Calling on All Child and Family Practitioners to Help Mitigate the Impacts of the Poor Behavioural Health of Children with Psychiatric Illness

Abstract

Adolescents and children (aged 6 to 17+ years) admitted to inpatient psychiatry or intensive out-of-home mental health programs (formerly called residential mental health treatment centres) are among those with the most severe psychiatric illnesses. Moreover, these children also have very poor behavioural and biopsychosocial health including sleep deprivation, difficult relationships, problematic use of electronic devices, academic difficulty, poor school engagement, insufficient exercise and poor diets; all of these were noted before the pandemic. The pandemic has only increased the social isolation, poor health behaviours and mental health challenges for many children and adolescents. The poor behavioural and psychosocial health of those in their youth with psychiatric illnesses can exacerbate symptoms and can interfere with academic performance, development and good decision making; these biopsychosocial health behaviours are modifiable. All child and family practitioners including pediatricians, family physicians, nurses, social workers, psychologists and psychotherapists have an important role in fostering the behavioural and biopsychosocial health (i.e., sleep, positive relationships, electronic device use, exercise and diet) of all family members and especially children with psychiatric illness. Enacting biopsychosocial lifestyle interventions before or during childhood and adolescence may reduce the burden of mental illness.

1. The Poor Behavioural and Biopsychosocial Health of Children with Psychiatric Illness

Children with psychiatric illnesses severe enough to be admitted for intensive treatments have been shown to experience many challenging health behaviours [1,2,3,4,5,6,7,8,9], that are in addition to their psychiatric symptoms, that can compromise their socio-emotional and physical development and adversely affect their academic performance, school engagement and future occupational opportunities. Compared to a provincial sample, these children have reported significantly less sleep, greater problematic use of electronic devices and bullying, including being bullied and bullying others [2]. These children have also reported very little physical activity, low consumption of fruits and vegetables, having difficulty falling or staying asleep, not being satisfied with their overall health, loneliness, social isolation and peer problems [1,3]. Many youth accessing intensive care for psychiatric illnesses are also using substances, have parents with challenges such as financial difficulties or mental illness and have trauma histories [10]. Taken together, these children may benefit from a multi-system approach, including healthcare and education to enhance behavioural and biopsychosocial health, to improve their developmental trajectory, quality of life and long-term outcomes [11].

Poor biopsychosocial health behaviours have significant adverse effects on youth and especially youth with psychiatric illness; the pandemic has magnified the challenges that the youth experience [12]. Mental illness during childhood and adolescence can disrupt academic achievement and psychosocial development. Of particular importance is the bidirectional role of sleep. Sleep disorders have been shown to be related to the onset and recurrence of depression in youth and adulthood [13,14], and considerable sleep problems have been documented in those in their youth across psychiatric disorders [15]. Poor sleep is associated with emotional and behavioural disorders, irritability, physical illness and psychosocial impairments, and hinders cognitive performance such as learning [16]. Promoting adequate sleep is important for overall development and daytime performance, including health behaviours [17].

Physical activity has been shown to help patients effectively manage psychiatric symptoms and improve their quality of life [18]. Moreover, people with severe mental illnesses are at high risk for cardiovascular disease, diabetes and metabolic syndrome [19,20], rendering physical activity a key component for overall health. Similarly, there has been growing evidence supporting high-quality nutrition for the prevention and treatment of mental illness in children and adolescents [21].

Of great concern are the adverse impacts that social media can have on youth mental health symptoms, behaviours and overall health. In several studies [22,23], social media use has been strongly associated with poor mental health. Social media has been correlated with increased symptoms of depression [24], mental illness [25,26], problem behaviours [26,27], poor developmental performance [28] and poor sleep [29]. Despite the current ubiquitous use of social media, some evidence suggests that interventions can lead to reduced social media use and improved mood and well-being (e.g., [30]).

2. Important Roles in Child and Adolescent Psychiatric Care

Pediatricians and family healthcare teams have important roles in the care of all children including, or especially, those with psychiatric illnesses. Pediatricians, family physicians and nurse practitioners are the first clinicians that children, including infants and their caregivers, encounter. Moreover, 62% of parents and families seek help first from family physicians for mental health challenges [31]. The family has an important role in shaping child and adolescent behavioural health [32]. Yet, many parents do not have a repertoire of parenting skills or understanding of how to engage with their children to foster attachment, healthy relationships and self-regulation, and children are not born with all the skills needed for healthy development. While helping families develop good lifestyle behaviours or habits at the start of life might prevent or minimize some of the challenges associated with poor behavioural health, prevention may not always be possible. Guidance from child and family practitioners is possible.

In intensive mental healthcare settings, much effort is focussed on helping children and adolescents develop good health behaviours in addition to treating their mental illness. Without continuity of care in the community once discharged, these gains may dimmish. The chronic nature, severity and complexity of these illnesses and adversities mean that these children will require on-going treatment once discharged from these settings. However, the wait times for specialized care in the community in Ontario is 92 days, while the wait times for some regions average about 1.5 years [33]; child and family practitioners may be a critical bridge in this gap of care and may be important allies in the continuity of care. Many of these youths also attend school; however, school mental health services target children but child well-being is a family affair. Therefore, pediatricians, primary healthcare teams and family practitioners can be highly pivotal to the behavioural and biopsychosocial health of children and their caregivers. Moreover, greater success may be possible if all systems that children and their families may encounter (e.g., the education, child welfare, justice and healthcare systems) deliver consistent messaging about the importance of behavioural health (i.e., adequate sleep, positive relationships, appropriate use of electronic devices, exercise and diet) in reducing the burden of mental illness that children and their parents experience; however, many families may need guidance and health coaching.

