I am passionate about the empowerment of those closest to children and young people; systems wide solutions; and metaphors and analogies. I was delighted, therefore, when I attended a recent Care Aims training facilitated by Kate Malcomess (@KateMalcomess) to discover that she is equally passionate about these things too. The systems wide perspective that the Care Aims framework promotes is not focused on children’s mental health, but on children’s services more generally. However, there is much relevance and crossover in her ideas.
In brief, Kate identifies the implicit problems in ‘specialist’ and ‘remote’ services retaining the expertise about the children they work with. More importantly she points out the pitfalls of professionals within these services holding onto children unless they are actively intervening to reduce risk. Specifically, she highlights how high caseloads and intermittent ‘checking in’ on children can serve to increase risk rather than reduce it. Of course, this is precisely the opposite of the intention of the professionals involved, many of whom find it hard to ‘let go’ as there is often so little out there to ‘refer’ the child back to. She points out how this can lead to those closest to children, and therefore best placed to assess risk, becoming less inclined to be proactive because the ‘expert’ is involved. Everyone breathes a sigh of relief that the child is ‘under the care’ of specialist services; and little distinction is made between active intervention and monitoring, which is all that is possible when caseloads are so high.
When it comes to children’s mental health I would go a step further and say that those adults with the closest relationship to the child are best placed to provide the intervention in the first place; and that specialist work directed through this relationship is often the most effective and sustainable. However, it has to be acknowledged that in an era where front line staff in children’s services have been cut to the bone, this model is even harder to implement, particularly for our more vulnerable children and families. The irony, of course, is that more pressure is put on specialist services to ‘sort the problems’ that this depletion has contributed to. Furthermore, frontline staff are so stretched that they understandably reject pressure to provide anything other than their core business – whether that be health, education or social care. This carving up of tasks and responsibilies, alongside a lack of acknowledgement that proximity and relationships are the most powerful ingredients for change in a child’s life, arguably lie at the heart of many of the difficulties we are facing in children’s services.
A helpful analogy that Kate describes is referred to as ‘Eagles and Swallows’. She doesn’t claim to have thought of it herself, but rather attributes it to a ‘wise professor of medicine’ early in her training. She can’t recall his name but my guess is he will be delighted to be referred to in this way; and even more delighted that it has gone on to inspire service developments nationwide. Hopefully that is acknowledgment enough.
The ‘Eagles’ are the worries about a child’s presentation that will cause harm if they are not intervened with. The ‘Eagles’ cause damage if not addressed, and understandably make everybody anxious. The ‘Swallows’ are the concerns that are part of the normal spectrum of childhood and will cause no harm or ameliorate with time. When the specialists are in remote services ‘Eagles’ and ‘Swallows’ look the same from a distance. You have to be close to tell the difference. Normal life goes on hold as everyone waits to see what the experts have to say. Lots of potentially unnecessary action is taken during the waiting period, and the ones who are actually ‘Swallows’ get treated differently just in case.
Kate argues that it would be much better to have some expert advice on hand in the fields – to help people to learn how to look up and spot the differences themselves. It would be so much more freeing to not feel anxious unless it is absolutely necessary. The time waiting for the expert to declare if it is an ‘Eagle’ or ‘Swallow’ could be put to better use; and everyone would be more at ease. I would argue that this is the same for children’s mental health where there is lots of concern over very understandable and developmentally appropriate expressions of distress that can, and should, be managed closer to home. More experts in the field helping others to spot the ‘Eagles’ and ‘Swallows’ would help enormously; and everyone would grow in confidence that actually the ‘Eagles’ are very rare indeed.
However, there is an additional complication in mental health in that many children, particularly those from adverse environments and who have experienced trauma, make themselves look that ‘Eagles’ in order to survive, so much so even the specialists find it hard to tell them apart. For example, a child who experiences neglect, domestic violence or abuse can present in exactly the same way as a child with neuro-developmental difficulties who was born that way and would struggle regardless of their environment.
Furthermore, when these adverse experiences are significant and prolonged they impact on the way a child’s brain functions – making them even more convincingly ‘Eagle’ like in their presentation. It is little wonder therefore, that children’s mental health is so complex, and even controversial. How can you say its a ‘Swallow’ when it looks exactly like an ‘Eagle’ even close up? Especially when there is so much judgement surrounding the ‘Swallows’ that look like ‘Eagles’, the implication being something could have been done to prevent this.
Fortunately, we are not dealing with ‘Eagles’ or ‘Swallows’ or even ‘Eagle like Swallows’; we are dealing with children. Even more fortunately, fundamentally what they all need more than anything else are warm, caring and supportive relationships with adults who tune into their unique and individual needs; accept them for who they are; and focus on their strengths. This is the key to working out what lies at the root of their concerning and risky behaviours, and, more importantly, it is the most powerful vehicle for change. If we focus on getting these things right, the ones who need specialist help will be more obvious for everyone to spot. Even so, we still need to adapt the landscape so they feel they have as much right to be there as anyone else.