We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to mind the kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist and child development programme director at UCL. And I'm Omar Tosseb a Professor of Psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature. And in conversation with invited authors, sift through the data, dilemmas and debates to leave you with our takeaways for academics and practitioners. Today, we'll be discussing hospital admission for children and young people with significant or complex mental health needs. This episode is called inpatient insight. Well, Umar, would you like to kick off. And what's on your mind in regard to inpatient care in particular? So I start most of these episodes with, I know very little about this topic, but I know some things, so I'm going to try and have a conversation around that. But I think this particular topic, I think I know very, very little, close to zero about inpatient psychiatric difficulties. I think my research-- well, my research focuses on common mental health difficulties that exist at the population level. And when it comes to severe difficulties that require inpatient care, it's just not within my remit or expertise. But what did pique my interest in this topic was the BBC News article that was out in November last year, which was about a 12-year-old who died in a hospital where she'd been detained under the Mental Health act. Of course, it's a tragic incident, but it did get me to think about this topic. And I was like, oh, this is really interesting topic. So that's where I'm coming out from. This is in knowledge of common mental health difficulties, very little awareness of inpatient mental health difficulties, and then a news article that piqued my interest. Well, look, I would say that I too-- I mean, it's not an area of clinical activity that I do very often. So most of my clinical activity is with young people who are outpatients, but occasionally, because certainly in the past, I did a lot of work with young people who had eating disorders, for example, there were occasions when an inpatient admission was implied. And I think that's certainly true when we're thinking about the populations that might be admitted to an inpatient setting during child and adolescent stages. So if there was a risk of harm to oneself or others, or where the nature or severity of the condition would need intensive care, or perhaps, which is sometimes the case and sometimes the case for young people, in whom there is such a complex presentation that an extended assessment is really needed. So it's an opportunity to think with the young person and their family what's going on in a deeper and wider way than one would normally do in an outpatient setting. So what we're practically speaking about is thinking about young people who have mood disorders, where there's a risk of harm and suicide, and that case that you talked about, the very sad case that you talked about one wonders if there was a mood issue underneath that, or there might be cases in which there's functional symptoms. So presentations where there's medically unexplained features. So that might be seizures or mobility issues. So there's a really broad portfolio of conditions, if you like, in an inpatient setting. And that's one of the things that I'm really interested about asking our guests about because you really have to be a master of so many aspects of significant mental health issues precisely because there is this breadth as well as severity of presentation. So it's a tough call, I think, as an expert. I think so. Well, we've got two experts with us today. So I think we should crack on with it because there's two people who want to talk to us about inpatient psychiatric difficulties. Today we're joined by Dr. Dawn Cutler, Principal Clinical Psychologist, and Guy Larrington, Principal Family Therapist from Great Ormond Street Hospital for children. Welcome to you both. Thank you. You would have heard the very short conversation that Jane and I just had. It would be really helpful just to start with definitions, as we always do. What's the difference between the kinds of mental health difficulties that we see in the community, in everyday life, that I might see in university students who are going about their day and functioning in society, and then the kinds of mental health difficulties that you would see in a psychiatric ward? I would say, I think you're really thinking about the severity of the impact on someone's life. And so, we do see children with OCD, anxiety, depression, but just at a level where life can't continue at home with that difficulty. And that may be because of the level of risk or the impact on them, or where treatment has been tried in lots of different ways, but hasn't had the impact that it needs to have for that child to return to life as they and their family would like it to be. And so is it severity and functional impairment? What about duration? As in, if something stays at a particular severity, has some level of functional impairment but has been going on for a long time, does that play a part? I think sometimes it does, but I think there does have to be the impact on functioning as well or risk because it's such a significant thing for a child, young person, their family to come and stay in hospital for treatment. It will only be considered by community teams when it's really needed and there's not an alternative. We also have some families, some children where actually things spiral very quickly. So it's not impossible that sometimes you're there-- almost their first contact with mental health services, that they might have