 Well, good evening everybody and welcome. I think we've got 959 participants for this webinar tonight, which is great. Probably indicates the struggle that a lot of us have with children with oppositional defined disorder. But welcome to all of you who are either with us tonight for the webinar or viewers watching the podcast. I want to start by reminding us that MHPN wishes to acknowledge the traditional custodians of the lands across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future, for the memories, the traditions, the culture and hopes of Indigenous Australia. I also want to apologise in advance for any background noise you might hear. There's digging an underground station outside my window here in Parkville in Melbourne. I didn't realise they worked through the night, but I'm sure we'll be OK. Anyway, my name is Steve Trommel and I'll be facilitating tonight's session. I also wanted to start with a self-care message that if any content in tonight's webinar causes distress to you as a practitioner or a parent, please seek care if you require it by ringing Lifeline on 13114 or dialing 000. Beyond Blue, 1300, 224636 or contact your GP or local mental health service. So I'm a GP by training that my current role is as head of medical education here at Melbourne Medical School, and it doesn't give me much opportunity for clinical practice. This is the first webinar I facilitated for MPHN as well, but I'm very grateful to one of my colleagues who's done quite a few who suggested that I should just mainly keep quiet, ask questions that everyone else is too embarrassed to and don't get in the way of the expert panellists. So in that case, let's get to the panel. The biographies were disseminated with the webinar invitation, so I will go through them in detail to make sure that we cover what we need to cover in the short time we've got together tonight. But I'll start by introducing Associate Professor Michael Fascher, who's been a GP for many years in Blacktown, New South Wales, as well as having academic appointments around Sydney. So, Michael, welcome. I've got a question just to get you started. And I'd be interested in what it is that you find most satisfying about working with young children in your practice. Steve, watching children skip makes my heart sing. And secondly, seeing their parents leave my room feeling more confident and more competent in their parenting roles than when they came in is profoundly satisfying. That's great, Michael. Thank you very much indeed. You actually did that without moving your lips, too, which is pretty remarkable. I think we've got a bit of a lag in the system. That's fine. We heard what you had to say, and obviously you do enjoy having kids in your practice, as do we all. I'm also introducing Georgie Fleming, who's a psychologist in New South Wales who has a clinical interest in children who display disruptive behaviours. Welcome, Georgie. Thank you. I understand that you're currently completing your PhD at the University of New South Wales, and I'm curious what your area of research is for somebody who has an interest in children with disruptive behaviours. Yeah, absolutely. So my area of interest is kids who have disruptive behaviour disorders, and my research, specifically, is looking at whether we can deliver evidence-supported treatment for things like ODD via teleconferencing, because we know that although these treatments work, people living out in the community aren't actually accessing them. So I hope that we can start overcoming that by using technology exactly like this to start getting it out to more people. Wonderful. Okay, great. Well, thank you. Thanks for joining us tonight. And our third panelist is Professor David Coghul, who's Chair of Developmental Mental Health, here at the Royal Children's Hospital in Melbourne at Melbourne University. So welcome, Dave. Now you've only been working in Australia for a short time. I'd like you to tell us about some of the differences you've found between Australia and Scotland. We'll take the weather as a given, so in mental health, particularly, what have you noticed already? Yeah, apart from the weather, I guess there are several things relevant to tonight's webinar that I recognize. Firstly, in Australia, I guess I've kind of been surprised by the degree of fragmentation in not just health, but also in social services. And that makes it much more difficult from my perspective to be able to properly coordinate the care, as I say, the bridge between the social service needs and the healthcare needs. And the other one that I'm sure we'll get to is the far greater use of medication to manage kids with oppositional behavior that I see here compared to my practice in Scotland. So I'm sure these are things that we'll pick up. But the other thing is that actually the willingness of all health professionals to get involved with kids like this has been a real pleasure to see in Australia. In the UK, people will try as hard as they can to not see. Okay, well, that's really important. And certainly, we will be touching on the issue of medication in these children. And also the focus of tonight is really is how we can work together. So to try and overcome some of the fragmentation that you've already remarked on. But good to hear that you've sensed a willingness of people to tackle what can be really quite a challenging client group. So thanks very much now. So there we are on the panel. Reassured to see that Michael is actually in living color in the flesh, so that's good news. We do have some ground rules. I won't read through those because I think you're all capable of reading those. But just to remind you that what's gonna happen is that the panelists will all give a brief presentation pertaining to their area of expertise. But the big focus is really on questions and answers. And hopefully people are able to submit questions via the chat box. And also we've had some really interesting ones submitted before the webinar started. So we're gonna give over most of the evening, I hope, to some really interesting discussion between these panelists. So the learning outcomes are there. And you can see that we're gonna focus on increasing skills and understanding in the diagnosis and management of children with ODD, as well as improving awareness of evidence-based interventions. And we will be talking about medication at some stage. We're also gonna talk about strategies to engage specialist services and improve referrals. And I'm noticing from the chat box that people are from all over Australia, from rural and even remote Australia as well as the city. So there'll be some discussion there about finding what services there are. And finally, the opportunities to include families in the therapy of children with oppositional defined disorder. Because we're certainly aware that, well, you will have seen the case study. Hopefully you've all had a chance to read through that. I won't obviously read it out here. But our webinar does focus on the case of Dylan, who's a seven-year-old, who's really doing it tough and whom I suspect we've all met at some stage in our professional careers or children a lot like Dylan. His home situation's fraught to say the least and things have come to a head at school. His mother Felicity has been summoned and told that she needs to take him to see a GP primarily for referrals. So, Michael Fascher, Felicity and Dylan have arrived for their first-ever consultation with you. No doubt you'll have 15 minutes set aside on a busy Saturday morning. So how are you gonna approach this