Holding Uncertainty: A Lifetime in Developmental Paediatrics with Associate Professor Jill Sewell

Associate Professor Jill Sewell reflects on a career spanning five decades in community and developmental paediatrics, highlighting the importance of holistic, strengths-based care, sitting with uncertainty, and understanding children within the context of family and community. She emphasises that rising childhood anxiety, social pressures, and over-pathologising neurodiversity require a shift toward earlier support, stronger advocacy, and more thoughtful, long-term developmental care. 

Transcript

Brad 0:01
So I'm Brad Jongeling, and we're here at the Australasian Society for Developmental Paediatrics 2025 conference in Queenstown, New Zealand, where the theme has been Speaking Well, Thinking Well, Being Well. We've got with us Jill Sewell, Associate Professor Jill Sewell from the Community Child Health Centre in Melbourne, who we're going to interview to really understand a little bit about her journey to be a developmental paediatrician, and to talk a little bit about the areas that she's been interested over many years. So, Jill, before we begin, we've asked this question of everybody who's been at the conference, and we'd like to just start by thinking about the theme of the conference, which is about wellbeing of patients that you see. But we really want to also understand about what do you do yourself to ensure wellbeing? 

Jill 0:50
Well, in my days of working, and I have retired two or three years ago now, part of it was doing my job well, and looking after my patients and being aware of my colleagues well. But from a really personal point of view, I think that being outside bushwalking has been one of my great joys, and I'm really drawn to it more and more as I go through my retirement. I can't go quite as high or quite as hard or quite as fast, but I really love being out in the bush. I really enjoy music. I really enjoy being with my family. I now have four grandchildren, and two of them live in Barcelona, so I just have to visit them a couple of times a year, and that's quite a nice thing to do as well. So it's a pretty typical thing, I think, to say. Family, music, bushwalking and other outdoor activities, and I'm doing a couple of volunteer jobs, which I also enjoy. So life is very varied and interesting. 

Brad 1:44
So that's great, Jill. You provided me with a slightly brief bio for me to go by, and I think I got the Community Child Health, Centre for Community Child Health a little wrong at the start. You've retired from there a few years ago now, is that right? And at that stage, you were in the role of both Associate Professor and Chair, or what was your role? 

Jill 2:06
I did retire two and a half years ago, and my role at that stage was, well, I'd been an Associate Professor for a number of years. I had been the Director of Clinical Services in the Centre for Community Child Health, but several years before I passed that job over to Gehan Roberts. I'd had an interesting last few years at the Children's Hospital, too, because I became the Clinical Director of the Children's Bioethics Centre and worked with Professor Lynn Gillam, who's a wonderful bioethicist. And so part of my stepping back from my clinical work was handing over some sessions to other paediatricians and for me, doing slightly different things. And so I really did enjoy that time. And also, in the last couple of years of work, I got very involved in advocating for play at the Royal Children's Hospital, not only for the children, but also for the staff and for the hospital to act as an example for the importance of play in child development for other children's services and in the community. So that got me involved with another group of people, which was a very enjoyable and interesting experience as well. 

Brad 3:11
Well, I think that'd be great to chat about. I might leave that question until a little bit later. I'd like to start with sort of really asking you a question about your own journey to be a developmental paediatrician and to work in the area, which is obviously much broader than just developmental paediatrics. But are you happy to talk through that a little bit and explain how you got to where you got to in your career? 

Jill 3:31
Yes, I'd be pleased to. I first started in paediatrics sort of a bit like a magpie, which I think I've done most of my life. I didn't really know what I wanted to do. I'd done an intern's year, been overseas, didn't know what I wanted to do. And I thought a year at the children's wouldn't hurt. And it didn't. And 50 years later, I finally left. But I was very influenced by one of my consultants that I worked with a couple of times in the hospital as a junior doctor and a registrar. He used to talk about what he called in those days psychosocial paediatrics. So he often talked about the family and the community from which the child had come, not just about the child in the hospital. And that really resonated with me. And then just with perfect timing, when I finished my basic training and passed my exams, three senior paediatricians in Victoria had decided that Victoria needed to train some community paediatricians, that there were a lot of children with problems and nobody really knew how to look after them. So there were, in 1977, there were three positions created, and I took one of them. And for that year, we did four months in the school medical service, four months in one of the institutions that looked after children with very severe disabilities, and four months in an outer suburban sort of child development unit, which had just recently been opened, it was a place-based environment for early childhood, well ahead of its time. And of course, it lasted for a few years and then went away and sort of came back again. So a very interesting year. None of us knew what we were doing in each of those places. We made it up as we went along. But that gave me my start in community paediatrics. 

