The Adverse Childhood Experiences evidence base–a wake up call to radically redesign Children’s Mental Health Services.
Throughout my twenty year career as a psychologist working in Specialist Children’s Mental Health Services (SCAMHS) two frequently repeated mantras have been amongst the biggest sources of frustration for me:
“It’s a social problem, not a mental disorder” and “the child needs to be stable to access therapy”; the latter often responded to with the helpless reply “but the child need’s therapy in order to be stable”. Indeed, much of the tension between Health and Social Care can be boiled down to these two themes.
I understand, of course, that service design and a splitting of health and social care lies at the root of this; along with a scarcity of resources and a need to carve the work up somehow. However, as a psychologist employed by health, I see a child’s context and life experiences as fundamental to their mental health and emotional wellbeing. Ironically, when it comes down to individual children, there is usually a consensus about how the difficulties have developed that is shared by everyone in the multi-disciplinary team. Rather, the divide that separates us most is the service referral criteria; and the barriers to accessing expertise that these impose. Fortunately, once a child has been accepted into the service; their environment and life experiences are absolutely part of the understanding of their distress in the majority of cases, at least.
It is at the point of referral, therefore, that instead of thinking about what a child needs, and who has the skills to provide it, we are forced to be organised by service constraints and whether the child meets the criteria for a ‘disorder’. Furthermore, it is absolutely the case that to deliver evidence based psychological interventions for a specific ‘disorder’ as outlined in NICE guidelines, a child has to be in a position to attend clinic regularly; supported by stable and engaged carers. When social issues such as extreme poverty (it can take three buses and two hours to get to clinic), domestic violence and drug and alcohol abuse are the dominant issues in a child’s life, accessing therapy is something they are rarely in a position to achieve. That does not mean, however, that these children are not presenting with deeply worrying behaviours as signals of their distress. Quite the opposite – their carers and the professionals around them are desperately concerned about them. As psychologists we are very experienced and skilled in knowing what these children need, and can support the carers and front line staff working with them on a day to day basis to be able to provide it. Yet in the current model of service provision, they are often blocked from accessing our expertise – either because the referral is rejected as being predominantly social; or because the families struggle to attend a clinic based service and ’disengage’.
In this article I will argue that the Adverse Childhood Experience’s (ACEs) evidence base provides a wake up call to radically overhaul how our services are designed. According to the ACE studies, what happens in our childhoods makes a difference to our mental and physical health, and impacts on the rest of our lives. Our environment and social context affects us in significant ways, and is inextricably linked with our physiology. The research is extensive and unequivocal, and amongst the most robust in the field of health and social care. As such it ‘trumps’ NICE guidelines for specific disorders which has been adopted as the primary domain of children’s mental health. The SCAMHS model has, historically, been developed along an adult mental health model of service provision which focuses on the individual, and relies on children engaging in the process and being supported by the adults in their life to achieve this. I will argue that clinic based, ‘within child’ models of service provision do not take into account the complexity of children’s lives; the impact of adverse childhood experiences, and the powerlessness of children to make changes in the systems that surround them.
In other words, if you are brought up in an environment with multiple ACE’s you are highly vulnerable to developing severe mental and physical health difficulties as an adult; and yet precisely because of these environmental factors, you are least likely to be able to access specialist mental health services as a child to prevent this from happening. This is illogical, and has to be challenged if we are to make any progress in addressing the enormous and costly consequences of Adverse Childhood Experiences. It is also discriminatory as it places our most vulnerable children at a double disadvantage. Not only are they in very damaging environments; but they are unlikely to be able to access the help from the professionals who are trained to support them.
Indeed, I would go a step further and put forward a perspective that the current service configuration perpetuates an unhelpful splitting of life experiences and mental health as though they are unrelated. Additionally, it adds to the stigma of mental health, reinforcing a notion that something is ‘wrong’ with the individual, rather than life events as a causal factor that we are all susceptible to. Furthermore, I would argue that this split is causing serious damage within our society. Children and the adults around them are steeped in a model that views ‘symptoms’ as signs of a disorder or illness, rather than ‘signals’ that all is not right in the child’s world. The problem becomes located within the child, who is then sent for therapy to be ‘fixed’ or prescribed medication to be ‘treated’. That is if they are well enough supported to be able to attend regular appointments. For those whose lives are too ‘chaotic’ to turn up to clinic – well, they get nothing. They are discharged and described as ‘did not attend’. These, of course, are the children who are most at risk of serious mental and physical health problems as they grow up.