family? Thanks, Steve. As I had the first glance at the case study we've been provided, the first thing that strikes me is that Felicity is likely to be reluctant when seeking help. She probably is more embarrassed by what other people think about Dylan's behaviour than she is actually concerned about herself. And the third thing I bring before starting this conversation with the family is the fairly certain belief that neither Felicity nor Brad, Dylan's current parents, have any insight into the impact that their behaviour in the present and in the past is having on Dylan's predicaments. So... Yep. Go on, Michael. Well, the other thing in scanning the case study is that I wonder about the role of Dylan's anxiety. I wonder if there is more to discover about the foundations of his learning difficulties. As in some diagnosable disorder as a cause of those learning difficulties? Yeah, or... That's right. Well, an understandable... I mean, I think we need to step back from diagnosable disorder and think about difficult predicaments. It may be a diagnosable disorder. It may be that he's getting to school without breakfast in the morning. I mean, there are myriad of potential causes for children not progressing academically. And I'm wondering about how his sister Sienna is coping beyond what we've been told. But ultimately, a larger team than the teachers and school counsellor will be needed to strengthen this family. And tonight I'm really lucky to have the opportunity of consulting with a great psychologist and a quality child and family psychiatrist. And in real life, I'll need to meet more often with Felicity before working with her on developing a plan and making referrals. Sure. So the first referral you're going to make is with a mental health care plan. You're going to refer Dylan, well, Annie's family, I guess, to Georgie, the psychologist. So Georgie, you've received a mental health care plan and referral from Markle. How are you going to approach your assessment of Dylan? Yeah, thanks, Steve. So I think first things first, chances are if you're involved in a case like this, you're going to... So if you're involved in a case like this, you're a mandatory reporter. So you're going to absolutely need to assess for risk and ask the question, are this child's basic needs being met in terms of his physical safety and his... In fact, it's related to neglect. So after synthesising the information that you receive from that referral and the information that you've garnered from your own assessment, you're going to then decide whether the risk is high enough to warrant a report to a child protection agency. And being aware as well that if other services are already involved in the case, a report like this, a similar report, it's probably already been lodged. So what do you want to be doing? Georgie, because one of our participants has actually raised the issue that a lot of times the professionals in this family's already come past Markle and past the teachers, and they might already think that the report's been made, but may not have been. So obviously, we can't assume somebody else has taken that difficult step. Is that something you would check on, I would imagine? Absolutely. And I would also not... If a report had been made, it also wouldn't stop me from lodging my own report. Often, we know the strain that our child protection agencies are under in terms of lack of resources. And so cases that probably do need intervention may not be reaching the threshold. So often it's necessary that more than one mandatory reporter makes a report in order to surpass that threshold. So I would absolutely recommend, even if a report's been made, make another one, not only to cover your own ethical requirements, but also could get over the line in terms of getting them some extra help that they need. Sure. All right, good. Thank you very much. Pleasure. Anything further you wanted to say at this stage? From your perspective as a psychologist, I think I cut Michael off a bit early before. Yeah, I mean, I'm happy to wait until Michael can cover more of what he wants to say, for sure. Sure. I do have a little bit more, but... That's fine. I think if it comes up in the discussion so much the better, I think you've introduced your role well there and also the role of reporting, which is really important, whether it's mandated or just something that you consider to be the right thing to do. So at this stage, the family's moving on to be assessed by a psychiatrist. People have been asking the question leading up to the webinar and even just now in the chat box about the possibility of coexisting psychiatric diagnoses alongside the suggested one of ODD. But I'm really curious, Dave, where do you begin as a psychiatrist with a family in this situation? Oh, sorry, I'm missing my slides. Here we are. That's okay. There you go. So I really have to restate what Georgie said very well that safety has to come first. A lot of people worry that if I'm going to make a report to Child Protection, I'll lose trust of the parents. I'll lose trust of the family. But it's really not possible to provide any other therapy until you've made sure that the children are safe. Let's assume now that they are and that we can be confident that they are. And then one would move on. And I would move on to thinking about assessment and diagnosis. And of course, building trust continues to be a part of that whole assessment process. From my perspective, I think one needs a comprehensive and integrated assessment. Really, if you're going to do the best, you need to share the skills as much as you can around professionals. I mean, I would want to be working with Georgie, with others that were involved, with those that were providing support to the family. And as part of that comprehensive assessment, you need to understand the family. You need to get a good family history. For me, that includes a family psychiatric history. And then you also need to screen for other, as you've suggested, mental health problems. I'd be particularly thinking about possible neurodevelopmental disorders, so things like ADHD, like autism. But also learning difficulties, both specific learning difficulties, like dyslexia, dyscalculia, and also generalized learning problems. And that then involves getting information back from school and from others that have been involved. OK, so the likelihood is that this child has already had quite a lot of input from the school. My sister, Penny, is a teacher, and she's spent a lot of time telling me about the number of strategies that might already have used. I wonder if we might just go back to Georgie from the psychological perspective and just think about what other factors might have cropped up at the school or other things that the psychologist might be looking at to try to get a better handle on the family. Anything further you can tell us there, Georgie? Yeah, so I guess in terms of the school, it's always my preference to work quite closely with the staff members involved in like Dylan's education, because they're the people who, other than his parents, are actually around him the most. So if we can get consistency between the settings in which Dylan is moving, then we have our best chance of success in terms of getting change in some of his behaviors. So the role of the psychologist in that way is a little bit of an intermediary between the school and between the parents. Hopefully, we can maintain a good relationship with both. The other thing that I think it's really important to flag is that working with a family like this, you really