Victoria C  00:00

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the traditional custodians of the land on which this podcast was recorded, and the traditional custodians of the lands and waters on which you’re listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people.

 

Renee D  00:23

Getting the messages out there about what we can do on a population level to make sure that we’ve got a good balance: is nutrition and feeling good in our bodies.

 

Victoria C  00:33

Hi, I’m Victoria Carthew, a journalist, presenter and your host of this series, the Clinician’s Guide to Women and Girls’ Health brought to you by Health and Wellbeing Queensland, in partnership with the Queensland Government’s Women and Girls Health Improvement Program.

 

Victoria C  00:49

From menstruation to menopause and all things in between, including sexual health, wellbeing and ageing, the Clinician’s Guide to Women and Girls’ Health podcast series speaks to leading Queensland experts about how health professionals can have effective, empathetic conversations with female clients, empowering them to take control of their health journey. Welcome to our second episode of the Clinician’s Guide to Women and Girls’ Health, where we continue to discuss the health of teenage girls. Today we’re talking to Dr Renee Denham and Dr Aaron Chambers. Dr Denham is the Medical Director of the Child and Youth Eating Disorder Program for Children’s Health Queensland. As a child and adolescent psychiatrist, Renee has extensive experience in supporting adolescents and young adults to explore and understand the factors that may be impacting their comfort or happiness. Dr Renee, we are so pleased you could join us.

 

Renee D  01:41

Thank you so much. I’m so excited to be here.

 

Victoria C  01:44

Dr Chambers has worked in general practice since 2006. He’s passionate about family practice, including paediatrics and obstetric care. Aaron is the Medical Director of the Australian general practice of the year, Growlife Medical and a school-based GP at Brisbane State High School. I can think of no better combination. Dr Aaron, thank you so much for joining us.

 

Aaron C  02:01

Thanks for having us.

 

Victoria C  02:02

For people listening across the state in all different types of schooling and education environments. They mightn’t be too aware of that intersection between the medical and education system. So, tell us a little bit about how GPs work in schools.

 

Aaron C  02:15

Yeah. So there’s a Queensland Government program where there are quite a few GPs around the state who are embedded, usually one day a week in state high schools, which is a fantastic program, because I guess it means that you’ve got GPS working alongside school guidance officers embedded in the adolescents community to kind of help understand them and provide better access in a bulk billed fashion.

 

Victoria C  02:35

And how do they come to you, in terms of it, not a referral process, and what sort of time are their appointments, links, that sort of thing.

 

Aaron C  02:41

So it’s just like any other access to GP, they’re unreferred services, although a lot of the students who might attend will be referred by the school guidance officers, but they can attend with their own from their own volition. Maybe their parents might have prompted them to or a teacher. And the advantage of the program is really flexible around students’ needs, because it’s block funded by the state, and with bulk billing applying, it means that often students can access longer appointments. There’s no out of pocket costs. It’s right there alongside where they go to school, so that the access issues are solved.

 

Victoria C  03:11

I was going to say, you know, throughout this episode, we’re going to talk about accessibility and cost of living. Seems to me that would be an incredible way to capture young people who perhaps otherwise might not be able to get into the system.

 

Aaron C  03:21

Oh, it’s amazing. And particularly for disadvantaged schools, I think is really important in the way of making that access to healthcare better.

 

Victoria C  03:26

Absolutely, the Queensland Women and Girls’ Health Strategy 2032 consultation outcomes report identified mental health and wellbeing as top three issue, particularly for girls under 30. So I guess you’re as close to anyone for people in that age bracket. What are the real mental health concerns that you come across for young girls in that bracket?

 

Aaron C  03:45

I think if I was to put the top of the list, I mean in terms of complexity, the top of the list would probably be eating disorders at the moment, although that has come off the boil a little bit since the peak of covid, anxiety disorders absolutely prevalent. And I think a thing that I’ve seen change over the last 10, 15 years is really much more presentation of ADHD and ASD as is really prevalent concerns, particularly those neurodevelopmental learning issues. And being inside the school environment, you do see a lot more of that learning and an impact on function that’s noticed by the school teachers or the school guidance officers, and that’ll refer them into the GP.

 

Victoria C  04:22

And because there is now more awareness and acknowledgement and identification, I suppose you are seeing it more as well.

 

Aaron C  04:27

Absolutely yeah.

 

Victoria C  04:28

Renee, from a psychiatrist perspective, are these the similar topics that you’re always seeing?

 

Renee D  04:33

Yeah, I think in my role, I obviously see a lot of young people with eating disorders in my Queensland Health role, but what’s really important. It’s they’ve got a whole layer of other challenges that they’re often navigating, in terms of via mood, anxiety problems. ADHD, we might talk later, is reasonably common, actually, within that population too. And then again, my more general work, too. I definitely those would absolutely resonate with me as some of the key concerns. And probably the areas that get particularly like sort of exacerbated and triggered by some of the system and structural elements of that time of their lives as well all the other things that they’re having to navigate and sort of resolve and clarify across adolescence, it makes those things harder.

 

Victoria C  05:16

So being 11 to 17, being a young woman, it’s

 

Renee D  05:19

It’s not easy no.

 

Aaron C  05:21

It’s super hard. I think the thing I didn’t mention, as well as I guess, you know, depression, obviously mood disorders, but self harm, I think, is also it’s quite a prevalent issue.

 

Victoria C  05:29

How do we differentiate, then, between what is a normal teenage mood fluctuation, as you’re saying, it’s a hard time in life for everyone, and the signs that there is perhaps a developing mental health condition.

