Anto Ingrassia, is a consultant child and adolescent psychiatrist, and Clinical Lead for the Children & Young People’s Health Partnership describes how emotional and behavioural issues can impact on the treatment and management on asthma.
“Physical health and mental health are undeniably interconnected. The care and treatment of physical health problems affects mental health and emotional wellbeing, and vice versa. However, the connections are not always easily made by families and professionals, particularly when services are often narrowly focussed on one or another specific aspect of a patient’s needs at any given point in their journey of care.
Physical health needs are not uncommon in children. In fact, for one in ten children problems are severe enough to affect daily life and functioning. Mental health needs also affect about one in ten children, and the presence of a chronic physical illness generally doubles the risk of a child developing emotional or behavioural problems. The risk is even higher (three times or more) for some conditions, for example epilepsy.
Emotional and behavioural problems, and neurodevelopmental difficulties can also influence a child’s engagement with treatment, and ultimately recovery. Many examples come to mind:
- A child with chronic constipation and oppositional behaviour is probably less likely to follow treatment advice about diet, fluid, and use of laxatives.
- A child with eczema and autism might struggle with the “feel” of their prescribed emollients and other creams on their skin.
- A child with asthma and recurrent anxiety may end up using too much of their inhalers because they may confuse anxiety symptoms with asthma attacks.
Crucially for children (and arguably for adults too!) the connection between body and mind needs also to take into account the child and family’s context. The famous statement by paediatrician and psychoanalyst Donald Winnicott, “there is no such thing as a baby” can be used as a powerful reminder that children’s health needs are best understood in the context of the environment around them; starting with parents and families, and extending to schools, communities, and neighbourhoods. Over two million children in the UK are thought to be living with a parent who has a mental health disorder. Thus, there is a high probability that a child who has a health condition will be living with a parent who has a mental health diagnosis. The important interface between the physical and mental health needs of children and parents is difficult to address within the current often siloed structure of health services. This may lead to inequitable access to healthcare for children. So the children with the highest level of need may struggle to get the care they need.
Take for example the care of a child with asthma. It is really important that the right care and treatment plan is in place, addressing the symptoms of asthma and their impact on the child’s overall health and wellbeing. This is much more likely to happen if any additional emotional and behavioural issues have been explored and addressed with the child and family. Equally important is the parents’ ability to look after themselves, whilst looking after their child’s asthma. Without additional support, a parent with mental health issues may find it more challenging to meet their child’s health needs. In addition, the family’s social circumstances (employment and finances, housing, neighbourhood safety, etc.) are inextricably linked with their ability to engage with the child’s treatment plan on an ongoing basis. Of course, this affects the child’s outcome – positively or negatively.
It is clear that if we want children with physical health needs to get better, we must do better at integrating mind, body, and context. This is one of the aims of the Children & Young People’s Health Partnership (CYPHP) , a large-scale child health improvement initiative providing a new model of healthcare across Lambeth and Southwark. To support this new approach to improving care, we developed the CYPHP Health Check, a questionnaire that can be completed by parents of children with eczema, constipation, asthma, or epilepsy (exemplar, or tracer conditions). The CYPHP Health check can be completed online by following this link:
What makes the CYPHP Health Check unique, is that it collects information about a child’s physical and emotional health and wellbeing, in the context of their family and environment, promoting a wider focus and understanding of health needs. Specifically, it looks at:
- Physical symptoms – the severity of the child’s physical health condition is measured through validated questionnaires, where possible. For example, the Asthma Control Test is used to look at symptoms of asthma in the last four weeks.
- Emotions and behaviour – the Strength and Difficulties Questionnaire gathers information about emotional and behavioural need, and their severity.
- Background information – this helps develop a better understanding of the family’s circumstances.
After completing the Health Check, parents receive a summary of their child’s results and a tailored Health Support Pack. The child’s Health Check results are added to the child’s GP record, supporting GPs to have a better understanding of the child’s physical, mental, and contextual needs. And the child’s results are used to shape the right clinical services to be provided by the CYPHP health team. Importantly, the Health Check can identify children and families who may require a higher level of care, or multidisciplinary care, from our specialist team.
Health Support Packs provide information, health promotion, and self-management support for parents and children. They promote better understanding of the child’s condition and health needs, and follow a similar three step approach to the Health Check. For example, the Asthma Pack starts with information about what asthma is, and what might make symptoms better or worse. It identifies ways to track symptoms and triggers, highlights common medications, and describes what to do if a child has an asthma attack. Importantly it then talks about general wellbeing, including advice about dealing with issues that may be experienced by children with asthma such as worries, difficult behaviour, and sleep problems. The pack concludes with sections specifically focussed on looking after yourself as a parent and looking after your family, with information, links and signposting to useful local resources.
The bio-psycho-social approach promoted by the CYPHP Health Check is an invitation to think beyond many of the traditional barriers that for so long have defined the way in which care is provided by Health and Social Care Services. For example, physical vs mental health, health vs social care, adult services vs children services.
Better health outcomes for our children rely on our ability successfully to meet the challenges of working better together. As eloquently put by a young person who took part in the Co-ordinated System Task and Finish Group of the Children and Young People’s Mental Health and Wellbeing Taskforce: “Joined up care – if it works well, you shouldn’t notice anything.”