Labels in child and adolescent mental health presentations - A Christmas stocking stuffer

 Here's another stocking stuffer.  In the same way as last time, it's just a mini-FOAMed post.

So next time you see a child or young person with a mental health presentation, I would suggest the following:

• Don't think of behaviour as behavioral.  Assume it is a symptom of something more complex.
• Don't feel pressured to give a label.  Many young people don't ever get a formal diagnosis.
• See each contact as an opportunity to discover more about what is going on and why.  While this may not always be something massive, sometimes it takes a lot of feeling safe for a young person to disclose something.  The bigger the thing is to them, the more time and space it may take.

Mental health problems in young people are complex and that can be daunting for us as front line clinicians.  If you ever feel that you are not finding it easy, you are not alone.

Edward Snelson
@sailordoctor

The Work Hack I Never Expected - How a Rainbow Badge Transformed Mental Health Consultations

Adolescent mental health is an area of practice where we need to take opportunities when they present themselves. This post is about something that has been a huge game changer for me.

When a young person comes with a mental health problem we look at various factors that are involved.  One of the most important factors that affect mental health is sense of self.  Like all elements of mental health, sense of self is complicated.  It is important that young people feel safe and accepted in order to be resilient to the stresses of adolescence.  This is a time of life where identity is being formed, and to do that safely requires an environment which allows a young person to explore who they might be.

If a young person feels that any element of who they are or might be is unsafe in any way, this creates anxiety.

While sexual orientation is only one element of a young person’s sense of self, in a world where heterosexuality is considered normal, a young person may not feel that discussing any other sexuality is a safe thing to do.  They may be concerned that they will experience rejection by family, friends or anyone that they discuss their sexuality with.  In many cases, they have already risked discussing this issue and experienced a negative response.

As health care professionals, we should be routinely asking the right questions to identify any issue that may be a factor in a mental health presentation in adolescents.  We should ask about stressors in general but it is also routine to ask specifically about common anxieties.  The more likely it is that the thing may not be volunteered, the more important it is to ask.

There are many reasons why health care professionals might themselves feel anxious about asking a young person about sexuality.  Here are a few of the common ones:

We don’t have experience of discussing sexuality with young people.  If you don’t have a framework for doing this, you’re not alone.  Very few of us grew up in an environment where anything other than heterosexuality was considered normal.  Unless you have experience of a society where any sexuality is accepted without judgement, it is likely that you will feel a little bit weird about discussing these issues.  The irony is that we might feel anxious that we will somehow get it wrong.

The solution: just do it.  The best way to get past the weird is to be brave and trust that your attempt will be well received.  Step out in faith.

We are worried that the parent(s) may be angry that we have this discussion with their child.  Our anxiety is often seated in our knowledge that society is still heteronormalised and that some people are fearful or uncertain of any other sexuality.  There may also be a fear based in the misconception that by asking about sexuality, we somehow alter or influence it.  That is an interesting and unfounded belief.  There is no evidence that an open discussion can result in a change in sexuality.

The solution: Speak to the young person on their own.  This should be a normal part of a mental health assessment in a young person.  We wouldn't allow a parent to be a barrier to acting in their child's best interest in any other circumstance, so why let a social anxiety be harmful now?

We are worried about the response that we might get from the young person.   I’ll be honest here, this fear is reasonably rational.  If you ask a young person about their sexual orientation they may well give you a funny look and a muted response.  That’s fair.  When you are 15 years old, it is not something that comes up in conversation with an adult that you just met 10 minutes ago.

The solution:  Expect the question to make some young people feel awkward, but put them at ease by asking the question like it’s just another question.

There is another thing that can help with all of the above.  Last year I started wearing a rainbow badge.  The badge is small but always visible.  The idea is that it lets people know that I don’t judge people based on their sexuality.  To me, people are people.  While there are things that will change my opinion of someone, sexual orientation is not one of these.

When I started wearing the badge, I thought that my patients wouldn’t notice or wouldn’t know what the message behind the badge was.  I was wrong.

Immediately after I started wearing the badge, I noticed a change in the way that mental health consultations went.  When asking open questions about stressors, a significant number of young people started volunteering that their sexuality was a major factor in their presentation.  The stories varied from young people who were unsure about their sexuality but were afraid to discuss this with anyone to those who knew that they were not heterosexual but had experienced unpleasant responses to that when telling their family or friends.