had to go to A&E and then come to an admission. And actually they've never had the contact with community CAMHS that you might presume that they have. Yeah, I think this depends a bit on the condition, doesn't it? Because it may be a child with anorexia, say, would come to the attention of services, have perhaps a paediatric admission and then come to us very quickly. So there's a real sense of crisis over a few weeks where that child has moved to a point where they're just simply unsafe to be looked after at home. However, we also meet young people who've been perhaps a child with anxiety or functional symptoms. There are children who've gradually lost aspects of their functioning, so they've been in their bedroom for two years, barely coming out. And I think Jane talked a bit about sometimes there's a question about assessment and complexity, and that can sometimes be the case that people say, we've tried everything. Can you have a look at this, see if you can think about making a difference. Actually, I think, though it is about people getting that point of really being worried about that child's developmental trajectory being severely knocked off. And that's not going to change. So if we're thinking about these young people, so there's a proportion that are in crisis and that's often no matter what their presenting issue, that could be the reason why an inpatient stay is indicated. And I'm going to say something deliberately provocative here. Is it true to say that an inpatient admission is useful for short-term crisis management, but not for long term management? I mean, the reason I'm saying that is precisely because of what Dawn was saying about that social context being lost at a time when, particularly for teenagers, the social context is all so that there might be a cost benefit to treatment and loss of connection. I know that's a complicated, provocative comment, but maybe you could pick up on some aspects of it. I mean, I think it's a question that's very much in focus because everyone, inpatient units included, want children to be at home and in school if they can be so. We all are working towards that. I think there probably are times-- this is not so much my experience just in terms of where I've worked-- but where actually there's a very acute crisis and a relatively brief time and a place of safety is enough to make things safe enough, again to be at home. And I suppose that's one of your intentions sometimes, is that response to a very quick crisis and then a quick admission to stabilise. I think there is also another group and another potential use, which is actually sometimes a slightly longer admission, because actually what you're doing is offering a treatment that actually the admission and the environment that the child is providing the treatment in that form. And that doesn't transfer so easily to the community. You've touched upon this, but I'm just going to probe more. When we're thinking about the children and young people who are in an inpatient psychiatric ward, how many of them if we give-- sorry, if we just think about rough, rough estimates, do lots of them have one stay and then never need to be in an inpatient ward again, or is it people who tend to have lots of different visits over the period of their childhood, adolescence, and even into adulthood? I'm not sure if there's the evidence for that. Certainly some children have repeated missions. Some children just come in once. And then I think the significance of that admission and the organising around discharge, making sure services are in place can get them on a different trajectory. But that number is difficult to know. And you touched upon the-- maybe there's something about the environment [INAUDIBLE] the inpatient ward where that is helpful and is therapeutic. I wonder if you could talk us through what the environment is in an inpatient ward, as in, it will be different. I can understand that depending on the part of the country, the specific hospital, the trust, but also the specific condition that the young person has been admitted. I think we can talk about the different ingredients which go into making a ward, a good ward. One of them is about awards that can be safe. And there's a lot of things that go into to making award safe. It's about a ward where their young people can build relationships and start building up some trust. It's a ward where there are the boundaries that are needed to keep children safe. Some children might need one to one observation and moving up and down through that. A ward which can think about taking some degree of reasonable risk is important so that children can learn to manage themselves. Probably a ward where there can be some teamwork between the young person to staff on the ward and parents, carers, what other people in the wider community is really essential because we're always going to be thinking about getting children to move on as soon as they can. That's always going to be important. And certainly one of the things we believe is that sense of a expanded care team around a child, parents, staff, team, the child themselves, young person themselves and people in the community is really essential. That's what an inpatient unit does, which a therapist in the community isn't going to do, that combination of care and therapy. And actually seeing an inpatient unit is doing. That is a very important thing. I mean, that's really powerfully put, the idea of a virtual unit expanding past the physical boundary of the ward, but out to the young person's family and community. And that because of that transition from-- there is a day when one perhaps goes on day