 

Renee D  05:38

One of the challenges, I think, for adolescents is it’s a period of such like growth and change. For young people too, they don’t have a roadmap for what their baseline is. So if they suddenly were increasingly dealing with more OCD or more anxiety or an eating disorder, it’s easy for a 14 year old to think, is this just what adolescence and adulthood will be like, because they don’t have that like lived experience. If you’re suddenly struggling with a mood disorder as a 20/30, year old, you have often had a period of relative stability that you can kind of see as your baseline. I think it’s really hard for both young people and their parents sometimes, because I guess one of the challenges is, is this adolescence throwing a bit of a spanner in the works, or is something else going on and it is. It can be hard to sort of tease that out. I guess some ways that people do it is they sort of with a trusted family member or a friend or a caring GP or school support. Sometimes they’ll sort of tease out whether what they’re going through, the amount of distress that they’re experiencing makes sense with what’s happening around them, and sometimes, if it’s more than that, that’s often a clue that So, for example, lots of people find this assessment period stressful or a friendship disruption really hurtful. But if the if, even when that’s not on their mind and they’re doing other things, if their mood and anxiety is sort of following them into those spaces, it’s often a bit of a cue that this has become a more, sort of fundamentally impactful thing than just a response to stress and change.

 

Victoria C  07:12

And when we’re talking about this age group for young women of 11 to 17, that’s actually quite – it’s hugely broad, isn’t it? I mean 11 to even 16 when you talk about those baseline of experiences and resilience. So you would see that with the young people that comes through to you?

 

Aaron C  07:23

I mean, it’s a time of growth and change. And I think you know, to echo Renee’s comment, it really is a time where adolescents are figuring out, Well, who am I? What is my role in society and life and in my social network? And is what I’m going through normal or not? And I think that’s where like so GPs are  expert in sifting out, well, what is normal, what’s not, and having that ability to sit with someone over time and see what the progress is. Is this something that’s just resolving with a bit of talking through and understanding and connecting with services, or is it something that’s actually really, I might go and get Renee involved, because it’s much more at the upper end of complexity and definitely a disorder. And it’s sometimes, it’s really tough to figure those things out without the passage of time.

 

Victoria C  08:07

So you’ve actually given me my next question about red flags, and when is it beyond a GP? And what are those things you’re looking for that it needs more than a GPs help it needs?

 

Renee D  08:14

Well, I think you sort of also touched on it. I’ll even, you know, got a lot of experience in some of these spaces, but if people kind of come to me in the first time, I’ll deal with whatever needs to immediately be deal dealt with to make someone safe and that which can be different things. But as to I try and sit in a state of curiosity for a relatively long time, while still, you know, trying to help with what seems to be in front of me, because I don’t have that longitudinal history. So I do think for a GP that does have that longitudinal history, I’d always be very inclined if you know they were capturing that sense. Hey, I’ve known this young person for some time. This is a real they’re just flatter or or these other elements that you know. They might have even struggled a bit with bits of their eating, but I’ve never seen this kind of degree of consistency or concreteness. I think I actually it’s the people that know them well saying this is different to usual fluctuations. It’s often the biggest red flag, I think. And then the GP would work with them, I imagine, and the councillors might work with them to tease that out. And often they’d then kind of come be escalated up if it looked like it needed extra support.

 

Aaron C  09:01

That’s right.

 

Victoria C  09:01

So, Aaron, for clinicians and healthcare professionals listening who don’t have necessarily experience in the mental health space, are there screening tools quite sort of generic things they could be thinking about using?

 

Aaron C  09:35

I mean, the first thing I’d think of is like a HEEADSSS assessment, which is really useful tool to kind of just go through some of the standard stuff that is about an adolescence environment. So, home, education, alcohol, drugs, sex and sexuality and suicidality, you know? But maybe that’s not necessary for depending on the type of clinician to delve into. I think there’s an even simpler way to think about it, and I think, so Simon Denny did a lot of research in this area, and there was one thing that I picked up on listening to him that was really important. So at our practice, we’ve got this philosophy around thinking patient, family, community, and they’re all dependent upon each other, so that individual doesn’t exist in isolation. They have a family who might be supportive or not supportive, and they also exist in a community that might be supportive or not supportive. And his his comment that Simon’s comment was, I’m really worried about an individual, an adolescent, if they don’t have anyone in their life who loves them. And it’s such an important predictor, because if they’ve got someone there who they know is in their corner, usually they’ll be able to work through whatever the issue is, and they’ll have the resources and support to make their way through, whereas the absence of that, and sadly, have definitely seen this in kids, where they don’t have that someone in their life. And I really worry, even if they hesitate, is there anyone in your life who loves you? If they hesitate to say, oh, maybe mum, that really worries me. And I think that’s where as health professionals, we really need to step in more. But it takes a while to get to that level of conversation, so I guess that’s what the HEEADSSS assessment tools really assessment tool is really important for, is it allows you to kind of just casually start to discuss, oh, you know, how things go at home, how things at school, with your teachers, your friends, and it’s mostly just a scaffold to understand an adolescent’s life. It’s just a great tool for conversation.

 

Renee D  11:16

It is a great scaffold and I think it also captures another sort of simpler truth of, are there things in that young person’s life that they feel a degree of achievement or containment or engagement with? You know, it’s not necessarily being the best at anything, but are there things, you know they love their soccer team and they’ve been doing that, or, you know, they’re marching along well in the computer game that they’re playing well and they’re feeling proud of that, like resilience is often a feeling like you’ve got some things that are okay, that helps you tolerate the things that aren’t okay right now, or at least feeling like that’s not all you are. What’s not working out for you, it’s having some things that help you feel good.

 

Victoria C  11:54

There’s more to it.

 

Aaron C  11:55

Totally.

 

Victoria C  11:55

The simplicity of that is so powerful. What you’ve just said, it’s really interesting. I guess, more broadly, it’s quite a generic question. But do you think the mental health and wellbeing of people, young people, across Queensland has gotten worse, and are there gender differences in there that we that we see?

