Who speaks for the bad boys (and girls)?

In a way, we are in a golden age for attitudes to young people’s mental health. Just this week, no less a figure than Prince Harry talked about his own help-seeking, both he and his brother and sister-in-law have campaigned for better services and more positive societal attitudes. Theresa May has discussed the issue in a not-entirely-bad speech.

But what if I was to ask you what the most common mental health condition is in the UK? Most people guess at anxiety, or depression. If pushed they might go for eating disorders. But it’s none of these. By a considerable distance, it’s conduct disorder.

Conduct disorder is, roughly, an established and disruptive pattern of anti-social behaviour, which impairs the young person’s life. The commonest objection is that this is not really  a mental health disorder, but that in itself betrays quite a restrictive attitude to what emotions and thoughts we regard as worthy of help, and which we reject and condemn.

Imagine two girls of 14.

One, Amelia, is lonely and sad a lot of the time, she doesn’t think her friends like her, and self-harms by cutting her forearms.

The other, Charlie, is angry and alienated. She thinks her mum hates her and they row a lot, and she self-harms by drinking in the park and getting into fights.

Which girl is more worthy of our concern and care? I would argue that they are both, equally worthy of our compassion and to receive the help that they need.

However, the narrative around mental health is exclusively about the type of problems that Amelia has, and puts Charlie in the ‘broken Britain’ bin of delinquents and ‘problem families’. And it isn’t just the media- I’ve been to discussions of young people’s mental health at the Department of Health, NHS England, the Royal College of Psychiatry and innumerable charities, think tanks and parliamentary groupings. I have never seen a young person with conduct problems attending, and no-one (other than me) has ever, ever mentioned this condition which, just to remind you, is the most common mental health condition in young people. When I do mention it, everyone nods, mumbles, and goes back to what they were talking about. Usually mindfulness, or apps.

Why is this? It’s not because people in the field are stupid, or uncaring.

One problem is that these kids do not have socially acceptable mental health problems. They are routinely rude, they often undermine attempts to help them (mainly because they don’t believe they are worth helping). They are not eloquent, typically, and are often ashamed of their feelings in a way that we encourage with our condemnation.

One big focus in mental health has been the role of schools in supporting pupils with mental health problems, but hand in hand with moves to train every teacher to deal with anxiety and depression is a hardening of attitudes to anything remotely anti-social, and the return of the disciplinary culture of the 1950s will do far more damage to mental health than any amount of amateur CBT can compensate for.

Anxiety and depression are, demonstrably, no respecters of social class. Conduct disorder, on the other hand, very much is- it is vastly more common in poorer families, and so society’s attitudes to poor families are transferred to their troubled offspring.

The help they require is complex, and requires co-ordination across multiple agencies, support for the whole family, and above all, patience. They can be helped, and there is a lot of evidence of effective interventions, but ultimately they are too difficult, and give too little political reward, to be the priority.

Conduct disorder is associated with every kind of negative outcome you can think of. It is a major, treatable, public health problem. Why are we not talking about it?

What next for children’s mental health care? (update of old post)

Pretty much every week, we get a report lacerating our care of children and young people with mental health problems. This time, the Royal College of Psychiatrists have concluded that services are inadequate in the vast majority of areas, earlier this year Youth Access pointed out the level of unmet need, as did the NSPCC. And, as always, the government responded with two things. The ‘historic’increase in funding, and the reform programme instigated by the ‘future in mind’ report.

Let me take these in turn. The increase will, by 2020, have restored funding for CAMHS (child and adolescent mental health services) to around 2010 levels. So a historic rise will follow an unprecedented fall. In any case, given that the money is not ring fenced, or in fact new money at all, there is evidence that it’s not reaching CAMHS at all in many areas.

But even if this money got through, it’s not enough to serve the need using our current model. The consensus is that only about a quarter of young people with a mental health problem get specialist mental health care, and that’s with everyone currently in CAMHS working flat out, so you’d either have to quadruple funding, or make everyone work four times faster, to serve the population need.