release and then there's a day when one has an overnight stay back at home. And those transitions are actually-- they are dichotomous if you like, even in the context of it being a gradual ease off of the care that the young person's getting. So I love the way you're painting that picture about the elastic and gradual change so that the transition into discharge is a part of treatment almost. And that's the way you're describing it. Would that be fair to say? Yeah, I think so. But I'm also thinking about shared care being part of treatment as well. And I think what-- I take you even back a bit more actually. I'm thinking about before admission. We're sinking in that kind of way. How do we create a shared care environment together when children are with, say, for instance, a child with an eating disorder, there's something really powerful about parents visiting-- most units have parents visiting a lot. It's not a case of moving from one care environment to another. It's doing something together. So parents might join for a meal for a child with an eating disorder, be an observer, and then have opportunities to think about what they're observing, to think about how they can do things differently with that young person. And that image of that blurring of care and treatment, I think is very important to get at. And we might then think about how's that going to happen in a creative way in the community either perhaps in tier 3 and 1/2 services before admission a bit more intensive services before admission or after admission. So Guy, I love that expression to your 3 and 1/2. You might need to explain that to non-clinicians. Well, one of the things that you have talked a bit about is inpatient admissions are a big step, and they do have a cost in terms of separation from community, from family and so on. They also sometimes that cost is being paid by the way that the child's illness is interfering with their life beforehand. I mean, a lot of children we meet are very isolated before they get to us. I think there's a real effort to try and have graded services before admission, to try and avoid admission. There's been some success inpatient admission. Number of inpatient admissions has gone down a little. And I think that is because there's been a real effort to put in more intensive services. What I think maybe there's been less thinking about is how to-- there's a difference between having two CBT sessions a week and a really integrated care and treatment package in the community in a way which would be a real alternative to inpatient admission. And those things I think are being thought about. There are some day services for young people to avoid admissions. And I think our colleague, in fact, Lee Hudson did, was involved in a systematic review looking at alternatives to inpatient care, which was interesting. And I obviously having been invited into this literature by virtue of this podcast, looking at crisis care in the community and the way that family can be involved in different models of high level and intensive care, but may not necessarily be exclusively in an inpatient setting. From the way you're describing that, is that perhaps the model of the future, or will there always be a place for an inpatient unit depending on the way the young person is presenting? I think there will always be a place because-- and I support that direction of travel. I think there's community services are definitely helping some children who can manage at that in-between level. But I suppose my experience is that the severity of the condition, the impact on not just the child, but their whole system, so their family and their carers, mean that actually they need the inpatient context for recovery, that it presents an opportunity where-- the separation is the hardest thing at the beginning to manage. It's hard to think about for the child and for their parents or their carers, but actually it offers them an opportunity sometimes to recover, to gather themselves to punctuate where they are at and recommence and learn new ways of doing things. Yeah. Parents and sometimes children often tell us this. They say to us, things have got so difficult at home that we weren't able to operate anymore. We weren't able to think. And actually the respite which came with an inpatient admission allowed us to start being parents again and to start thinking about our child again. It's a very, very profound thing they're telling us there. They tell us how traumatising being a very ill young person is, but also caring for that young person. And actually there was something about the headspace, the break of an inpatient admission was really important. And often parents got to the point where they were completely absorbed by just trying to keep children safe. And actually, one of the things that inpatient admissions can offer is a bit more safety and a bit more of a chance to start thinking and being a parent again. And you're really coming back to this idea of sheer care in a different model. So there's a lot of responsibility going across divides in moments of crisis, and then there will be a resolution of that where responsibility will go back to where perhaps it should have been or we would hope it would be, but there is a transitional period of share. So we're talking about a multi person, multi-agency, multi profession effort here. And when I introduce you, Dawn, you're a clinical psychologist, Guy, you're a family therapist, and I wonder whether you could give us an indication or just describe what kinds of professionals might a child or young person and their families come across in an inpatient ward. I've mentioned