Brad 5:21
And did you train overseas as well, or just Melbourne in the end? 

Jill 5:26
I spent a year in Melbourne, and then I had my first child and went to England for a couple of years. And during that time, I worked for a year, half time, at the Thomas Coram Research Unit, which was a community-based research unit of London University, but it was basically a community paediatrics job. And worked with two, well, both the director of that was a man called Martin Bax, who was a really interesting character, and a couple of very fine women who taught me a lot about how to be with families outside the hospital. So once again, we would work in what we might call maternal and child health centres and schools. And then we went to America, where I didn't work, and came back to Melbourne, where I finished my training as a senior clinical tutor at the Queen Victoria Hospital, and then went to work in what's now called the Centre for Community Child Health, and was called the Department of Ambulatory Paediatrics back then. That was 1984 when I started work there with Frank Oberklaid, and a great gaggle of people ever since. 

Brad 6:33
Yes, and some well-known names. 

Jill 6:35
Very well-known names. 

Brad 6:36
So one of the things that you put in your bio, which I want to lead into a question about what is a developmental paediatrician, what makes someone a developmental paediatrician, was that you were particularly interested in advanced paediatric training in community child health. That's one of the things that you've been involved with. And of course, one of your roles has also been the president of the Royal Australian College of Physicians. But can you comment to begin with about what do you think is a developmental paediatrician? What makes someone a developmental paediatrician? Is it training? Is it a way of thinking? In your view? 

Jill 7:10
Well, it's certainly training and a way of thinking, but it's actually based on a body of evidence. And I think when we first started, that's what people didn't understand. They thought that everybody knew about child development, and we were just a whole lot of wankers, really. But there was already, by the time we got started in Australia, a very sound body of evidence about child development, about the influences on child development, and beginning to be the body of evidence of how important it was for the life trajectory. And I think that interested me, and also my interest, I think, in people, a child and children as part of a family, family as part of a community. I come myself from a family of six kids, so we were used to sort of banging elbows and jostling at the table and looking after each other and getting cross with each other and learning from all of that. And so I just enjoyed all of that, and I could see that that was a way of serving families and children's growth in families. And I was also quite interested in the more psychological side of it. So I did a little bit of what was basically psychiatry training in my advanced training. I found that aspect of it very interesting as well. So it was really a mixture. And I think that I was also becoming aware of the service need. At that stage, you don't really know all that much about it. But I was becoming aware just how many children in the community weren't being served in a way they should be. 

Brad 8:37
So if you were designing a training program now for a developmental paediatrician, what would you suggest? What do you think a developmental paediatrician or someone doing community paediatrics really needs to be that complete clinician? 

Jill 8:52
Well, I certainly think they need a very good background in what we might call general paediatrics and acute paediatrics and to understand child health as part of healthy development. But I think what they really need is working in the community and understanding other community groups that contribute to the health and development and education of children. I don't think you can do this work. You can do it working in a hospital, which we've always done for the Centre for Community Health, but we've sent our trainees out into the community to work with people who are living and working and playing with kids every day. And I think that's absolutely critical. And then I think of running an educational program that's based on that sound evidence that I spoke about before and contributing to the developing evidence about child development and the importance of it for long-term outcomes in life. I think those are really the really critical things. But I think the other thing is to also teach, demonstrate and mentor young people about the pride that we should have in our work and our place in the diaspora, if you like, of specialist paediatricians. We're not cardiologists, but we're just as important, if not more so, than people like cardiologists, because we really make a difference to long term outcomes. 

