My path to becoming a child psychiatrist was a little unusual. I trained in other branches of medicine first but got more and more interested in what was going on psychologically with patients. I found this aspect of medicine more stimulating because it was less algorithmically driven – it really engaged my brain and I wanted to deal with more complex and challenging decision-making. So, I applied to do psychiatry specialist training, during which I spent a year doing child psychiatry with an incredibly inspiring consultant. That was when I decided I’d found my niche in medicine.
Every child is different, and every family is different. I currently work in paediatric liaison, which is where you’re a child psychiatrist sitting within the paediatric department of a hospital. I deal with children and young people under 18 who come in during crisis. That includes overdoses, psychotic experiences, or really abnormal behaviour. A very unusual change in behaviour can be because of something autoimmune or because they’re psychotic, or maybe because they’ve taken some drugs and had a bad reaction. I also work with children with psychosomatic symptoms, and children with long-term physical conditions or life-limiting illnesses, such as cystic fibrosis or cancer.
Child and adolescent mental health services (CAMHS) – whether in the community or in hospitals – are facing a huge challenge, because demand outstrips capacity so much. I’ve got community CAMHS colleagues who are desperate to do a good job but they’ve got thousands of referrals coming in. Their waiting lists are long and continuing to build up. And everyone knows that the longer these young people wait, the worse their outcome. It begins to feel dangerous, and it’s soul destroying for the clinicians who are having to bear witness to this totally unmet need.
At its best, my job is a fantastic mix of complex project management and intellectual rigour. For example, if you’re doing court work or even ordinary child protection work as a child and adolescent psychiatrist, there’s something about being able to lend your voice to the child’s. The system gives you authority to have an opinion and comment on things in a way that means you can join up with the wider system – such as education, social care, general physical health – and people will listen to you. We often “translate” the young person’s behaviours into plain-English descriptions, of what their behaviour suggests about their emotional experiences and relationship patterns at home and school. That way, the multi-agency groups we work with can make well-informed decisions about what’s in the best interests of the child emotionally.
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It’s terrible for young people whose mental health crises are driven by abuse or neglect to not have that recognised. They are left thinking: “I finally plucked up the courage to say something to somebody, and now all the adults in the system know, and yet they’re not doing anything.” It leaves many of them feeling hopeless and desperate. When we see mental health crises in young people, they’re often not due to being mentally ill or there being something “wrong” with them. It’s because they’re struggling to manage emotionally unbearable circumstances at home or school, and sometimes those circumstances are, frankly, abusive.
There’s great potential in working with young people because they’re still developing, particularly their brains – but there’s a limit to what we can do. Most of what we see is driven by contextual factors, such as the wider political climate and social inequality. We’re working specifically around the factors that really impact young people’s lives and their emotional states.
Whenever the government announces new funding for the NHS, we know that children and young people are at the bottom of the priority list. One-off boosts to funding do little – there’s no way we can recruit new staff within a single year of funding. It’s really demoralising for CAMHS staff, because the public expects services to improve, and they don’t, because we’re set up to fail with those timescales. Government announcements seem to be more about creating headlines than meaningful investment. And cuts to funding for lots of community services, such as youth clubs and parent training in schools, mean more and more children are coming to us through A&E in crisis. These services really help early-stage child mental health issues and now they’ve mostly gone. It feels like there’s a terminal decline in the wider psychological support systems for under-18s.
We need to encourage more people into this area of medicine, so we can provide the care and support that young people need to thrive. Child psychiatry consultant numbers are tiny compared with paediatric consultant numbers, but you can’t change that overnight – it takes nine years of training to get to consultant level. I’d like to see the government committing to a workforce strategy that evens up the offer for children needing mental healthcare, so there’s greater equivalence with physical healthcare. And if support for children, families and in schools could be restored to what it was before austerity, it would also help ease the pressure on the system and address some problems before they become crises.
It’s great working with children and young people; they have an energy and a take on life that’s different. And you’re more likely to work in a multi-agency way too, which I love. You can’t do effective work with a child without thinking about their educational setting, their home setting, and their peer group. You can’t do it in isolation, because otherwise you’re not going to have a particularly successful outcome.
The trouble is that everyone – schools, social services, hospitals and CAMHS – is firefighting right now, which makes it difficult to think creatively together or to go the extra mile for a child in crisis. And I’m certain that children and their families sense this problem too, and how it results in a minimising of these profound issues, and a tendency to ignore and look the other way.
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