 

Renee D  12:10

I always find this one a bit challenging, because I think my general sense is that there’s much better recognition of mental health as a variable on a continuum in a way that’s really powerful. I know that when I started my career, there’s a manner, sort of sense of you had to be really sick to sort of be seeing someone for mental health that I probably entered my career with to more the idea that, like many things in our life, it’s something we want to optimise as well. It’s still worth seeing someone, even if you’re only moderately anxious, if they can give you some really good strategies that reduce its impact on you. You don’t have to, you know, get into a degree of distress that I think historically, people had to. So I think that does influence some of our statistics, because the people accessing care is higher, but it’s sort of what’s the outcome of that accessing if it means people actually sitting in a bit more of a thoughtful and confident space in their mental health, and that’s actually excellent. I do think our broader systems are more complicated, though, and some of the pressures on young people are much more significant. So there are definitely other elements of the environment and our lifestyles that make it really hard. So I do think the extremes of mental health difficulty are fairly significant.

 

Victoria C  13:19

So I’d like to ask you both, I guess, about those key factors that you think are contributing to why we’re seeing that.

 

Aaron C  13:24

I talk a lot to the adolescents that I see around the concept of social networks and how preventative that is. You know, the more social networks you have, the more likely you are to have positive mental health. And I kind of explained to them briefly. I said, Look, a social network isn’t the number of friends you have, it’s a number of different groups that you’re part of, and I put it up on the whiteboard, and I sort of map it with them. Okay, so you know, you’ve got your family

 

Renee D  13:56

You like whiteboards as much as i do. I love a whiteboard

 

Aaron C  13:57

Yeah, a whiteboard is great, and it gets it across, and they’ll tell me and this. And you can also use it to explore what’s going on in their life, but also use it to help trigger, well, okay, you you’re playing in tennis, you’ve got your gym group, you might play chess as well. Actually, you’ve got a lot of social networks. And just because something’s going wrong at home right now doesn’t mean you have other places to draw from where you might get some strength. And you can also include your teachers in that. So pointing out to adolescents around well what options they do have, sometimes really helpful. And if they’re not willing to even think about that or step beyond thinking where their current problem is, that probably worries me a little bit more. But then to think about the prevalence related issue, I think the other thing that’s really important to think about is their access to screens, the unique challenges that they’re faced now, where they’re not necessarily feeling safe at home, around being exposed to social media, the concept of sexting, and, you know, there’s some of this really manipulative stuff, where we’re digitally connected but socially distant, and it’s it’s a real challenge for this generation I think.

 

Victoria C  14:48

Are there other barriers? I’m thinking about access to mental health and services, and obviously in schools that have got someone like you there that’s incredible to hopefully have someone they can go and speak to. But what about the barriers our young girls face to getting, you know, accessing mental health?

 

Renee D  15:02

There are definitely barriers, and it’s often literally within different family. They might have different cultures within that family about where they see mental health and and how much they, what comfort they have. The young person will sort of come and they’ll say, look, you know, my Dad gets pretty anxious too, but he sort of says, you know, he’ll just push through. And, you know, so it took a lot for me to kind of like escalate and ask to get into there where another young person may not have persisted in a different family, it might be the family, the parent’s got their own sort of challenges, organises access pretty quickly and calmly, like in the same way you see your your GP and your ENT specialist to keep an eye on your hay fever, they might link in with mental health supports. So it does vary a little, and I guess it’s the quality of their like environment online as well, because there’s a lot of health information out there, which can be great in terms of directing them to where they should go, or it could, it can tell them things that aren’t accurate that makes them think that they’re better off, like navigating it just with that advice too.

 

Aaron C  16:11

I think a lot is explained by socio economic factors and and it really worries me that we’re having a society in Australia where is this increasing gap between rich and poor, and it’s as a GP working in disadvantaged communities and very advantaged communities, it is astonishing the difference that it makes when you have access to those resources, and it’s usually financial resources. So if you have the finances, you can get psychology, you can get access to everything you need, whereas if you come from a family with a disadvantage, socio economically disadvantaged background. It’s much, much harder, because even the public services which exist, they’re overwhelmed. You know, the service that Renee is currently directing fantastic, and I interact with them really positively, but there’s a huge unmet need of people who don’t quite meet their criteria, where it’s much harder because you don’t have that funded, no gap, accessibility, and particularly for private psychology, it gets very expensive over time, and where you’ve got a student who is disadvantaged and having trouble to access care, that’s part of the reason why I think the GP in schools program is really effective, because it doesn’t have a gap, and you can provide that kind of support and then link in with the resources that are available without any out of pocket cost.

 

Victoria C  17:23

And I think for you to say that, I then think about the bigger picture of our whole state, and for those that are much more more remote, for those that are not in hubs, or perhaps don’t have a big enough school to have a GP, and that’s where this access issue and the mental health challenges come along as well, isn’t it? Because they just can’t access it because of where they live and how they live.

 

Renee D  17:43

We see that, that’s exactly right. The challenges socio economically are profound too. Because, the way, because I’ve got a foot in both worlds, in in the private system, the regularity of appointments, that is, when you’ve got a something like an eating disorder, it needs a lot of intensity early on to get good momentum. That means it’s a lot of appointments with private providers, and there is a eating disorder mental health care plan to facilitate it, but then it’s often a gap, and there often needs to be a gap because of the cost of those services, but that is a disincentive and I think then they’ve also got the other costs too. You’ve got to have a parent that’s got enough flexibility in their workplace to attend all the appointments and facilitate it too. So it’s like financial costs from both what you’re paying out and the missed earning and sort of other life opportunities of trying to coordinate it all.

 

Aaron C  18:35

Yeah, exactly. It’s layered beyond just the out of pocket, isn’t it? You know? Yeah, the parental availability, having two parents makes a massive difference too.

 

Renee D  18:44

I do think the school-based GP definitely would reduce a lot of our young people need to see GP very regularly in the initial part of care, for support, but also for monitoring of their physical things. And that’s an extra appointment you have to take that child to and amongst the other appointments they’re already having.

 

Victoria C  19:02

So if I could take that back, then I’m wondering about the GP based in the school, how that works back into the primary care if you’ve got another family GP, how does all of that sort of system tie in?

