 Good evening everyone and welcome to the Mental Health Professionals Network National webinar for tonight. I think that was a lovely introduction to the Mental Health Professionals Network for those of you who are not familiar with it and the local networks are excellent if you have that opportunity. So tonight's webinar is working collaboratively to support students experiencing exam anxiety. My name's Mary Amalaes. I'm a general practitioner and psychotherapist from Cairns in Far North Queensland. It's really exciting to see so many people logged on. So there was about 2,000, over 2,000 people have registered for tonight and so far there's about 640 different logins and it's excellent to have everyone joined together in this way. MHPN wishes to acknowledge the traditional custodians of the lands across Australia upon which our webinar presenters and participants are located. And on that note I do want to just note that there are a lot of people from regional and rural Australia logged on which is excellent. And we wish to pay respect to the elders past, present and future for the memories, the traditions, the cultures and the hopes of Indigenous Australia. And on this particular topic I also want to acknowledge that Indigenous people have a particular view around social and emotional well-being which I think is really relevant for our conversation tonight as well. Now you did have an introduction to our panelists tonight in the, their bio was sent to you when you registered. So I'd just like to welcome each one of them individually first of all and then I'll explain to you a little bit about the structure of the webinar. So first of all I'd like to introduce Associate Professor Craig Hassad who is a GP in Victoria and he also works at Monash University. Craig you have a special interest in mindfulness and I wondered if you just wanted to tell us a little bit more about your mindfulness programs at Monash. Well yes we're bringing it in very much as a part of the core training for nearly all of our degrees by now as core curriculum but because it's really a life skill that helps in so many ways and mental health obviously is relevant tonight but also to help to function in challenging work environments and for those who are interested as well the FutureLearn course, the free online course that we have running through Monash and FutureLearn is just went live again on Monday so people may be interested to have a look at that. So that's one of the initiatives that we're offering to the world. Thanks Craig and we're really pleased to have you with us this evening. I'd next like to welcome Paul Jameson who's a school social worker. Now in our preparation for this Paul told us that he works across 24 schools which I find astounding. Paul can you just tell us a little bit about the kind of work that you do in schools and perhaps the range of schools that you work in? Sure Mary, I do work in a network of 24 schools but I don't actually visit all 24 very often at all and I have main schools that I work in. The kind of work we do we support students from government schools, all government schools so including special schools and we help students that are experiencing difficulty at school so that might be due to mental health problems, might be due to learning difficulties, maybe due to a disability of some kind or other difficulties that students have. So we work primarily to help children experiencing difficulty at school and helping them to overcome those barriers to education. Thanks Paul, it's great to have you with us for this particular topic so thanks for being here. Next I'd like to welcome Jodi Nielsen who's a clinical psychologist from Far North Queensland. Jodi, you got an interesting addition to your training in that you did a degree in anthropology as well and I just wondered how that influences your practice as a psychologist. Absolutely, I did a lot of social cultural anthropology so it just adds to the cross-cultural dimension so it means that as a psychologist I'm always thinking culturally which is beliefs and values as the kind of centrepiece of how we construct the world that we live in. So just basically I think with every person that I see I'm thinking so how are they seeing the world. Okay and that's great to have you here as well. I know that you do a lot of work with year 12 students. Loads at the moment actually. I'd say May is the really pointy part of the year with year 12 students. Yeah and I would also like to welcome Professor Valsa Eepen who's a psychiatrist from New South Wales. Valsa you do a lot of academic work and you have a special interest in ASD I understand but also a lot of interest in young people with anxiety. Is there anything that's of particular interest to you in your work and your research at the moment? Probably the most important thing that's relevant for today is the comorbidity issue when you have autism with anxiety or obsessive-compulsive type of symptoms or depression that's comorbid with a neurodevelopmental disorder particularly autism, how do you differentiate, how do you manage and those kind of things are of particular interest. And it is a bit of a challenge sometimes. Recently we were thinking about how suicide risk assessment might happen in a young person but also autistic traits and how difficult it can be in assessing risk. So particularly maybe overlap between the different neurodevelopmental and anxiety depression. Thank you and I know Valsa our audience submits questions when they register. I would just note that we cannot address 2,000 people's questions so apologies if your question doesn't get answered but we have taken note of all of them and Valsa quite a lot of the questions were around ASD and anxiety so that's really helpful having your expertise. Welcome. So just a few ground rules. Just remember that in the chat box everybody can see what's happening so just remember that it is a public forum so behave as if it was a face to face activity. Please feel welcome to post your comments and questions for the panellists into the general chat box. If you find it too distracting you can click the small down arrow at the top of the chat box and there's a little highlight there for you now and that will make the chat box go away. If you do enjoy it you're very welcome to chat with each other and depending on how busy we are the panellists might also be involved with that chat box so please have fun with it if you'd like to and your feedback is really important to us so please complete the short exit survey which will appear as a pop-up when you exit the webinar. So and what will happen is that our panellists will each give their particular disciplinary response to the case study and then we'll facilitate a question and answer session and try and bring in the questions from the audience as well. So these are our learning outcomes so we're going to explore anxiety in students and using our case study. So looking at how to engage with young people to assess anxiety, looking at the key principles of providing an integrated approach in the early identification of young people at risk of suicide or self-harm due to stress and anxiety from the end of school studies and identify challenges, tips and strategies for how we can provide a collaborative response together. So you've already read the case and in the interest of time I'm not going to go over it again but just to remind you that our discussion is going to focus around Jessica who's a 17-year-old completing year 12 and experiencing various life complexities including in her family. So I'd first of all like to welcome Craig from the perspective of I guess both the GP and the mindfulness practitioner as to how you might respond to Jessica's story. And just to acknowledge Craig's had to use the handset on his phone which is perhaps a little uncomfortable but it