But doesn’t ‘future in mind’ offer a new vision for CAMHS? Yes and no. It’s a strange document, and I say that as someone involved in writing it. On the one hand it sets up a very efficient ‘engine’ for specialist CAMHS to give time-limited, evidence based intervention via the CYP IAPT programme. It talks a lot about counselling in schools.But outside of this, it offers mainly aspirations and wishful thinking.

The reason this is a problem is not because CYP IAPT is a bad programme. For delivery of specific interventions for specific problems, it’s great. But at present it only really addresses mood disorders and offers parenting courses. Add to this the clear guidance and increased funding for eating disorders, the focus on counselling in schools, and the increased resources for inpatient CAMHS, and it’s easy to see the groups that may, eventually, do well. Broadly, it’s adolescents presenting with anxiety, sadness and anorexia. This is, in many ways, a great thing. But it’s not enough.

Most people reading this will be aware of the much used statistic that shows that 10% of children have a diagnosable mental health problem. It’s not well known, and needs to be, that half of this number have not mood disorders, but various degrees of conduct problems, in other words, behavioural problems. This group have been almost entirely airbrushed out of the picture. Also, in practice, young people whose mood problems are mixed in with social vulnerability and special educational needs usually cannot access IAPT effectively. Add in children with mental health problems presenting either as physical symptoms, or in the context of chronic conditions, and you can see that a broader vision is required.

Another thing has struck me recently. When you talk to someone who had, for whatever reason, a troubled youth, from which they recovered, treatment does figure, but care is so much more important. What I mean by this is someone, be it a parent, a teacher, a youth worker, whoever, consistently holding the person in mind, and looking out for them, consistently and unconditionally over a period of time. It’s not at all clear that the new IAPT engine is very good at this sort of care. And, in the words of one senior civil servant, it’s ‘the only game in town’.

So we have a paradox. Everyone thinks that only specialist treatment counts as help- for example the Centre for Mental Health present delays in accessing CAMHS as ‘children with mental health problems wait a decade for help’.  There isn’t enough specialist treatment for everyone, there can’t be, and the services that exist are narrowing themselves into particular areas. But what actually helps long term is care.

Is care enough? Sometimes clearly not, but if informed by adequate training (of professionals or parents), integrated across agencies and informed by advice from, and consultation with specialists, then really very often difficulties can be contained outside specialist settings. However, because parents and professionals feel disempowered, opportunities are lost waiting for a magic cure that, more often than not, just isn’t there.

We need badly to empower parents, non-CAMHS professionals, and young people themselves to be able to support these needs in the long-term.

So we need specialist treatment services, but only in the context of a wider local mental health support system. I can’t give you an immediate blueprint for this, but here are some ideas:

  • Mental health to be taught in schools as part of compulsory PHSE
  • Universal access to parent training and support.
  • All local health and well-being boards to have responsibility  for promoting cyp mental health
  • Commissioning budgets pooled across health and local authorities to prevent duplication and gaps in provision.
  • A ‘local offer’, analogous to the local special educational needs offer, developed as an extension of current transformation plans.
  • CQC/OFSTED inspection of local CYP mental health systems, focusing on collaboration and prevention
  • Improve information sharing by changing professional cultures and putting parents in charge, using informed consent to bypass restrictions.
  • Appropriate mental health training for all professionals working with children, building on the work of MindEd.
  • Local, funded strategic networks including parent and young people, as well as voluntary sector, monitoring the offer and promoting accountability for services.
  • CAMHS specialist services to be funded to provide consultation to other agencies locally.
  • Work undertaken to adapt NICE guidance to educational settings e.g. for conduct problems.
  • Schools exclusions guidance examined to ensure that all pupils are properly assessed for underlying difficulties before permanent exclusion.

 

There is work progressing in some of these areas- NHS England will be coming out with guidance on access to mental health care, and RCPCH will be pushing the ‘local offer’ idea. Watch this space.

 

The pointless fight over mental health classification

In the wake of any mental health related story, in this case the death of Robin Williams, there is always a renewed flurry of criticism of the very concept of mental health diagnosis, as practiced by psychiatrists using the DSM or ICD classification. The neuroimaging scientists, geneticists and some psychologists are calling for paradigm shifts in our understanding of mental distress and illness. So what do they want, and what should we do about?

