CAHMS Guide Final

Essential CAMHS
ENTER
Acknowledgement
Bringing this learning resource together would have been impossible without the knowledge, experience and hard work of a wide range of
CAMHS colleagues across Scotland. The aims, objectives, format and content of the resource have been outlined and monitored by a very
active steering group. Their insight and guidance has been invaluable and NES would like to thank:
Graham Monteith, CAMHS Nurse Advisor to Scottish Government
Andrew Smith Clinical Operations Manager, CAMHS, NHS Ayrshire & Arran
Judy Thomson Director of Training for Psychology services, NHS Education for Scotland
Wendy Halliday Wendy Halliday, Mental Health Improvement Programme Manager, NHS Health Scotland
Michael Follan Clinical Nurse Specialist - Practice Development, NHS Greater Glasgow & Clyde
Lee Cowie Nurse Consultant, NHS Fife
David Brand Service Manager, Children and Young Peoples Specialist Services, NHS Greater Glasgow and Clyde
Mike Sullivan Community Mental Health Worker, NHS Western Isles
Suzanne Forrest Programme Director Nursing, NHS Education for Scotland
Dr. Michael vanBeinum Dr. Michael van Beinum, Consultant Child & Adolescent Psychiatrist, NHS Borders
Dr. Fiona Calder Educational Projects Manager, CAMHS, NHS Education for Scotland
Dr. Gavin Richardson Clinical Practice Director, NHS Education for Scotland
Laura Gillies Education and Workforce Development Adviser, Scottish Social Services Council
David Brand Educational Projects Manager, NHS Education for Scotland
Margaret Conlon Lecturer, Napier University
Child & Adolescent Mental Health Services | Introduction |
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Module 1 Module 2 Module 3 Module 4 Module 5
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Indeed helpful contributions have come from too many clinicians to mention here, however NES would particularly like to thank the following
for their contribution and support toward individual modules:
Module 1: Child & Adolescent Development and the
Development of the Family
Martin McGaughan, Lecturer, Napier University
Dr. Gavin Richardson, Clinical Practice Director Glasgow
Module 3: Mental Health of Children & Young people
Dr. Michael van Beinum, Consultant Child & Adolescent
Psychiatrist, NHS Borders
Module 2: Engaging with Children, Young People & Families
Dr. Fiona Calder, Educational Projects Manager, CAMHS
Michael Follan, Clinical Nurse Specialist - Practice Development,
CAMHS Specialist Childrens Services
Lee Cowie, Nurse Consultant, NHS Fife
Judy Thomson, Director of Training for Psychology services,
NHS Education for Scotland
Mike Sullivan, Community Mental Health Worker,
NHS Western Isles
Lorna Fitzsimmons, Clinical Nurse Specialist, LD-CAMHS,
NHS GG&C
Kirsti Long, Equality & Diversity Adviser, NHS Education for
Scotland
Dr. Gavin Richardson, Clinical Practice Director
Module 4: Assessment and Formulation
Dr. Fiona Calder, Educational Projects Manager, CAMHS
Caron Grieve, Consultant Speach and Language Therapist,
NHS Greater Glasgow & Clyde
Module 5: Therapeutic Interventions
Dr. Graham Shulman, Consultant Child & Adolescent
Psychotherapist, Lanarkshire
Dr. Brenda Renz, Programme Director. Psychology of
Parenting, NHS Education for Scotland
Dr. Marita Brack, Programme Director, Psychology of
Parenting, NHS Education for Scotland
Gavin Cullen, Clinical Nurse Specialist, NHS Lothian
Nicole Brodie, Occupational Therapist, NHS Greater
Glasgow & Clyde
Finally, it would have been impossible to complete this resource without the efforts of Sandra McGuire, Educational Project Lead, CAMHS,
Derek Lawrie, Graphic Design Offcer, NHS Education Scotland, Karen Adam, Educational Development Offcer, NHS Education for Scotland
and both Nicola Fraser and Rachel White of the NES Psychology Directorate administration team.
Introduction
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How to Use the Learning Resource
Aims
Essential CAMHS is an educational / training resource designed to
support staff through the transition into working in a Specialist CAMHS
environment. The materials are designed to support the development
of a range of knowledge, skills and attitudes which will promote
collaborative, safe and effective work with the children, young people
and families who attend services.