was just to improve the quality of our sound. Thanks Craig. Good, well thank you very much. There are some things just to note on the history that Jessica's got a stable home situation is very good at least from what we've seen. Conscientious but like many conscientious students they're very vulnerable to anxiety perhaps because they're a little bit too so. Conscientious social isolation which seemed to be there as well. Although the work is having a positive effect grumpy and emotional and it's not always easy to tell is this just normal adolescence or what point is it actually part of a mental health problem because moodiness and so on can be very common. It's not always easy to tell for other family members. Irregular sleep which is a concern would be is she online at night and I'll come back to sleep later on. And she seems to be reluctant to see the doctor but she wants to be a dentist but is it her motivation or a parent and that wasn't 100% clear from the story and have to tease that out what's really driving her motivation to achieve. And a GP refers Jessica to a psychologist so the question really about what can a GP offer some GPs are very experienced in managing mental health problems and maybe the primary care in other situations would be very appropriate to refer depends on the individual GP and obviously what they negotiate. And also noted her tendency to worry or ruminate a lot and we'll come back to that in relation to mindfulness. Now from a holistic perspective or GP perspective an open and non-confrontational consulting style so just important to be curious and inquiring rather than sort of a top-down approach or in any way telling or instructing or pushing her so it's really she's essentially an adult and non-confrontational style and it's really important to find out what's her agenda and what's she interested in, what are her issues rather than perhaps how it might be framed by somebody else. Family or doctor as well to really inquiring to her agenda. Would probably not prescribe medications not convinced about the evidence necessarily for adolescents and children although getting into adulthood I mean if prescribing antidepressants could be appropriate and probably more in severe depression but certainly wouldn't be inclined to prescribe myself and what I'd like to put a lot of emphasis on is a lot of the other things that can be really helpful in this kind of situation in preventing or managing mental health problems and I'm just going to touch on a few things here mindfulness, sleep, exercise, diet, spirituality and self-compassion and it's very important perhaps to consider all of these areas because the aim is really to empower Jessica not impose treatments on her so to let her know there's a whole range of things she can do. Now I apologise in advance because I've got a number of slides here but I just wanted to present examples of evidence for the various things I'm going to be speaking about just very briefly but this is one among dozens of studies now on depression and there are review papers in many, many journals but just to illustrate the point 160 people, multiple episodes of depression before given mindfulness based cognitive therapy plus treatment as usual or treatment as usual and the red line's the relapse rate for the mindfulness group so very few people or far fewer people relapse into depression if they have mindfulness training along with whatever other treatments they're receiving. The blue line is just treatment as usual mostly just the prescribing of antidepressants without other psychological therapies and by 12 months more than half have had their next episode of depression compared to the red line where relapse was much less common and of course is it appropriate for adolescents and then studies started to look at younger age groups so mindfulness based stress reduction again similar to adults, less anxiety, depression, somatic distress increased self-esteem and sleep quality. The self-esteem is not about trying from a mindfulness perspective trying to think positive things about themselves it's just not constantly feeding a negative self-talk that might be very common so that rumination how mindfulness can help to switch off that default mode rumination is very, very important. There are also programs in schools and this is one review of 24 studies recently and it's pretty clear that it improves resilience and ability to cope with stress and mental and emotional health but also seems to improve performance at school as well because poor mental health can seriously impair academic performance. And this is a study that we did with Origin Youth Health and we looked at an in-depth qualitative study and in very short space of time adolescents learning mindfulness skills really develop a lot more self-awareness awareness of their own minds and bodies and how to work with that in a self-compassionate kind of way. Now, I won't say too much about default brain but rumination and worry as I said with depression anxiety forms of default mode and it's pretty much the mode of mind we go into and we're not mindful. So studies show that mindfulness switches off the default mode so as soon as the attention re-engages with the present moment through the senses then the brain becomes quiet again and switches out of rumination mode but there's not time to go into that more depth. I'll just skip on from that. Just talking about sleep chronic insomnia is a major factor for depression. A lot of kids these days are getting depressed because they're online at night and sleeping poorly and for many people with depression they actually need to learn to sleep better and a major, a very significant majority will have their depression resolved when sleep problems are a part of depression and I just wanted to mention that it's as common that depression is a product of poor sleep as a product of depression. Exercise and mental health, particularly aerobic exercise has a range of mental health benefits including anxiety and depression and obviously if it's engaged with other people as well and there's ways of being active that she enjoys then that could also be an important part of the therapy as well. I just wanted to mention about nutrition. Deakin University have done a lot of work in this and just to draw your attention to this study there was over 7,000 Australian adolescents and Q1 that's the 20% who had the healthiest diet but Q5 the 20% with the poorest quality diet they were nearly twice as likely to get mental health problems like depression and nutrition is almost totally forgotten as being a mental health intervention particularly for kids who are not getting any whole food in their diet much more likely to have mental health problems. The other thing to mention as well about spirituality and I don't necessarily mean that to be religious although that's the way in which most of the studies look at it but this is one review of studies on nearly 100,000 people. Two things I want to draw my attention to is one I think that the search for meaning is an important human need but this just draws attention this study to the fact that an intrinsic sort of religious or spiritual dimension to a person's life is associated with better mental health when it's just an external show extrinsic then it's not associated with better mental health. The other thing is if a person's got a very negative coping style so that feeling the problems in life are all about being punished and so on rather than actually having a sense of a compassionate and caring sort of connection to the universe like Einstein said believe the universe was a benevolent place so if a person has a very negative view of religion as a coping then it's associated with poorer mental health. So anyway I just make the point that where does she find meaning in life? What gives her life