Thinking across the whole range of child development. And it's good to have a good heart to do that, but you need a good mind and a good body at the same time. 

Brad 10:27
So that really brings the question up of, where does being a medical practitioner, particularly here as a paediatrician, where does that role, that training prior to doing advanced training, what does that bring to playing in a space that obviously has quite a psychosocial component to it, as well as the biology? What do you think we bring to that assessment process, that discussion, that formulation, that if you don't have that training or that background, you may not bring? 

Jill 10:59
Well, I think it's both a breadth of knowledge and understanding about the human body, about what happens in health and what happens in ill health or disease. But it's also a rigorous way of thinking about problems. You don't just look at something and think, there's something in my face, I'm just going to deal with that and be done with it. You always have to think around the edges, what's behind that, what's contributed to it, what might it contribute to in the future. And I think that's a very good training, that medical training overall, will then contribute to the breadth and the broadening of that understanding of the child as a whole person and not just a sort of a series of bits and pieces of the body. Okay. 

Brad 11:43
So, you know, one of the challenges, as you know, at the moment, and I think you've outlined it a little bit about the importance of celebrating what we can bring to the area of developmental paediatrics. There are lots of voices out there at the moment. I think we've talked here a little bit about the role of other groups, such as general practice in assessment of children with for query ADHD. Do you have a view about how those different groups can both work together in a successful way to ensure that there isn't over-diagnosis, there's appropriate assessment? Because it's a big controversial area, I would have to say, at the moment. 

Jill 12:18
Yes, I agree. And I don't think I've got a fully formed view as yet. I know there are several trials going on, particularly in Australia, about paediatricians working with GPs. I'm very against a sort of a, here's a one-off solution because there's so many people with ADHD. Let's get GPs diagnosing and treating and then everything will be fine for many reasons. One is we know that many children with ADHD don't just have ADHD, and it's part of a lot of other problems that need that broad holistic approach, which is what we paediatricians bring. And I think, I mean, GPs can be very good at that, but they're limited by time and the constraints of their practice. So they, just like we get very frustrated because we can't, we don't have the same time as psychiatrists have with our patients. So GPs can get very frustrated about very good GPs who do understand a lot about this, but their time and finance constraints mean that they have to do it quickly. And when you have to do things quickly, you take shortcuts. I mean, we do that sometimes as well. We're under a lot of pressure with our waiting lists, but having that broad knowledge. And if you're taking a shortcut, you know that you're taking a shortcut and you're putting some parameters about the shortcut rather than just making a diagnosis and getting it done. And I worry about putting our health energies into more and more of something like that, rather than putting our energies into support for children from a very early age, so that they don't get into as much developmental problem or have as many environmental contributions to diagnoses like ADHD or something that looks like autism spectrum disorder, for example. That's where we should be putting our energies and thinking, and it's a very difficult thing to do politically, we know. But we shouldn't run away with rapid diagnosis, rapid treatment as the solution for children's problems. 

Brad 14:09
So that really brings up that question of upstream factors that are leading to the kind of almost tsunami of neurodevelopmental diversity and disorder and potentially diagnosis. Do you have a view about what's changed? Why in the last five years, if I reflect on my own services's numbers, we've gone from 2,500 referrals to 3,000 in 2018 to 6,000 last year, just for paediatrics alone and more than 12,000 kids on the wait list, as well as many being seen. Why are we where we are now at the moment? And what's the solution at both a child development service or a developmental Paed level, but also potentially political or societal level? 

