I think it’s 25. And so what I’ve been  finding, like, being a 19-year-old now,   is it’s the most chaotic time of your life.  Like, you – when you go from primary school   to secondary, secondary to college, college to  university, university to a job, like, so many   things happen. And I think having CAMHS changing  when you’re 18 is just another thing thrown in   the mix that doesn’t need to happen. ‘Cause I  found that really challenging, because, yeah,   I just think that the – just because you reach  a certain age doesn’t mean that’s it, goodbye. Dr Jane Gilmour Absolutely, and I – it’s – you  know, Bella, you know, you’re absolutely right,   and again it’s a good indication of how on  the ball you are. We know that – we talk   about the teenage brain in the – in medical and  psychological literature. And actually what we’re   talking about is brain development up until the  age of 25. And so, that period of transition,   you know, when you’re moving, and sometimes  young people are moving out of home into college,   there’s a lot of change and stress. And  so keeping that continuity, particularly,   you know, with their mental health support team,  would be absolutely, you know, fundamental. And   so it’s something that I think there will be a lot  of professionals nodding their head when you said,   you know, “Let’s not say it’s you get  to 18 and it’s goodbye.” It should be   a transition that’s gradual. So that’s really  valuable, and you are describing it, you know,   with such a high level of capacity and being so  articulate, it really helps paint a vivid picture. The other thing that really strikes me is that,  you know, you talked about the relationship you   had with your keyworker, and it wasn’t just  what they did in terms of practical support,   it was the relationship that you forged, and  so that continuity of care is so important,   and maintaining, you know, the staff team, as much  as one can, is a really important point. And I   think, Bella, you should be Health Secretary,  and I have no doubt you will be in a few years. Okay, so we’re going to turn to our  final question, and the question is,   now what? So, Bella, we need just one simple tip  for professionals working with young people. Now,   you’ve given us a lot of good stuff already, but  what would you add, what would you leave us with,   as one thing to consider? One way, perhaps,  to change a service or add to our service? Isabella Plows I think be consistent and  if you make a promise keep that promise,   and make sure that you know that you can  actually carry out that promise before you   promise it. Because having children and young  people waiting and expecting you to do something   and you don’t do it, it’s just another blow,  and we don’t need any more of – any more issues. Dr Jane Gilmour Yeah, well,  well said. Okay, Bella, we…