purpose? What's going to enrich her? And self-compassion is perhaps the last thing I'll mention but if a young person has self-compassion rather than self-criticism this is very important. Not only for making amends for failing in a study and a test for example of making errors in life but if a person meets those kinds of problems with intense self-criticism and self-judgment then that's associated with much poorer outcomes and there's quite a literature now that developing an attitude of self-compassion is not complacency but an ability just to give ourselves a bit of latitude to be human and to be a little bit kind to ourselves. So that's perhaps all I wanted to say for now and we may return to a few of those issues and unpack them a bit more later on so thank you very much. Thanks a lot Craig. If anyone wants to look at the slides for the presentation now and the documents box then obviously you can access that after the webinar as well. Craig it was great to have that discussion for our discussion in that really holistic approach. Now I'd like next to welcome Paul Jameson who's a school social worker. Hi Paul. Hi Mary. Hi everyone. Yeah thank you Craig for your comprehensive presentation and I guess my perspective as a school social worker is really coming from a perspective of education. In the case study it didn't really talk a lot about what was happening at school so I guess it lead it open to inquire as to what might be happening and how we can intervene to help Jessica. Now one of the things that I would be very interested in is how she's going at school. The case study notes that she's a very conscientious student but it doesn't say anything about what sort of grade she's getting or is she passing VCE or is she behind and what contribution that might be having towards stress and mental health so that was definitely something I'd want to find out from her teachers and her coordinators and speak to them and depending on how she's going to look at exploring any other options for completing Year 12 and in fact if she does even have to complete Year 12 and do the exams and get an ATAR score or is a Year 12 pass sufficient for her in terms of what pathway she wants to go so schools can do a lot with students around that and it would really depend on where she's at and talking with Jessica as well. The other questions I have around school is her level of engagement and are there any concerns around disengagement, any non-attendance or school refusal issues and again that's not clear in the case study but I would be inquiring with her coordinators around that but then any things we can do to improve her level of school engagement is definitely a protective factor for Jessica we don't know what her level of engagement is at school how well connected she is what sort of social network she might have at school what sort of relationship she has with her teachers and anything we can do to improve that and get her more connected will help Jessica's overall mental health. There's also in school referrals or in school support and schools have a lot of options for this and often it's an easier way for students to access help at school so often schools will have a psychologist or a social worker a lot of schools have chaplains a lot of schools have adolescent health nurses and other school counselors and well-being staff so generally a lot of high schools are well equipped to support students needing extra help so it would really depend on the nature of the difficulty she's experiencing and presenting her in a family with options the other thing I'd be interested in is there any safety concerns for her and is there a need to do some safety planning at school and I'll talk about that more in a minute the other area I'd be interested in because she's doing year 12 and coming up to her end of schooling and proceeding to tertiary education is really what kind of pathway Jessica wants now the case that you talked about interest in dentistry we don't know why that is or what's inspired that interest or motivated it or she's explored other pathway options and career options there is a lot of support out there schools are very good at helping students with this and again there's careers counselors you can get through schools there's also career exposits many students attend and that provide a lot of help for students and there's online careers course help also lastly I want to talk about risk assessment and safety planning again the case study doesn't make it clear what risk factors there are what are if there are any real safety concerns there's certainly risk factors present for Jessica and Craig touched on a lot of those the social isolation is one the her real sense of dedication and wanting to do well at school and how much pressure she puts under herself is could be a concern it's also a strength as well we don't know if there's been any history of suicidality and that's something I'd want to explore with her and well for it to be part of the assessment has there been any history of suicidality with Jessica history of suicidal thoughts current or previous plans previous attempts has there been a history of self-harming behavior if she's engaging in self-harming behaviors again we don't know that and we can talk directly to Jessica but the teachers may also be able to offer insights for that as well so what's the level of self-care the current level there's concerns around sleep Craig raised issues around diet we don't know what's happening for her in those areas online behavior it's also something I wonder that with the isolation and the being up late does she engage in online behavior media is that a risk for her is it a potentially a protective factor for her what her habits and what's her behavior like online we know with a lot of young people it can be very protective for them but it can also cause them to be very vulnerable as well is there any substance misuse issues for her is certainly something you can explore with young people and any other risk behaviors I've put some links in the additional resources in terms of risk assessment and safety planning there is quite a bit of support out there there's some good tools you can use to developing safety plans there's also a safe minds package which has been developed for schools and it's been specifically developed for Victoria but other people from other states can access it as a guest and I've also put that in the resources page as well thank you very much Mary I'm going to finish on that and I'm happy to answer other questions later thank you so much Paul and it's great to hear that there's so many possibilities in the school and we'll be exploring it more in our discussion later I'd now like to welcome Jodi as a psychologist and how you might think about supporting Jessica thanks Mary I think Craig and Paul have done a pretty good introduction I think the first thing that we do that I do definitely when I meet someone who's studying and appears quite anxious and depressed do a comprehensive biopsychosocial assessment of what's happening I think in terms of year 12 students and anxiety and depressive symptoms you want to work pretty quickly just because there tends to be a lot of kind of drama surrounding everything falling apart at the last moment definitely agree with what Craig said eating, sleeping and breathing being the kind of three key things that we start to look at to try and stabilise a young person the idea that an animal in distress is a person who's not eating is not sleeping and is not breathing properly so if those key factors aren't stable everything else is going to be quite wobbly around the edges and then looking at problem solving so this is where schools come in really well and working closely with school support I find tends to manage a lot of the stress and anxiety really quickly so getting straight