The DSM is a descriptive classification. It allows professionals to look at a person’s pattern of behaviour, thoughts and emotions and see whether they fit into a constellation of difficulties in which certain interventions have been found to work, so that a reasonable guess can be made at what is likely to help this individual. It’s obviously a bit more complicated than that, but that’s the gist of it.

Many researchers, and prominently the National institute for Mental Health in the US, want psychiatry to be more like the rest of medicine, guided by genetics and imaging to target intervention at biochemical or neurocomputational pathways, using the bleeding edge of technology to bring psychiatry into the age of the brain. I have two main problems with this: firstly the rest of medicine isn’t really like that. Ask a good GP how much of her practice is determined by blood tests or imaging, she’ll tell you not very much. Most of the time doctors act on what people tell them and what they see in front of them, and long may that continue. Secondly, the linkage between a particular gene or imaging finding and people’s actual problems is never as straightforward as excitable journalists or ambitious research scientists are keen to tell you. There’s a really good interview by Vaughan Bell which develops this theme.

On the other hand psychologists, notably Peter Kinderman and Lucy Johnstone of the British psychological society, seem to want a shift away from descriptive classification altogether. They argue that the DSM is too biological, and robs people of their psychosocial context. They want an approach which will “contextualise distress and behaviour, and to acknowledge the complexity of the interactions involved”. In a sense they want to give people their stories back. There’s a lot to recommend this approach, and it can be particularly helpful in regarding people’s distress as part of a process, rather than a fixed disorder. The trouble is, because everyone’s story is different, this approach isn’t as good at generating research data on what works in particular situations, because one person’s response cannot necessarily be generalised. The danger here is that you lose your evidence base, and planning intervention starts to look more like guesswork and theorising than science.

I’m also not sure that it’s meaningful to criticise the DSM for being too ‘biological’. As a  descriptive system, strictly the DSM is neutral as to the cause of these conditions. And unless you believe in a non-physical soul which animates the inert computer of the brain, all of these complex processes are, at some level, biological.

Finally, unless you also discard clinical diagnoses like constipation, migraine and IBS, this approach implies that diagnosis is fine for physical complaints, but not mental distress. But this introduces exactly the kind of unhelpful mind/body dichotomy that we’ve all been trying to avoid for years

Here I finally get to my point: each of these ways of describing people in distress is valid, each has its own limitations, but I can’t see that they are in any way mutually exclusive.

I realise this may have been rather heavy going so far, so let’s talk about Norman Price. Yes, Fireman Sam fans, that Norman Price.

There’s a story to tell about Norman. About his father who set off for Wrexham one morning, and never came back. About his mother’s weird mix of over-the-top terms of endearment and total failure to interact positively with him in any other way. About his struggle to be accepted in a peer group dominated by those airbrushed irritants Sarah and James. This story might lead you to useful conversations and reflections that move the situation on.

If you scanned Norman’s brain and his genome, you might find microdeletions on 15q, dopamine receptor depletion in the meso-accumbens pathway, whatever. This might suggest a helpful molecule that some bright spark has put in a pill. Or it may not.

Finally you could sit down with him, his mum and his teacher and work out whether his pattern of behaviour and cognition is similar enough to a group of people that you know about, that what worked for these people might be useful for Norman. Again, worth a try.

None of these is the right or wrong way to approach him- you could do all three. But equally the descriptive approach is not obviously the worst one. As I have argued before, it’s not so much the classifying, diagnosing approach that’s the problem, it’s when that’s the only approach on offer, and when decisions are distorted by perverse commercial incentives to diagnose, and treat, inappropriately. And when categories appear to have been made up out of the blue.

I’m sorry if it looks like I’ve spent a long time saying something fairly obvious, but in all the thousands of words written on the subject I’ve not seen anyone make the point that all of these people are talking about the same thing, just in slightly different ways. We need to move between these approaches according to which is going to help us address a given situation, stop picking needless fights with each other, and get on with it.

