Children’s Mental Health is suddenly on everyone’s agenda. For all the wrong reasons of course; but sometimes things have to get really bad for people to take notice. It’s a bit like children’s behaviour generally. It is often ignored until it escalates and starts to affect the lives of others. Those children who trundle along under the radar rarely get attention – but that doesn’t mean all is well. It can no longer be said that Children’s Mental Health Services are trundling along under the radar- they are rarely out of the spotlight. Looking at this positively, it does provide us with a real opportunity for systemic change in a system that has been broken for years. More of the same won’t work – but politicians and policy makers don’t know that. (How could they?) Those of us in Mental Health Services need to tell them why it wont; and more importantly; we need to show them what will.
A recent evening stroll, and happening upon these ducks all in a row, inspired me to write this blog. Are we ready to take advantage of the opportunities that may be around the corner? Are all our ducks in a row when it comes to inspiration and ideas for reconfiguring children’s mental health services to make a real impact? Or are our heads down; busily firefighting the constant demand. Will we grasp the opportunity to do things differently? Or, out of desperation, will we grasp any resources that come our way to keep doing more of what we have always done in the hope that just a bit more of us will relieve the pressure? I have attempted to identify the ducks I think need to be in a row to be really innovative about how we invest, or reinvest the scarce resources available in children’s mental health services; and in children’s services more generally. I think all are equally important and so they are not in any particular duck order.
Duck 1 – things need to change
Is there a recognition that things aren’t working as they currently are? Or is there a culture of agencies blaming one another for the problems? Is it all CAMHS ‘fault’ for their unhelpfully strict referral criteria? Is it Social Care’s ‘fault’ for asking health to fix problems that they are responsible for? Is it education’s ‘fault’ for insisting on an assessment or even a diagnosis in order to justify additional support for children in school? So long as these old narratives are floating around there is unlikely to be a climate that can cultivate real and lasting change. The failure in the system is no one agencies or professions fault. The problems are too big for more of the same to be the answer.
Duck 2 – change involves everyone
Is there a recognition that everyone has a part to play in every individual child’s mental health and wellbeing? Or is the modus operandi one of ‘referring on’ to specialist services for ‘diagnosis’ or ‘therapy’ or ‘medication’ or a combination of all three to ‘fix’ the problem? Is the ‘innovation’ to have these specialists in schools – perpetuating a model of more therapy (albeit closer to home and less stigmatised) as the ‘big’ solution. Is there a central, multi-agency space where children of concern are discussed and the pros and cons of different approaches and pathways talked through? Or is the acceptance and rejection of specialist services done in writing against a tight set of criteria? Are these referral criteria organised around the medicalised language of disorder that separates out the social context of children’s lives? Or is there an understanding that children’s mental health difficulties are complex and arise as a result of a range of interacting factors; and that a range of services may be more or less helpful for that individual child at a particular point in time? Unless there is a recognition of this complexity we will continue to seek simplified solutions, and more of the same will prevail.
Duck 3 – change involves an element of risk and experimentation
Is there a recognition that whilst evidence based practice has a vitally important role, it also has it’s limitations? Or is an openness to flexible and creative solutions blocked by an insistence on approaches that meet the unrealistic criteria for randomly controlled trials? Is the direction of travel towards delivering more and more single modality and manualised interventions? Or is there an acknowledgement that skills in complex formulation and systemic approaches are equally relevant and important? Do these voices have an equal say in service development? Is there a recognition that many of our most vulnerable and in need children and families are not able to take up clinic based interventions either because of poverty of resources (physical and psychological), or ongoing trauma and adversity which means they are unable to engage in the work even if they could get to the venues on a regular basis? These acknowledgements quickly lead to the conclusion that we need much more creative solutions to meet the needs of our most at risk children and families. The Adverse Childhood Experiences Research brings this into sharp relief; and outlines the importance of a trauma informed workforce who have ready access to specialist advice and consultation to support them in their challenging front line work. That is not to say new solutions should not draw on research and practice based evidence; and, of course, be fully scrutinised and evaluated. We just don’t know what all the solutions look like yet; and an openness to ‘informed experimentation’ in the absence of answers is crucial.