on to the school educating the parents about how to talk to the school to get some pathway planning in trying to get some specialised school support around how to get out of exams or get extensions for assignments just to get a bit of breathing space so everything can calm down and move forward as quickly as possible but it also gives that sense of support and then validates the next step of therapy it's almost like it shows that things can change quickly because what we want to do is kind of begin to change someone's perception about a hopeless situation because often by the time you get to the stage where you're this withdrawn and this anxious and this depressed kind of holding that together and changing that kind of bunker down point of view is one of the most important things so sorry, I've changed my slides so something that I definitely look at in terms of psychological treatment developmental stage the person's at we're talking about a year 12 person that situation is quite different from a year 11 student which is different from a year 10 which is again different from a year 9 or the perfectionism and stress and anxiety that we might see in a year 8 student so just noticing that through this teenage years and anyone that works in schools or a lot with specifically this age group you know that the differences in emotional maturity from one end to the other end is quite extreme so you need to work within firstly the kind of age range you're talking about but also I think looking at the degree of separation from parents some 14 year olds are quite emotionally mature and independent whereas some 17 year olds aren't so being able to gauge that's also quite good just to see where that ability to self-regulate sits at so in terms of choosing a treatment style for people I think it comes down to the individual, the stage but then also even like a multimodal approach is quite important I agree with Craig mindfulness is just fantastic particularly for an anxious mind it comes it down and it focuses it really quickly and it's something that can be used in school and at home but I'd also say some of the act diffusive techniques we get really good feedback on those like learning how not to respond to a thought I'd say that but I think that's the key particularly works well once that stress and anxiety has been removed from the picture if you try and rationalise with a particularly anxious school student that whole cognitive debate that needs to happen tends to fall apart pretty quickly and they don't seem to engage quite so well when they're at a heightened level of distress so I'd be considering that in my treatment options I'd also definitely be looking at some existential therapy and everybody has raised the big elephant in the room and that is why are you doing dentistry it's a hard one I think if she had said she wanted to be a doctor we might not question it as much but there's something about dentistry that makes everyone say why are you doing dentistry so I'd be looking to see where the pressures are coming from them is it because she had the idea when she was seven that she liked to be a dentist is that because it's not quite medicine is it because she has a passion for oral health there's going to be something amongst that for some reason and if that loses meaning then the motivation is going to drop back something I would say though if we're talking about shifting somebody's perception of a situation to try and get them around to challenging it and changing it something that I see quite regularly is if we jump straight in and start talking about things that they can do to fix their cognitions they tend to shut down pretty quickly it's almost like we're blaming them for the way they see the world and that's not very helpful whatsoever so I think firstly trying to jiggle their perspective into looking after their health showing that things can be done to change the situation at school and then turning in and starting to look at the beliefs and values and the thoughts that are influencing their really strong emotions tends to kind of make things far easier so the specifics to this case I think there'd likely be a lot of catastrophic thinking involved such as you know what are we going to do you're going to drop out of school she's going to fail, she's not going to get to uni so calming that down as quickly as possible would be my first focus and everyone's noted as well the relationship with mum and now I'd be looking at that relationship first so there's obviously some perceived pressure there mum wants me to do this, mum wants me to do that so I'd be looking at trying to work out if that's really the case or is that a faulty cognition is that just a perception because mum really wants me to but does mum really want me to or is she just happy with me doing what makes me happy so getting those two talking even though mum says that they're a happy family they get along well together and also have evidence that she's been hiding in her room for the past two years studying so I would be wondering why so is it perfectionism or is it to escape the family lounge room so looking at the family dynamics and what's going on there will show a lot of the underlying tensions that often fuel so everyone in year 12 is stressed well not everybody that's an exaggeration so most people are quite stressed particularly if they're going for a high rank and it's the line where someone crosses from typically stressed or slightly anxious to depressed and so anxious that I can't complete any work it generally has to do with something else in their life so either there's a lot of external pressure pushing down from school, from home or from friends even so a lot of competitiveness amongst friends or it's a lack of support so I'd be looking for that to resolve that pretty quickly I'd also do work on parents about educating them about how to talk to the school often parents don't understand that they can advocate for their child at the school and also find that career pathways now are so confusing even for me that and I talk about it all the time I'm still not clear so I know that there are rank systems to get into university but I know that they don't really count I think I need one rank to get in but it's likely that with another rank I'll slip in somewhere so I think that that creates even more anxiety for young people because you can't adequately plan your future if you don't know what you need to get there I'd also say that this is likely to be a crisis of her developmental stage so Jessica if she has had a stay at home mum and if there has been any investment there we know she doesn't have a wide circle social circle we know that she's just had this job taken on this job that she really enjoys that she's temperamentally kind of quite likely to be conscientious and shy is she going through like a normal kind of process of individuation where she's trying to separate from her family but can't isn't able to acknowledge that or voice that or do that in a healthy way that would be one of my thoughts so I'd definitely be talking about her existential crisis in some degree like what do you want to do what gives you meaning and talking with her about living a life without joy or a lack of human connection because those are both really key things that I think are missing and can I just look at those questionings of those beliefs and values and being able to support those in a healthy way rather than just saying that's it I'm out Finally I've got a few questions that I'd probably ask about what was happening so asking where someone's most comfortable or least comfortable is a really good question to ask because it shows the place in which someone feels most accepted or emotionally safe so if they say at work that's quite indicative okay I found this place that I fit so that's likely to make me