the two, as in your roles, but what other roles are there within the patient, within the ward that the child or young person might come across? And then how do they contribute? I mean, the people that are at the centre of the child's experience are the nursing team. They often will have particular members of that team, different wards will do it in different ways, where they'll be key workers who they can go to. But they're 24/7 day and night. They are providing relational care in that context. So when you were talking about what does it look like, actually what it looks like, I think is probably a bit more like a school than people might imagine, that there is educational provision when children are ready for that. There are groups on the ward. There will be-- I don't know. There's often a library and games and activities to do. So I think the key group in their experience of their care is the nursing team and all the different people within that, so the healthcare assistants and nurses, and often a mixture of paediatric and mental health nurses, I think. And then there are the other kind of professional disciplines alongside nursing. So psychiatry, then a mixture of the therapeutic profession. So you've got me as a psychologist. Guy as a family therapist, child psychotherapists as well. It's not often wards will have an occupational therapist, a physiotherapist. I mean, they have a combination of people that is very difficult to assemble. There'll be children with physical health needs who will need a dietician and paediatric input. And you can see why they start to need to come to hospital, because it's like, how do you gather that for a child who's in an acute physical health crisis because they haven't been eating, so they need a medical care. But they also need access to therapies, support during the day. It's a kind of combination which is particular. Yeah. And these teams are very difficult to maintain, particularly nursing teams, keeping-- for a unit to be offering the children, these young people, the security they need, you need a stable workforce. It's something that obsesses us, how to retain staff is a really important thing to think about. I was also thinking, there's one of the things that we think important. As well as primarily the staff, that sense of being able to build relationships, there's also the structure is important, having a day which is structured and planned. We often work with children who've lost that sense of structure to their lives, because their problems have completely dominated their lives, and being able to bring back that in a thoughtful way is important. Being able to have a structure that any child with very, very different needs can enter is important. So we've thought a lot in recent years about having an environment that can cater for children with very neurodiverse needs. And that's been very, very important for us to develop in that way. That's really interesting. I mean, one of the things I'm particularly interested in, which will be-- and when you're talking about structure, it made me think about this, about a structured way of capturing good outcomes because one-- so, for example, let's say we're thinking about a young person who is at risk of suicidality. Our outcome is, a lack of let's say, harm, which is difficult to-- it's difficult to deliver that, if you like, as an outcome. And one of the things that-- I know Dawn, you've written about this and I suspect you will be using this on the ward. So it would be really useful to talk about it our goal-based outcomes, because that's a way of really getting something meaningful into the child's world that has a very clear outcome. Can you talk a little bit about if you've used them, or is that something that you use in the ward, and is that something that-- describe what they are and why you find them useful, or perhaps why you don't. I don't know. We do use them. We also use other more questionnaires that will ask you about mood and how you're feeling. But we do use goals. They are really helpful in understanding what's important to that child, and we will generally set goals with the child and their parents or carers as well. And they don't always align exactly, but they normally have a [INAUDIBLE]. And actually in inpatient context, often at the beginning of the mission, children find it really hard to set a goal. Actually, they're not always-- you sometimes have to come back to it a few times. And actually often it's to go home, which is interesting in the way we think about goals, but is a goal that we can all agree that we want to work on together. They probably show the most reliable change out of the things that we use. And when you take the time as a team to connect around them with the child and their family, I think they also help orient you to what's important in a really complex presentation, what needs to change, because then that helps you to say, well, what well, actually, what do we need to do so that you can go home? That's really well described. Yeah, absolutely. Umar, have you got anything else on your mind because I have an eye on the time. One very quick question if that's OK. And it was the point that I wanted-- I think Guy you mentioned making the environment inclusive for neurodivergent children. One of the questions I had before then I didn't get to ask was, do you see a disproportionate number of neurodivergent children in an inpatient ward compared to neurotypical children, for example? I mean, we really believe we do. I mean, there's been lots of thinking about there being higher proportions of children with, say, anorexia who neurodivergent. But I think