Maintaining this as the status quo is perhaps convenient because it means parents, carers, educators and politicians do not need to look at themselves and what their behaviour may be contributing to the difficulties. However, the long term consequences are enormous, and in my opinion, are a factor in the exponential rise in children’s mental health problems that is rarely out of the news. This is because the logical conclusion of this approach is that we need more and more therapists to ‘fix’ children; and so less focus is placed on their environment and life experiences as contributory factors. Specialist CAMHS are put under increasing pressure to provide the ‘solution’, and their failings in delivering this provide a helpful distraction from the root causes of the problems. This is exacerbated by the fact that the more complex and multi-layered a child’s adverse experiences, the less accessible to being ‘fixed’ by therapy they will be – and so they get no specialist help at all. Worse still, the system labels them as ‘failing to engage’ adding blame to the complex mix of disadvantage.
Let us take bullying as a simplified example to illustrate the point. It is regularly at the top of the list of concerns facing children and young people; and tragically is often cited as a trigger when a young person dies from suicide. However, the default position that children need to be sent to specialist mental health services to have therapy to address the impact of bullying risks reinforcing an idea that the problem lies within the child who has been bullied. Of course, children need to be able to talk to a caring adult in confidence – and it may take a number of occasions before they feel safe enough to confide their concerns. However, the most therapeutic response a child can have is for an adult to take action to make the bullying stop. Rather than a referral to a remote specialist service; far better to have an Anti-Bullying Champion in every school, and a culture where the child knows that they will be taken seriously. Most importantly, the Anti-bullying Champions should have immediate access to specialist advice both to plan and support the implementation of psychologically appropriate interventions; and to discuss the children they have particular concerns about. The children who bully will also have reasons for their behaviour; and this is as important to address as what happens to those on the receiving end. There may initially be anxieties about going to see the Anti-bullying Champion – but not if they had other roles within the school, and made it their business to meet with children regularly for a range of proactive and positive initiatives. This is how you destigmatise mental health – let’s start treating bullying with the seriousness it deserves.
Unfortunately, a frequent outcome in the most severe cases of bullying is for the child to be labelled as having an anxiety disorder because of the impact it has had on their social functioning. For the individual child that is potentially a very disempowering message. For society it separates the ‘solution’ from the cause of the problem. Of course some children will inevitably need specialist help – but lets be sure no stone has gone unturned in the endeavour to intervene at the root cause of the issue.
I could say the same for separation and divorce, bereavement, domestic violence, sexual abuse and a whole range of life experiences that trigger distress in children. Sadly these are common events – so let’s set up services that have these as the focus, and let’s offer the adults, not the children, support about how these experiences are managed. Is it fair that, in the current system, it is the child who is sent for help when it is their parents who are fighting every night and threatening to kill each other? Is it appropriate that it is the child who is labelled as having a disorder when they wont leave the house because their mum might start drinking? Or are they responding in very understandable ways to prolonged and traumatic experiences in their environment that the adults need help to manage appropriately?
Instead, the message I believe we need to be delivering is that these experiences impact significantly on children’s emotional and physical wellbeing; challenging the notion they can be sent to therapy to get fixed. Parents, carers, teachers, social workers, policy makers and politicians need to be made aware of the impact of experiences such as bullying, racism, neglect, abuse, domestic violence and divorce have on children; and take action to recognise and minimise their impact. “This should not have happened to you” is perhaps the most therapeutic thing a parent could say, followed by “and we are going to get through it together”. It is vital that the adults in children’s lives are helped to take responsibility for the part they may have had to play in both the cause of the problem; and supported to play the biggest part in the solution. This is potentially incredibly painful as it puts them in touch with things they perhaps could have done or should be doing differently. As psychologists in SCAMHS we try to achieve this through building a trusting and therapeutic relationship with the parent or carer – but we loose many along the way because what they are hoping for is that we will ‘fix’ the child – and society and the way services are designed reinforces that very idea.
A typical clinical example from many years ago springs to mind that illustrates this point. A boy had been referred to me with very challenging behaviour. His mother drank heavily had been the victim of domestic violence; which the boy had witnessed on many occasions. Whilst acknowledging how difficult his behaviour was for her to manage, over time I was helping the mum to make the connection between what he had experienced and why he was behaving in the way that he was. It was very painful for her but we were making tentative progress. In the meantime, the GP, desperate to help the situation, had also referred the boy to a paediatrician. They duly went along to the appointment and the boy was diagnosed with a ‘conduct disorder’, a label that simply describes that he has significant behaviour problems. The mum phoned to cancel future appointments with me because the problem lay with her son after all. The paediatrician discharged the boy; unaware of how the diagnosis had changed the mother’s perception of her son’s behaviour. Very sadly, I met the boy a number of years later when he was in a foster placement. When I asked him how he came to be in care he told me it was because he had a ‘behaviour disorder’. This is an extreme but not unusual example of how a service that locates the problem within the child influences the nature of interventions it is then possible to deliver.