question my future because this is where I feel belonging if it's at school that someone feels most comfortable you know why not home what is it about school if someone feels comfortable at home then that's a good thing I'd also ask about what Jessica wants from her parents so what would be useful for them what do you need to hear from them to make this easier for you and I'd be talking with parents about the ways that they can support Jessica rather than just pressure and badger another question I'd also like to ask is asking somebody about their day so really clearly saying tell me about your day yesterday it's stolen from Irvine Yalom who's a psychiatrist in the States and it always gives a really accurate picture of what a day looks like for someone and I'll probably get more data from that than I do for most other questions just because you get a sense you're getting to really talk through everything in the day are they talking to anyone or are they talking to everyone I found out that someone got to think help from like three or four different sources just from asking that question so I think I should finish there because I know Valsa's going to speak now and she's going to actually talk more about the assessment so I hope that's covered everything I just tried to get everything in there Thank you and we did sort of talk on the dentistry question earlier and I'm sure we'll come back to a lot of it and so thank you for that probably being the psychiatrist Valsa you might be the person who met Jessica after some of the others had and so I'd really like to hear how you would think about this situation Thank you very much it's probably a good thing that I'm going last because most things have been covered but I'm going to assume that by the time they come to see a psychiatrist a child psychiatrist either it's because it's more severe or there are other issues also going on so I'm going to probably take that extreme end for a minute to describe what might happen in that space definitely in the assessment situation you'd be considering the severity the duration and also how long has it been going on sometimes you don't realize when it really started you might think that it started three months ago that may have been symptoms from before there may have been a past history of few symptoms here and there for a period of time so those kind of things will need to be carefully explored and if you think that there is a severe anxiety together with some depressive symptoms then you need to consider the urgency of treatment and again in an HSE student are we talking six weeks from trials on what kind of treatment would you suggest in that situation might be slightly different if you saw them at a different point in time so that's kind of very important to gauge when you're assessing within the clinical features it's also very important that anxiety can sometimes be the front runner and maybe there is depression and related symptoms hiding behind so it is very important that we try to unpack that a bit mostly going into the specifics of what are the kind of anxiety for working situations is it more social, is it more general is it about everything is it only about assignments or the whole life in general and again with depressive symptoms you might want to go a little bit into the sleep and appetite it can be either more or less either of it can be a symptom and also you will be looking at everything has become an effort are they very tired and there is a lot of psychomotor retardation and that kind of thing would also give you a glimpse that it's kind of really probably a little bit more silly than what originally was seeming to be of course you might also look into whether there are any bipolar type of symptoms or psychotic symptoms especially if a young person has been kind of drawing themselves and what else is happening would be very important to look into sometimes somatic symptoms like headache maybe or abdominal pain or nausea vomiting that may be the symptom that is the main concern for the person but it may be resulting from anxiety which is underlying those somatic or physical symptoms once that presentation of that is clarified you would then need to look at where is it coming from what are the things is there any families of course what we heard is that it's all well in the family we are happy and all that but sometimes a family history may not come out in the first instance and you may need to fully ask about what kind of a person is each one and are they really joyful bubbly their take on life is more negative so those kind of things would be very important even if there is no major mental health issues exploring what kind of personalities they have relationship issues would be extremely important both at school and at home sometimes friendships or either not fitting in or sometimes an acute breakdown in a relationship may be what's presenting the severity or the to the forefront at this point in time so interpersonal conflicts both at home or generally friendship relationships would be something that you would want to really understand in a person presenting with anxiety and probably depressive symptoms as well also you need to dig a little bit into what happened at the time when they relate to us the start of the symptomatology was there any bullying was there the pressure of wanting to get the grades to be a dentist became head on at the start of year 12 is it the high expectations that the person has put on herself or is it coming from the parents or others sometimes they have internalized it so much that they think it's their own but it may be coming from others sometimes they may be projecting it onto others and thinking that we want me to do but it's actually their own high expectations and their own agenda so we do need to understand a bit more of that and being perfectionist is a great thing at times but can also get things undone especially when you're working under time pressures with assignments one after the other coming on that probably would really be a huge stress on a person who is wanting to get everything right there so risk assessment would also be something that has already been covered and so I will just give the risk assessment part I would also look at whether there are any other diagnostic considerations I said about the bipolar disruptive mood dysregulation disorder is a new category that DSM file brought in mainly for persistent irritability anger outburst in a person but not really it's not bipolar premenstrual dysphoria disorder is again a common thing maybe that's super imposed on and underlying anxiety and that can really bring things to a head but the temper relationship with the menstrual cycle would give you the clue if substance misuse or any other medication or something else induced mood change due to your medical condition particularly in a thyroid issues vitamin deficiency now when you are treating your goals of treatment would be to relieve the symptoms reducing the functional impairment that's very important then how can we improve the person coping adapting and being functional is a key thing as a goal for your treatment along with improving quality of life and again you have to have the patient on both they think that you can have the best treatment but if they don't come on board then that's not going to be any good so engaging the person it's a patient centric perspective collaborative approach that is very important for treatment adherence and again failing if they are failing to engage at all or failing to engage in kind of sessions where they have to come and talk to someone internet based interventions can be sometimes useful for the person to get some help if they are not willing to come and engage with the person again school and family support would be important too so the medication would be reserved when it is