Children exist within a context that, for the most part, they are powerless to change. Bronfenbrenner illustrated this in his Ecological Model of Child Development back in 1979, outlining the layers of influence at every level of society that impact on a child over time. From family to school to community to political climate; what happens to our children depends on a complex interaction of numerous external factors in their lives.
As Clinical Psychologists working with children and families this fits entirely with our perspective; and what we refer to as a normative, contextual, and developmental understanding of a child’s distress. In other words, children behave as they do for a reason; and their ‘symptoms’ are usually very understandable ‘signals’ that all is not right somewhere (or sometimes everywhere) in their world.
Our starting point with any referral is to undertake a detailed and comprehensive assessment and, in collaboration with the child and family, develop a formulation to understand the factors that are contributing to their difficulties. Of course, factors internal to the child will be highly relevant – their developmental stage, temperament and physical or learning difficulties, for example. However, life experiences and environment are hugely important both in terms of understanding the trajectory and maintenance of their difficulties; but more importantly, in identifying and harnessing where changes can be made.
In theory this is far from controversial; and books and films and real-life stories abound where children have flourished in changed circumstances. From Dickens’ to Roald Dahl we are drawn to tales where children are victims of their environments; and a light in the darkness transforms their lives. Anne of Green Gables is a classic where Anne’s behaviour is troublesome because the grown-ups treat her poorly and a move to Green Gables and a gentle kindness from Matthew combined with the countryside and sea air makes all the difference. She is still ‘spirited’ – that is her personality. But how that ‘spiritedness’ is interpreted and understood is something Lucy Maud Montgomery had a sophisticated insight into back in 1908 – an era when children should be ‘seen and not heard’.
Despite this, the dominant narrative in today’s society is that ‘distressed’ or ‘troubled’ children need ‘therapy’ to fix their problems. This article examines what this belief may be rooted in; and how potentially damaging it is for children; and for society as a whole. It will refer to a number of ‘elephants in the room’, by way of drawing attention to issues we really need to start talking about if we are to stem the tide and begin to address the mental health of future generations.
The first elephant in the room is the inappropriateness of transposing an Adult Mental Health model of service provision onto children’s services. Adults are very different to children. They present themselves for therapy; and they have some agency and autonomy to change their world. Indeed, many therapeutic approaches have at their heart an aim to empower the individual to take control of their lives – firstly by providing insight into how their difficulties arose; and secondly by taking action to make changes. A child’s ability to do this is much more limited.
It is also a potentially damaging message to give a child that; even though their difficulties have arisen because of things happening in their environment; it is their responsibility to make changes. Take, for example, bullying. Of course, it is important for a child to have an adult they can confide in; and perhaps individual therapy can have a role in helping them to understand it’s not their fault and provide strategies to cope when the bullying happens. However, the most powerfully therapeutic response that can happen for a child is for the adult to enact that the bullying is not acceptable; and take action to make it stop. In environments where this reliably happens as a matter of course is therapy really necessary? Far better for there to be an anti-bullying champion identified within the school who is there to listen, and responsible for developing a plan to help tackle the problem.
It is important, therefore, to ask the question what message does being referred to see a therapist inadvertently give the child? Worse still, when we move into the language of mental disorder, the child and everyone around them is given a clear message that the problem is located within the individual and becomes locked there in time. Furthermore, because this is a model society is so steeped in from adult mental health services we don’t even stop to consider what potential damage it does to children, and their sense of why they feel a certain way. Instead of what is happening to them being the focus, the dialogue changes to what is wrong with them. Rather than a ‘child who was severely bullied’ the conversation shifts to a ‘child with a severe anxiety disorder’ – a potentially very disempowering message.
The second elephant in the room is the notion that children can be ‘fixed’ by therapy. We live in a culture where we can outsource more or less anything – from writing a C.V. to house clearance following the death of an elderly relative. The one exception is our weight, and despite promises of miracle diets and magic pills we always come back to the same message – watch what we eat and exercise more. It’s unappealing, slow and incredibly hard work – but it is the only way to get results.
I would argue that our children’s mental health is similar. Outsourcing it to a therapist is rarely an answer. For the most part it is only by being with our child; tuning in carefully to what they are trying to tell us, and making changes at the source of their concerns that we can really make a difference. Indeed, just the very act of trying to do this can be all the difference they need.
For some things, like bereavement, there is nothing we can change about what has happened. It is devastating, and it makes children very sad. Being with them and accepting their sadness and how it cannot be fixed is far more therapeutic than a stranger doing it instead. Therapy can of course be useful in helping a parent, who will be in pain themselves, to be able to do this. But this needs to be the focus of the work; and not therapy for the individual child as is often the misconception.
Anxiety is another example. Of course, there are helpful tools to manage it that we can all benefit from; including learning how our bodies respond physiologically; how our thoughts affect our feelings and antidotes like relaxation, mindfulness and distraction. These would be great skills to teach on the National Curriculum. However, a child may be anxious for a whole host of often very valid reasons – from worrying about a parent who is drinking too much; to violent gangs roaming their neighbourhood.
Even the extremely common worry of exam performance needs to be considered in this context. Should children be given more and more coping strategies to deal with the increasing pressure they are put under? Or should we be challenging a system that expects all children to achieve academic success and considers them to have ‘failed’ if they don’t?