Jill 14:58
I've thought a lot about this, Brad, because what I saw in the last 15 years of my, probably 15, maybe going on to 20 years, but particularly 15 years of my practice, was a very significant increase in childhood anxiety in younger and younger children. So I think that's something that's underpinning. I also think that we now have around the world a vast majority of children living in cities, many of them in very big cities. And I've come to the conclusion that big cities are not a particularly good place for all children to be in. There'll always be some kids in cities, but there's hardly, I think in another 10 years, about 80% of children around the world will be growing up in cities. And that means a lot of things in our society. It means that both parents are often working, children are in care for long hours of the day, on either side of a school day, for example, as well. So that's another element. I think there's another element, which is that we are having children. I'm thinking about families now. We're having children at older ages. We're only having one or two children. So that sort of simpler family life with connections to community has been lost a lot. I think all of those are important factors. I think that children are harried by being this competition for everything, whether it's resources or going to ballet or going to violin or playing footy or everybody's competing for resources. So there's another element of it. There is another element of these precious children of a lot of professional families. And I'm mainly only speaking one element of our society, but they think all of their children are at the top of the centile mark. So they've got to do well with everything. I think there's a lot of pressure on children in that sort of way. But children whose families aren't quite as head on, if you like, about high level education and high level activities around the clock are still under an awful lot of pressure just to get through the day and have a roof over the head and reasonable food to eat and not having to drive three hours to work because they can't live near where they work. So there's all sorts of issues in here. And I think all of those are contributing factors. And what I don't know about, and people have been looking at this for 20 years now, is there something in the environment that's poisoning us? I don't know. But it's a feasible thing to think about. Microplastics all through us. What do plastics do overall? Does it change our brain? And I also think that our better understanding about epigenetics and multigenerational change is also significant. So I think it's a maelstrom of things that are upending children's lives. And some of that looks like neurodiversity. Some of it looks like more direct mental health. Mostly it looks like a mix. 

And in a social media age, people are onto all of this straight away. And they want change. And they want their kids to be fixed. So there's a lot of pressures. 

Brad 18:21
So that raises the question of the difference between neurodisability, neurodiversity, It's quite a big issue at the moment. Because we play in that complicated space, I find, of at times providing a diagnosis which implies a disorder. Even though we know it's on a continuum, we know it's not categorical. But at the same time, the concept of neurodiversity is also important. That these kids don't have a disability. They're just different and they think differently and their families think differently. How do you walk that line of over-pathologising, over-diagnosing, over-labelling versus, recognising neurodiversity but may need support? 

Jill 19:07
I think we've gone far too far down the neurodevelopmental disorder pathway through the whole community for a long time. And I sort of welcome the neurodiversity pushing us back a bit from that, from going too far. On the other hand, then neurodiversity has its own impetus, if you like. Everybody wants to be neurodiverse. And I prefer to think of just people or a range of people. We all remember people that we grew up with or adults that we knew as we were growing up. And as adults that were a bit odd, a bit strange. But, you know, they got on with life. Their family supported them. They found work that they could do and enjoyed. So I think it's all the labelling that's the... I find labelling the problem now. And I think we've got to find a better way of talking about it to get back to the concept of there's a whole... Human beings are a huge range. Most of us fit in pretty well, given a bit of support with the society that we live in. There's always going to be a group who need a lot more support and who don't fit in so well. And we need to be really thoughtful and respectful about how we do that. But I think we've just gone from one sort of labelling to another, which is not... I don't think it's very helpful. 

Brad 20:21
So one of the talks that we've heard today, which I think Sharon Goldfield and Yvonne Anderson presented, really picked out some of that data around social adversity and the social determinants of health. And I think I've been to a few conferences with you where Michael Marmot and others have spoken over the many years. It's always been the theme, it's always been there, but getting significant change at a political level to support families around housing or finance or all those things is a challenge. How much do you think that that is contributing to what we see now? And how much should we be really encouraging political masters to actually focus on that as a solution to the challenges that we see with children today? 

Jill 21:09
I think it's really significant. It's always been there. And I think socioeconomic variety is somehow widened. We've got a very multicultural society that brings in different pressures and issues with that diversity across our population. I find it really interesting and frustrating that I think politicians at a personal level can really get that and they understand it. You can go and sit with them and they can explain it, but it's a very difficult sell. And it's just not a vote getter, unlike more prisons for delinquent teenagers, which does seem to be a vote getter every three or four years, depending on which jurisdiction you're talking about. So I still don't think we're good enough at understanding how politicians operate, what pressures they're under. 