Duck 4 – measurable outcomes don’t tell the whole story
Is there a recognition that measuring the success of services on ‘waiting times’ fails to represent the quality or even the utility of the activity being delivered? That is not to say, of course, that there isn’t great work happening; but waiting times alone is not a demonstration of this. In fact, they could have the opposite effect as the pressure becomes one of discharging families as soon as possible to free up clinicians to focus on ‘through put’. There are many other things that we equally need to measure – objective outcomes, of course, and the satisfaction of children, families and referrers with the service they have received. This happens to a lesser or greater to degree but these are not the headline measures and the ones that make the ‘news’.
Indeed, I would go a step further. How many families come for a one off assessment and are sent on their way? Sure, this can serve a useful therapeutic function and reassurances that there are no ‘significant mental health’ concerns; and that families are doing all they can to support the child or young person. But is that really the very best use of a scarce expert resource? Especially when a week, a month, or six months down the road things may have changed for that child or young person anyway? Is the system open to thinking more creatively about the use of this resource? How about the expertise being available to the professionals who work with children day in and day out and can tune into their changing worlds?
A classic example can be found in neurodevelopmental services. Families wait for several months or often much longer for an assessment. For one third they will receive a diagnosis; which often results in relief but no direct intervention. However, up to two thirds receive nothing – and yet the problems that got them accepted onto the waiting list in the first place persist. Surely this model is ripe for creatively rethinking; especially as so many resources are tied up in maintaining and even enhancing it? How about developing formulation based family intervention services that are relevant for all children who present with puzzling behaviour; and retaining the specialist assessments for those children who still present with difficulties following this? We have great examples of services working in this way, and the comprehensive pre-assessment understanding they generate really facilitates the more formal assessment process.
Duck 5 – all practice in children’s services needs to be informed by our knowledge and understanding of child development and the promotion of emotional well-being
Is there a recognition among policy makers that the systems in which children exist often contribute to and exacerbate their mental health difficulties? Education is the classic example, where an increasing focus on results fails to acknowledge that this takes its toll on children’s emotional well-being. In therapy a child might be getting the message that they have unique strengths; and not to judge themselves by their grades. For the rest of the week they will be getting the message that this is their most important year; that their success depends on how much effort they put in and how hard they work; and advised that their social outlets and hobbies should take a back seat for the exam period. I say this as a mother of a 16 year old sitting GCSEs.
There are many many examples across all children’s services where we are giving contradictory messages to those we know to be the most therapeutic response for children because it suits the organisation to work in that way. Signing children off when they do not attend appointments in health, for example, fails to acknowledge the impact of trauma and the complexity of the lives of our most vulnerable families. Changing social workers because the child is moving from ‘assessment’ to ‘long term’, or is now ‘sixteen plus’ fails to recognise the importance of relationships and trust with those who have known them longest, and who know them best. The list is endless; and an openness to challenging the status quo is essential if we are to become truly child and family centered environments.
Duck 6 – partner agencies need to develop trusting relationships and demonstrate compromise
Does everyone in children’s services get around the table, or better still, the coffee urn on a regular basis? By everyone; is that those in the most senior positions with access to budgets and power to influence service delivery and those with front line and clinical experience, recognising the importance of both perspectives? Does that include Mental Health? Public Health? Physical Health? Social Care? Education? Police? Early years? Leisure? Housing? Voluntary sector? Parents? Carers? Children? Young People? Who else? It can feel daunting, but regular meetings, month in month out, year in year out is the only way to make this happen. Those with energy and passion for change will keep coming, regardless of frustrations and wondering if time could be better spent. There is nothing liked an integrated pot of money to prioritise bids against for sharpening focus, and working through barriers. Are there examples of jointly commissioned services that demonstrate the effectiveness of working in this way?
So these are my ducks. And in our area I feel very excited that they are all more or less in a row, or at least beginning to line up. We are already delivering services at a range of levels from infant mental health to repatriating our most troubled children – all working in a formulation informed; multi-agency way. They are often inequitable; and often funded on a short term basis; but they are a start in a way of working that involves everyone coming together and agreeing what the next priority should be.
One of the first lessons I learnt as a psychologist was that consistency in children’s lives matters. Back then my focus was parents, grandparents, teachers and social workers– now it’s everyone who comes into contact with children and who makes decisions about how services should be delivered. The ducks are bigger and harder to get in a row – but think what could be achieved when they are?