 

Aaron C  19:11

Actually, I was exactly going to bring up that same comment, and the GP in schools program is not intended to disrupt the relationship with a regular family GP, because I think that concept of having an individual and the family who’s looked after by a particular GP, managing that longitudinally, managing the complexity and providing the continuity over time, has myriad benefits beyond just that individual consult. And I think it is, it is a real challenge in our system. How do we make sure that the people who are most socioeconomically disadvantaged, who most desperately need that continuity in the managing of quite complex conditions, are able to access the same level of continuity that someone with socioeconomic means has. It’s such an important concept, and I think the GP in schools program does definitely help fill some of that gap, but it’s not the whole solution, and I think we really need to think more carefully about providing better health equity.

 

Victoria C  20:02

Renee, this is very much your space. You’ve done some extraordinary research and been working in this for so long. But some of those contributing factors, psychological factors to towards eating disorders.

 

Renee D  20:12

Yeah, that I think it’s a really rewarding space to work within. I feel like you learn so much from the families and young people. I think developing an eating disorder, as much as being unlucky in the sense that we’ve all buffeted by different stresses and challenges. Our own vulnerabilities we might have mood or neurodevelopmental vulnerabilities might be life experiences and eating disorders often can happen where those arise in such a way, for some reason, eating and starvation occurs, and then that can get really solidified into an eating disorder. And I think that that’s a helpful message, because I think it’s people quite concerned and scared, understandably about eating disorders and thinking it’s something that happens to others and and you hope it’s not you or the people that you loved. But actually one of the real revelations in the science of eating disorders has been where historically it was seen as so predominantly psychological, that if you really understood why that they were choosing not to eat, there was a movement a way of realising that people that are really starved, and even when they’re starved in completely non psychological circumstances get a lot of rigidity and challenges with their thinking that sort of seems to really capture and hold them in that space where it’s even if they want to they can’t recover. And in fact, there’s there were studies done on conscientious objectors from previous historical wars when they’re on starvation rations, these well off, mentally stable people had much more trouble returning to their normal eating after a period of starvation. so that’s the

 

Victoria C  21:50

I’m sorry, from a non-medical person that makes so much sense, because we all think about how we feel when we’re not you know, when we when we when we’ve not eaten, how we can’t focus, we can’t do anything. And you’re talking about young women who have so much else going on.

 

Renee D  22:02

Exactly, exactly. So that’s been the change. One of the really important phenomenological shifts in eating disorders is understanding that while everyone is rich and complex and there’s a lot of other things we do need to hold in mind. At its core, losing the habits and losing the nutrition of eating is the predominant initial thing that needs to be resolved, and so that that’s basically caused a paradigm shift where, historically, when I started my training, people would spend a lot of time in hospital if they were had a severe eating disorder, and they were given care and support, but really trying to help them decide to eat again. The movement to understanding we just want to nutritionally support someone. If they’re not well enough, we might help them via supporting them with the meals or even having a nasogastric feeding to nutritionally recover. So obviously, in a severe eating disorder, you can actually move out of that space where that young person’s brain and their decision making and their emotional regulation is improving, they’re in a much better position to then do all the other sort of layers of psychological and social support work that is needed for their dilemma. That also means that their care can then happen in the community. For a lot of young people using hospital when required for nutritional safety or to really help with some entrenched challenges, but ideally, most of the care happening at home, it’s around your loved ones, so those connections, those relationships, your schooling, can remain intact.

 

Aaron C  23:28

And as a GP, I think there’s a big piece that comes before this, and it’s that idea of continuity. Things as simple as and I’d really encourage the primary care clinicians out here, be it practice nurses or GPs or other health professionals, just keeping a track of the height and weight and growth measures – that recognition of someone who’s descended into the point where actually they’ve got a significant eating disorder. It’s so, so helpful to have those previous weights and measures to kind of understand where the changes happen, because often families aren’t recognising or seeing it in their own child.

 

Victoria C  23:54

Having those baselines?

 

Aaron C  23:57

Having the baseline is really helpful, and that’s where continuity comes in. I think it’s also just to kind of think about like Renee is dealing with the really pointy end. It’s so, so rewarding to work with these adolescents in the community, and then watch them kind of almost go out the other end. You know, we had one who recently finished grade 12, who we’d been looking after for many years through our clinic, and just seeing that, that young person, go out and off into a successful life. Having passed beyond that phase, it’s really, really rewarding work. So, you know, leaning into it as GPs.

 

Renee D  24:28

We sometimes say that the young person’s strengths and abilities when they’re really unwell or in the midst of severe distress often being co-opted by their distress system to make it harder. So often, it’s sometimes young people that were really driven and and passionate and really caring about their community, if they find themselves unlucky enough to have an eating disorder that for a while, is like co-opted by the eating disorder to make the you know, really drive them in a way, but that sense that these are still really good things about that young person, and what this young person is going to be able to do, if they can, kind of like recover, is

 

Victoria C  25:07

Comes through.

 

Renee D  25:08

Yeah.

 

Victoria C  25:08

Stay with us, we will be right back to continue our conversation.

 

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And now back to the conversation.

 

Victoria C  25:45

I’m wondering from both of you, you did touch on it earlier about the information people are receiving online, but I’m interested because you’ll be seeing it in schools and in practice around social media and disordered eating and the impacts that’s having.

 

Aaron C  26:01

I think I’ve seen it where adolescents either with an incipient eating disorder, with an eating disorder in their engaging communities where this is discussed, and this kind of mechanism, I’m sure, in a sees a lot of it, but it’s really difficult, because that social pressure to become part of a cohort where this behaviour is normalised, it’s very unhealthy.

 

Victoria C  26:20

So they’re tapping into something that already exists that is promoting this behaviour?

 

Aaron C  26:25

Yeah, and then, and then it seems normal, and then they’re kind of drawn into it, or reinforces their own avoidance of eating and, I think, is that what you’ve experienced Renee?