While some of the necessary information is contained within the text, there are links
to a variety of external resources which will offer more expansive descriptions and
explanations, but will also offer the opportunity to consider and follow many of the lively
debates which continue to abound in the world of Child and Adolescent Mental Health
Services. Our aim is to stimulate your interest in these debates and to develop a better
understanding of the values which underpin effective work within a CAMH service. We
also hope the activities will encourage you to refect on your own attitudes, beliefs and
work practices and how they might interact with the clients you will meet in your daily
work.
We suggest that Essential CAMHS is best used within your existing supervisory
arrangements. While reading and refecting are effective means of gathering and
even understanding the application of new information, the support and guidance of
a more experienced clinician often provides a richer context for the learning as well as
offering the opportunity to talk through many of the issues, dilemmas and debates you
will undoubtedly experience. Studying the modules should be an agreed part of your
personal development plan, where you can decide which modules and units you need to
study.
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Structure
The Essential CAMHS training resource consists of fve modules:
Although the resource is not designed to be read straight through from beginning to end, Modules 1, 2 and 4 represent a core body of
knowledge which would allow any member of staff who is new to child and adolescent work to make sense of the experience of working with
children, young people and families. Completion of the remaining modules should be planned in collaboration with your supervisor and in
line with the requirements of your role.
Child and Adolescent
Development and the
Development of the
Family
Engaging with
Children and young
People.
Mental Health of
Children and Young
People
Assessment and
Formulation
Therapeutic
Interventions
We have also provided an Evidence Portfolio which allows you to record your strenghts and training needs and a place to gather evidence of
your learning and development
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Content
The overall objective is that the knowledge and activities in the resource are considered in the light of your
clinical experiences. Through this refective cycle we hope your new knowledge and experiences will be
contextualized and will build on your existing skills and understanding. With this in mind, alongside some
essential content, each of the modules has a range of devices to promote learning opportunities.
Each module has a set of prescribed learning outcomes which are linked to the CAHMS Competence Framework. At the commencement
of each module, you will be asked to identify and record your learning strengths in relation to those learning outcomes. Once you have
identifed your learning strengths you should agree with your supervisor particular learning needs and as you move through the modules
there will be opportunities to record and save the evidence of achieving these outcomes.
Participation
Compare Harts ladder of participation
(Table 5 below) for children or youth with
Shiers Pathways to Participation (Table 6)
what do you see as the strengths and
limitations of each?
Textboxes like this contain Activties related to practice and involve
you researching a defned topic, consulting with colleagues or
carrying out an activity in practice. These activities include:
Using family examples to refect on how you would work with a
child or family.
Study of journal articles and refecting on their relevance to
practice.
Accessing relevant websites to increase your knowledge.
Using the learning material to evaluate your own practice and
the practice of your service
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The other learning opportunities are Refections which are written in textboxes
like this.
These learning opportunities ask you to refect on your experience in relation to
a particular theory or topic or an aspect of practice.
Refecting on your own skills and values.
Using the learning material to refect on your own practice and the practice
of your service
Consider how you use refection and
supervision. What were the last three
issues you took to supervision or refected
upon?
Make notes in your portfolio about the
process and the topics you discussed.
Both of these activity types will offer the opportunity to record responses, thoughts and refections in your portfolio. This document can
be saved to your own computer and can be added to and reviewed as you progress through the resource. These entries can also be used
as evidence for recognition of prior learning should the learner choose to use the learning resource as evidence of learning for a higher
education programme of study
Throughout the document you will fnd web links to external sources and cross references within Essential CAMHS. Web links (or hyperlinks)
are written in blue underlined text. The web link opens in a new window and gives you access to the document or website. Cross references
work in a similar way, you will be taken to the text in the document which is being referenced there is a button on the page which will take
you back to the original place in the document.
The resource has recommended a range of resources, reading lists, and websites. Throughout the learning material we refer to a number
of key learning documents with particular relevance to CAMHS, including Angela Sergeants (2009) inpatient CAMHS training guide, New to
CAMHS (Heads Up 2006) and CAMHS in Context (Skills for Health 2010). These documents are all readily available on the internet and maybe
useful resources for you to download and keep. Many of the other resources are available through the Knowledge Network or Shellcat.
