The Crippen Diaries - 2008 : November (1)
What do you want to do when you grow up...November 2008 (1)
I saw Amy this morning. She is 11 years old, and as bright as a button. Six weeks ago she presented looking distinctly pasty with a history of weight loss and urinary frequency. I dipped her urine to find glucose +++ and ketones +++. A BM stick showed a blood sugar well into double figures. A new diagnosis of diabetes in a child is always a shock, more so to the parents than to the child. And even though they had already thought this was going to be the diagnosis, Amy’s parents were still shocked. I sent her into hospital. As is the fashion nowadays she was only kept in for 24 hours or so, stabilised, started on insulin (a dose with each meal, and one at night) and sent home with all the kit. Amy is now doing her own injections both at home and at school and is managing extremely well. Of course she is still in the honeymoon period, both of the physical side of the diabetes and, more importantly, the psychological side. At the moment, indeed, she is positively enjoying the attention. The novelty will wear off.
She was in to day because she had earache and a temperature. She is not eating much and so mum had suggested she missed a couple of doses of insulin. It’s a common mistake, particularly in the early days, and we talked it through. She had a bulging purple eardrum and so I started her on some amoxicillin.
Chatting to mum, she said that later in the week Amy had an appointment at the child psychiatry department. “You mean CAMHS?” I said. Mum laughed. “Well, that’s the trendy acronym, but it’s still the psychiatric department, isn’t it? I guess it’s better than calling it the child guidance clinic as they used to.”
I have known this family a long time. I cannot conceive of them needing psychiatric help of any sort so I asked why they had been referred. Mum said that it was “policy” that all children with newly diagnosed diabetes should be referred to CAMHS and the diabetic nurse specialist had duly made the referral. “Whether or not they want to go?” I asked. Mum laughed again. “It seemed churlish to refuse, they have all been so helpful at the hospital, so we went along with it.” Then she stopped smiling and said, “Trouble is, if you don’t go, and then sometime in the future there is a problem, you would be open to criticism, wouldn’t you?”
Oh! Brave new world!
Trouble is, Mum is right. It is the sort of refusal that would count against parents in a report to social services. I cannot imagine Amy and her family ever needing social services but then you never know. A lot of adolescent, teenage diabetics go through a difficult period during which they semi-deny their illness and neglect their treatment. At that stage they need sympathetic support and management. I still hate this protocol driven knee-jerk referral. It removes original thought from the process. It is an intrusion into the civil liberties to which Amy is entitled, despite her youth, and despite that fact that she does not yet know what “civil liberty” means. Amy has developed a chronic medical condition but she is not potty.
She won’t see a psychiatrist. It will be a “senior mental health worker” whatever that is. Whatever it is, even though it is not medically qualified, it is well meaning. It is, I suppose, some sort of replacement for the extended family. Mental Health workers, like nurses and all other health care professionals these days, are always labelled as “senior” this, or “senior” that. If the “junior” sub-group of HCPs exist at all, they are not let loose on patients. It amuses me. Count the number of times you see the word “senior” in this context.
Amy will be fine. Her family are sensible and supportive. The diabetic nurse specialist is excellent despite all her referral protocols. Amy has good support from her GP too, if I dare say that. She does not need to go to CAMHS and it annoys me that she is being sent. It is insulting and it is a waste of resources. This is one of the reasons why it is difficult to get help for children who do have serious mental health problems.
I saw Amy this morning. She is 11 years old, and as bright as a button. Six weeks ago she presented looking distinctly pasty with a history of weight loss and urinary frequency. I dipped her urine to find glucose +++ and ketones +++. A BM stick showed a blood sugar well into double figures. A new diagnosis of diabetes in a child is always a shock, more so to the parents than to the child. And even though they had already thought this was going to be the diagnosis, Amy’s parents were still shocked. I sent her into hospital. As is the fashion nowadays she was only kept in for 24 hours or so, stabilised, started on insulin (a dose with each meal, and one at night) and sent home with all the kit. Amy is now doing her own injections both at home and at school and is managing extremely well. Of course she is still in the honeymoon period, both of the physical side of the diabetes and, more importantly, the psychological side. At the moment, indeed, she is positively enjoying the attention. The novelty will wear off.