need to consider whether or not the family has capacity to engage in a parenting intervention. Because what we know from the literature is that for children who are Dylan's age, so that preschool to early primary school age, that the gold standard approach to treating a disruptive behavior problem, your opposition will define your conduct disorder, is parent management training. So if you're working as a psychologist in really trying to target ODD, can't decide you're going to do parent management training. But parents often present to clinics saying, here's my child, this is what's wrong with him, fix him. And it can often be really hard to hear a psychologist tell you, well, the treatment I recommend actually is going to involve quite a lot of time on your behalf as the parent. So definitely in my assessment, what I'm aiming to do is try and identify some of those barriers that may actually prevent this family from participating effectively in a parent management training approach, particularly around mom's capacity to engage, is it feasible to expect her to commit to a parenting intervention given her own mental health, given the other psychosocial stresses? And I also think it's important as well to include the stepfather figure, because whether he acknowledges it or not, in the case study he does not, he is a part of this parenting team. And we know that these treatments work best when both all members of the parenting team are involved in the treatment. So my take-home message with that would be, involve all members of the parenting team as much as possible in every single stage of your intervention, your assessment, your treatment, your follow-up. Best of luck with that. In this case, Georgie, I think most of us would feel there's not a lot of parental engagement here. Correct, correct. So your assessment also, you know, as a psychologist, I always view my assessment as yes, information gathering, but also therapeutic. I'm hoping to do a little bit more of that motivational interviewing in order to get the parent to recognize that this is a problem, potentially be able to do a bit of more of a functional analysis to see, this might be my role in this, because we know with ODD, parenting practices likely to play a quite significant role. So if I can somehow shape my assessment to get the parents to start owning their role, potentially, in how this is all developed, how it's all maintained, then potentially we can get them by in that way. I think we'll come to that in the discussion as well, because I know Markle's got some ideas on assessing the risk within the family. So interesting to have that discussion across the three disciplines. Okay, great, thank you very much. So I guess it's back to you now, Dave, do you have anything further you wanted to say from this psychiatric perspective? Yeah, so I think that if we've done our assessment, we also need to be thinking about the oppositional behavior. And you'll see on the slide here, I have a suggestion, oppositional defiant disorder versus disruptive mood dysregulation disorder. Now, many people in the audience may be familiar with disruptive mood dysregulation disorder. It's a new diagnosis that's been brought into the field. And a lot of us are somewhat skeptical that we fully understand it, but I must admit over the past few months and years, I've warmed to the idea that it may be very helpful, particularly for us to fully understand boys like this who present with not just disruptive mood, but that's not just with oppositional behavior, but also with irritable mood, with very angry presentations. And what we're learning about this group is that those who have persistent mood problems, persistent irritability, persistent anger, and we're talking about really significantly persistent and significantly elevated, that they actually in the future tend towards having mood and anxiety problems rather than an extension of the oppositional defiant problems, which is conduct disorder or antisocial behavior. So it looks like it's a very important distinction to think about what we would say the affective, the mood part of the irritability versus the oppositional part. So this is something that I think I would like to be clear about, but it's something that really we're just getting emerging information about. Okay, so very difficult and there's a huge number of questions. We're now up to I think, what are we, 1,500 people online now? And most of the questions being asked are about how you tease apart the various possible diagnoses and what's the line between an Asperger spectrum issue and properly diagnosed ODD. I also noticed you used the male pronoun there, Dave. You said, well, not pronoun, you actually said boys. Is this something that you see only in boys? No, it's not, that's my mistake. And I guess I was thinking not about boys, but the boy we have in front of us. And I have to be honest, and I forgot Dylan's name for a second there, which is why I called him boys. But no, this is something that actually is seen equally in girls and boys. We traditionally think about oppositional defiant disorder being much more common in boys, but certainly it's not restricted to them. I think if I could go on for a second, that the issues about diagnosis are very important. And in one sense, the issue about how to tease apart these different diagnoses is a simple one in that if we ask about the specific symptoms that we find in each of the disorders that are described in each of the disorders, then that very much helps us tease them apart would be one way of looking at it. But of course, you can have autism, high functioning autism and ADHD. You can have ODD and ADHD. You can have disruptive mood dysregulation disorder and ADHD. So often it's about a combination of factors and disorders rather than having them independent of each other. And that also goes with mood and anxiety disorders that it doesn't have to be one versus the other, again with attachment disorders. Quite often we're actually finding both there. So I think skilling up on asking the specific questions about each of the disorders and then having confidence in your ability to describe those helps you understand whether it is just something or another thing or it's one thing and another thing and obviously sometimes more. Good, thanks Dave. So it's probably time for us to get into the discussion part of the webinar now with all of our panelists involved. Going back to the beginning, there've been a lot of questions asking about the cause of Dylan's situation and just how much of this we can put down into the family situation, developmental trauma, early life trauma. I was wondering what the panelists thought about that. How much can we sheet home to Dylan's family situation in his current presentation? He's going to go first. Well, thank you for that. Go, Georgie. Let's go with you, Georgie. There. OK, well, I think this is an interesting question to ask and it's often a question that parents will ask me. How much of this is my fault? How much is the child bringing to the table? And my answer to that is always it's both. We're unlikely probably to tease it apart because we can't know necessarily genetically what the child's contributing. I would say that not all conduct problems are created equal in the sense that what we know about conduct problems and kids who present with them now is that they're actually subgroups. And I think what they did a really good job at doing was explaining that within children who presenting with disruptive behavior, you have certain groups of them. And I think