Chapter 13 Working with children and young people
Learning outcomes
Introduction
Although some disorders are shared across generations, they may differ in their form of presentation at different developmental stages. For example, children suffering from depression may be more agitated or have a variety of somatic symptoms, whereas some depressed adolescents might be antisocial, aggressive, withdrawn or involved in substance use (Thompson & Mathias 2000). Some problems common to adults may start in childhood or be influenced by events that occurred early in life. Some problems may resolve with neurological development or emotional maturity, or with a stable, supportive environment. Likewise, with effective intervention and treatment there may be other problems from which the young person can achieve a complete recovery.
Over the past decade, discoveries in neurological research have reinforced the idea that the human brain is quite ‘plastic’ and that some areas are influenced during development by the environment, including such factors as the level of stress or anxiety a young person experiences. There is also greater awareness of the interaction between genetic endowment and the surrounding world. These developments are helping to provide new understanding of how individual children cope with emotional difficulties and gain control over their lives. They have also reinforced the effectiveness of a wide range of therapeutic interventions (Hoagwood & Serene 2002).
An important factor in considering the effect of any kind of illness on young people is the disruption it may bring to every aspect of development and education. Although in adulthood our lives can be dramatically changed through illness, we have usually completed the basic developmental tasks of life and have finished the foundations of education. For the child or adolescent, however, various problems may develop simply due to the interruption caused by illness. Bowlby & Robertson (cited in Walker et al 2004) illustrated the effects on young children of being separated from their family during hospitalisation. It is largely due to their efforts that in most general hospitals we now have liberal attitudes to parents and siblings being able to maximise contact with the sick child. In addition, in most major centres, consultation liaison services provided by teams of mental health professionals, including mental health nurses, give expert opinion and support for children and young people and their families when dealing with severe or prolonged physical illness.
Specialised child and adolescent mental health services are frequently not available in many areas of Australasia (Sawyer et al 2000). If one takes the view that there are critical periods in life when particular development tasks can be achieved, it is possible that these problems may have a long-term effect on people’s lives (Brannon & Feist 2000) ch 9. It is important therefore that services be developed and extended to more young people and that issues of equitable access to services are pursued vigorously.
Diagnosis in child and adolescent mental healthcare
The American Psychiatric Association, in its Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR, APA 2000) lists the disorders usually first diagnosed in infancy, childhood or adolescence (see Box 13.1). The major categories within child and adolescent services are listed, with some examples of specific diagnoses. The list in Box 13.1 is not exhaustive—for complete descriptions, refer to the DSM-IV-TR.
Because some disorders are not unique to this stage of life, they are not included in the DSM-IV-TR list. Depressive disorders are an example, although depression is becoming increasingly common in children and adolescents (Sawyer et al 2000).
The diagnostic categories listed in Box 13.1 are internationally recognised, although, in a national Australian survey (Sawyer et al 2000), mental health problems were assessed using the Child Behaviour Checklist developed by Achenbach, (1991). The checklist is used in many services in Australia and is shown in Box 13.2. As you can see, this checklist places stronger emphasis on behaviour and problems than categories of disorders. Problems are categorised into two general and eight specific areas, as shown.
Box 13.2 Child behaviour checklist
Source: adapted from Sawyer et al 2000.
By contrast, static diagnostic systems can tend to lose the fluid, changing and reorganising nature of young people’s experience as they progress towards adulthood, and may also run the risk of encouraging a focus on one ‘problem’ in isolation (Hoagwood & Serene 2002). For this reason, this chapter describes mental health problems in the context in which symptoms are observed, rather than in relation to categorical diagnostic criteria.
Incidence
Writers in various Western countries have often expressed concern about the prevalence of emotional problems in the earlier years of life. Within countries surveyed, the incidence ranges from 10% to 20%. The World Health Organization has predicted that these figures will double by 2020, making emotional problems one of the more common causes of illness and disability in children (WHO 2001). This pattern is reflected in Australasia, with a current incidence of 14% (Sawyer et al 2000). Interestingly, on average, roughly the same number of children had externalising problems (12.9%) as internalising problems (12.8%) (Sawyer et al 2000). Externalising problems are more noticeable and may therefore demand and receive more attention. Conversely, introversion and depression may go undetected because the child is often well behaved and sometimes what may be considered ‘too good’ by family members or ‘overly compliant’ by professionals.
Mental illness in context
Mental health problems can affect many other aspects of young people’s lives and therefore the problems must be seen in context. The more significant the mental health problem an individual has, the greater the possibility of problems in other areas of their lives. Furthermore, parents and other family members may often see these problems as affecting their own lifestyles and activities. Not enough is known about the long-term outlook for these young people, but it is important for professionals to see young people in the context of their everyday experience. Help may be needed across a broad range of life issues—with family functioning, social skills or school problems, for example. While the mental health problem may have caused these difficulties, it is equally important to consider that the life issue may have been the cause or an aggravating factor in the disorder (Sawyer et al 2000). A balanced view is required, so that causal factors are not attributed to one area without adequately observing what is happening in other aspects of the young person’s life. It may be that the child or adolescent is acting as a ‘barometer’ for problems existing in the family—the young person may be presenting with symptoms that reflect problems in the family or between parents. This may not be recognised initially and may only be revealed after some time. That is why an important aspect of assessment of children and adolescents includes an evaluation of the family’s functioning and coping skills.
Services available to children and young people
In most Western countries, specialised services are usually called child and adolescent mental health services (CAMHS) or child and youth mental health services (CYMHS). Previously known as child guidance clinics and as paediatric psychiatry, the services have expanded their scope considerably, offering a range of specialist assessment and treatment options. These services are usually found only in main centres.