She was in to day because she had earache and a temperature. She is not eating much and so mum had suggested she missed a couple of doses of insulin. It’s a common mistake, particularly in the early days, and we talked it through. She had a bulging purple eardrum and so I started her on some amoxicillin.
Chatting to mum, she said that later in the week Amy had an appointment at the child psychiatry department. “You mean CAMHS?” I said. Mum laughed. “Well, that’s the trendy acronym, but it’s still the psychiatric department, isn’t it? I guess it’s better than calling it the child guidance clinic as they used to.”
I have known this family a long time. I cannot conceive of them needing psychiatric help of any sort so I asked why they had been referred. Mum said that it was “policy” that all children with newly diagnosed diabetes should be referred to CAMHS and the diabetic nurse specialist had duly made the referral. “Whether or not they want to go?” I asked. Mum laughed again. “It seemed churlish to refuse, they have all been so helpful at the hospital, so we went along with it.” Then she stopped smiling and said, “Trouble is, if you don’t go, and then sometime in the future there is a problem, you would be open to criticism, wouldn’t you?”
Oh! Brave new world!
Trouble is, Mum is right. It is the sort of refusal that would count against parents in a report to social services. I cannot imagine Amy and her family ever needing social services but then you never know. A lot of adolescent, teenage diabetics go through a difficult period during which they semi-deny their illness and neglect their treatment. At that stage they need sympathetic support and management. I still hate this protocol driven knee-jerk referral. It removes original thought from the process. It is an intrusion into the civil liberties to which Amy is entitled, despite her youth, and despite that fact that she does not yet know what “civil liberty” means. Amy has developed a chronic medical condition but she is not potty.
She won’t see a psychiatrist. It will be a “senior mental health worker” whatever that is. Whatever it is, even though it is not medically qualified, it is well meaning. It is, I suppose, some sort of replacement for the extended family. Mental Health workers, like nurses and all other health care professionals these days, are always labelled as “senior” this, or “senior” that. If the “junior” sub-group of HCPs exist at all, they are not let loose on patients. It amuses me. Count the number of times you see the word “senior” in this context.
Amy will be fine. Her family are sensible and supportive. The diabetic nurse specialist is excellent despite all her referral protocols. Amy has good support from her GP too, if I dare say that. She does not need to go to CAMHS and it annoys me that she is being sent. It is insulting and it is a waste of resources. This is one of the reasons why it is difficult to get help for children who do have serious mental health problems.
19 Comments:
A warm welcome back to the Crippen Diaries. They have been much missed.
Agree. This is the best bit of your blog, so more please!
Yes, great to see the diary is back, anyway to business ;o)
The National Service Framework for diabetes (as a matter of priority) calls for:
"the provision of emotional and PSYCHOLOGICAL support as an integral part of a diabetes care package" [Standard 3].
The annual Diabetic UK survey of PCTs found that "only 38% of PCTs provide emotional and psychological support for adults and 51% of PCTs provide this for children and young people".
There are around 20,000 children in the UK with type 1 diabetes, and further 1,000 type IIs - less than 3% receive a FULL RANGE of support across all of the services intended to deal with this condition.
Transfer (from paediatric to adult services) is also generally poor with only 60% reporting that it was arranged at an appropriate age.
If we accept that the NSF offers the best approach when it comes to diabetic care presumably that the call for psychological care is pertinent.
They do not say that is it essential that children see somebody that "medically qualified" (when it comes to psychological support) perhaps because of the role of GPs, paediatricians and endocrinologists ?