for Dylan, he's much more of a subgroup that we would call the primarily impulsive subgroup. So these kids tend to present with disruptive behavior that is impulsive and highly reactional and highly emotional. And this is a more common presentation and it's more responsive to those environmental factors. So likelihood is for Dylan that quite a significant amount of what's going on for him is to do with what's going on around him. And if I can quickly just talk about the other side of the coin, because I think this is really important for us as practitioners to be aware of, is that the counterpart to Dylan is a child with who we would describe as having callous and emotional traits. And so these children tend to have disruptive behavior that's much more severe, much more aggressive. And it tends to be associated with worse outcomes in later life, but also a really distinctive lack of remorse, lack of empathy, lack of guilt following the misbehavior. So these children, it tends to be much more a genetic thing that's contributing to the development of their difficulties, but always it's gonna be an interaction between what the child is genetically, temperamentally, biologically bringing to the table and then what's happening in their environment as well. So never a satisfying answer, but both really. Okay, so we're not laying the blame on any one factor that I was pointing the finger here. It's just that it's a complex, multifactorial situation that's led to a child in a stress, so we're here to help. So thank you, Julie. Absolutely. Michael, I'm curious from the general practice perspective or your perspective in particular, where do you stand here? How would you go about building a therapeutic relationship with Felicity in particular? Dylan's mum. Well, first of all, I would entirely agree with what Georgia has said. That is where the debate about whether it's nature or nurture has long since gone. I mean, the developing brain is interrelating to the nurturing or traumatizing environment all the time. And whatever else has to be sorted out in Dylan's life, from my view as his general practitioner, it is the way his family is currently functioning. Okay, well, the family's not functioning terribly well, so how can you intervene as a GP? Well, so initially, my job, if I haven't already got a relationship with Felicity, is to see that if I'm going to attribute any of these to Dylan in the future, I have to deal with the relationship with Felicity in which she has some trust. And that uses the techniques that all of us would use as being very interested, empathic, appreciating that Felicity's situation in life is much harder than mine. And beginning to use those communication skills we all use to get Felicity to start talking to me about the world as it appears to her from her point of view. The only thing I'd add to that is that I was going to make quite sure that sometime down the track, I had a chance to explore that with Dylan also. So I'm mightily concerned that I don't just accept what the adults say about Dylan's world without exploring that with Dylan. Thanks, Markle. And actually you've raised an important point that I'm curious from our other two panelists. How much time do you spend with Dylan and how much time do you spend with Felicity or other family members in your consultation? Do you three have a different sort of ratio there of time you spend or does it really depend on the way things are going? Well, if I do my job well enough, then Georgie and Dave will be well on the journey. I think the problem for everybody in the system as Dave correctly described as fractured and dislocated and non-stitched up is the quick pass. If I saw this family sent to me from the school and sent them straight to Georgie, then she has to do my job as well as her own. Okay. Yeah, and I think as a bit of an aside, I mean, it will always depend on the context, particularly a lot of the children that I work with over the pre-schooler age. So your three is in your fourth and your fives. So it makes less sense to do a one-on-one work with them in an assessment perspective. But what I'll always try and do is observe the dyad. So watching the parent and the child interact with one another, whether that's in a structured way in an observational play task, for example, or whether that's just how they interact in the waiting room before they come into the clinic. Because I think that gives us such an important information about what might be going on between, because this is a system, right? This is a dyad. It's bi-directional, it's back and forth. One's contributing, the other's reacting and vice and so on. So I think it's really important that you get a sense of how the two are working together and not just going off, you know, as Michael says, what the parent says, not just going off what the child says, but how it's all coming together in the brilliance that is parent-child interaction. Yeah, let's thank Georgie. Go on, Dove, yeah. Yeah, I think it also depends where you're at in the process and what it is that you're going to be doing. So very much of the assessment stage, Dylan is seven years old, I'll probably be relying much more on observers of his behavior to understand how he's behaving. But what I want to know from Dylan is what's it like to be you? What kind of experience are you having? How do you feel about school? How do you feel about the way in which your life is playing out? And then when you come to the therapeutic process, I agree very much with Georgie that behavioral parent training approaches are the first line evidence-based approach here. But of course, there are many different programs. Some of them work just with parents. Others, which I actually prefer, will work either separately with parents and children and then bring them together or we'll work with the dyads together to actually improve parenting really in vitro and in vivo maybe. But actually to have that work there done explicitly within the sessions and then practiced outside the sessions. But it's extremely important to get Dylan's understanding of where he is and how he is feeling about where he is. Thanks, Dave. And actually somebody's asked a very important question about Sienna. She seems as the sibling, who's only a couple of years older, seems to already be playing a few parental roles in Dylan's life and not being thanked for it. Does she have a role in this? Is there any point in working with Sienna? Yeah, I think I would very much want to and need to understand where Sienna's at. I mean, she's not the person who's been referred, but from my perspective that doesn't matter. She's part of this family. And one would be, I've talked about the dyads and we've talked about the dyads, but also we do need to remember that Brad is part of this too and we'll be having a big impact. So working with the family, understanding Sienna and part of that safety is that Sienna shouldn't be in a parental role at the age of nine years. She shouldn't be having these responsibilities. That's not safe for her brother, but it's also not a positive factor for her. So we mustn't forget that. True. Somebody else has also asked a question. I'm not sure who's the best place to answer this, Dave or Georgie, I suppose, but about the earliest age at which you'd be comfortable making the diagnosis of ODD in a child. When is there enough evidence, I guess, chronologically to make that diagnosis? Georgie? What's the youngest you've heard, Georgie? Yeah, so I intervene in... I actually... The main intervention that I'm doing at the moment is actually one of