It saddens me to find organisations expending energy on attacking the way other people approach these problems when mental health services are being cut mercilessly, while NHS privatisation drives a consumerist model that will lead to over-diagnosis and over-treatment of those with the resources to access care, while the rest cling to the shrinking raft of what remains of public services.

So please, psychologists, psychiatrists, social workers, teachers, whoever, can we please stop squabbling over methodology and work together to help vulnerable and distressed people? Thanks.

Do 40% of children suffer harmful parenting? Er, no.

There was a mild amount of interest yesterday in the Sutton Trust report on the impact of infant attachment on later development. The press release trumpeted how this showed that 40% of children “miss out on the parenting needed to succeed in life”. This is strong stuff, suggesting that there is some key ingredient missing from this (vast) group of children. The researchers feel that they have find this ingredient. It is secure attachment.

Attachment needs some explanation. The simplest way to explain it is broadly that during the first year, the baby learns to trust their caregiver to reliably respond to their needs. This process can go wrong in a few ways.
A tiny number of children seem to be unable to form attachments at all. A slightly larger tiny number form attachments indiscriminately. These problems appear to be quite largely genetic or neurobiological, and we can quickly move on for our purposes.
Some children (about 15%) seem not to be able to work out whether to trust the parent. This seems to be linked to parents being either frightened, or frightening, and therefore unpredictable. This group, described as having disorganised attachment, have undoubtedly poor outcomes, although we have no idea whether the attachment pattern is a cause of the later problems, or an alarm bell for other underlying problems.
This leaves us with children with organised attachment, who seem to have worked out a strategy for responding to parents. These have been split by attachment theorists on the following basis:
Basically, in lab conditions, the child is separated from their caregiver. They either respond too much, not enough, or ‘just right’, or as statisticians would call it, in the average range. Children at both ends of the range are classified as insecure, and this insecurity is claimed to be due to either parental under- or over-responsiveness. These children have, however, never been shown to have any clinically significantly worse outcomes that those in the ‘secure’ middle. This report makes some claims that these ‘insecure’ children are in some ways worse at communication, but as it’s not a systematic review, it’s hard to evaluate these claims.

As you might have guessed, I have a few problems with this report:
Firstly, they conflate disorganised and insecure attachment to increase the proportion of children with an indicator of poor outcome from 15% to 40%, making their conclusion misleadingly dramatic.
Secondly, they make the assumption that the only predictor of the child’s attachment pattern is the parent’s behaviour. This kind of ‘blank slate’ thinking is simply not consistent with the growing evidence if genetic and temperamental factors in attachment. Among those with organised attachment, any slight difference in outcomes could be due to these factors, rather than parental responsiveness. We just don’t know.
But let’s accept that there is a sizeable number of children in the UK with disorganised attachment, which should act as an alarm bell for potential poor outcomes. The authors present evidence that attachment style can be altered with intensive parenting work, but they offer not a single piece of evidence that changing the attachment style improves outcomes. To use my alarm bell analogy, it may well be that changing attachment style is the equivalent of switching off the alarm, rather than putting out the fire.

Why am I going on about this? Surely there’s no harm in at-risk parents getting help? Well, firstly, of 40% of parents who could now be told that their parenting is harmful, most are doing nothing wrong. This seems terribly unfair.
Secondly there is an opportunity cost. Resources for early intervention are limited and shrinking (for instance 2/3rds of CAMHS services cut since 2010) and diverting resources to attachment-based intervention with no evidence of impact on outcome, when we could instead address parental mental health, poverty, substance misuse, domestic violence and all the factors that set off this alarm, would be a tragedy.

Now I need to stop ignoring my children. They are becoming disorganised. And silly.