very severe extreme panic, extreme distress as I said before hopelessness, guilt, suicidality or psychomotor retardation severe obsessive compulsive symptoms you would need to also look at comorbidities because autism or ADHD complicate both the presentation and your management substance misuse and personality traits would also be a consideration I will sum up with this slide many of the things on the end with the lifestyle factors have been covered I would also think that the psychological, psychosocial support issues have been covered the medication when you do use it it's only for moderate to severe and for very specific markers that you would think about carefully before you start medication or think about medication but having the patient on board and the family on board is extremely critical for that so it would be a biopsychosocial lifestyle model is probably what would be worth going in with thank you I'm going to open this up to the question and answer session and I'd like to start by inviting Craig back in now Craig as a GP I know that you spoke about engaging with Jessica herself who's nearly an adult as a GP you often see the family well how would you approach it if Mum for example had an obvious anxiety disorder of her own which was impacting on Jessica but Jessica you know but the problem is people are trying to locate the problem in Jessica these are the sort of questions that have come up a lot from the audience as well so how do we think about the family oh look I think that's a really relevant question there may not be a problem with Jessica at all I don't think we're assuming that in this situation but sometimes parents are worried and it's their own anxiety they project very often parents who have a very anxious way in their own life will teach their children from an early age to be anxious I was quote one study I do a lot of work with schools and I was looking at 5 year old children and their level of maths anxiety and maths performance and how that correlated with their parents maths anxiety and performance and they found there was a strong correlation but only if the parents regularly help their children with their maths homework if a parent was anxious about maths but didn't help their child with their maths homework their child was fine with maths and they weren't anxious about it I guess it just illustrates the point that very often parents aren't teaching their children what they think are they're teaching them how to be anxious so you would want to have a conversation with the parents if Jessica was happy to have a conversation with them both together of course having a conversation with Jessica by herself but it's going to be a family issue in how they cope but also in what the parents are projecting onto absolutely it's a really important point Thanks Craig and now I wonder Paul if this is really about collaboration so how would you feel if for example Craig as a GP or Chats Jody as a psychologist rang you as a contact person in the school what are the sort of nuts and bolts around how those conversations go Yeah good question Mary look it is really critical the collaboration from a school's perspective and we're school based or certainly my role is school based so we need to collaborate with external professionals and specialists so I would be very welcoming of being to collaborate with someone like Jody or Craig it's probably trying to work not overlap and not duplicate what we're doing so really having a discussion around what kinds of things we can help with at school from the school perspective and also what you'd be looking for an external service provider to be able to do I guess the other really important thing is ensuring we've got proper consent and ability to share information but just making sure that we're communicating and we're both talking about what we're doing so if the school's already having discussions around career planning and pathway planning then it may not be necessary for someone like Jody to explore that in as much depth and similarly if the school's already had the discussion around doing something in terms of the course and her studies and possibly reducing her study load or lengthening the time period that she's going to complete a VCE over then it wouldn't be necessary for external people to look at that so I'd be really keen to get the good communication happening so we're not duplicating and not causing more confusion for Jessica and her family. And I think you had a question for Jody in particular around the family I'm not sure whether you'd like to frame that one. Yeah I would and look it was I guess it was similar to the question you put to Craig but Jody what would you suggest or recommend to support the family with mental health issues in the family and challenging preconceived expectations and gender roles? I think in terms of supporting the family something we do here it depends it depends on what's going on if there are dynamics within the family suggesting that parents get their own support and knowing those people in the community so having good working relationships with different services so the mum or the father or both in a few times and you know that they're going to get good care and everything's going to go well and smoothly and there's not a big waiting list for example. That's one thing in terms of agenda issues that goes down to that beliefs and values side of things so we know that mum's education has a direct influence on how likely Jessica is to go to university so that research is out there so we know that mum's expectations might be hard but being able to support Jessica to do that might be difficult so the gender roles that maybe Jess sees replicated in her house aren't necessarily the ones that are being explained to her or put onto her but her beliefs and values will be a really tense complicated version of both of them put together so I definitely speak to her about those just so she can at least understand where that tension comes from. Thanks Jodi. And thank you Paul. I'd like to just I was interested in Valsa's slide at the end with the biopsychosocial perspective and that lifestyle things included things like exercise and nutrition whereas Craig had raised the idea that they were in fact biological treatment so I think I'd like to just invite Valsa and Craig perhaps Craig if you start just around exercise I guess as a biological treatment. Yes it's there's quite a large literature on this particularly aerobic exercise just by itself is therapeutic for depression and anxiety but it's not just the physical activity I believe I think it's also that when a person's doing something they love or something that really engages their attention they're actually being mindful at that time as well so the mind's unhooked from its usual remediation that person's had a break from that for a while so the person feels a bit more clear headed and a bit more relaxed energized and so on but the other thing to add too in exercise particularly if it involves other people being active with your friends and it you know wants to be a form of activity that she enjoys but you've got the social interaction as well and the nutrition side of things there's quite a literature on this as well and I don't think it's recognized enough in mental health areas that if the body's not got the right nutrition coming in then the body can't make all the neurotransmitters and everything else it needs to make it can have a pro-inflammatory effect which is unhelpful as well and if there are specific deficiencies vitamin D, folate for example if those deficiencies are not affected then you don't get the same therapeutic outcome and there's quite a literature growing up around this now as well it's not like if a person's got a normal vitamin D or it's got healthy levels of folate if you give them more they're going