I think that starting to wear a rainbow badge has been one of the most important innovations in my career.  I never expected such a small thing to make my life easier in such a big way.  I’m now somewhat concerned that the use of the rainbow as a symbol in the COVID-19 pandemic may have diluted the impact of my rainbow badge but I hope it hasn’t.

If you want to get information about sourcing rainbow badgesfor your organisation and the training that goes with the project, you can do that here.

It may not have been designed as an part of a mental health toolkit, but for me, the rainbow badge has become an essential piece of equipment for my job.  2020 has been an odd year.  It turns out that I don’t need a tongue depressor, but I do need a rainbow badge.

Edward Snelson
Also ship-shape award badge owner
@sailordoctor

The simple bit of equipment that will transform your child and adolescent mental health assessments

Mental health problems in children and young people (CYP) are common and on the rise.  Identifying these problems in CYP is particularly challenging due to a variety of barriers.  Some of those barriers exist within ourselves (misconceptions) or our working environments (time pressures).  Often the barriers come from the child or young person.   All of these barriers can be overcome.  Let’s look at how that is possible.

The first place to start is with ourselves.  We need to make sure that our attitude towards CYP and their mental health is such that we are open to see and hear the signs that indicate what is going on.  A positive attitude is also essential so that the CYP and their family are likely to want to disclose what they need to in order to get a good picture of what is happening.   All the usual things that apply to working with young people apply in a mental health assessment but are more important than ever due to the patients mental state.

Next we need to look at our working environment.  The time pressure issue is a big one.  The bottom line is that unless we find a way to make time for mental health presentations, we can’t expect these contacts to be effective.  There are many other environmental factors to consider which are key to helping CYP access the help that they need.

Finally there are the barriers that seem to come from the CYP.  As suggested above, it is a good thing to see any such barriers as expected.  The worse the situation, the bigger the barriers are likely to be, and the greater the need to have these barriers overcome.  The right attitude and environment are both hugely important in overcoming these barriers.  It also helps to name them with the patient and their family.  That goes something like this:

With the family present- "I know that it is really difficult to put how you feel into words.  It’s also usual to be thinking that if you tell me what you’ve been thinking, I will think you’re crazy.  I won’t.  Anything that you can tell me will be really helpful.  Just tell me in your own words and take your time.  You’ll get a chance to talk to me without your family being there so feel free to save anything that you’d rather talk about without them there for then."

With the young person on their own – "We always give people a chance to talk about what is happening without their family sitting in.  That’s important for a couple of reasons.  Firstly these things are complicated and quite often young people feel that their family either don’t understand what’s happening or have strong opinions that make it difficult for you to say things the way you see them.  Here on your own you can talk about things and know that I’m just interested in what you want to tell me about what’s happening and how you are feeling.  Secondly, there are some times that there are things that really need some privacy to be able to talk about.  That can be things that you feel you can’t tell your family about, like taking drugs, or it can be things that I need to know such as if someone is harming you in any way.  I’ll treat things you tell me with confidentiality wherever possible.  If someone is harming you then I would need to act on that to keep you safe."

Even when you go through all of that, it is sometimes the case that all you get is shrugs and a marked lack of usable interaction.  At that point, you have another ace to play.  It is a valuable piece of equipment in CYP mental health assessment and it looks like this:

Giving the patient the opportunity and the space to write instead of speaking is a game changer in ways that you might not expect.  In a spoken interaction, CYP in a mental health crisis are likely to find it difficult to find the words to say how they have been feeling and thinking.  They will worry about the response that they will get to what they say.  This fear of being appraised can be paralysing.  Even if the person they speak to does everything perfectly in terms of verbal and non-verbal communication, the CYP may over-think everything they see.  Such is their hyper-acute mental state that this happens easily.  “They just frowned slightly.  Does that mean that they don’t believe me?  Perhaps it means that what I said is completely mental.”

A piece of paper doesn’t have an opinion and there is no response to misinterpret.  It doesn’t rush you and you don’t have to worry about getting your words right.  You can write it down and see if it looks OK before anyone else sees it.  A piece of paper accepts everything you put on it without interrupting or giving your family the opportunity to tell your story differently.

Try it out as a strategy the next time a child or young person is struggling to communicate in a mental health consultation.  You might be very surprised and pleased with the results.

Edward Snelson

@sailordoctor

Something Old and Something New - Social Media and Young People's Mental Health

And now for something completely different...