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BACK
Module 1: Child and Adolescent Development
and the Development of the Family
Child & Adolescent Mental Health Services | Unit 1: Child and Adolescent Development and the Development of the Family |
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Child & Adolescent Mental Health Services | Module 1: Child and Adolescent Development and the Development of the Family |
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Introduction Module 2 Module 3 Module 4 Module 5
Child & Adolescent Development
Introduction to models of development
The early years (and before)
The Antenatal Period
The Perinatal Period
The Postnatal Period
Infancy (0-3 years)
Middle Childhood
Adolescence
The development of the family
Module 1: Child and Adolescent Development and the Development of the Family
ILOs
Child & Adolescent Mental Health Services | Unit 1: Child and Adolescent Development and the Development of the Family |
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Module 1
Knowledge of Child and Adolescent
development
Knowledge of Family Development and
Transitions
Knowledge of the impact of the care
environment and its interaction with
child development
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Child & Adolescent Development
In general, the CAMH services within which we work accept referrals for children and young people in the range
of zero to 18 years. Some will be restricted to an upper age of sixteen and others will have a lower age of fve
years. Whichever are the limits of your service, the fact remains that that we will meet children who, regardless
of personal, socioeconomic and cultural context, will be functioning at many levels. Furthermore, each will
be experiencing the rigours and demands of what would, on the face of it, appear to be the most natural of
processes; growing up. It is easy to take this process for granted, after all almost everyone emerges from the
other end. However the experience of this journey, even for the most accomplished traveller, can be challenging,
anxiety provoking and confusing. From the perspective of parents, adaptation to the constant change can be
bewildering, exhaustive and thankless.
It would seem to make sense then, that before we embark on developing knowledge and understanding of some of the more extreme trauma
and distress experienced by the children and young people who attend our services, that we gain some understanding of what this journey of
development may look like for the majority of children and young people. This could be considered normal development but, hopefully, it
will become clear that normality is in itself a range which is achieved and experienced differently by different individuals.
However, this journey does not occur in isolation. Far from being a simple incremental process, growing up is a complex interplay of physical,
cognitive, social and emotional development, all of which are infuenced by, and in turn infuence, the context within which they occur. Most
often development occurs within some social context, or family. While the composition of the family may vary, each has in common a network
of individuals, relationships and beliefs. They too are embedded in the cultural and social contexts within which they exist, and must survive
and develop over time, for the good of the individuals and the family as a whole.
In this Module we will cover some of the ways we can help ourselves understand how families interact and in particular which aspects help the
individuals to survive and fourish. We will also cover briefy key parenting tasks at each stage before moving on to think about families and
how they develop.
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Introduction to Models of Development
Over the next few pages, we will encounter some of the many
models of child development. Each will represent some aspect
of the growth and maturation of a child, perhaps describing key
stages or milestones. Some will discuss cognitive development
and others will describe how a childs social and emotional world
become increasingly more complex as they gain experience of
the world. Yet others describe how a childs brain develops with
accompanying pictures of cell pruning and mylinantion. Each
will have its own concepts and lexicon and will carry a sense of the
childs progression. It is worth bearing in mind however, that each
is describing the same process, simply from differing perspectives;
the increasing complexity of the individuals capability and
experience.
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To consider one model in isolation or above others in signifcance misses the richness of the totality of the child and their experience.
Some may say that the neurological model is the most signifcant, since brain development underpins all other psychological processes
(although genetics could be viewed as even more fundamental). However, there is increasing evidence of the infuence of experience on the
development of the early brain.
Models of attachment, cognitive development, social development and so on offer descriptions of particular classes of phenomena and
each is a powerful tool in understanding the child or young people with whom we work. However developing a sense of how these models
integrate and combine allows one to gain a richer understanding of the young person, and offers far more opportunities to help the young
person and family to share in this understanding.
You may already be familiar with the content of some of these models. Below is a list of the models which will be referred to in our thinking
about the development of the child. While these models are, in general, concerned with the development of the individual, as you progress
through this unit, it is worthwhile considering the task of parents, and the need to adapt their approach, as they negotiate these stages along
with the child.
Cognitive development (Jean Piaget)
Psychosocial development (Erik Erikson)
Attachment Theory (John Bowlby)
These are a sample of the many models used to describe child and adolescent development. You might want to consult kids development
and consider the other theories which are outlined. You should also consider Carol Gilligans (1993) work on gender difference in moral
development.