And I think we're going to be on a back foot, particularly because children don't vote. So I think, you know, the Sharon's of this world are very good at doing this. So I think we just have to speak politicians' language. It's like when we're talking to educators, we have to speak, we have to understand teachers' language. We don't speak it because we're not teachers, but we have to understand that it's different. And rather than just getting frustrated and hateful about politicians because they don't listen to us experts, I think we have to understand the pressures that they're working under. I also don't think we use the voices of lived experience enough. I mean, some of those families who are talking to us this afternoon, who, you know, they undergo horrific journeys with trying to get some help and support for some of their very disabled children. We know that politicians respond to stories, and I think that we need to do that more. I also think, being a grandparent myself, that we don't use grandparents enough as a political force because there's lots of us and there's going to be relatively more of us over the next 20 or 30 years. And the grandparents ought to be there alongside us saying we want our grandchildren to have the best life that they can. And it doesn't mean the most important or the most wealthy. It's the best developmental life that they can have. 

Brad 23:21
So that raises the question of, what can societies such as ASDP do to advocate for things like that, for change in systems or a system of systems approach, change for encouraging involvement of lived experience in families and, in this case, grandparents, which is a great idea because I think they've got that experience to and probably a bit more time to push the boundaries of things. And what would you suggest that both ASDP and other groups could do to improve where we are? 

Jill 23:53
I think we've got to get more professional in our advocacy and we need to, you know, get people who are expert in the area. There's many of us who've worked over many years in advocacy on top of our clinical and educational and research work. And we can, you know, we're fairly good at it, but they're real experts in advocacy. So we need to use better expertise. 

We need to work alongside other groups with very similar advocacy directions so that we speak with one voice across many organisations if we can. This is complicated to do when we're a small organisation ourselves. And I think we need to get better at harnessing our members. We've got very many members with very good experience and they want to help, but actually getting them around a table to do things is often very difficult for very obvious and very good reasons. Everybody's busy and they want to help, but at that moment, they may not have the time. So I think it's a matter of using our collective voice, having a more professional way of demonstrating it, understanding the group that we're advocating to so that we meet their needs, politicians, for example, and working with similar organisations, which might be something like the RACP for some of them, might be a grandparents organisation for another to actually amplify our voice. 

Brad 25:20
So one of your roles was as president of the RACP. What do you think that group brings to both the role of advocacy and supporting developmental paeds in their roles? 

Jill 25:33
Well, at the time that I was senior in the college and coming up towards being president was really the first time that the college employed a full-time advocate who later became the CEO of the college. And so there was a team actually who could do that work. And at the time, which was not long after the time when paediatrics had stepped away from becoming separate from the college and decided to stay in, and I was part of that decision-making, paediatrics was riding strong in the college because we had good ideas. Because we were often leaders in changing and having a more enlightened education program and a broader education program. And we really pushed forward, and we were very important in advocacy. We pushed forward advocacy. So we were well heard in the college. And I think that's got more complex since then the college has got bigger with other groups. It's a much more challenging environment for the college overall. So I think that what we can do with the paediatrics arm of the college is obviously do the education very well, and I'll come back to that in a moment, but also to be out there, to use the college resources. At the moment, the ASDP gets these things from the college, they say, next week, could you advocate for this or that? And we need to be more proactive with influencing what the college do because they've got more resources than us. 

Brad 26:59
So I'm probably somewhat critical of the college at the moment because I actually don't think our voice is loud enough. It's not prominent enough, and there are other groups who are much more vocal, and the college of general practitioners would be one of those in the ADHD space at the moment. Do you think we should be out there, or should we be letting these voices go, or would you advocate, as you kind of have already, to say that actually the paediatricians bring to the argument both experience and knowledge and interest in the child? Because I think sometimes it's seen as we're patch protecting rather than having the interest of the child. 