While we tend to associate winter with infections and respiratory complaints in children and young people, it is also a time of increased mental health problems in young people.  It is often asked, "Is there a genuine rise in mental health problems in young people?  Are we just recognising it better?  Have we simply moved the goalposts so that what was once called normal is now labelled as mental heath problems?"  There has been an apparent increase in mental health problems in young people in the UK according to the best evidence.  Various factors are thought to be contributing, and the rise of social media use is one of these factors.

Allow me a story to give some context to the world in which we now live.  Since we are currently within the centenary of the first world war (WW1), this story I'm going to tell you is one of modern times.

Three months after the outbreak of WW1, a German warship, the SMS Emden, had been causing havoc in the Pacific.  She had captured or sunk ships running into double figures and the captain decided that it was time for the ship to have some repairs and the crew to get some shore leave.  He steamed into the island of Diego Garcia, which was at the time under the control of the British.  Despite being three months into a war between these two countries, not only was there no resistance from the British garrison but the local force welcomed the cruiser, helped with the repairs and presumably made them all tea.  Why?  Because the British Garrison didn't know that they were at war.  No information about the hostilities between the two nations had reached them.  True story.

Fast forward a few generations and think about the world that our young people live in.  Everything is fast, if not immediate.  Everything comes with an expectation (I know what a few dozen people think about the next hotel I'm going to stay in) and gets rated and reviewed.  One of the problems of modern times is that this is happening to our young people, not just to hotels and restaurants.  they are themselves being rated and given instant, sometimes brutal feedback every time they go online.

One of the known risks to mental health is any detrimental effect on self esteem.  If the world tells  a young person that they should be thin and beautiful and rich often enough, this has an effect on their self esteem.

Another problem that comes with social media is that it is a fickle friend.  Young people need to feel accepted or validated as part of a healthy psyche.  When something brings you down, it helps to have a solid person in your life to let you know that you are an OK human being.  Social media has made it possible for young people to be connected to hundreds of others.  The trouble is that what these 'friends' or followers say or don't say can be detrimental. Online interaction can be any degree of unpleasant and all varieties of negativity are seen in various forms.

Social media gives you a value.  How many online friends do you have?  How does that compare to other people?  How many 'likes' did your latest selfie get?  Why so few when someone else in your class got 300 likes?

The online world brings a great deal of opportunities for young people but it also brings risk.  If a young person is vulnerable to mental illness, then the negative effects of social media can be the trigger. (1)

What can be done about the risk?  If a young person is showing signs of mental health problems then we need to be able to offer helpful advice.  The debate about how to intervene is never-ending.  This week, Facebook was in the news for its new under 13 year old version of Messenger, which Facebook is currently testing.  Facebook argue that since 12 year olds simply pretend to be older online, it is preferable to have a safer version of Facebook, specifically designed for this age group.

Most discussions around the issue of social media and the risk to young people's mental heath centre around parental controls and managing the media.  Another way to approach the issue is to concentrate on everything but the social media itself.  Emphasise everything that is likely to have a positive effect on that young person's mental health:

• Stable relationships
• Positive family interaction
• Affirmation
• Participation in hobbies and sport

Many parents and carers find that it is an impossible or divisive task to police and interfere with a young person's social media use.  Parents need to know that they can intervene positively in their child's social media use.  However, if that seems to be exacerbating any stresses, it may be more constructive to fill the voids in that young person's life with things other than social media.

To return to the original question, mental health problems in young people do appear to be on the rise.  Recognition of mental illness is just one of the challenges that we face.  Prevention and treatment are seemingly unachievable within the resources available, however we need to take the issue of mental health as seriously as we do any other group of  childhood illnesses.

It is probably unnecessary to get caught up in a debate about whether social media is to blame for the rise.  Adolescence is a time of emotional vulnerability and any trigger can be to blame for a mental illness.  The negative effects of social media are one possible trigger.  We need to be aware of this and share this knowledge with families who present with concerns about the mental health or an adolescent.

Edward Snelson
Looking for validation elsewhere thankfully
@sailordoctor

Disclaimer:  Rather than my usual nonsense, I would like to allow myself a serious footnote.  Over the time I have been writing GPpaedsTips, I have noticed what gets the most and the least attention.  If I was to maximise the numbers of shares and clicks, I would never mention mental health ever again.  Although we should indeed be interested in treating asthma and sepsis, suicide remains a leading cause of death in young people (2) and the impact of mental health problems in adolescence is massive.  Although I wouldn't normally ask, please share this post.  How else will I be a valid person if I don't get enough likes?  If I get enough clicks on this post, I promise to write about sepsis next time.