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The early years (and before)
Since the focus of clinical activity, resource and Government policy
is moving down the age scale (Scottish Government Early Years
Framework) and chronologically it makes sense, we begin the story
in the early years. It can be useful to think in terms of distinct
although overlapping developmental phases to help you organise
your assessment, e.g. birth to 3 years, 4 years to 10 years, 10 years
to 13 and adolescence.
We know from research how important the periods of prenatal, perinatal and
postnatal development are to the infants development, and the enduring effect
that continuous disruption in these stages can have on a child. Knowing what has
happened during these phases can help make sense of someones behaviour later in
life. This next section (drawn from NewtoCAMHS) describes how the foetus develops
and how this period can impact on the childs perceptions of the world it is entering
and mums perception of the baby.
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Antenatal Period
In-utero growth and development is entirely dependent on placental feeding. A wide range of nutrients is
essential, especially for growth during the last trimester of pregnancy and frst six months of life. Foetal life is an
active, rather than a passive, experience. For example, in-built refex movements occur early (kicking, stretching,
nesting), with susceptibility to sudden movement and noise, and responsiveness to the mothers emotional
well-being (Schaffer (2004)). These foetal life experiences are mediated by central limbic structures [fgure 1
below] within the brain, which develop quite early. These structures also have a signifcant role in the control of
emotion, or affect.
The limbic system is the Part of the
human brain involved in emotion,
motivation, and emotional association
with memory
In-utero preparation for delivery involves pre-programmed behaviours of the baby. Similar
pre-programmed behaviours are observable after birth, e.g. sucking and holding refexes,
and visual fxation and following behaviour. Although much of what happens before birth
is subject to genetic control, the intra-uterine environment can also affect development.
Alcohol, in common with many drugs and some infections, can cross the placental barrier and
can have signifcant impact on the development of the foetus. Exposure to alcohol is perhaps
one of the best known examples of the impact of maternal behaviour on the developing
embryo. Excess consumption, particularly during early pregnancy, can lead to a cluster of
diffculties including a small stature, distinctive facial appearance and mild learning disability
(Autti-Ramo 2000).
It is worth bearing in mind however, that even this early, the new life is already beginning
to impose itself on the world. Its very existence has profound physical impact on mums
physiology as, driven by the template of genetics, baby absorbs the necessary nutrients and
creates the optimal environment for growth and development. These changes in chemistry
can have a direct infuence on mums mood, while the adjustment to role can impact on
her psychological functioning. Already baby has begun to shape the environment within
which she is developing. This reciprocal relationship will continue to shape both babys
development and the environment within which that development takes place in complex
and sometimes unpredictable ways.
Figure 1
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The Perinatal Period
After an extended period of relative safety and security, the infant must now emerge into a distinctly different
environment. While the impact of the transition has been the subject of debate, the change is universal.
However the nature and timing of that change can differ widely. While the majority of mothers will experience
a normal delivery, many will experience medical interventions from forceps delivery through to caesarean
section. While the birthing process itself is unlikely to have signifcant physical impact on the baby, with the
exception of anoxia*, the experience for mum can have lasting physical and emotional impact (Laing(2001)).
1.1 SCBU
Assuming no physical or neurological
correlates, in what ways might an
extended period of time in SCBU impact
on the subsequent development of a
child.
While few pregnancies would last beyond 42 weeks, some may result in birth
much earlier. Premature babies may be born two months, or more, early. In
terms of their development (and readiness to deal with the rigours of the world)
this is a signifcant difference. Advancing medical knowledge and practice is
increasing survival rates in younger and younger babies. Conversely, however
prematurity has been identifed as a risk factor in the development of a range
of later behavioural and psychological diffculties. The mechanism behind
these outcomes is less clear however, since premature babies also have a
higher prevalence of medical problems which may require prolonged or intense
treatment, including extended periods in incubation.
* Anoxia A condition characterized by an absence of oxygen supply to an organ or a tissue
Laing KG (2001). Post-traumatic stress disorder: myth or reality?. British Journal of Midwifery. 9, 7, 447-451
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Post-natal period
As with physical development, brain development continues after birth. New experiences, interactions and
sensations lead to new connections (see Figure 2) between brain cells or neurons (see Figure 3). Although
these early experiences will inevitably be forgotten the resulting neural connections will lay the foundation for
cognitive structures and processes that will emerge over the following years.