 

Renee D  26:33

Yeah, I think there’s really mixed messages. I think that one of the underpinning ideas in some of the eating disorder therapies is, you know, this family once has known how to feed this child, and we’ll put them back in the centre, but there are lots of mixed messages about what people should be eating and how to live well. And I think if you’re particularly starting to struggle the anonymity of the internet, you will find often young people, unless their friends are particularly struggling with disordered eating at the same time. They may not even always ask their friends about it. They might be sort of guided by the patterns that their friends but if they’re actually researching, what should I eat? It is online, and we tend to confirm our own biases when we’re doing searching. So you can find communities where people are sort of really sitting with not always an anorexia, but maybe like a chronic set of sort of disordered eating patterns that are really endorsing eating choices that aren’t safe and particularly also that confusing, what sort of recommendations suit an adult versus a young person whose body is still actually actively trying to, you know, build organs, develop brain, build bones. The energy and nutritional requirements of young people are very specific to their different stages of development.

 

Victoria C  27:48

We’re discussing healthy lifestyle, physical and mental health of our teens and adolescents, and this second episode of the Clinician’s Guide to Women and Girls’ Health. And there’s a lot of wisdom coming your way, which I’m really enjoying from Dr Renee Denham and also Dr Aaron Chambers. And rest assured that any papers, any research, any links that we discuss throughout this episode will be with you in the show notes, so you can access it all later. Aaron, I’m just wondering about parents and all of this, because not only are they perhaps, maybe they’re not aware that it’s happening, but when they are, how they manage it and cope with with this disordered eating, because it’s a huge load as well on the parents.

 

Aaron C  28:21

Oh, it’s so evidently a whole of family issue. The way it absorbs the entire energy of a family around that individual with disordered eating, it’s, it’s, it’s such a burden. And I think it probably goes to a little bit of the way that the treatment is happening these days that Renee will kind of talk more about very family orientated. And I think it’s, it’s all about setting up that environment that allows that young person to feel safe, supported, and get that nutrition that helps the brain function come back to normal. At least that’s my simplistic way of thinking about,

 

Renee D  28:49

No, no, I think that sort of is the core of,  and it also sort of then speaks to what we can do to sort of protect young people from this too. It is as simple as some of that is, is having those consistent routines and rituals.

 

Victoria C  29:03

That’s so good of you to say that, because I want to talk about protective factors. You know what we can do as families to support the right environment for our for our girls, to help them move in the right direction.

 

Aaron C  29:14

There’s a really simple one, I think, and that’s I heard once, that eating dinner together is really predictive of good family function and positive mental health later on. It’s such a simple intervention, but I think it’s disappearing.

 

Victoria C  29:26

So talk to me about nutrition, sleep, physical activity in children, you know, in teenagers, mental health. We know that it’s an age when girls particularly are often bouncing out of physical activity, but those three things, it’s consistent across our lives. But for young women to get these habits now, to take them through life is hugely important.

 

Aaron C  29:43

So important. I think this is my territory. Primary care intervention stuff is you see it in the schools of the cohort that we look after as a GP in schools is completely underrepresented in extracurricular activities, where you’ll see a student where they come in for something sort of relatively simple and minor, maybe it’s a contraceptive pill or just a check up for some other asthma, maybe. But the kids who are affected by poor mental health or any of these more complex psychosocial disorders are so far underrepresented in their extracurricular activity that I think there’s probably a bit of cause and effect in there. And the evidence for exercise is so so clear in terms of its beneficial effect on mental health, its beneficial effect on your cardio metabolic health. It’s something we need to be making sure happens. And I think it’s really easy for it to disappear in high school. It’s a little bit outside a healthcare clinician’s ability to influence that directly, but working with schools, working with communities to make sure it’s normalised and as part of regular everyday activity, that’s probably the one that I think is important. And we also have a big challenge in our society around disordered eating, not just at a eating disorder, anorexia level, also at the opposite end of poor nutrition and low nutritive foods. High calorie, low nutritive foods are just so prevalent. How do we solve that? I think as clinicians, we need to be advocating for change, but it’s probably more at a public health level than an individual clinician level.

 

Renee D  31:10

I do think sometimes our systems can struggle a little bit, because I think that’s when young people are going through a lot of the exercise, very much achievement orientated, when it could have been like I sometimes talk to teenagers and their families, I’m like, think about it as what social support are you going to do as a 20 year old? Think about doing it light on that sort of basis. Yeah, because I think sometimes, you know, you see when young people sometimes dropping out is because it’s like, they either go step up and do their ballet six times a week, or they don’t sort of do it, or they need to go into the soccer academy, or they don’t do it.

 

Victoria C  31:33

It’s the extremes, isn’t it?

 

Renee D

That’s exactly right.

 

Victoria C

You’ve made me feel so much better, Aaron, about my over scheduled children. We do a lot of extracurricular and now I’m feeling not so bad. The other one, I think plays into all of this, and I’m mindful of making sure I get through all of the fascinating topics still to come is around sleep and we know teenagers, that’s when it all changes, and it goes out the window. And added to what is normal teenage body rhythms is around technology and the other inputs as well.

 

Aaron C  32:09

It’s tricky. I mean, I always talk to adolescents. There’s quite a common reason to present to a GP saying, Oh, I’m always tired in the morning and and so often it’s just normal adolescent circadian change, and you’ve just got to talk through that. Obviously, look at things like nutritional factors and iron deficiency and other other elements. But the big one that’s different now, I think, is screen time. I think screen time has an incredibly negative effect upon many aspects of adolescent health, including sleep. We did a little just spot survey at a at an assembly at the school and asked the adolescents, how many hours of screen time does your device say that you had on average per day in the last week? And the mean was six hours per day. I was just utterly blown away. I thought far out. You know, when guidelines are sort of talking about like an hour or less per day, and we’re seeing that the mean is up at six hours, I think we’ve got a big problem on our hands. And just having conversations around this, making sure that parents are really aware that it is totally appropriate to put screen time restrictions on their adolescent’s devices. I’m totally shocked for all the parents out there, how few parents actually enforce those restrictions on their on their adolescent’s device. Parents, we have a responsibility. We shouldn’t be giving them the car keys before they can drive. Same is we shouldn’t be giving kids full access to screen time without some restrictions and just safety barriers in place around the duration and use of that.