the parent-child both in the room, treating them at the same time, treatment that Dave was mentioning before. We do this treatment with children all the way down to two years. Conduct problems can be reliably measured and they're fairly stable, even as young as that. So in terms of the diagnosis, it depends how helpful that diagnosis is going to be. As a psychologist, I'm much more inclined to work with a case formulation or case conceptualization rather than a label. However, if we need a label to access funding or for other reasons, yeah, I would consider it maybe four to five, but that's not evidence-based. The evidence-based is that we can reliably measure these symptoms at that age. But, yeah, Dave, do you have any perspective? Listen, I'm a psychiatrist and I really love diagnoses, but this is an area where I'm not stuck on them. You know, it's about the behaviors, it's about the consistency of the behaviors, it's about the parenting, it's about the development of the child. So I'm very happy to refer to Georgie, refer to others to provide parent training or to deliver it myself without the diagnostic label. I think to get hung up on that in this case would not be beneficial for the child. There are other times when I will be insistent about making a diagnosis and having a clear idea. I'm not gonna start ADHD medication without a diagnosis and that means you need to be a certain age because we need to see stability and tell what is and what isn't normal and abnormal behaviors. But in this type of case, I wouldn't have a lower limit for recommending support and parent training to give it its more formal title. I think you see where the need is, you see where the gaps are and you work to that. This is actually an issue within general practice, isn't it, Michael, putting labels on patients in order to access mental health care plan services? This can be quite a confining issue, but it does enable services as well. So I would agree with the way the conversation is drifting there, but there's a general practitioner I put another perspective. That is that I am really well positioned and placed and interested in prevention. So what I actually want, both Dylan and Sienna have a living in an environment with high adverse child experience. The outcomes for the rest of their life are deplorable and let that change. And I think that as a GP, with all the people who are listening to this webinar, what we need to be doing is promoting more nurturing parenting from the first moments of life. Another way of putting that is that we have to try and help families where the parents themselves have high adverse child experience scores, raise children with lower adverse child experience scores. So prevention and promotion need to be in this discussion. Okay, all right. So very important in that area. I think prevention and help promotion is always on the GP's agenda. Speaking of treatment though, and Dave, you said that as a psychiatrist, you love diagnoses, you're pretty keen on drugs. I think you've already declared yourself as not being a heavy medicator, but a lot of your colleagues are. What is the role of medication in somebody with a presentation like Dylan's? You muted, Dave? Dave? Sorry about that, yep. Now you're on, yep, that's good. I apologize. Actually, I'm a psychopharmacologist by trade. I work a lot with medicating children, but I do have real difficulty with giving medications like Respiradone, Aripiprazole, and other really pretty heavy antipsychotics to very young kids without an exit strategy. And as I said in the beginning, I've been really quite surprised at how that happens. However, I think one can understand why it happens sometimes. When practitioners work in isolation, when they don't work within a multidisciplinary team, when they don't have easy access to either a psychologist or others to provide the parent training, then the typical, I think, response is, well, what else can I do? These medications work, and I think they're in the benefit of the child. The problem we have is that the atypical antipsychotics have huge adverse effects and huge risk of adverse effects, particularly if we don't monitor, and those risks are highest in the younger children. So I think there are many other things that we should be trying first. It's about setting up the systems and the networks and the funding to make sure that those things can happen and that these children and families don't end up isolated from effective care. Okay, so in the absence of a clear diagnosis, which is clearly the medications indicated for and a failure of other supports, we'd have to say that we're restraining the child with the medication rather than having any therapeutic intent beyond sedation. If we're using medications like the antipsychotics, if, for example, I saw Dylan, I assessed Dylan, and I felt he had significant ADHD, I wouldn't have a hesitation of considering medication to treat his ADHD. That would be a very different situation. But if I'm going to be having to think about using antipsychotics to treat his aggressive behavior, then that does trouble me. Okay, well, again, encouraging people to post their questions via the chat box. A number have come in talking about how we would engage the family or Dylan's mother and her partner, Brad. We'll start with you, I suppose, Michael. What sort of words would you be using with Felicity to try and engage her in the therapy of Dylan? How would you build trust with somebody in Felicity's environment? What conversation do you have with her? Well, Steve, the conversation might start out like this. Thanks for coming in, Felicity. Thanks for getting Dylan to wait outside with Julia, our receptionist. Things have been really tough for you lately. Yeah, well, I'm only here because I was told to come and get a referral to go and see somebody who knows what to do to help me. That's part of the problem. And I find in working out ways to help boys like you are Dylan, I often find it really helpful to better understand what life is like for his mother. How is life like for you at the moment, Felicity? It's pretty grim. I've got an abusive partner. I think I'm drinking more than I should. And the school's on my back about not being able to manage my son. So those are the issues that we're going to start. Let's start developing a plan for a way forward for you, for Dylan, Brad and Sienna. But we're going to have to deal with those issues with the pressing on you first. And as time goes on, it may well be that it's in Dylan and Sienna's best interests, we have to actually get family and community services involved in trying to help us find a way forward. OK, well, thanks for that, Michael. I mean, I'd like to hope that Felicity would get care for her own problems as well. I'm interested though, Georgie, you've talked about, I mean, Michael very wisely parked Dylan in the waiting room to terrorise his receptionist. You, Georgie, I think, said that you've got them both in the room and you're working with them together. How do you actually establish that dynamic? So at some stage, I'll get them both into the room. Definitely initially, I'll want to bring parent into room to do that initial rapport building and allow her essentially to air out her concerns because it is often an airing out without Dylan being present because I don't want to expose him to the types of negative comments that you're probably going to get from mum who's quite stressed out. And as we know from the case study, quite embarrassed about his behaviour. But I also don't want to set the precedent that in my room, in