Emotional and behavioral problems in children and young people are complex. Specialist assessments and treatments are time-consuming and increasingly hard to obtain. And yet the vast majority of children with children with these problems get nowhere near a psychologist or psychiatrist. They are looked after as best they can by teachers, doctors, nurses, family support workers, and above all parents. But the training of this informal workforce is inconsistent, and often messages are mixed and contradictory.
We in the PMHA know that the system needs radical overhaul and investment, which is why we’ve been involved in the future in mind report produced by the Department of Health.
But any system needs to be built on the foundation of everyone who works with families knowing the basics, and being able to communicate consistent messages.
Our small contribution is 5 minute tips. We will produce a number of blog posts over the next few weeks to communicate important messages that you can transmit to families in a fairly short time (although we can’t guarantee the 5 minutes!).
This post, though, is background for you to read first. Because in order to produce sharp advice, You need to be able to understand the family’s story, and help them make sense of it. And yes, that part does take longer than 5 minutes!
These are complex problems, but it is a myth that you need to be a specialist to understand them.
What you do need to do is learn to think in a particular way. paediatricians like me are trained to think about symptoms and signs, find a cause, and apply a treatment; but these situations just aren’t like that, and you need to adopt approaches from other disciplines.
If you asked a historian why the first world war happened, and she simply said ‘Franz Ferdinand got shot’ then you might not think much of her skills. Instead we would expect her to tell a story, firstly outlining the predisposing factors which made 1914 so combustible, describing the chain of events which led to (precipitated) the declaration of war in September, and then explain the factors that perpetuated the conflict and made it so devastating. A good historian would range across economic, political and military aspects to really give the story explanatory power. In the same way, professionals need to create a story with families about how the child was predisposed to difficulties, how the difficulties were precipitated, and how they are being perpetuated. To generate a compelling story you need to range over biological aspects, psychology (that is the child’s own thoughts and emotions), and their social context and interactions, both within the family and outside. This sounds complex, but most of it falls out when you apply your curiosity and common sense to some of these questions.
- What is the problem?
- How does the problem affect the child and family?
- Who is in the family? Are there other problems in the family?
- Has the child themselves suffered any adversity?
- How did the current difficulties start?
- What else was happening at the time?
Doctors reading this may have switched off a bit. This is standard medical history stuff. You can wake up now.
- Next ask: how do people respond to the problem?
- What do you think about the problem? What does the child think?
- What worries everyone most?
- What are you doing about it already?
- Are there any times when it gets better?
These deceptively simple questions, if pursued with follow up enquiries, will allow you to populate, either in your head or on paper, something that looks a bit like this.
You can then use the information you have to agree a story with the family about what is happening.
Why have I told you all this? Because out of this story will fall useful interventions, and adaptations to the generic advice that will be contained in the 5 minute tips. The problem with generic advice on its own is that it treats people as if one size fitted all, which of course it doesn’t. By combining your own on the ground understanding of this family’s predicament with the evidenced advice, you can make a huge difference to families, believe me.
Let’s take a short example of this process:
Ahmed, 4, has a tantrum every night at bedtime. His health visitor has advised his mother to shut the bedroom door and ignore him, but it’s not working. Table 4 shows her 4p framework.
Table 24. Use of 4p framework for Ahmed
|Predisposing||Preterm birth||Maternal anxiety|
|Precipitating||Break-up of parents’ relationship||Domestic violence|
|Perpetuating||Screen use (TV) in bedroom up till bedtime||Anxiety of mother||Mother unavailable due to depression|
|Protective||Healthy, good communicator||Good relationship with mother during the day||Family well-supported by grandparents|
This leads to some simple, hopefully helpful interventions:
- Stop screen time before bedtime
- Mother to seek counselling/ treatment for depression.
- Grandparents asked to help with domestic tasks so mother can spend time with Ahmed
- Gradual withdrawal of mother from bedroom at bedtime, following good ‘wind-down’.
Please see our upcoming post on sleep problems for more details!
We hope that you can see that by adopting this narrative approach and combining it with generic advice (and a flexible approach to finding sources of support!) then you can achieve an awful lot for children and families.
Of course this approach won’t work for everyone, but it’s always a good starting point, from which other interventions and assessments can build.
Got it? Have a look at our anxiety post. More to come.