1. O'Keeffe, G. et al, The Impact of Social Media on Children, Adolescents, and Families - Pediatrics April 2011, Vol 127, Issue 4
2. Pearson. G et al, Why children die: avoidable factors associated with child deaths, Arch Dis Child (2010). doi:10.1136/adc.2009.177071

Ctrl F and Child Mental Health Problems - Making everything simple

Recently, someone showed me something that has changed my life.  If you press the Ctrl and F keys on your computer (Command +F for Apple) at the same time, a magic box pops up.  This is the 'find' function.  If you don't use it much, you should.  It makes a lot of things much easier.

Here's a non-medical example:  Let's say that you are looking for a payment that you know you made sometime 2-4 years ago from your bank account.  (I don't know, maybe the insurance company want to know how much you bought your laptop for.  Just go with the example please.)  You download the last five years of bank statement from the website and start trawling through for the money that you know that you paid to Amazon for the laptop.  Well stop that.  There is a much easier way.  Press the Ctrl and F keys and then type 'Amazon' in the box.  Hit enter and watch the magic begin.  Using this witchcraft you can find what you are looking for instantly.

Here's a medical example of how I use this function all the time.  Go to the NICE guideline for gastroenteritis in children.  Download the full guideline, not the summary.  Now read it until you find the evidence statement for how the guideline group formulated its decision regarding use of loperamide.  No, don't do that.  The document is over 200 pages long.  Instead use Ctrl and F to start your search, then move on using the arrows (or 'next') until you are where you want to be.

This little trick works for word documents, spreadsheets and anything else.  My favourite trick is to use it on a webpage to find something that I can’t see (like unsubscribe).  Since I was shown how to do this, it has made so many things much easier.  What is amazing to me is that not everyone knows about it.

I don't know what it is like in the rest of the world, but trying to help a child with a mental health problem in the UK can be a lot like trying to find something in a 200 page document.  Primary care clinicians can put a lot of work into trying to help children and young people (CYP) with mental health problems and it can feel like we never get anywhere.  Recently, a child psychiatrist told me a few things that helped to make a lot of sense of these problems and how to help CYP with them, including how to get your referral to the Child and Adolescent Mental Health Services (CAMHS) to get the most appropriate response.

What he told me all made perfect sense.  So I thought you might like to have me share his beautiful and simple insights into child and adolescent mental health problems.

1 - There are usually three factors which lead to children and young people's mental health problems

One of these factors is the child's genetic predisposition.  You can't do anything about that but it is still useful information.

The next factor is the child's environment.  Note that the weight of the domains of a child's environment change as they grow.  For example, the importance of different domains for a 4 year old might look like this:

Then as a child becomes more independent, the importance of each domains changes.

Of course, this is a gross oversimplification, which is exactly what I need in these kinds of circumstances.  By the time you reach adolescence, I suspect the weight that each domain holds over the young person varies greatly, but what the future holds (health, wealth and success or lack of) starts to become much more significant.

The third factor is a trigger.  This brings the intrinsic into contact with the extrinsic factors, precipitating the mental health problem.

2 – Every Child needs an anchor

Children and young people usually have at least one functional and dependable adult in their lives who they can rely on to give them consistency and who will make the CYP feel that they are worthwhile individuals.  A child who never has one of these people in their lives is unlikely to escape mental health disorders.  A child who loses their anchor is at high risk of developing a problem.   Ask, “Who is the most important person in this child’s life?”  If they used to rely on their grandmother who has recently died, this is very important information.

3 – Children and Young People get different mental health problems at different ages

It’s fairly obvious to say that but it does help you when it comes to assessing a problem.  When we are deciding whether something is a mental health problem in the first place, our first question should be, “Is what is happening normal for this age group?”

So what problems do CYP get at different stages?  They get mental health disorders which fit their stage of psychosocial development.  Young children tend to get behavioural problems and neurodevelopmental disorders (oppositional defiance disorder, attention deficit disorder, separation anxiety disorder).  Older children get problems that are related to their transition from child to adolescent (anxiety and self harming).   The top end of the CYP age group (in the UK this goes up to 18 years old) will get the beginnings of adult mental health disorders.