Brain imaging and neuropsychological studies
have demonstrated a close relationship between
brain structure and function, and the presence of
sensitive periods of development. For example,
sensory deprivation in early infancy diminishes the
growth of myelin sheaths* and neural pathways
(see Table 1). Without early stimulation, stunting of
neural pathways may occur (see fgure 4 on next
page), leading to irreversible stunting of affect and
the childs future capacity to form relationships.
Inadequate stimulation can occur for many
reasons - for example, developmental studies
have shown how maternal postnatal depression
can diminish reciprocity in the mother-infant
relationship, fattening their inter-subjectivity, i.e.
how attuned they are to one another (Trevarthen
and Aitken 2001). It is important to remember
however, that such an outcome is an interaction
between child and mother, rather than a de facto
outcome of postnatal depression.
Proliferation of nerve cell connections
(synapses) in the frst two years of life.
Neurone is just another word for nerve cells.
Nerve cells are highly specialised and are a
different shape from simple cells
Figure 2 Figure 3
Figure 4 Comparison of infant brains
*Myelination Myelination is a term in anatomy that means
the process of forming a layer (myelin sheath) around a nerve
to allow nerve impulses to move more quickly.
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New born babies are not however passive recipients
of their environment. While genetics may lay a
blue print for development, the fnal expression of
characteristics such as behaviour or sociability will
be shaped by the experience and environment; an
environment to which they contribute in signifcant
ways through their interactions, temperament
and behaviour. Furthermore, there may be
signifcant differences in outcome for children
with similar environmental experiences. Why is it
that, from cohorts of children with similar levels
of disadvantage, neglect or even abuse, some will
emerge into well adjusted lives, while others
might remain in destructive and maladaptive
patterns of relationships and behaviours? There
has been growing interest and research into what
has become known as resilience or the capacity to
show adaptive functioning in the face of signifcant
adversity (Schoon 2006)
1.2 Resilience
a) After reading the Appleyard article (below), consider how one
of the young people you are working with may have displayed
resilience. What factors may have contributed? What were the
risk factors for the young person?
b) If resilience is based on the assumption of successful or positive
outcome, can you see any diffculties inherent in making these
judgements? How does this impact on your view of resilience
as a concept?
Appleyard, K., Egeland, B., Van Duleman, M. and Stroufe, A. (2005)
When more is not better. The role of cumulative risk in child
behaviour outcomes. Journal of Clinical Psychology and Psychiatry
46:235-245
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Infancy (0-3 years)
Whereas newborns were once thought of as having limited ability to engage with the world around them,
John Bowlby suggested, (along with most parents) that even at this very early age, children have a range of
hardwired skills for attracting and maintaining attention. Alongside the usual crying and smiling, even very
young babies are able to engage in reciprocal interaction: what has become labelled by some as the dance*.
These innate abilities and behaviours are designed to maintain the interest and attention of adults. While on a
very basic level this interaction maintains safety and security for the child, as time goes on, the product of these
interactions is that the child learns how to develop and maintain relationships and begins to make sense of the
world.
At this very early age, babies understanding of the world is minimal. Jean Piaget described a framework for helping us understand the
development of a childs ability to think and learn about its environment. For him the babies world consisted of what it could see, touch smell
and feel. With little sense of itself as a separate entity, the baby seeks to understand its world through senses. Only late on in this period can
the infant begin to understand permanency and the idea that objects or people maintain, even when they are out of sight. More recently,
research has suggested that the development of these skills such as object permanence can be enhanced by the childs interactions and
environment; this perhaps highlights that, even at this very early age, the relationship with carer is the flter through which the child learns to
understand the world. The quality and level of interaction, the focus and content of activity and the valence and intensity of emotion all serve
as templates for the childs schema. In the main the child can only be exposed to the experiences that the parents provide, therefore they lay
down the form of the preverbal schema into which the child will later come to accommodate and assimilate new experiences.
Erik Erikson, a German Psychiatrist, in his theory of identity formation, highlighted the importance of love and nurturing if the child is to
develop from the trust versus mistrust confict with a sense of optimism, confdence and security, while those who experience threat or
inconsistency may emerge with a sense of insecurity, worthlessness, and general mistrust to the world. Similarly refected in Ainsworths idea
of **secure attachment, the suggestion is that sensitive and appropriate parenting leads to children with a positive view of the world and of
those around them.