to get you know happier it's just that if the person's got a deficiency you get a much poorer therapeutic outcome unless you correct that deficiency and so in the total management of mental health problems we need to be thinking from all sorts of different perspectives because when you put all of these things together you have a much more powerful therapeutic outcome than if you just direct your interest and attention at one avenue for therapy Thanks Craig and I would like to bring Valsa and I noticed that Valsa also you also spoke about the biopsychosocial approach and exactly what Craig was just saying about considering all those things I guess would this be an unfair question to spring on you but would there be a message that you would like to convey to general practitioners around using SSRIs and young people? Yeah I would say that if you carefully select the ones that you would want to put on the medication that would be very rewarding especially if you have got someone who is having significant panic symptoms your ability to get them to do any psychological work with you or even the lifestyle modifications might be extremely difficult so if you have got severe panic symptoms, if you have got severe psychomotor retardation everything is an effort there is no motivation effort, lack of interest those kind of patients you probably would be wanting to keep the medication with all the biopsychosocial lifestyle bits the reason why I say it is important to get the other bits in is when you are in stress whether it is panic it is fight, flight, reaction or otherwise you are using up a lot of your chemicals and it is only natural that the levels are going to go down and down and you put yourself in a very vicious cycle so there is only so much you can spend less and I always say that psychotherapy and other interventions supportive ones are about spending what you have got well so you can spend your chemicals well using all those strategies or boost up your chemicals by having the exercise and the diet and everything and sleep hygiene so it is a little bit of both when your levels are so low when you are really broke you do need a bank loan so you would use the medication in those kind of situations but that will not improve your situation unless you learn to spend it well and get your balance kind of in order so it is a bit of combination of the two and very carefully selecting those patients with severe anxiety very severe panic psychomotor retardation or urgency because of suicidality or hopelessness you can lift them to a level where other measures of intervention and teaching them how to spend because well and all those things can then come on board but then that initial phase it may be a very important thing for them to kind of lift themselves up a little bit to a position where they can then use the other methods of treatment And also Val, so there has been a lot of questions from the participants around any special considerations when people have ASD you know, trays or a full diagnosis obviously it's more complicated and you spoke about the importance of trying to assess what's what is there any particular considerations with regard to if you make a decision to prescribe medication and ASD Yeah, because you may not be able to engage the patient in a way that you would like to understand what's going on what's the severity etc you would be looking at external factors like is there any significant recent change they used to enjoy something or they used to do this but now they are not interested in that or when you see something which is very recent which is an important change and then you put the pieces together and the sleep and appetite the biological symptoms, vegetative symptoms can give you the clue that it is very severe it again even if they have got ASD symptoms they are trying to get the person on board and then together with that patient and the family you develop the kind of management plan and I think that just because somebody has got ASD especially this is a person attending school and functioning okay then it is possible to get them to at least engage with you on a particular symptom that they would like to get rid of sometimes they would say there is nothing wrong with me or there is no problem or don't want to engage but see where there is an issue where you can agree that there is a problem sometimes it's sleep or sometimes it's something that you kind of stumble upon from somewhere but you do need to find that little anchor point where you get the person to engage a little bit better and wouldn't that be good to do that and shall we give it a try and so it's very important to find that common ground somewhere even if it is a little bit of a sleep problem or it's a irritability that they recognize it's not good or inability to focus or things that they enjoy which they can't which is frustrating them that they can't do it anymore because they have become apathetic and so there was one young person who actually told me that the empathy was killing him I mean to come that from a a sea person I thought was kind of truly remarkable but it may be possible if you really kind of get them to explore with you what would be the one thing that you would want changed or agree on something where you kind of meet on the crossroads and then take them with you and then take them with you I should have said we have had 860 people we had 878 earlier we are approaching the end and as usual this discussion is never long enough but I would just I know that Jodi you had a question for Paul around when you as a psychologist become aware that the young person's hopes and expectations for themselves probably are not academically possible would you like to just address that to Paul? Yeah I was just wondering if Paul had this where someone is incredibly anxious and distressed because they are trying for a certain rank to get to university and then when you actually look at their marks or the feedback for me from the school is they are never going to get there so I have a problem as a clinician because I practice unconditional positive regard completely aligned with young person yeah you can do this to a certain degree but then when there is this crushing reality that this isn't going to happen but that isn't being conveyed directly by the school I was wondering if you had any ideas about how to approach that Thanks for the question Jodi look it is something that does come up and it is a difficult issue to manage it's not all that common but it is something that does need to be dealt with because for a young person they can put themselves under incredible stress and anxiety in trying to achieve something that just may be completely unrealistic for them so it's got to be a process and I think you do need to include the parents in the discussion with the young person but you would hope that that discussion could be had earlier with the young person so that you can be talking to them about what their goals are and I guess trying to steer them towards something that might be more realistic for them and helping to manage some of their goals and what they wanted to do and achieve and you can use certainly the careers councillors at school can help with that but also their coordinators can help as well and when they are in year 12 their coordinators do work quite intensely with the young people around their course and how they are going and how they are tracking with it and monitoring their stress there could be a role for the well-being, specialist well-being staff at school but it really depends on who she is linked in with externally so I guess my advice would be to try not to identify it early a collaborative approach is really important and the sooner you have the discussion the better with the young person and bringing other people to assist as well can be really helpful