Knowing that something is abnormal doesn’t tell you how significant the problem is.  What tell you the answer to this is the same thing that almost always tells you about how significant a problem is in paediatrics: function.  So, the next question is, “How does this problem impact on the child’s ability to do the things that they want to do or should be able to do?”

And there you have it: your child psychiatry equivalent of the ‘find’ function.  A little understanding goes a long way when it comes to assessing and referring CYP with mental health problems.  Knowing what to ask always brings the best answers.  The answers to these questions just happen to be what a CAMHS consultant needs to see in a referral letter.  By including all of this information, we maximise that consultant’s ability to prioritise you patient.  Sound’s good eh?  So here they are again:

OK, so it’s hardly a keystroke, but considering that we are talking about one of the most complicated problems that we will see in our work, a five question model for getting what you need is pretty good going.

Edward Snelson
Impulsive clinician with a short attention span
@sailordoctor

Acknowledgement - Huge thanks to Girish Vaidya (@DrGirishPsych) who has helped me to understand the core principles of child mental health.  His ability to make the complex simple is a real gift.

Non-specific abdominal pain and medically unexplained symptoms

In the early days of GPpaedsTips, I wrote about how I don't like to diagnose non-specific abdominal pain unless constipation has been ruled out.  I think that especially in the pre-teens, undiagnosed constipation is a big factor in mysterious abdominal pains.  In the child where such causes have been ruled out, it is curious that we have kept the term 'non-specific abdominal pain' (NSAP) or 'recurrent  abdominal pain' (RAP) when the label of 'medically unexplained symptoms' (MUS) fits just as well, if not better.

First of all, let's deal with the elephant in the room.  Medical terminology is always evolving and it is sometimes hard to keep up.  Many of us heard different terms used when we first studied medicine (such as functional or psychosomatic) for what seem to be the same clinical scenarios that are now labelled as MUS.  I don’t like perpetual re-labelling of problems. Medically unexplained symptoms, for me, is an exception to this dislike.  MUS removes the judgement of how much a problem is psychological and how much it is physical.  MUS acknowledges that there is always a combination of the physical and psychological.  How much of each component exists is neither measurable nor essential to know.  Is it 60:40 or 30:70?  I don’t know.

The other benefit of calling the situation MUS is that it recognises the possibility that an unknown physical cause may exist.  If a symptom has no medical explanation, the problem may be that medicine has failed to explain the symptom.  Although very few MUS scenarios end up with a eureka moment later on, a significant physical cause is sometimes found.

One definition of MUS is, "symptoms for which a treating physician or other healthcare providers have found no medical cause, or whose cause remains contested."(1)  When a young person presents with recurrent abdominal pains, once the physical medical causes have been ruled out, what we are left with is a medically unexplained symptom.  Labelling the scenario as NSAP is historical and has the potential to be revisited.

Is there anything wrong with the label of NSAP?  I can see two potential pitfalls, both of which arise from that way that it sounds a lot like a diagnosis.  The first problem is that both family and clinician may see the matter as closed.  This carries the risk that a diagnosis might be missed, especially if it is one that easily goes beneath the radar, such as coeliac disease.  This publication lists various pathologies that were found following a diagnosis of NSAP. (2)

Nor should we over-investigate.  As discussed in a recent review article on MUS in ADC (3), the problem here is the "impossibility of proving a negative."  Rather than give every child with abdominal pain an endoscopy, the middle way of leaving the diagnosis open while observing and looking for a recognisable pattern may be safer than labelling as NSAP.

The second problem is that any psychological component may not be addressed.  Is there a psychological component in NSAP?  I would say that there always is but for different reasons depending on the scenario.  The more physical the problem, the more distressing it is to have chronic symptoms that cannot be easily explained or be treated.  If the symptoms could be described as being secondary to a psychological cause, then the psychological component is self-evident.  There is no chronic abdominal pain scenario that I can think of that would not benefit from a dual physical-psychological approach.

I think that this dual approach is what tends to be done with NSAP already, whether it is managed by GP, paediatrician, gastroenterologist or surgeon.  An open minded and holistic approach is essential when managing medically unexplained abdominal pain in young people.


Managing medically unexplained abdominal pain in young people in Primary Care

In some cases, a cause of abdominal pain is obvious.  Common pathologies are constipation and reflux oesophagitis.  Both can be managed in Primary Care if there are no red flags and the problem responds to treatment.  Even when the cause is less obvious, the cause is often constipation, which is why it is worth really asking in detail about diet, bowel habit and the pain.  I also believe that a trial of macrogol laxatives is often a good strategy in the absence of an obvious cause.