*The dance Trevarthan This refers to the complicated interaction between carer and baby which includes turn-taking, mirroring as well as verbal
**Secure Attachment An emotional bond between children and caregivers. Children with secure attachments reportedly showed minimal distress when their mother
left them alone and sought comfort when their mother returned. These children appeared to trust their caregivers would meet their needs. Additionally, the caregivers
of children with secure attachments responded appropriately and consistently to their childrens needs. In contrast, the children without a secure attachment to
their caregivers displayed more fearful, angry, confused, and upset behaviours than the securely attached children. The caregivers of these children did not respond
consistently or appropriately to their children (Mary Ainsworth).
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As the childs capacity to represent the world internally
develops, so they come to realise they are independent
beings and share their space with other independent
beings. Unfortunately, however, as is the case with
emergent skills, and will be repeated throughout the
developmental stages, alongside new opportunity,
there is new confusion and anxiety. While she begins to
recognise her separateness, she has little sense of the
existence of other minds. Theory of Mind* will not
develop until later; for the moment effectively, hers are
the only thoughts that exist (in as much as she considers
the existence of thoughts!) and all others know and think
the same as she does.
1.3 Parent Behaviours
This egocentric position can be frustrating for parents and children alike.
As the child begins to appreciate the enormity of the world in which she
lives her desire to explore and learn (develop schema or internal working
models) grows.
In light of our comments about parents acting as a flter for the childs
understanding, in what ways might the behaviour of:
An highly anxious dad
An autocratic or critical (strict) mum
shape the development of the childs understanding?
As the infant becomes increasingly goal directed (driven by their thoughts and with a growing understanding of cause and effect), their
drive to discover the world increases. Armed with a secure base, the childs job is to explore and make sense of their physical and social
environment. Meanwhile, the increased mobility and range offer opportunities for success and for failure bringing joy and frustration.
Throughout this period, and mirrored in other periods of cognitive development, the capacity to experience and understand thoughts is
greater than the capacity to communicate them. The growing self awareness and experience of not being understood can lead to angry or
aggressive behaviour; this behaviour could be viewed as another form of communication. More signifcant than the behaviour, however, is the
parents response to the behaviour.
New understanding of the world brings new and different perceptions of threat. At this early stage and throughout their development,
childrens growing knowledge, underpinned by increasing capacity to think in the abstract, shape their understanding of danger. Typically,
children at the upper end of this age range will experience anxiety related to separation from caregivers, injury, insects and small animals. We
will see later that these fears, if managed appropriately by parents, will subside and be replaced by fears based on newer understanding of the
world.
*Theory of Mind The ability to ascribe mental states to others or oneself and to explain or predict behaviour in terms of those underlying mental states
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This is the key stage in the journey for parents; the platform from which the
developmental journey will be launched. The sensitivity and mindfulness
required to provide a secure base requires effort and imagination. The patience
to manage the interminable questions of the toddler attempting to make sense of
the world.
In describing a normative course of development, albeit with a signifcant level
of variation, we should acknowledge that not all children fall within this range.
Inevitably there will be children who do not meet their physical, social, cognitive
or emotional milestones through each stage.
Additional Reading
Davies, D (2004) Child Development: Guilford Press, New York
Holmes J (1995) John Bowlby and Attachment Theory: Routledge , New York.
Schoon, I (2006) Risk & Resilience: adaptations in changing times. CUP; Cambridge
Parenting the toddler
There are many good texts on the subject of parenting the infant as there are, at the time of writing, many web sites and television shows
which offer advice on parenting skills. For some parents this has had a paradoxical effect; mysticising parenting and increasing strain as they
strive to get it right or seek advice on good parenting from, of all places the library. For others they prove confrmatory for their instincts.
1.4 Starting Nursery
What might be the key considerations for a parents
of a toddler who may be starting nursery in a
few months. Try thinking in terms of the childs
physical, emotional and social development?
For some thoughts and ideas, visit
ready steady toddler
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Middle Childhood
4-7 years old
This is a period of signifcant change for the child. Cognitively, the
child moves to a position of increased awareness of the psychological
world of others, while socially, the child will move into a new world
populated by strange adults and peers. The transition to school may
be received as an opportunity for greater exploration, or may be a
separation too far.