I do not know how many psychiatrists (specialising in children) work for the NHS but 21,000 seems like a fair size case load, and given the current trend to pathologise behaviour amongst very young children I wonder if such specialised doctors have the resources to meet yet further demand ?
Maybe Zaruthustra will have some thoughts on this matter [given his CAHMs background].
About time too, Crippen returning to what he knows best. He should leave politics to those who know what they are talking about.
I agree that the Crippen Diaries are the best bit; good to see them back again.
By the way, it's a strange co-incidence that the name (presumably false) of the young girl should be the same as that of my sister, diagnosed with the same problem at a similar age.
A lot of adolescent, teenage diabetics go through a difficult period during which they semi-deny their illness and neglect their treatment.
That's what we found.
This reminds me somewhat of a comment I heard from a mum of a young girl with Down's on the Beeb yesterday morning, following the release of the report about the number of Down's babies is increasing. Mum said ( paraphrasing ) it was interesting to note that she would have been offered more in the way of counselling if she terminated her baby than she has been coping with a disabled youngster.
Multiply that up by 14 years, add in two "healthy" siblings, change to a different and rarer genetic disorder and I thoroughly agree with her. We did have to use CAHMS last year with our oldest girl who suffered disablist bullying from her peers about her disabled brother plus issues of self esteem etc...meaning that she was writing hateful notes to herself and involved a police investigation, concluding in arrest for wasting police time.
I suppose that wait in the queue for CAHMS was partly taken up by families feeling that they "had to" attend rather than us who needed the help sooner rather than later...part of me wonders if the CAHMS help or similar was introduced to our family sooner the problems with our daughter might not have escalated so much.
Anonymous said...
About time too, Crippen returning to what he knows best. He should leave politics to those who know what they are talking about.
Tuesday, November 25, 2008 4:00:00 PM
+++
Pah! Whose pompous today!
John
Yes, great to see the diary is back, anyway to business ;o)
The National Service Framework for diabetes (as a matter of priority) calls for:
"the provision of emotional and PSYCHOLOGICAL support as an integral part of a diabetes care package" [Standard 3].
++++++++++
and good to see you back on form too!
I assume that you have your tongue in your cheek becuase normally you have insight. You cannot serioulsy be espousing this sentious botty wipe. What a complete crock of shit it is.
"the provision of emotional and PSYCHOLOGICAL support as an integral part of a diabetes care package" [Standard 3]."
SO SO new Labour, isn't it. Psychological support whether or not you need it.
No wonder the system is going down the tubes!
John
PS I am sure the Z. will be a strong supporter of this protocol driven crap... but then he would be, wouldn't he!!!
Dr C,
Nail on the head here – access to CAHMS is a great idea; compulsory attendance is not.
A perfect example of an instance when commonsense is notably absent because of a blind adherence to protocols.
Incidentally, in passing lots of Type I diabetics find control much easier to come by after the honeymoon period is over (physically at least). It’s much easier to set basal dosages once your body has stopped producing random bursts of insulin.
At least I now know why when I refer one of my students - who, to my completely untrained eye has severe mental health issues and is crying out for help - can't get an appointment for 9 months. Unless they attempt suicide in which case CAMHS will see them in 4 months. Not a suggestion I wish to put to the student.
Hmm, how things change. Despite my record of odd, peculiar and sometimes disturbing behaviour as a child, I never saw any psychiatric health professional until I was 24. I was finally diagnosed with Asperger Syndrome at 32, something they now pick up at 7 or 8.
Now kids get sent to 'the shrink' even after being diagnosed with non-MH problems...
This post has been removed by the author.
Blogger Socrates said...
A&E Charge Nurse,
Crippen got there before me but:
"the provision of emotional and PSYCHOLOGICAL support"
That's the job of her mummy.
And anyway when she does make it into the mental health system it'll be full of loonies and boarderline psychopaths, with us patients left to fend for ourselves, while the staff chase their HealthCare Commission "Excellent" rating.