my therapy space, that it's appropriate to talk about the child in that way. So I absolutely want to get parent in on their own. Ideally, both caregivers, like I said, let's involve them both and really give them time just to speak through what's been happening. And like I said, I try and make my assessment therapeutic. So part of my rapport building is to just validate this parent that, of course, you're at the point where you're at now. Given everything that you've got going on, how could anyone not be at this point? And think of them really as this kind of like deflated balloon and if there is anything that I can do that's therapeutic in that assessment to expand that balloon to help them leave feeling a little bit more empowered or a little bit more hopeful, then that's my aim really. So within the assessment, trying to do those functional analyses where I'm understanding how these problems have developed and why they're still happening as they are and really giving her some feedback. So it sounds like when he throws a tantrum, that makes you feel incredibly frustrated. And so then what you do is withdraw. Makes sense then. He wants your attention in that moment. So he's going to really ramp it up and really try and make it clear to her how this might all be working together. Hopefully then I get my in to say, well, if we move forward with this treatment, that's exactly the thing we're going to try and target. So that's how I would go about building that trust with a mum like Felicity who's probably said this to so many people by the time she's come to me. So I try and make it as therapeutic as I can. So she doesn't feel like she's just saying it all over again. Okay, so it sounds like you'd emphasise with her and her experience would have been understood, which would probably be something a little bit novel for Felicity. It doesn't sound like Brad is a very supportive partner. Do any panellists have any thoughts about how we might help Felicity and Dylan and Fiona with the Brad situation? Is that any of our business? I mean, I think it's absolutely our business. Like I said, Brad is part of the system, whether he acknowledges it or not. I would try and... So I think the field is not very good at the moment at having very clear guidelines about whether or not to involve a caregiver like Brad in treatment, particularly for a parenting intervention to conduct problems, whether it's contraindicated or not. My feeling is if I can get him in the room and I can do so safely for all the other participating family members, then I will. And really that's about rapport building with him and making him feel like it's a safe space for him to air out some things as well. But remembering that if you're a psychologist on this case and your client is the child, you have to work really hard at balancing the needs of this system. So I think it's a risk that a lot of psychologists run to transition into like a couple of counseling mode when they're trying to do a parenting intervention because that's a part of the system. So I think setting the boundaries quite early in terms of what this intervention is going to look like and this may not necessarily be a space for you to air out what's happening between the two of you will be quite important, but always, always, always letting that person, Brad, or Felicia in particular, if she needs more support, know what services are available and facilitating linking them in with that support. I think setting boundaries is really important is my point in a case like this. And I think it's a very delicate balance that one has to have there. And I pick up on Georgie's point that I actually would be looking to work with mum, work with Felicity to help her to feel more in control and safer. I think that the evidence for being able to change Brad's is really not, it's not strong. So one does have to be very careful. And of course, if you do have Brad in and you're exploring where he's at in his thinking, I think at that point it would be important not to have Sienna and Dylan there because you're going to almost certainly have some disagreements and have to do some talking about what's appropriate and how far you can go with keeping confidentiality, but also you can't not challenge some of the really negative behaviors that we see in the case history. That's going to come back to the GP, I would have thought. Michael, are you in a position to confront Brad on his, well, the way they're described, their abusive behaviors, there's no question. Would you be able to deal with somebody like Brad and try and get him to see the impact he's having on the household in which he's arrived? Steve, I've got a plug-in failure here. Okay. That might be a good way of getting out of a very difficult situation. Brad's in your waiting room wanting to see you. Apparently you've been interfering with his life. That's okay. I think we've lost you, so we'll move on from there. I don't think it was going to go anywhere. I think it's difficult. Michael, we can still hear you, so are you able to talk to us about how, in your general practice, you might try to connect with somebody like Brad? Well, I mean, it's like the issues you do as you do with anybody else, and particularly an angry person that might be, well, come in, Brad, I see you're really angry. And we take it from there. But I, I mean, whatever else is going on in Dylan's life, in the medium to longer term, either his mother and Brad had to get their acts sorted out, or they have to separate. I mean, it's not, these children are being subjected to ongoing traumatizing experiences. And so... Yeah, we're not actually sure about his wider family. Somebody in the chat's pointed out that we haven't discussed his biological father or maybe grandparents who are sometimes pressed into service in these sorts of environments. I don't know, do any of our panellists have any thoughts about maybe extending the family circle? I mean, already we've discussed the fact that their system's fragmented and Medicare doesn't support couples counseling or the sort of family therapy that we've been talking about. But could we actually connect with other relatives in Dylan's circle? I think that's a very good point, Steve, and whoever made it, I think, has clearly been thinking. Often kinship care is something that can be very helpful here. So where, as you say, aunts, uncles, or most often grandparents are rather than pressed into action, brought into action, and to provide support, either on a semi-permanent basis or on a respite-type basis. So that can be very helpful, both in stabilizing the situation, but also providing other supports to change behaviors. Well, props to Julie Cornwall for that question. What about other members of the mental health team, such as occupational therapists, social workers? Would there be any other extension we could make involving professionals who could work with us? Or Georgie, with psychologists, do you work with OTs to try and help kids in this situation? Yeah, so a lot of the children that I see are linked in or then become linked in with other allied health, so OTs, speech paths, and so on. My feeling with this question for this case is that we really need to be aware of over-servicing this family. If I'm also suggesting that this child links in with a speech pathologist, and that's another session that the family has to attend during the week and more money that they have to outlay, I'm gonna worry about disengagement. So my priority is, like they said, is to stabilize this family and get them to start making some shifts