Thanks for that Paul now we are just we are going to just be finishing up so I think Jodi we might get you back on for a moment and I just wonder if there is just one final message that you would like to share with the panel and the participants before we close I think the big thing with year 12 stress particular it has been identified by lots of teachers that they all get sick of it so there is a percentage of everything that is happening in Jessica's life that is completely typical and normal and it is about isolating that and pushing it to the side and then problem solving from my perspective pretty quickly to help her push back those depressive symptoms as quickly as possible Thanks Jodi Craig we have not heard from you for a while and I am sure you have been thinking a few things so I just like if there is any kind of final messages that you would like to give us all around just how we help someone like Jessica with exam stress in year 12 Well look I think so many wonderful points have been made by the whole panel and I think one of the things for somebody at this age to also consider is that at various times life can be very difficult I mean if I reflect on my own life there are some pretty challenging times year 12 university and so on and I think if a person can have a larger view at this time of life that having challenging times is certainly very uncomfortable but this is a real opportunity for growth and insight and if she learned to work with this in the right way find support from important people explore things that might be useful then she will come out a far better person than she was before so to turn adversity into advantage I think is a really important way to have an idea of growth and development as you go through your life so I think that is an important sort of underpinning attitude for the therapist and also for a young person such as Jessica Thanks Craig I know that question about growing through adversity did come through in the questions from the registrants at the beginning so that sometimes people need to make mistakes and learn from them and that's how we build resilience I'm really glad that you've raised that and I would like to invite Valsa back in just to give us some final points that you think are really important to leave us with I probably would want to stress that each and every person who is coming with an anxiety or depression or a different type of issue to do with mental health I think the first and foremost and the most important ingredient in any approach to help them would be that establishing that relationship and getting them to share the most difficult bits with you and that patient centric therapeutic alliance, no matter what your role is that probably would be the most important thing that you would be doing for that young person much more than probably your professional role which you do professionally the number one ingredient would be that relationship that you build with the person that's probably the one that you need to initially conflate most on so getting to understand the person the person thinking that you are there really for them their well-being is at the heart of what we are doing and until they take that on board whatever else we do it's a really important point that I like the way that Dan Siegel proposes a model of the mind stating that it's both embodied and relational and I think that's really come through tonight we've talked a lot about biological and body things and you've just really beautifully reminded us that all of us as people who work in schools or therapists or social workers GPs have this opportunity so I'm really grateful to you for bringing that in and last but definitely not least I'd like to just invite Paul to just sum up some final points for us Thanks Mary yeah look for me I guess the critical issue is around making sure communication is good between the school home and the external agencies involved with Jessica and that everyone is able to talk and there's a common understanding about what's going on for Jessica and both that school and at home the other thing that I think is really important is she's new 12 and she's coming up to finishing her schooling and we don't know how significant the engagement and attachment to the school has been but that's about to come to an end and thought needs to be given to that transition from schooling which might have been a real protective thing for her and a strong connection for her and there might be a lot of anxiety around her finishing starting at school a place where she's been for a long time and moving on to what she or about so there could be some work that could be done there to help her and assist her and also her family and I think that would be really important to look at as well. Thanks Paul that's a really critical point and I must say some of the young people I see with anxiety in Year 12 it's not about Year 12 it's all about the future and the unknown so really grateful to you for raising that as well now I can see that the participants have been really engaged and finding this a really valuable discussion tonight so I'd like to thank all our panelists participants if you just stay on for a couple more minutes it's really important for us to get your feedback at the end when you log out I'd like to thank Craig for just reminding us about having a really holistic approach thinking about exercise and nutrition and physical well-being, relational well-being and Paul has really opened our eyes up to the number of possible supports in the school which is probably a lot more than some of us knew were there and the flexibility that's possible and the importance of trying to engage with the school in problem solving which is I guess one of the things that Jodi emphasised is to actually quickly act to try and help solve problems which can help reduce stress and Jodi has also kept just thinking about the importance of the culture for the person which might be their actual cultural background or it might also be their family culture and how are they viewing the world and then Valsa has reminded us also about the value of medication sometimes in very severe symptoms but also beautifully at the end that no matter what your profession, what your background the therapeutic relationship with the young person is really the most important thing and I guess without it you know other things that can never be as effective and interestingly I am aware that that even includes medication so thanks so much everybody for participating tonight for the audience for being so lively in the chat box and for all our panellists for an excellent and interesting discussion now you'll notice there on the screen that there's another MHPN webinar on the 20th of June which will be equally interesting with young people so working together to support people who deliberately self-harm is a topic that often causes us great anxiety and I'm sure that the discussion will be really helpful for that please ensure that you complete your exit survey before you log out and it'll come up on the screen and you will get emailed to your certificate of attendance for this webinar within a couple of weeks and you'll also be sent a link to all the online resources associated within a week and if you are interested in joining one of the youth networks you can see the link there or any other local networks in fact it's really helpful to also meet face to face with people in your local area and those local networks help with creating collaborative care which is best practice and results and the best outcomes for clients and before I close I'd like to acknowledge the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present and I'd like to thank everyone for your participation this evening and we look forward to seeing you at another webinar. Good night everybody. Thank you, good night.