Interestingly, the answer to this question often depends on if it is your own child or someone else’s. Just about every parent you speak to will complain about the exam pressure their children are under; and the results driven culture that is dominating their childhood. Despite this, it is a rare parent who would choose to take their child out of a high performing school they have purposely bought a house in the catchment area of. It is mostly the same for children’s distress. We will look and cast judgement at other people’s choices and parenting styles; immediately making the link to how that is impacting on their children. However, the prospect of our own parenting decisions and lifestyle choices being questioned is much harder; and the obvious preference would be for a therapist to sort the problem instead. It is the hardest thing in the world to think that our own behaviour may have inadvertently contributed to our child’s distress.
This is not about ‘blaming’ parents. Quite the opposite. It is about empowering parents to realise they are the experts on their child; and are best placed to help them. Every child is unique and requires a bespoke parenting style to maximise their potential; and sometimes that ‘goodness of fit’ is very difficult to achieve. It is about recognising that your relationship with your child is the most powerful vehicle for change – and it takes a lot of work and maintenance if it is to run smoothly; and may even need a complete re-calibration. Therapy can, of course help to achieve this, but only if parents sign up to their part in the process.
The third elephant in the room has been made much more visible by the Adverse Childhood Experiences research. The evidence is unavoidable – what happens in our childhoods has an impact on our physical and mental health for the rest of our lives. Domestic violence, neglect, physical and sexual abuse, critical parenting, not being brought up by both biological parents amongst other things; changes us in very significant ways.
Moral judgement doesn’t come into it – it is about what happens to children’s brains and immune systems when they are placed under significant and prolonged stress. Many of these stressors are beyond a parents control. No-one asks to end up in a violent relationship or to become an alcoholic. But these things make a huge difference to children’s lives; and to their life chances into adulthood. As a society we need to be talking about this, and the need for interventions that address these wider social issues as a far greater priority if we are to really tackle children’s mental health. That ‘mental health’ needs to be tackled with more therapy is a red-herring distracting us from a much bigger and more significant picture.
The final elephant, and perhaps the biggest, is understanding just how significant the impact on a child’s brain these Adverse Childhood Experiences (ACES) can be. For those children experiencing multiple ACES, in order to survive and ‘keep safe’, children move into what is referred to as ‘fight, freeze or flight’ mode. This renders them unable to concentrate, to learn, to take on advice. They withdraw or become aggressive in order that they can be removed from environments that require them to engage.
These are the most distressed and traumatised children in our communities and yet they are least able to make use of therapy. They are unlikely even to turn up to a clinic in the first place. Indeed, the disadvantage they experience is exponential, as the whole education system is based on an assumption that children can concentrate in a classroom environment, attend regularly and be supported by equally engaged parents.
The good news is that by acknowledging these elephants there is much we can do to address them. The first is demystifying therapy and the myth that it is a cure all for children’s mental health. Yes it can help – especially in situations where children are well supported and the grown-ups have insight into their own part to play in making things better. It can give children a voice; highlight issues that families are unaware of or underestimate the significance of; and give time and energy to improving relationships. However, it becomes increasingly less appropriate the more complex and unsupportive a child’s environment is. Ironically, of course, these are precisely the children we need to be most worried about.
The second is recognition that there is no quick fix for sorting children’s distress. Caring relationships that prioritise a child’s needs and spot their signals is the only way to support their mental health. Ideally this happens in the home, but when it can’t it needs to happen in the places where children live their lives. Foster care, nursery, school, youth club, football training, dance class. Empowering the adults to look out for and tune in to the children in their care is our greatest resource. However, this takes time, energy, persistence, and support – and is incompatible with league tables, results, short term contracts, ‘episodes of care’, cuts to frontline services and discipline systems based on rewards and punishments.
Furthermore, the work these adults do needs recognition, and quick access to expert knowledge and advice. These are our most vulnerable children and underestimating how difficult this work can be is society’s biggest mistake.
Thirdly, interpreting children’s behaviour as a sign that something is wrong rather than a problem that needs to be fixed is a crucial shift in society’s mind set. Again, it’s one that we manage easily in the world of fiction – the much loved Tracy Beaker is a fantastic example of a girl who is always in trouble, but at the root of it is a desperate sadness about being rejected by her mother. Indeed, there are many stories of loveable rouges on the wrong side of the tracks because of their tough start in life. It is much harder when we are faced with managing the problem ourselves – especially in a family with three other children, or a classroom of 30.
And finally, recognising that ACES do not come alone. Poverty and disadvantage are inevitably associated with stress and disharmony; alcohol and drug abuse; domestic violence and mental illness. Resilient children in resilient families can manage one or two adverse life experiences. They may be knocked for a while, but if they are well supported they can build themselves up and even learn valuable life lessons from the experience that will help them in the future. Therapy may or may not play a part in facilitating this, although it is certainly not always necessary.
However, when these experiences are layered one on top of the other, in communities where they are the norm and have been for generations this is the real breeding ground for children’s mental health difficulties and where the focus of attention needs to be. It is also where the simplest solutions can make the biggest difference. Helping parents to talk to their children, read to their children, play with their children, show warmth to their children, listen to their children, believe in their children, give hope to their children – all in a context of doing the same for the parents themselves who didn’t receive it in their own childhoods, is far more powerful than any therapy. This doesn’t happen quickly – again it is about being alongside families in their communities and facilitating them to do things differently by providing the most basic of resources, support, consistency and encouragement.
So why is a psychologist writing this article? Surely I am talking myself out of a job? Well yes, therapy is our bread and butter and a fantastic vehicle for learning about the psychological needs of children and their families. However, as psychologists we have an equal role in strategic and service development, and in early intervention and prevention. It would be unethical for us to go along with the consensus that more therapy is the answer. Creating a therapeutic culture that is sensitive to the needs of children is far more important – and far more challenging. This is where psychologists belong.
Dr Elizabeth Gregory
Consultant Clinical Psychologist