How Aric Sigman pwned the medical establishment

Two years ago, independent psychologist Aric Sigman was a bit of a joke to me. Wingman to Susan “I point to autism” Greenfield, he seemed a faintly ridiculous character, whipping up hysteria about the modern predilection for screen-based activities, and linking this to all manner of physical and mental health problems. Ben Goldacre, for one, wasn’t buying it.
So how come Sigman ended up being uncritically quoted in this week’s chief medical officer’s report? And why does this matter?
Sigman was a speaker at the 2012 Royal College of paediatrics annual meeting, invited by a tiny specialty group who wanted to hear some challenging ideas. (Ok, my tiny group, but not my idea)
He was then invited to write an article for the college journal, the archives of disease in childhood His article was wildly misleading (for reasons I outline below), but does not appear to have been adequately peer-reviewed. However, when the authors of the CMOs report were looking for evidence about the effect of screen time on children, here is what appeared to be a review article in a highly respected journal. It’s understandable, if unfortunate, that they didn’t look more carefully at the evidence, but just reproduced his claims without qualification.
So claims that are at best tenuous have made it into a highly respected report, with significant influence over health policy.
So what? It’s not as if Sigman is definitely wrong, after all. He claims that screen time is an independent risk factor for obesity, heart disease and ADHD, among many other conditions. Maybe, but the evidence just isn’t there yet.
In order to make his case, Sigman distorts the evidence in a number of ways:

Firstly he unhelpfully  lumps different forms of screen time together,when both experience and evidence suggests a widely varied set of effects.

Secondly cherry picks data, as Pete Etchells has pointed out.

Thirdly,  interprets associations with a feature of a disorder as a definite causal link to the full disorder, whereas more sober analysis reveals a complex picture of association with aspects of the conditions with predisposition to use screens. 

In short, he’s unscientific and unbalanced.

So challenging Sigman matters because evidence matters.

Children’s well-being is threatened by a variety of factors, so to scapegoat lifestyle factors like screen time, rather than take a balanced view of the social, economic and psychological factors at play, as the recent Natcen report does, is to do children a disservice.
The story is also a interesting illustration of how authority works in medicine. None of us have time to read and analyse all of the data on questions that we work with every day, so inevitably we have to rely on a shorthand- some combination of who is writing and where they are published. Someone writing in a big journal like the archives might be assumed to be taking a balanced view, and professional researchers and clinicians are obliged to.
This I think is where Sigman’s lack of a university appointment matters; it’s not a question of academic snobbery, but of accountability. Sigman is not accountable to anyone. He can say what he likes, and the shame is that paediatricians have allowed him into the charmed circle that allows him influence at the very top of the medical profession.
I’m not sure what the moral of all this might be, but I do think organizers of conferences and journal editors need to be more careful to ensure the scientific rigour of people who are invited to contribute, rather than invite controversial people to spice things up. Those of us who rely on evidence need to be alert to the quality of evidence, not the reputation of the source.

More screen-bashing in the media, but the picture is far from clear

The Guardian  headline reads:Research links children’s psychological problems to prolonged screen time

As once again a complex and lengthy report is reduced to ‘screen time is evil’. The article bundles computer gaming, screen time and sedentary lifestyles together into a septic whole, and blames them for psychological problems (by which perhaps they mean mental health disorders). It might be worth pausing to think about whether such bundling is actually valid or useful, and what the report, by Natcen, actually says.

The report is called ‘Predicting well-being‘, and is based on a cross sectional analysis of the Millennium Cohort Study (7year-olds) and a cohort of the Understanding Society survey (11-15year olds). There’s already a problem here for the kind of causal linking suggested by the Guardian, in that this kind of analysis will only yield correlations, and as any science bore will delight in proclaiming, correlation does not imply causation.

So any casual claim made on the basis of this report needs to be treated with caution.
That said, the section on screen time in children is interesting, as much for what it doesn’t say as what it does. They asked about all sorts of screen time, but only found an association between computer gaming and well being in adolescents. This data is interesting, and I’ve grabbed one of their graphs below.

graph

So, gaming for more than 4 hours on average on a school night is associated with lower well-being scores. But imagine if you heard that a young person was shut in their room playing Call of Duty till 1am every night. Is it sensible to think “let’s throw away the Xbox”, or to ponder what issues are being avoided by escaping into this hermetic, predictable, rewarding world? The fact that the well-being scores seem to plunge so much at 4 hours seems to me to be consistent with this intensity of gaming being a warning sign of problems rather than their cause- if computer gaming was harmful in itself, how come 2-3 hours per night had no negative effect?