in that home environment that's more conducive to child safety, that's more conducive to a functional, secure parent-child-attachment relationship, that's more conducive to setting firm boundaries around behavioral expectations. If at the end of treatment, once we have gotten some consistency in how Felicity and hopefully Brad are parenting, then I would consider, what are the remaining concerns? This often happens with ADHD, and so at the end of a treatment chunk, I'll often then refer on to a child psychiatrist to assess for and potentially intervene for an ADHD presentation. I think one of the potential benefits of a publicly funded CAM service, Child and Adolescent Mental Health Service, is its multidisciplinary nature so that you have those professionals working within one team. Well, one of the problems we have is that many of those services aren't always optimally funded or functioning, and there's even a sort of internal fragmentation or lack of multidisciplinary treatment, but when services like that function well and you're not adding cost or complexity because you're trying to work in concert with others, that can really be a big benefit. In our services in the UK, in Scotland, where I worked, we had an awful lot more nurses working within our teams, and actually they were hugely helpful in cases like this because they had the skills to provide the parent training and the other interventions, but they also had the benefits that come with why they chose nursing, that they were there to help, they were there to engage, and so we relied an awful lot on them to provide the coordinated treatment to the kids we see. I think, I take George's point, and I think when you're working in private practice, it's much more difficult to be able to provide that care without over-servicing, so we need to try and get the balance right. I must say, Dave, I was really pleased to visit a service in the UK and there was a CASE conference for a severely disabled young man with, I think he had autism and cerebral palsy, fragile X, maybe, but the CASE conference didn't start until the GP arrived and actually came and was one of the key people in the CASE conference. Not something that we really have here in Australia, sadly, the fragmentation cuts across all disciplines at scenes. Yeah, I mean, I think that I really miss that and the integration of the GP into that system of care, as well as, again, the ability here in Australia to doctor shop at times. If you don't like what you've been told by not just doctor, but professional shop, if you don't like what George has told you, you can go and choose to go and see another psychologist rather than be working as part of a team where there might be less choice, but there may be more engagement. That's true. What are your thoughts on that, Markle? I absolutely agree with everything that Dave and Georgie had been saying and that's why in Western Sydney, health system reform is a really high priority and I'm fortunate in this part of the world that I would have a health one child and family GP liaison nurse who would be enormously helpful in building a relationship with this family and connecting up a multidisciplinary team in the community. But I think it's really good that we don't finish this webinar without thinking about the need to assist in reform. Absolutely. Good. I'm curious, do people have sort of a couple of top tips for managing ODD or two questions actually from what the participants have been discussing in the chat box? One is how sure are we of the diagnosis in this case? There's limited information, obviously, but is this a classical presentation of ODD with traumatic triggers and also what would be sort of the top tips for dealing with a family in this situation? I mean, I think as far as the diagnosis of ODD goes, then we've got some very strong pointers, but what we haven't done is the broader assessment to say, what else is there? What other problems may be contributing? And again, one of the traps that we fall into is that we see all of the potential traumas, we see the abuse, the neglect, and we assume that the whole presentation is due to that. So that's really why I always think we need to be asking the questions, is there anything else? So, I'm confident to say, yes, there's ODD here and if it isn't ODD, then it may be this DMDD, the Disruptive Mood Disregulation Disorder, but having said that, I still want to make sure what else is there? We hear about feeling sad, we hear about anxiety, we haven't asked at all about ADHD. So we need to know some of the other things as well before we close our minds and say this is just a typical ODD. Okay, so thank you for that. And Georgie, putting you on the spot a little bit, but if I am a thoroughly reconstructed Brad or Felicity in this situation and you're working with me, what might be two or three parenting tips you would give me to change, to try to change the way I'm looking after my kids and what impact it's having on their health? So what are some of your top tips for parents? Yeah, so I think my top tip first would be for the practitioner working with the parent to come back to your theory underpinning intervention for ODD, where what you're really trying to do in your intervention is engender an authoritative parenting style in these parents. That's what the literature tells us is conducive to the best outcomes for this child. So when we talk about an authoritative parenting style, we're talking about an equal emphasis on being nurturing and warm and responsive and loving and squishy on the one hand, but also having an ability to be a really consistent limit setter on the other hand, because when they're out of whack, like this, our parenting isn't going so well. So that would be my first tip that your goal as a practitioner is to engender this parenting style and then to provide this family with very practical strategies about how to go about making that balance between the positive parenting on the one hand and the consistent limit setting on the other. My other top tip, it would be to use analogies, which is, use analogies to enhance parent buy-in. So one of the best tips I ever got as a practitioner starting off in the intervention that I do, which is parent-child interaction therapy, a master trainer called Cheryl McNeil said, use analogies. So if the parent is not engaged, if they're on the fence, if they're like, this isn't gonna work, what analogy can I use to enhance that buy-in? So selective attention is often a hard one. You want me to ignore when my child is whining or you want me to do play with them every day in order to enhance that parent-child bond, I would use the analogy to be like, yeah, I want you to do play, but I don't want you to think about it as play. I want you to think about it as therapy and your child needs a daily dose of this therapy. Medication, would we expect a medication to work if they're only getting it once a week? Okay, so play as therapy is time in. I know one of the resources that will be available after the webinar talks about time out and it's got a bit of a bad rap. Some of the teachers at the conference are also interested in the techniques that they can put into place in the school where the children are spending a large part of their time. In the couple of minutes we've got remaining, what, before we sum up, what would be your advice to teachers in terms of managing a child who's in a group learning situation? I think that the first thing that I always establish with teachers is a parent-teacher communication log. So I need a fairly constant back