 

Renee D  33:35

I mean, we’d all benefit from someone restricting ours at times. Yeah, I think that there are their generations of the technological natives will probably tease some of this out, but the time of transition, it’s been really hard. I think sometimes I like the idea of it’s like the diet of what you consume is as important as how much you’re doing it as well. But I do think that things like understanding how engaging it is that you can go on your phone to maybe check your school email, but find yourself, you know, on Instagram scrolling, and that scrolling itself has probably got dynamics, not unlike playing slot machines,

 

Victoria C  34:10

And  then we and we talk about social connection and the connectivity for kids, and at this age, you know, young women are working out how it works, how you make friendships and how you extend them, and so much of that connectivity happens on their phone, their whole conversations, and so it’s where, how you teach them that kind of digital health isn’t it?

 

Renee D  34:27

And I definitely do know, because they’re kind of like awesome, creative, sometimes quirky young people I tend to see in my practice, having a broader world at their fingertips also had some protectiveness too. Like, if you’ve developed specific interests in like musical theatre and Japanese anime, there may be also the fact that there are other people out there in the world that actually have similar interests, being reinforcing, if you’re being a bit unlucky, that your school cohort isn’t really kind of providing that. So I do think that that sort of sense of understanding out of the brilliant diversity that the internet can offer. It’s just, it’s, it’s, again, it’s the balance of it, like, how do you get the good parts of it while being thoughtful of what the the challenges are? And I sometimes suggest to parents to thinking of their kids, like thinking of both the amount of it definitely keeping it away from bedtime, not having it in the room overnight, is really helpful for all of us. It’s really hard for a young person, we’re so socially wired. If a friend pings you at 1am because they can’t sleep, it is very hard for a young person, being kind and socially minded, to disregard that, to try and preserve their sleep.

 

Aaron C  35:33

Totally. And I think adolescence is a time where people find their tribe and understand who they are. And I think there are some really healthy elements of that, where you can find your tribe online. It’s about, I guess, adults stepping in, making sure that the appropriate guardrails are in place to make sure that that finding of tribe, finding using and engaging through devices, is safely enabled.

 

Victoria C  35:54

I want to talk about the unhealthy behaviours which are the hallmark of teenagedom across generations, across history. And of course, you know, from smoking to alcohol, other drugs. And of course, now we have the scourge that is vaping as well in the mix. What sort of, in terms of usage you’d be seeing that across the state, what sort of the big numbers that we’re having to manage and deal with?

 

Aaron C  36:12

I think vaping, vaping has come off the boil since we’ve seen the changes, and I have seen locally, definitely it seems to have come off the boil. And in fact, I’ve had quite a few adolescents come and seek help to cease vaping, which is really encouraging. Beyond that, I’ve actually seen them start to get a bit of positive peer pressure, pushing back on this nonsense that is, like just big nicotine companies trying to sell these things. And I think smart adolescents are seeing it. They see they’re just being manipulated by some big companies that want to sell their product. And there’s kind of like a bit of a pushback, even from some of the ‘cool’ kids, which is really encouraging to see, because I think adolescents are pretty smart, you know, and they can kind of, they’re young and idealistic. And if I think, if they can come up with a positive vision for themselves as to what their future looks like, I think they can make some good decisions as well as poor.

 

Renee D  36:58

I feel like that’s the way to approach young people around those things too. I really like giving people the information or context around their decisions while also validating the things that might be leading them in those directions. You know, it’s easy to validate that, if you’re in a friendship group, that you really enjoy many other levels, and they’re all smoking or vaping, that it might be that is a social benefit of joining that, but you almost need to validate where they’re coming from. So you can say, but hey, this is the other part of it, and that ultimately, as they’re getting older too, your influence and what you are going to be able to manage is, is you can definitely, like, say, no, none in the house. But there’s an element that you need them to sort of start being thinking it through on their own basis, so giving them information.

 

Aaron C  37:43

Yeah and also just talking about whether it’s cool or not, like there was this spate where they were hiding their vapes in the toilet cisterns, in order to be able to vape in the toilets. You can point that out to a an adolescent and say, Hey, isn’t kind of gross that everyone’s picking them up out of the cisterns? And then bang, next thing you know, well, that’s a really uncool activity, because then they can take

 

Victoria C  38:06

And I’m so interested to know, so you’re, you know, you’re at an inner city, suburban Brisbane school, and I’m interested to see where that’s spreading across the state, and if that kind of reach and and level of not coolness anymore is is stretching around the state. So if it’s not, what sort of support systems are there for, our for our young people, to try and manage it.

 

Aaron C  38:22

I mean there are plenty of good online resources, GPs. They do get trained quite a lot in behaviour change. And just engaging with someone talking about what’s motivating them, and going through the typical steps in motivational interviewing, it’s really useful. You know, you’re just kind of helping to assess what state of change are they that. Are they pretty contemplative? Are they contemplative, or they’re ready for action, and then supporting them with that, and linking in with appropriate resources based on what their state of change assessment is.

 

Renee D  38:47

Yeah, I do similar. I see lots of young people that have got casual marijuana use, and it’s tricky in their population, because it is, like, pretty endemic, you know, it’s around. And I think, you know, being able to come in on an angle that you know it’s around, and being able to talk of in a way that’s specific to their situation. I see a lot of young people with ADHD, and I think it can be really, they can like marijuana. It really, we know that they’re vulnerable to addictive substances anyway, but marijuana really sometimes reduces some of that background anxiety they’re navigating. But I’ve often found us being really honest. Of, Look, I know it’s around other people might use it, but my experience with ADHD, you sort of tend to sit in your in attentive, low motivation state, without being worried about it, which actually gets you really behind. And often they’ll see that play out, and they’ll make choices, healthy choices, around that.