Jill 27:39
I don't think that was the case when the college first started to do advocacy in the late 90s, early 2000s. But I think a lot of things have changed, and I think that we've got to be a bit careful that we don't spread our resources too thin. If we want to put our energies into the ASDP role, we may not have the same energies to put into the college role. And I think that's happened quite a bit. The college role has been the educational arm, if you like, and we can contribute to that with curriculum development, et cetera. And that's obviously the college has to do that. But also, I think the colleges as a whole are not, the politicians aren't very happy with the colleges as a whole at the moment. So I think maybe at this stage, we might be better off working with other groups. It's like College of GPs, sometimes the College of Psychiatrists, and other groups in the community. But we've got to keep an eye on what's happening in the college, because it does have a lot of resources. And if we can get voices heard there that amplify our voice, we need to keep that in mind. 

Brad 28:41
One of the other areas that you, I think, mentioned as an interest was in bioethics and ethics particularly. Do you want to talk a little bit about that and how that relates to developmental paeds, but more broadly, paediatrics as well? Why was that an area that you picked up? 

Jill 29:00
Well, I think I was lucky working at the Royal Children's Hospital, where we had a multidisciplinary bioethics centre led by very fine people, very good thinkers, very good, very much able to articulate the bioethics issues, and very much able to work with doctors and nurses in the hospital to help them to see the issues around bioethics, rather than pushing back from the, I'm the expert and I know. So I just found it was a very, I mean, I'd always been a little bit interested in ethics, but I came, you know, I came into it much more, well, half time for five years, probably two days a week for five years. And it really, I really learned a lot towards the end of my career, and it made me really understand to have our ability to listen to parents' voices much more, to listen to children's voices much more, particularly adolescent voices much more. But also to understand how the power plays that go on in hospitals and always have with hierarchical types of situations and how that influences the final decisions that are made about complex, often we're dealing with very complex acute care. But also how much, if you think from a bioethical perspective, how much power it can give you to shift direction when that direction is really needed to be shifted. So some of those examples might be blood transfusions into families who don't, you know, who don't, who won't, who won't make a decision about blood transfusions. But I think bioethical decision making has enabled a pathway, certainly in Victoria and I think around most of Australia to say, okay, we're going to bypass the family. We're going to make the child what we could loosely call a ward of the state for a week or two, get the child transfused, and then back to the family. So the family have upheld their religious convictions, but their child is still alive, which they're very grateful for. So that's quite a powerful role. And there were various times in my bioethics years where we stood right up to families from a child protection point of view and said, you know, we won't allow this child to risk dying from their leukemia or whatever it was, because you believe something different. And when you use that power with respectful authority, you can really make a difference. So I thought that was a really important lesson and something that all people who work with children need to understand. The other thing is that just makes you a much better understanding individual people as well, because you're thinking from a different context as well. I think that when we're thinking about it from a developmental paediatrics perspective, we don't have so much, you know, direct ethical issues that come up, but there's little things that are happening all the time. Things like consent, decision-making for adolescents, transition to adult care and all the things that that brings up, some of the medication that we use, and also how we use our authority and, if you like, power to influence what happens to the children in the community. So there's ethical issues around that. 

Brad 32:24
In fact, one came across our desk recently of a young adolescent, probably 15, 16, who has probably learning issues and autism spectrum disorder who's at home with his parent, very difficult for the parent to support and manage him, wants an autism assessment, probably does have autism. but the young adolescent does not want one. So we have asked our ethics board to have a look at this question. Of course, if they're not going to cooperate, I suspect you can't do the assessment anyway, but what would your view of something like that be? 

Jill 32:56
Well, I think this is the voice of the child type assessment, and then it's about competency to make decisions. And at 15, that's a very difficult decision, as you know, from a number of different perspectives. But the prime issue is listening to the child. But there's a safety issue there as well, as long as it's safe to do so. But I agree that if the child doesn't want an autism assessment, I don't know how that you, how you can do an autism assessment really. So then you have to be thinking about why is this being wanted by the family. 

Brad 33:24
I think, I think in this case, it's because it will lead to supports and particularly post-school supports, which the child comes to might might actually need. So it's a, it's a really difficult one, but it's a good example in how it's interfacing. 

Jill 33:37
Yeah. And I think that's the sort of thing where in a couple of years time, that young man might be able to make a, you know, might be able to think about it again and make a different, a different decision. But you have to respect where he's up to, I think, with his thinking. 