I don't believe it. That is the most insane thing I've heard in a long time!
It's a bloody nightmare to get a CAMH appointment in any CAMH service I've come across. I'm amazed that the CAMH team even countenance reading the referral - there's no way it would meet criteria!
How do they define emotional and psychological care? I would see responding to an individual's emotional state in a sensitive manner or recognising and addressing the particular difficulties they have with treatment would count as emotional and psychological care.
I find it frightening that any wouldn't see providing emotional and psychological care to patients as part of their role.
Incidentally, I think referring a child and family to CAMH with a new diagnosis of diabetes is a monumentally stupid move. What's the biggest barrier to treatment adherence in any medical condition? (It's stigma, in case you aren't aware.) What do you get if you're referred to mental health services?
Yes, lets just pathologise the normal adjustment process that children and families go through when a chronic illness is diagnosed. Perfect. Well done policy makers. The only saving grace here is the mum's good humour about it.
Trainee Clin Psych
"Emotional and psychological support" = a referral to CAMHS?
What a bizarre protocol. CAMHS is for children with severe mental health problems, not kids needing the kind of "emotional and psychological support" that can and should be provided by the diabetes clinic.
Ridiculous.
By the way, I'm proud to still be a 'junior' doctor six years after I left medical school as I accept that I still have a lot to learn...
If you will forgive the differing circumstances:
At one point in time I was told that any help my family might be offered by Social Care Services would be entirely dependent on whether or not we chose to accept Social Services' offer of a referral to CAMHS for our eldest child.
The child in question is very severely physically disabled, bright, determined, and at the time of referral very young and very frustrated, especially in terms of communication. As parents, we were also frustrated, but more significantly, absolutely exhausted and unable to arrange a much-needed break from the 24-hour care of a child who, as well as being entirely dependent by necessity, would scream and spasm uncontrollably in terror at the slightest unexpected sight, sound, or touch. Hardly unusual behaviour for a small child with this particular neurological injury and related sensory/communication/medical difficulties. For the above reasons, the referral to Social Services was made through the local NHS paediatrics department, and stated that although we were excellent parents who provided a high level of care, we could not continue to cope without a break.
We were disgusted at being bullied by Social Services to accept the referral to CAMHS and adamantly refused.
We felt that the buck-passing dismissal to CAMHS, carrying with it, it seemed, a label of "behavioural problems" until reported otherwise, was inappropriate, unhelpful, and downright unethical when others genuinely need to access this service. Fortunately the sizeable number of medical and educational professionals already working with our child agreed that such a referral was right off the mark, and eventually, after a fair bit of fuss was made, the CAMHS referral became a non-issue, never mentioned. Whether such a non-issue will be exhumed and re-instated in the future remains to be seen.
In any case, the child in question enjoys life, for the most part immensely, now has a useful understanding of the persistent infant reflexes that once terrorised him, is clearly mentally stable, and is successfully gaining more and more independence through communication devices. The care involved is still bloody hard work. Incidentally, we receive a minute amount of help from social services.
Nevertheless, we remain certain that accepting the CAMHS referral would have had the potential to cause more serious future problems for our child than the un-doubted black mark on our family's Social Services file.
@Charge Nurse
Maybe Zaruthustra will have some thoughts on this matter [given his CAHMs background].
I've no idea about it. I've never heard of this protocol. All I can say is that CAMHS in our area aren't receiving referrals due to a diagnosis of diabetes.
@John
PS I am sure the Z. will be a strong supporter of this protocol driven crap... but then he would be, wouldn't he!!!
Nope. Not a supporter of it, but then, like I said, I've never come across this.
All I can say, if any families were referred to us purely because of a diagnosis of diabetes, then unless there was actually some kind of help they actually wanted, I doubt we'd do very much with them other than quietly discharge them.
I would think it's either a very new directive or just a local interpretation. It's the first I've heard of this approach and I'm in touch with lots of parents of children with diabetes across the country.
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