 

Victoria C  39:39

You’re listening to the Clinician’s Guide to Women and Girls’ Health podcast. Stay with us as our conversation continues. after this short break.

 

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Victoria C  40:25

Thanks for listening. Now, let’s return to our conversation.

 

Victoria C  40:29

I’m interested in terms of other stresses and lifestyle factors that come into mental health for young women in this space, is around academic schooling, pressures around study, that sort of thing. Do we feel that’s still contributing as it has in earlier times? I feel like it’s harder than ever at school right now, and there’s so much pressure.

 

Aaron C  40:47

You do see a lot of the sort of type A personalities coming in as well, more on the anxiety disorder end of the spectrum, I would say. I find that sometimes a little bit more simple in some ways, because if a school has access to often as a provisional psychologist or a psychologist that’s in the school. And I just talked to those adolescents and say, look, talking treatments really helpful for this. Talk about some simple strategies. The other thing that I often work through with them is around the Yerkes Dodson curve, which is all about the level of stress and performance and and I kind of point out to them. And often I talk about the the stoners who might be taking marijuana. I say, well, they’re down the left hand in they may not be very stressed, but they’re not having a whole lot of performance. But then you push it up the curve, and maybe they get chased by a tiger and or their performance will go up a fair bit, because they’ll start running, and then they hit that peak performance curve. Then I talk about the, you know, they’re often kind of the kids who are performing high in athletics, and then they’re doing really well in their exams, and they’ve pushed themselves over the top. And I’ll say, you know, you’re up this end, and if you get more stressed, your performance is going to drop. So we need to push you back down and, like, take the pressure off yourself. Go and do some talking treatment with psychologist. Keep doing your exercise, because that’s really healthy. Don’t do too much. And I think it’s just that, like, a lot of normalisation and talking about how stressful exams are, and go look, you’ll get through this and getting them kind of a site beyond what’s directly in front of them, I think is really important.

 

Renee D  42:09

I think there can be a bit of tunnel vision in across high schools, but it is a difficult time where you’re bringing a whole lot of young people, having a lot of changes, all into close proximity, and getting them to really achievement orientated tasks. Sometimes navigating that system and sort of proceeding through that gets such sense of urgency, having talking to someone, talking to family, to get a sense of the broader world outside, that is really helpful, too. I think there are young people that can sometimes almost get in state if I didn’t get if I didn’t immediately go to university, I won’t even have a job. And I’m like, No, oh my gosh, you’re warm, you’re friendly, you’re a really good problem solver, you’re super quick on your feet. There are so many workplaces that you would really thrive. You don’t need to find your perfect job right out of the thing. If you know, there’s all these other paths and trying to keep that focus on the enjoying the learning as much as possible. And I often talk about kind of growth mindset, sort of ide. You can prepare really well for something, and if you really enjoy a subject, or if it’s useful for you, definitely you’re there anyway. You may as well try and enjoy it and learn from it. But keeping in mind, you can have done reasonable preparation, and there’s a lot of unknowns on that day, how fatigued or not you were, whether that question threw you emotionally, the teacher marking it how they were feeling by the time they marked your one and I think that sort of helps a little bit, that they can’t control every variable, and almost if you can, if you feel like you’ve done what you can relative to also how many other assessments you were juggling at that same time. That’s a good effort. And I remember Ash Barty talking about that change in her mindset to seeing she’d done her work well, what happened on the day was like its own, different category. And I think that’s really helpful for school students.

 

Aaron C  43:59

Actually, it’s interesting you brought in elite sports people, because I’ll have a chat through with students around this, around embracing failure.

 

Renee D  44:05

Ash Barty’s my favourite one

 

Aaron C  44:06

Yeah, she’s great. And like, storytelling, I think is sometimes really useful for adolescents. You know, they respond really well to stories of what’s happened with people before them. And sometimes I’ll bring up, and there’s a various array of ones like this, but I’ll talk about embracing failure to point out those super high performers if they don’t fail at some point, and understand what it’s like to fail and then claw their way back out, it actually reduces resilience, which I think is a big problem in our society right now. There’s this is the expectation that you won’t fail and you won’t kind of go out do something, make mistakes, and allowing them to understand that actually you should embrace those mistakes, because it allows you to learn and do better next time. And the kind of examples I bring up are medical students. You often see it in medical students when they’re there as students in the room, you can ask a question that maybe in general practice, a lot of the questions we have around patients are really like, great. They have no answer. They’re nebulous. There’s a lot of uncertainty, and often a medical student will struggle to answer a very simple question in that environment where the there’s no really right or wrong, but they’re afraid to answer because they don’t know that the answer is going to be right. And I often point out to them and say, Look, there is no right answer to this. It’s just a prediction, and it’s a probabilistic, risk-based thing. And I’ll even go and talk to the adolescents about that and say, Look, you know, we see this happen with medical students. You need to learn now how to just make a mistake and go, Okay, I got 99.5 instead of 100% actually, that’s okay

 

Renee D  45:27

Yeah. I actually, sometimes the best thing I’ve seen happen is a young person that’s really held themselves up to an idea that how they’re performing is who they are. Like, it’s the sort of and circumstances. Sometimes it like, it’s, not uncommonly, something like navigating a severe, you know, period of distress or an eating disorder throws them off their game, or their just literally ability to prepare is impacted, or they’ve missed long parts of school. I’m always really proud when they, you know, we’ve decided it’s suitable for them to actually sit an exam, going in knowing that they weren’t really in their ideal degree of prep and just giving it a crack, because I think that’s an important life skill. Like, how many of us have written an email that we didn’t really feel prepared to write? But also, I often talk to young people that resilience isn’t this magical quality, in the sense that resilience is often have had a rich and varied enough life that you’ve failed and experienced so many different anxieties, challenges, awkward situations, things that didn’t pan out, that you know, that you can survive them. So I think that that’s often I sort of say, look, I was much more anxious as a like, socially anxious as a younger person, because, you know, the first time I felt really embarrassed in front of my friends, I didn’t really have, like, a radar for how to navigate it by the time it was the 60th time, I’ve got it down pat, and I also know that it doesn’t change my world too much if I sort of respond to it certain ways. I’ve got like and that’s, I think, a lot of what resilience is.