Exactly. 

Brad 33:51
So one of the questions I asked Michael McDowell a couple of years ago was thinking about the role of paediatricians in sitting with uncertainty. So the concept that, when we're working in developmental paediatrics, we have a hypothesis as to what the child's challenges might be, whether there's a diagnosis or a formulation for, for why they're presenting in a particular way, noting all those other psychosocial biological factors, family factors, community supports, et cetera. Do you think that that's something that we're well trained to sit with? 

Jill 34:28
I don't know about how well we're trained, because I actually think, I think we, we try to train our trainees, but it actually takes time and maturity, I think, to sit with that uncertainty. And I think I can remember when I first started to train in community paediatrics and it's when I was sort of running a training program at the children's in community paediatrics. You see it every year, we had, we had fellows with us for a year, deliberately, not, not six month terms, but 12 months times. And it usually took about three months for them to let go of acute health and fix somebody up with an antibiotic or something or a surgical procedure and start to deal with uncertainty. It takes, I think it takes time, but I think it also takes courage to deal with uncertainty and it also takes very good communication skills with the associated child and family about their uncertainty and us taking a role in holding it, helping them to hold it by us giving a framework for, for doing it. And I think that certainly happens in many other areas of medicine, but it's a really big area for us to do. But I think part of, part of holding that uncertainty is also that has to be done over And when I look back at my experience as a developmental paediatrician and the families that I looked after for many, many years, sometimes infrequently, once or twice a year, that whole concept of just hanging in with the family. So I think that, you might not actually achieve very much, you're often holding uncertainty, but you're there for the family. And I used to say, sometimes these families have been through, you know, about five child protection nominations and social workers and GPs and this and that and the other schools. But we see them, we remember them, we remember the names of their dogs sometimes, you know, we're sort of part of the family. So I think holding that uncertainty drifts into our long-term care, which is really valued by the family, even if they can't articulate it very well. 

Brad 36:33
No, I agree entirely. That longitudinal view is very important. And unfortunately, it's a little bit at risk, isn't it, with this move to, and I'm in my own service, encouraging it a little bit to share care with general practice and not see them for 12 months or something like that. I think that that starts to put that relationship at risk a little bit, that long-term view, which really does concern me because I actually think that is probably where we do the most benefit over a period of time. I think the other observation I would make, I agree entirely with you about the need to have experience over a 12-month period and that first three months. And I remember with Dr. Trevor Parry, you know, going through a phase of thinking, I think I know what I'm doing. I have no idea what I'm doing. I think I know what I'm doing. I have no idea what support I'm doing. And then only realising over that six to 12 months that actually that's an upward journey, but it continues forever, actually, that up and down nature. And I think that's developmental paediatrics for me, at least. And to conclude, because we're probably running out of time a little bit, I want you to have a think about what you might have done in the last five or six years when you were working as a clinician or before. What do you think would be the one or two main things that you would have done then with families or in your role that you think will still be making a difference in 5, 10, 20 years? 

Jill 37:57
I think that supporting the family to make their decisions and for the child and increasingly the young person to hold on to their, to understand their problem and hold on to their problems and take a step forward each day or each week or each month. 

and empowerment to the child and family, does, i think, have a very long term effect? i don't know that I always did that very well, but i've tried to do that, and i tried to, I tried to teach that. And the other thing I think is encouraging young people and families who often used to come along with a list of things that have gone wrong. So now I'm thinking about a strengths-based approach to help the family to understand about strengths and help them to understand in a way that they'll carry that into the future as well. So I think those are, they're almost the same thing, but not quite, not quite the same. I think those are very, very important things to take into the future. 

Brad 39:01
And I think that's something we've taken from the conference so far, haven't we, as well, that concept of strength-based approach, as much as we can, less pathologising, more normalising, but picking up what families, and I'd have to say, from my perspective, what communities as a whole can bring to support the family and the child in case. So it's been a real pleasure. Thank you, Associate Professor Jill, for chatting with us today. I've really enjoyed it. Hopefully everybody else online will as well. So thank you for coming. I've enjoyed it too. Thanks.