It is believed that one in five young people suffering from mental health problems throughout the Western world will receive the expert help they need (NIMH 2002). In Australia, most children aged between 4 and 12 years with mental health problems are seen by paediatricians, whereas most teenagers are seen by school-based counsellors. On average, 3% of children and adolescents with mental health problems have attended a mental health clinic, while 2% were seen in a hospital psychiatric service. Approximately 50% of Australian parents either think help for their child is too expensive, or do not know where to access it; 46% believe they can manage the problems themselves (Sawyer et al 2000). Clearly, doctors and schools play an important role. It is a recommendation of the 2000 Australian Bureau of Statistics survey that the help provided by the different services be better explained to local communities and that specialised mental health services provide strong support for these other services (Sawyer et al 2000).
For adolescents in particular, simply providing a traditional outpatient or inpatient service may not be enough. Many teenagers worry about what others would think if they asked for help. Even more say they prefer to take care of their own problems, as they struggle with their sense of identity and relationships with adults. Unlike children, because of the adolescent’s striving for increasing autonomy, a family approach may not be useful. A variety of unhealthy or ‘at-risk’ behaviours may be present. Half of adolescents with mental health problems also smoke or drink and a third report binge drinking. There is also a close link between mental health problems and suicidal behaviour or thinking (Sawyer et al 2000). Many health services and programs tend to focus on single issues, such as drugs and alcohol, or medical treatment, with insufficient attention paid to comorbidity (Andrews et al 1999). There is a need for more collaboration and more funding for generalised adolescent health services and outreach programs. In some centres in Australia and New Zealand, there are adolescent health centres where no appointment is needed and teenagers can go unaccompanied. These provide a wide range of services and programs for all health and lifestyle matters.
A particular group within the community with special needs is the children of parents with mental illness. Over many years the Australian Infant, Child, Adolescent and Family Mental Health Association has campaigned for support for these young people. Since 2001 the Australian Government has provided funds for a project called Children of Parents with a Mental Illness (COPMI 2007) to enable provision and sharing of resources and support for various groups around Australia working with these families.
Although not specifically aimed at children and teenagers, new Australian Government initiatives provide funding for mental health services in the community. General practitioners and psychiatrists can refer people with mental illness to private psychologists, with a Medicare rebate for that service. As well, there is an incentive payment to general practices, private psychiatric services and similar organisations in the community to employ mental health nurses to provide care to mentally ill people (Australian Government Department of Health and Ageing 2007). Whether this will result in better services for non-adult people remains to be seen.
The nursing role
Working with children and adolescents can be challenging but fulfilling and rewarding. As children and adolescents are still developing as individuals, an intervention in their young lives can often make a dramatic difference for the rest of their life. Early intervention is often more effective than managing difficulties that have extended into adulthood. With adequate care and a supportive environment, young people can grow stronger emotionally, psychologically and physically. Working with a child and adolescent mental health team provides the opportunity to use a wide range of clinical treatment strategies and therapies. A multidisciplinary team approach is frequently used. Nurses often play a significant role in various aspects of care, including that of therapist. It is usually expected that a nurse wishing to enter this field will have some years of experience as a mental health nurse and further education, thus possessing a solid grounding in theory and clinical practice.
Apart from graduate nursing programs, child and adolescent mental health nurses have options available for advanced studies in specialist areas of mental health, through postgraduate and Masters programs. In addition, nurses can enter a variety of psychotherapy training programs available for all professional disciplines. Various governments (Australian Nursing and Midwifery Council (ANMC) 2006; Ministry of Health New Zealand 2007) are also providing for suitably experienced and educated nurses to become nurse practitioners in a variety of specialties, including mental health. Nurse practitioners are registered nurses educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other healthcare professionals, prescribing medications and ordering diagnostic investigations (ANMC 2006).
Raphael (2000) has pointed out the need for Australian child and adolescent mental health services to recruit health professionals with a high level of knowledge and skills, also raising the issue of the shortage of professionals in all disciplines. It is encouraging to note that governments are now actively responding to state, national and worldwide shortages in recruiting suitably qualified nurses to work in the increasingly challenging area of mental health, including child and adolescent mental health. Recruitment strategies include incentives such as financial support for training and ongoing tertiary education, and in some cases relocation costs, to encourage skilled staff to venture to rural and remote communities.
The following list of core knowledge and traits regarded as fundamental for all professionals working in child and adolescent mental health services has been generated from unpublished research by Limerick (1999, cited in Limerick & Baldwin 2000):
Engaging with children and young people
One of the most useful skills the mental health nurse can acquire and refine is the ability to engage clients and establish rapport. Engagement between nurses, young people and their families is fundamental to developing a relationship based on trust. A relationship founded on trust will foster a willingness to work together towards change. Faber & Mazlish (2005) identify the outcome to which the beginning mental health nurse working with young people should aspire as essentially: to master communicating so that children and teenagers will listen, but also being so good at listening that the young person is more likely to communicate.
The participation of young people and their family in mental healthcare should not be confined solely to therapeutic outcome. Organisations have much to learn from consumers about planning environments that are sensitive to the needs of young people. ‘Family-friendly’ environments also need to include processes that are responsive to the specific needs of younger people, particularly those who are experiencing significant emotional or mental health difficulties.
Engagement of young people and families across cultural contexts is key to accurate diagnosis and comprehensive treatment planning. There are implications for the way in which mental health professionals approach the assessment of their clients and families in multicultural Australia. The nurse’s understanding of specific cultural practices and beliefs held by clients is imperative to developing trust. Asking for information in a way that recognises cultural norms will promote the client’s confidence in the care provided (see Ch 6 and Ch 7). Clients are more likely to provide accurate information if they believe that the nurse understands their cultural needs and has genuine respect and commitment to a recovery plan that is culturally sound.