we probably believe that the population we serve with all the different mental health diagnoses, there are lots of children in each of those pockets who are neurodivergent. Sometimes we don't entirely know that because the children are so ill when they come to us that they're not really, if they haven't been assessed previously, they're not going to be assessed by us. But we say we sometimes have children who come to us who are already diagnosed as neurodivergent, but there are children who haven't had diagnoses, who we think may be. And it would sit well with the review of the Mental Health Act to-- I think there is a call-- I think Simon Wesley asked for more focus on young people with neurodivergent profiles. And so you're seeing it in practise with a higher level and a higher level of need. Yeah, I think it adds to the complexity. There'll be all kinds of reasons why there may be overrepresented, but you wonder whether it's because our treatments don't fit well, who knows, the world's more stressful. I think maybe we sometimes get a bit either or about this. We need to be thinking with many of the young people who come to us, that there could well be issues of neurodivergence going on and mental health problems which have fed into each other over time, really. Whether they're reached the level at which there'd be a diagnosis or not, we still need to be thinking that for all children. We perhaps need to get better about how we conceptualise this. Well, Umar, that really makes me think of the previous episode we did about autism diagnoses. We called it the long and winding road because particularly with girls, there was such an extraordinary story about young people's diagnostic unfolding, if you like. And autism was often in the picture, but overlooked and often overshadowed by, let's say, an eating disorder, for example, or the averse. So I think what you're saying is absolutely astute. So the idea-- autism is it's part of the picture very often and it cannot overshadow the other issues, but it just needs to enrich our understanding of the young person and their presentation. So that makes sense. I think when we're doing our formulations, we often think about, try and think back about, what's this child's experience been like over the last number of years? And so children may have had different tricky experiences, say parents separating, but thinking about what their experience is. Are they someone who finds, say, all the moving and the changing that happens when parents separate particularly difficult. Trying to drill down a bit into children's experience. So that then we're formulating from that point is, feels good for us to be doing-- and we have the opportunity to do a lot more in-depth formulation work. That's one of the privileges of inpatient work. So we've been talking about inpatient treatment. And one of the things I think you've been hearing is in that context, because the child is resident and they are in the environment, we have the opportunity to use that environment to be helpful to them. And in effect, the environment becomes the treatment for children. Now, like all treatments, we want to know how to make that work effectively. And we look to the evidence and to understand what there is. Unfortunately, in this area, the intervention is really complicated. There are a lot of things that make up an inpatient admission, and it's an area that's underserved by research at the moment. So I have just shifted to a research role where I will be completing a PhD. I'm funded by the NIHR, which is the National Institute for Health research. And what I will be looking at is how we can understand how to use the environment as a treatment for children, how to best make sure that environment is therapeutic. I think we could go on and on, but I think we should let these good people go about their business. Very thought provoking ideas. And it's not a coincidence that you spend your life thinking about systems and young people's experience in that because your responses and approaches are indicative of that. It's been really, really helpful for us to clarify the experience from those that are not working in this area. I think this will be a fascinating episode. So Dawn and Guy, thank you so much for joining us. We really appreciate it. Thank you for inviting us. Yeah, thank you. It's been lovely to meet you. What an interesting conversation, Umar, wasn't it? Yeah, I think this is an example of where I started from zero. [LAUGHTER] It was all new information for me, which was very nice. And I think that I felt a bit like I was asking very basic questions, but I think that's what I needed to know. And I imagine that's what lots of people needed to know. I think so. And honestly, I'm a huge fan of the basic question because what it does is when you're talking to experts like Dawn and Guy, you will reveal their thought processes. And there's so much rich information that I think is a wonderful thing to do. So I think never apologise for asking a good question, which I think it was really valuable. I thought the bit about Dawn saying the inpatient ward to some extent might look a bit like-- I think she said it might look a bit like school, as in like there's a routine and then there's a playroom or whatever. It might be and lots of different things going on. In my head, that's not what it looks like. So again, that kind of visualisation or visual description really helped me to think about what we're trying to achieve with children and young people who end up in an inpatient ward, and how are we doing that. And it's the therapeutic environment as well as the therapy that happens