The correlations between computer gaming and well-being for less intensive patterns are not statistically significant, but it is worth pointing out that people who do a little gaming have slightly better scores than those who do none.

The Natcen report only includes positive results, so we can assume that there was no correlation between overall screen time and well-being, which certainly isn’t the impression gained from the media coverage.

Also, there’s no mention of screen time in younger children. This can’t be because the question wasn’t asked, because the same data was used for this study, published in March, which found a tiny association between TV but not gaming and conduct problems in 7 year-olds.  We have to assume therefore that Natcen didn’t find any correlations.

What about the Guardian’s claim that this study ‘supports doctors’ concerns’ about children’s lifestyles? The concern expressed was that children were getting too little exercise, which is certainly a concern as regards obesity and physical health generally, but exercise did not predict well-being in the 7 year-olds looked at by Natcen, and was not analysed in the adolescents (p.35). So the idea that screen time leads to less exercise leads to less well-being is not supported by this data.

So there may be reasons to limit children’s screen-time (and good reasons may emerge), but this study does not provide any.

To round this post off, I thought I would post what the Natcen researchers thought did predict well-being in children and in adolescents.

For seven year olds: “Primary school context and friendships emerge as important, but the data suggests that homelife and relationships with family are even more so. Seven-year-old children were happiest where they got on well with siblings, reported fun together with family at weekends, and had parents who did not shout or smack them. Children’s self-reported wellbeing was not affected by having a disabled parent or by living in social housing. Having one parent or two at home did not impact on how happy or worried children reported feeling, so long as they had a parental figure. However, parent perceptions of their child’s wellbeing were associated with some of these things. Lone, disabled or ill parents, and parents who could not afford to take their family on holiday, were all more likely to feel that their child was unhappy. It is possible that these parents feel anxiety about their circumstances affecting their child’s wellbeing. They may be reassured to know that more important than issues of family structure and physical health are the dynamics of warm, supportive and playful relationships within the family. Enjoyment in being together and engaging in a variety of activities in moderation were positive indicators. But young children’s assessments of their own wellbeing were also clearly and strongly associated with the wider neighbourhood in which they lived. After controlling for other factors, children as young as seven were more likely to feel unhappy and worried if they live in a deprived area. These findings support the continuation of public health policy focused not only on the family, but also on the wider neighbourhood”

As a prescription for family-friendly policy and early support for families in difficulty, it’s hard to better.

For teenagers: “As young people go through their secondary school years, child wellbeing progressively declined. This is a critical stage in the life course, when there are many physical, emotional and social adjustments to be made. Between age 11 and age 15, the proportion of young people with low levels of subjective wellbeing almost doubles. It would be easy to dismiss this as the inevitable consequence of hormones and physical change. However, when controlling for social and environmental factors, associations between wellbeing and age are no longer significant. This suggests that the very real dip in wellbeing in the teenage years, that is strongly evident in unadjusted analyses, is the result of social context and therefore responsive to changes in circumstance. Substance use and excessive computer gaming become more common as children grow into young people, and both of these activities were also associated with lower levels of wellbeing. Disruptive behaviour at school continued to be linked to low subjective wellbeing. This was the case both for the young people who were being disruptive, and for those who witness the disruption. A secure environment at school – free from bullying and classroom disruption – remains important to this age group. Home dynamics also continue to be critical to positive wellbeing. Similar to the findings for young children: whether parents were disabled, in ill health, or lone was not relevant to young people’s wellbeing once other factors were controlled for. What mattered were things such as feeling supported and sharing meals together as a family. In recent years there has been increasing focus on the early years, with the establishment of Sure Start and Children’s Centres across the country. There is also a clear rationale for support to address needs throughout childhood, including through the difficult teenage years as children increasingly start to feel low.”

The clinical take-home message for me is that if there’s excess screen use, we have to look at why the young person feels they need to escape from reality, and to understand this in their family, social and school context.