and forth between the parent and between the teacher and myself as well. And within that I then will help the teacher set some very explicit behavioral goals upon which this child is working. So this might be, if it's an impulsivity thing, raising my hand before I speak in class. If it's an aggression thing, keeping my hand to myself. And what I might do then is set up, basically contingency management plan where when we see, when we catch this child using those behavioral, meeting those behavioral expectations, we work out a very consistent, very structured reward system. But also, depending on the school as well, to have a consequence system. I think consequences are important. However, I think it's important to note that some kids are differentially reinforced by punishment, they reward. So your assessment needs to inform the advice that you give to teachers in terms of what's going to work best to motivate behavior change in this child. Is it consequences? Is it moving my, the photo of me from happy face to sad face? Is it a thinking chair, a calm down corner? Or will it be much more the token economy system that's going to be effective? I think using both, but being driven by your assessment and your conceptualization as well. And my big sister told me about the traffic lights that some teachers use to give the child. We love traffic lights. Yeah, we love traffic lights. So traffic lights have been used for a number of things with families that I have worked with. So traffic lights are often an emotion regulation strategy. So if we think of stop, warning, go, it might be something like stop, have a think, do. And this is often a part of anger management that we teach kids. It's part of kind of like a baby CBT approach. Traffic lights can also work in terms of that behavior management as well. Hopefully we want the child to be remaining in the green area, the good area. But if they're doing consistently those things that we want to see less of, they might move into orange, it's warning time, and then into red where there might be a consequence. So the visual aid for kids can be very, very helpful, particularly for children who are on the autism spectrum. But I think it can benefit, you know, kids across the board as well. Great. And what about you, Dave? Have you got any thoughts for teachers? Dave, I love psychiatrists that you can't hear, but we can hear. I'm great, yeah. There you go. I talk to people for a life. I told you I was easy to manage. This is the truth. The one thing I would add to what George's said is that often teachers will come back and say, well, I can't do this. I can't reward this child for behaving moderately well when actually the other children aren't getting rewarded for behaving the same. And one way around that is to reward the whole class for an improvement in a particular child's behavior. So actually it then becomes something that the whole class is engaged in, in helping the good behavior of kids who are having difficulty behaving well. And often that will work, and it makes sense to the teachers as well, because you're not differentially rewarding one child for only moderate behaviors. OK, great. So not singling them out and also engaging with the whole class. It's time for us to wrap up now and hear from our panelists one last time. The you, Michael, I guess, if we look like the Brady Bunch now, this is intriguing. So, Michael, what are your thoughts as we finish up this case? What way do you see us going with this family? Look, I think the options have been beautifully covered. The traps are to focus on the child as a problem and to think that he is a disease to be managed rather than a child in a family, in a school, and in a community. And I think that our discussion has followed that line very well. OK, great. Thank you very much. What about you, Georgie? Any final comments or thoughts from you? I think drawing on what Michael said that with cases like this, it's so important to really foster empathy for how this family has gotten where they've gotten and to identify those points of intervention where it's possible for you to create change and to always, always, always look for the strength in this child and to inflate the parent's sense of parenting self-efficacy by pointing out the good things about this kid, because there will be good things. It might just be a little bit hard to see behind all the not-so-nice stuff. Yeah, awful to think that people would see this child as broken in some way and needing to be fixed. It's obviously a situation that the whole family is trapped in in one form or another and what can we do to help out. Thanks very much. Dave, any final thoughts from you? Yeah, I would have said almost the same, that we've got to set ourselves up into a situation where the family can succeed. So we've got to look at how we can build or engineer the right kind of situation in the environment so that they can make the changes that they're going to need to make if things are going to get better. I think my only other bit would be about remembering that we haven't uncovered everything yet. There's a lot more assessing to do and understanding to do before foreclosing on saying that we understand everything because of the situation. And Steve, as you know, as you know, Steve, in general practice, we never foreclose. No, we don't get that option. It's not about foreclosing. It's always follow up to do. And that's obviously very important. So back to the school, back to the family. All right, well, thank you very much. A number of people are still asking questions, which is great. There's obviously lots more discussion to happen around the country about this particular topic. I would ask people to particularly fill out the survey feedback. You'll see there's a little gray tab in the box that way. I think I'm pointing the wrong way. There you go. Anyway, where it says survey feedback, please tick on that and fill out the evaluation. I would encourage you to attend future MHPN webinars. You'll be notified when they're coming up and they're widely publicized. The next one sounds fascinating. It's on the 29th of May. So in four weeks time, Department of Veterans Affairs is supporting one on suicide prevention in veterans so an incredibly important topic. MHPN does support the engagement and ongoing maintenance of practitioner networks, as we've seen tonight. The team, the network is essential for appropriate management in these sorts of areas. We do encourage the sharing of tips and resources, building local referral pathways and engaging in CPD activities. So you can learn more about your local practitioner network by contacting the mental health professional's network or go to the new section of the website and in the exit survey. So please don't forget that survey. You will be sent an email follow-up. I can't quite find my note about that, but you will be sent a way to access the resources that will be available after the webinar in a week or two. So we're approaching the closing time of the webinar now, but before I close, I would like to acknowledge the consumers and the carers who've lived with mental illness in the past and those who continue to live with mental illness in the present and we wish you all a very healthy future with the challenges ahead. So thank you to all our panel, to you, Michael, to Georgie, to Dave and thank you to everybody who's taken part, lodged a question, been involved in the chat and also to the mental health professional network for putting on the webinar. So thank you all for your participation this evening. Good night.