It feels important here to talk about how Adverse Childhood Experiences impact on children’s brains and functioning, adding an additional layer as to why therapy is rarely the answer for these children. When a child is exposed to prolonged and severe levels of stress, in order to survive and ‘keep safe’, they move into what is referred to as ‘fight, freeze or flight’ mode. This renders them unable to concentrate, to learn, or take on advice. They withdraw or become aggressive in order that they can be removed from environments that require them to engage. Individual therapy, which requires a child to turn up regularly to appointments, engage proactively in the work and even undertake tasks in between sessions, is therefore wholly inappropriate. Consequently, these are often the most distressed and traumatised children in our communities and yet they are least able to make use of many of individual therapies available within SCAMHS. They are unlikely even to turn up to a clinic in the first place. The idea that more therapists in clinics provides a solution to the mental health problems for these children is missing the point of the impact of trauma. Indeed, the disadvantage these children 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.
As psychologists we know exactly what these children need, and models and interventions informed by attachment theory and systemic approaches are central. Furthermore, the interventions need to have a focus on developing trusting relationships within the context of trauma informed environments. A regular and reliable relationship with a trusted person they see on a daily basis within the context of their lives is a far bigger priority than meeting a therapist once a fortnight in a remote clinic environment. Developing psychological formulations with a network of childcare professionals in the child’s system is a much more appropriate intervention; alongside the provision of regular supervision and support for the staff who struggle day to day to understand and manage the behaviour.
I propose that we have an opportunity to take action; and rethink children’s mental health services entirely in light of the new and robust evidence base that the Adverse Childhood Experiences Research provides. The following steps, if embraced wholeheartedly, are potentially cost neutral as in reality much time and energy in SCAMHS is spent either rejecting these referrals, performing assessments that conclude there is no mental disorder, or trying to manage the children who do get accepted and present in this way in a clinic based service that is not fit for purpose. I have identified ten steps as follows:
1. In addition to a Specialist CAMHS Service that is orientated to a ‘within child’ understanding of distress; develop a Multiple ACE’s Service (MAS) equally resourced with experienced clinicians trained to work and think in this way. This would become the first port of call for children experiencing distress as a result of their life experiences. (I would argue that the two models are largely incompatible; and so expanding the SCAMHS remit as an option would be less successful. This follows many years of trying to include these children within the remit of Specialist CAMHS; alongside significant experience of developing and managing bespoke trauma informed models of service provision outside of SCAMHS.)
2. Resource the Multiple Ace’s Service by a) redirecting the significant resource within SCAMHS that goes into rejecting inappropriate referrals and attempting to fit complex children into a clinic based models and b) consolidating the many trauma informed services that have been developed by the voluntary sector and social care but are currently inequitable; funded on a short term basis and often invisible in the ‘mental health’ landscape and c) reinvesting funding that goes into emergency and ‘therapeutic’ placements when their families or foster care placements break down.
3. Have as the priority for this Multiple Ace’s Service (MAS) the training of child care professionals; and the development of trauma informed schools and child care environments – instead of long waits for therapy this service has as it’s focus supporting children through an already existing workforce of childcare professionals. The recognition of supportive relationships with children in their daily settings is at the heart of the model of intervention.
4. Have accessible consultation at the core of service delivery so that all child care professionals have quick access to expert support. Provide psychological formulation sessions to direct the work delivered by community based support staff. Develop bespoke services with this as the model of intervention. (We have developed a number of successful examples of this).
5. Redefine ‘symptoms’ as ‘signals’ that all is not well in a child’s wider environment – let this become the common language of our child care systems
6. Organise support for parents/carers and front line staff around adverse experiences that impact on children rather than ‘symptoms’ children display – what does abuse mean for children? What does neglect mean for children? What does domestic violence mean for children? What does bullying mean for children? What does critical parenting mean for children?
7. Give a clear message to referrers and families that individual therapy from the Specialist CAMHS service is only offered when a child is in a position to be able to benefit from it; and supported by psychologically insightful adults who understand their role in the process. Make this the exclusion criteria – not whether they meet the criteria for a disorder.
8. Allow SCAMHS to focus on delivering evidence based, clinic based psychological therapies and interventions to children and families in a position to work in that way. If they are not, they can be referred to the equally specialist MAS service.
9. At point of referral give professionals and families a viable option – is the child and family in a position to engage in regular therapy and all that it demands? or would they benefit from an expertly resourced service that has a focus on community based interventions instead?
10. Link closely with Public Health to deliver the message far and wide that childhood experiences impact on their mental and physical health throughout their life time. If we act now we can change the future.
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