 

Aaron C  46:58

Totally. Look at us now we’re here on a podcast!

 

Renee D  46:58

I know!

 

Aaron C  46:58

I was socially anxious kid as well you know.

 

Victoria C  46:58

I literally said to my son yesterday, he said, Oh, you’re a bit yappy mum. I said, No, I’m not. I said, I’m just not embarrassed to keep talking to someone because I’m interested in them, they’re interested in me, and we’ll keep talking. As a young child, as a young person, you don’t know that, that people are actually interested in you and what you’ve got to say. So on that. In terms of young people, they want to fit in. They don’t want to be embarrassed by what they’re saying. How do we make sure, as clinicians and as healthcare professionals that that kind of stigma or discrimination associated with going to see a GP or a mental health professional, how we really get our kids to realise that it’s not there and it’s okay?

 

Aaron C  47:34

Yeah, if you’re a GP in school, working with your school guidance officers, they’re such cool people. And even if you’re not in the school

 

Renee D  47:41

I hear the school-based GPs are pretty cool

 

Aaron C  47:43

Yeah, they’re actually pretty cool. But no, working with them, and just having that warm introduction, you know, it’s really, really helpful. And I think it’s surprise this the thing that surprised me about the current generation, they seem to have much less stigma about mental health disorders than existed previously.

 

Renee D  47:59

And I think that one of the benefits of the internet, it’s got so many challenges, it’s such a mixed bag. But is that normalisation. Because I think people talk more about their internal experience online than they might if they’re talking about the weather. So I do think people have talked more about the continuum of experience. So it’s not just people talked about being a little bit anxious, moderately anxious, quite anxious. And I think there’s a lot of, like, hilarious memes, and there’s, there’s a lot of, like, really engaging ways of getting certain sort of universal truths across. And so, yeah, I feel the same like a lot of the young people I see. And I definitely, when I talk about, you know, diversity and ADHD, I do very normalising positive frame on it to the point that people are happy to like, hold that and just it’s that gives them language to describe themselves to others. And that’s often what they’ll say with ever since I had a better handle on my social anxiety Renee, they’ll say. It’s kind of good, because I can kind of say to my friends in a quiet moment, I get really nervous sometimes, and that helps them decode me and why I might have responded a bit awkwardly or didn’t kind of find my feet. So it actually smooths paths a little bit. And obviously you got a bit aware of boundaries and who you can trust with different things. But sometimes you can, kind of like, do little chips, you can say something. I was a bit nervous this morning, and you already made a little bit easier to have those dialogues.

 

Victoria C  49:22

Smoothing the path. I feel so grateful today, we’ve had a wonderful conversation around adolescent girls with Dr Renee Denham and Dr Aaron Chambers. Before I let you escape your final kind of words and thoughts?

 

Renee D  49:33

I guess, with my sort of eating disorder hat on, I guess it is a really hopeful space. There’s a lot that I think the messaging, the great work of Inside Out, Butterfly Foundation, Eating Disorder Queensland is getting the messages out there about what we can do on a population level to make sure that we’ve got a good balance of nutrition and feeling good in our bodies. I think that if, though, it is something that can happen to the loveliest young people in the most caring and thoughtful families and understanding that no one’s asked for this. I think people worry almost mentioning the idea of an eating disorder like summons it. But actually, in a world that often won’t talk about not eating as a problem, talking to a young person, hey, you could eat a little bit. I’ve noticed you’ve, you know, you’re moving a lot more now. And this is this eating is falling off. I’m going to sort of, let’s just put a bit more thought into it. It’s actually giving them a really useful message, even if it turns out that that was, wasn’t such a big deal and it wasn’t on the path to something more concerning. I think it’s really helpful to show them that how we balance these things.

 

Aaron C  50:43

I’d encourage health clinicians to just embrace working with adolescents, because it’s such a fun area to work in

 

Renee D

So fun.

 

Aaron C

Drawing upon your own life and experiences your own adolescence, and thinking about how you felt at the time, and just exploring and being curious about their world. I’ve learned an incredible amount about being a parent myself, in dealing with adolescents and learning what they’re going through, gives you a whole lot of perspective in life. And I think our role as clinicians, I think, is really to be a place where they can have that confidentiality and talk about societal taboos in a safe space where they can raise them and know that they can get good advice and be appropriately directed in a supportive environment that allows them to kind of, you know, I guess, take those risks. It’s normal to do so as an adolescent, but with some guardrails around it so they can actually do it safely and come back and know that they can get redirected if they reach an issue.

 

Victoria C  51:36

Well, I think on behalf of all the clinicians that are listening, thank you for your insight and your time but I also think for your patients and those that you come across in your practices, a huge thank you as well, because I think we’ve been very lucky to listen to what you’ve got to say and also take in your advice and your words of wisdom. So thank you so much for joining us.

 

Renee D  51:53

Thank you.

 

Aaron C  51:54

Thank you.

 

Victoria C  51:59

Today, we’ve been talking to Dr Renee Denham and Dr Aaron Chambers about supporting the physical and mental health of adolescent girls. For more information and show notes from today’s episode, visit the Health and Wellbeing Queensland website at www.hw.qld.gov.au and if you’ve liked today’s conversation, be sure to subscribe for future episode updates. We’ll see you next time on the Clinician’s Guide to Women and Girls’ Health.