3. Tools for Addressing Poor Behavioural Health

The Center for Disease Control and Prevention (CDC) has developed easy-to-use guidance (https://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/index.html, accessed on 30 October 2022) to help parents develop positive parenting interactions with their children to foster development, health and safety, and can be used by physicians and other practitioners to help families foster healthy development overall including adequate sleep, positive relationships, exercise, diet and media usage [34]. Information in this guidance is specific to eight age groups from infancy to late adolescence. The guidance includes an overview of developmental milestones, social and emotional changes and thinking and learning strategies that parents can use to nurture a positive relationship with their children, as well as how to promote healthy development and behavioural health including sleep, parent–child and peer relationships, physical activity and diet, and guidance on how parents can create a family media-use plan. With direction from practitioners, the online and print materials can be shared and reviewed with parents and children. Some parents may benefit from reviewing the print materials with a practitioner who can help the parent absorb the information and enact the guidance. This parenting guidance is also developed for infants and toddlers; thus, if used early, many of the biopsychosocial challenges children with psychiatric illnesses experience may be prevented or reduced. There is also guidance on how parents can communicate, establish structure and rules and provide direction and discipline [35], along with a section on practicing these parenting skills (https://www.cdc.gov/parents/essentials/overview.html, accessed on 30 October 2022). The Canadian Paediatric Society [36] has also developed the ‘Information for Parents’ online tool that contains helpful information on attachment, behaviour and development including digital media and positive discipline strategies (https://caringforkids.cps.ca/, accessed on 30 October 2022). Practitioners can navigate this source by topic to locate and provide guidance on specific topics to caregivers and children or refer parents to this source.

Strategies to improve behavioural health should be implemented at the start of life and at anytime the child or family comes into contact with a family practitioner and while waiting for specialized care. Consideration of the temperament of the child and the ‘goodness of fit’ with the parent may suggest whether successive small changes might lead to a greater chance of at least some success and/or whether there can be success with the implementation of some rules. In some instances, a highly skilled practitioner may be needed to help motivate the unmotivated and ease the overwhelmed or incorporate cognitive–behavioural or family-based interpersonal therapeutic techniques [37] as part of a comprehensive care plan. When children have a severe mental illness, the idea of behavioural health change may be overwhelming, but it should be viewed as an essential part of nurturing health and development.

Families with members with severe psychiatric illness may experience treatment burden, stigma and vulnerabilities including financial difficulties and trauma histories. In addition, the side effects of some psychiatric medications include increased blood sugar, cholesterol and abdominal girth including adverse cardiometabolic effects and weight gain [38], rendering encouragement of these health behaviours paramount. These goals for improved behavioural and biopsychosocial health should be in place for all children including those living with biological, step, adopted and foster families, and those living in short- or long-term stays in institutions or semi-institutions, treatment group homes, hospitals and all out-of-home settings including those designed for children with developmental disabilities, in need of protection, involved with the justice system and respite services. These initiatives may be even more important for children living in the care of Child Welfare. Pediatricians, primary healthcare teams and family practitioners are well suited to help children and families establish these important components of health.

4. The Biopsychosocial Model

Biopsychosocial aspects of the aetiology and treatment of psychiatric illness are involved in the complex co-existence with physical health and health behaviours [39]. Risks for poor health behaviours and mental illness stem from the interaction of biological, psychological and social factors [40]. In particular, the social determinants of health have been shown to be associated with mental illness including social adversities [41], low income and education [42]. Moreover, health-related behaviours co-occur [42]. Thus, approaching the prevention and treatment of psychiatric illness with the biopsychosocial model [39,40,43] may prove beneficial.

Engel proposed the biopsychosocial model noting that the psychological, physical and social contexts of patients require consideration in assessment and treatment. The model has been updated to include the personal context such as personality and expectations, and a temporal context such as time since onset of illness and stage of life [40]. This model is particularly apt for application with youths with psychiatric illness. Those in their youth are embedded in diverse psychological and social contexts; youths with psychiatric illnesses may be experiencing the risks factors for their illness in these contexts. The biopsychosocial model includes the behavioural, psychological and social dimensions of health and illness [43] and so can be applied to both the risks and the health behaviours. Reliance on the biopsychosocial model may offer greater collaboration between sectors where care and services are provided for youths with psychiatric illnesses by placing the youth at the centre of care.

5. Guidance and Health Coaching

The availability of these tools provided by the CDC and the Canadian Pediatric Society can help practitioners who may think they do not have the time to include a focus on biopsychosocial and behavioural health. Health coaching has been shown to improve patients’ self-management of their health conditions and improve health behaviours, and shows promise as an emerging practice within multi-disciplinary healthcare settings [44,45]. Modelling positive interactions and developing an alliance with patients [46] may enhance patient adherence. Lifestyle interventions [47] can help those in their youth and families manage the symptoms associated with the psychiatric illness and concurrently improve the overall health and quality of life of these patients.

6. Conclusions

The poor health and well-being of children and adolescents with psychiatric illnesses is a grave concern. Family physicians, primary care teams and family practitioners can play a major role in delivering or overseeing care to address the poor behavioural and psychosocial health that adversely affects youths with psychiatric illnesses and their families. Practitioners can be instrumental in helping families build overall health and these aims should be consistent across all sectors that interface with the youth, and especially systems designed for children with complex needs. Where possible, a family approach or an approach within the children’s dwelling, home or unit may help children with psychiatric illnesses develop, as much as possible, a foundation of biopsychosocial health. The complex and chronic nature of psychiatric illnesses and circumstances that these children endure often require interface with several systems including child welfare and justice; however, family practitioners may offer a consistent connection to professional care that is child- and family-centred, and consistent with patient-centred [48] clinical care.