In more extreme cases, there may be red flags such as weight loss, or bloody mucousy stools.  These children should be referred though an urgent route (inpatient or out-patient depending on the circumstances).  If the symptoms are severe enough to warrant immediate admission and investigation, laparoscopy finds a cause in about half of patients. (4)

There are also cases where there appears to be a psychological cause, often related to stresses such as school, bullying or even abuse.  It is still important to consider physical causes but there is nothing wrong with moving to address the psychosocial causes early on.

In some cases there is genuine ongoing uncertainty.  The usual pathway for these children is to refer to paediatric surgeons, paediatrics or paediatric gastroenterology for further investigation.  After this, clinical psychologists are often involved.  I don't know what they do.  Witchcraft or something.

Edward Snelson
@sailordoctor
Unexplained Medic

Disclaimer - If you can't explain it, it's not my fault.   You're clearly not trying hard enough.

References

1. Medically unexplained symptoms, Wikipedia
2. Sanders, D et al, A New Insight into Non-Specific Abdominal Pain, Ann R Coll Surg Engl 88(2); 2006 Mar
3. Cottrell, D, Fifteen-minute consultation: Medically unexplained symptoms, Arch Dis Child Educ Pract Ed 2016;101:114-118
4. Decadt, B. et al, Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain, British Journal of Surgery, Vol 86, Issue 11, pages 1383–1386, 1 November 1999

Socrates to the Rescue - When "Why?" Becomes How to Recognise Child and Adolescent Mental Health Problems

How can a paediatric subspecialty be so difficult and shrouded in mystery?  Even the name, Child and Adolescent Mental Health Services, is complicated.

What do they do?  The mystery extends to the online world of open-access medical education.  Because I am putting together some resources for a university course at the moment, I went on my usual trawl for journal articles and online resources that might give me an idea about how we mere mortals should be doing our bit for child mental health problems.  Compared to similar advice for asthma, sepsis or even just the limping child, there is virtually nothing out there for the clinician who recognises child mental health as a personal educational need.

What to do?  Phone a friend.  Yes, I spoke to an actual person.  My expert told me that there are simple things that we can do to be a bit better at this.  We need to ask more questions.

In order to do this we must enter the mind of a two and a half year old...     ...or an ancient Greek philosopher.  You decide.

If you've never taken a two and a half year old for a quick jolly down to the shops then you've really missed out.  It goes something like this:

Socrates taught his students to question everything, including the answers to their questions.  In this way, the answer behind what was superficially apparent comes to you.  It's something that we all knew briefly when we were two and a half, but sometimes forget now that we are grown up and a bit dull.  What is superficially apparent can seem to be the end point, but in child and adolescent mental health, it probably isn't.

Let me apply Socratic (if Socrates was two and a half) method to some common presentations to General Practice or the Emergency Department:

A 12 year old has abdominal pains that only occur during school terms.
Obvious answer: School avoidance.
Ask the question, "Why school avoidance?" - Answer: Anxiety symptoms due to undiagnosed dyslexia.

A 13 year old is smoking cannabis every day.
Obvious answer: Bad parents and a chaotic home.
Ask the question, "Why?" - Answer: They have been having anxiety symptoms every day for nearly a year.  Months ago, they were given some cannabis to try and they found that it helped take away that feeling.  They started using it to feel more 'normal', not to get high.

A 15 year old has multiple symptoms for which there is no sensible medical explanation.
Obvious answer: Attention seeking
Ask the question, "Why?" - Answer: No obvious reason, so what else is going on?

The list of things that young people present with that are viewed as behavioural include cutting/self-harming and anorexia.  The reasons may be elusive, but they may also be identifiable.   There may be a safeguarding issue.  

Every one of these children deserve to have someone ask the question "why?"

In many cases they may not know why.  They may not be able or ready to articulate it even if they do know.  However, many young people can explain why they do what they do if someone is willing to give them a safe place to do so.

The important thing is to move away from making the obvious assumptions and instead always assume that there is more than meets the eye.  The evidence is that mental health problems in young people are often not recognised.

In Emergency Medicine there is a saying, "The easiest injury to miss is the second one."  That is equally true of child mental health. How do we make sure we always find the hidden problem? I don't know. Ask a two year old.

Edward Snelson
@sailordoctor