there. And this goes back to the conversation that we had with Ian Goodyer earlier in the series, where he was interested in, well, what is it about-- for outpatient, what is it about the different therapeutic modalities? Is there something common and that's beyond the actual therapy? And I think here it is a similarity. And what is it about the environment that might help the child? Or what is it about being in an inpatient ward that might help the child that's not about anything that happens there particularly? And the bit about the parent respite was really interesting as well. Absolutely. And I think that implicit work, and maybe it's generalizable across any model-- as you're saying, relative to the ideas that Ian had in an outpatient setting are so important. But what we are doing is modelling to the young person and to the family that there are boundaries and there are expectations, and that routinized activity is good for you. And you're not just talking the talk, you're walking the walk, quite literally. What we didn't get on to and I because time ran out and we had a lot of questions to ask our experts, but we didn't get on to the ideas that have been raised with one of our other colleagues, Susie Walker, about the inequalities to inpatient admission that are systemic. And she has done some really interesting work on the patterns of inpatient referrals, and some of which include involuntary detainment. And she looked at the data for young people and found, perhaps might say, unsurprisingly, that there was equivalent inequalities to the adult literature. So Black young people were far more likely to be detained in an inpatient setting than white young people if you hold constant their severity of illness, and so on. So those structural inequalities that we know exist in other aspects of inpatient care in the adult setting seem to be starting earlier. So what Dawn and Guy were talking about in terms of the systems and the community and the culture are doubly important knowing that the connection with community and how that young person is understood in the community. There's so much systemic meaning in what they were saying in the context of that data that Susie Walker has brought into the literature. I also found it really interesting in terms of the question I asked around the different roles within the ward. And when they responded, I was like, oh yeah, that's obvious now that you've said it. But in every time I've looked at mental health nursing or child mental health nursing, I didn't quite understand where they fitted into the mental health professions. And then now that we've had this conversation, I'm like, yeah, that absolutely makes sense. That is where they fit into this. And I was like-- because I think it's because my frame of reference is always outpatient and common population level mental health difficulties. And I'm like, well, what's the nurse doing in a population level mental. Are they doing CBT like-- but actually when we're talking about inpatient, it's very obvious what the nurse's role, is very, very-- yeah, it's very transparent and obvious what the role is there. And that relation that they talked about, the relationship that they're forming really speaks to trauma informed care or trauma responsive care because that capacity to hold a relationship through a good day and a bad day, somebody that looks out for when you know things have gone not your way, or perhaps you've acted in a way that you hadn't hoped to do, and somebody who's there, maybe a named nurse, that is-- you wanted to drill down to those specifics in terms of trauma informed care in another episode. But that relationship that Dawn said, it's nurses day and night that are with that young person, and they are really allowing that young person to develop rich relationships in the context of developing their interpersonal skills and their emotional regulation and so on. It's really important. The takeaway that I have for academics is thinking about the ingredients of various different practises that are trans modality, trans whatever it might be, and thinking about when we're investigating what works to help young people or young people's mental health rather than thinking about the individual-- the intervention specific characteristics, we think about intervention, non-specific or generalist characteristics that might be helpful. And in this instance, and even in Ian's podcast, it was around therapeutic relationships or relationships with trusted adults and those kinds of things. And those can be achieved in lots of different ways. So we might-- I don't know-- an intervention that looks at the effectiveness of CBT. And if it's seen as effective, we might attribute that effectiveness to something about CBT. But actually the effectiveness might also be to do with the therapeutic relationship or something that's not specific to CBT. So my clinical takeaway is similar in many ways because I'm thinking about the transdiagnostic issues. I was struck by the idea of transdiagnostic skills being very much at the centre of inpatient care. And also, I really enjoyed the discussion about those goal-based outcomes. They're relevant. They're easily described in the context of having a clinician helping, having these sort of behavioural anchors in what I want to do. And I think those two capacities, that transdiagnostic skill, using goal-based outcomes, although we're talking about them in the context of an inpatient setting, they're principles that could be applied to any work. Join us again next week when we'll be speaking to Dr. Sarah Parry about adverse childhood experiences and trauma. [MUSIC PLAYING]