Adjustment and development through this period is heavily dependant on earlier
experiences. Children who have developed internal working models which include
adults as positive and reliable will have greater capacity to manage these transitions (not
least because their default view of the new teacher is likely to be positive) and to take
advantage of the opportunities the new environment offers.
Decreased supervision, both at school and the home has an impact on the nature of
interaction. The child will have experiences of which the parent has little or no direct
knowledge; therefore shared understanding can be more complicated. The childs
story may be incomplete and/or inaccurate, based on flling the gaps of understanding,
leading to confusion and frustration for parents
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When the child attends nursery or school the focus of the developmental history shifts slightly. Of course relationships with parents, siblings
and other family members are still important and remain a major infuence on the childs development, but the shift is towards social and
group interactions. Opportunities for new friendships and relationships arise. The child needs to learn how to get on with children and adults
they have not met before. Intellectual and social development is to the forefront. Most children manage these changes and challenges
without too much diffculty. For some children however the school years will become challenging and even overwhelming. How the child
manages these new changes may be an indication of their management of future diffculties. It is around this time that issues such as
Attention Defcit Hyperactivity Disorder (ADHD), Conduct Disorder and Pervasive Developmental Disorders may be more readily recognised.
Teachers are usually good at knowing what can be expected of children and are aware of the developmental norms of this age group.
Teachers are therefore in a good position to recognise when things are going awry. Specifc learning diffculties may be recognised and there
are opportunities for interventions in all these areas.

1.5 Child Development Quiz
Construct a quiz which addresses development for a
child between the ages of 6 to 12 years. What kinds
of questions would you include which would indicate
the respondent was aware of the challenges of this
developmental period?
Some issues occur over the lifespan such as illnesses, parental
divorce or separation, parental mental or physical health,
parental substance misuse, homelessness, loss and bereavement,
child sexual abuse and other traumatic events. The impact
of such events will be different depending on the age,
developmental stage and resilience of the child.
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8-11 years old
This age range is often viewed as relatively unremarkable, perhaps because unlike other developmental stages,
physical growth through this period is typically slow and steady; in contrast to the rapid changes in earlier stages
and in adolescence. Perhaps also because children in this age range, as we will see, are generally developing a
better understanding of the world and better control of their emotions.
By the time children reach this age range, motor control is mastered and the focus through this period is on improving strength, speed and
co-ordination. For boys in particular this can become a focus: within their peer group competition is rife. The childs increasing capacity to
hold more stable and abstract representations of the world grows and they become increasingly interested in, and aware of, the inner self. The
7 year old when asked to describe themselves may say they are tall, have brown hair and can run fast, while the 11 year old is more likely
to describe themselves as friendly, quite clever and likes playing football. This shift in understanding, along with the shift to more stable
schema, allows the child to begin to develop a more stable sense of their self.
During this period, children are likely to have fewer novel experiences, not to mention more ways of coping, than in the earlier years so
may face fewer signifcant challenges. While the need for a secure base does not reduce, the need for proximity may be less obvious. This
reduction in the overt need by the child can be experienced as diffcult for parents. Indeed the focus of confict, which may have previously
centred around routine behaviours such as toileting or bedtimes, now shifts to disagreement about the childs developing independence; can
I go to Toms on my bike, he only live three streets away.
1.6 Eight - 11 year old stage
Think about a child you know who is moving through this stage. Think about the way they talk about themselves and others.
What can you learn about their view of them self?
What are the things you think they value in themselves and others?
Why?
Are there any inferences we can make about their understanding of the world?
Record your thoughts in your portfolio
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Growing independence means increasing immersion in the world of others. Friendships become a progressively more important aspect of
the childs life and in general friendship groups become bigger. Early in this period children tend to gather in exclusively boy and exclusively
girl groups. There may be some forays across gender boundaries, but they tend to be rare and short lived. As mentioned earlier, play among
boys can be competitive and even aggressive, where as girls often engage in more co-operative play (Bee 1994). Interestingly, however, boys
are generally more accepting of new additions to the group. This expansion of the peer group can, and does lead to increased confict. There
appears to be an increase in bullying during this period and these experiences can have a lasting impact on the childs self esteem and self
effcacy.
Perhaps one of the key elements which support the widening peer group is the increasing capacity for emotional regulation. In moving
through this stage, children become more adept at containing, or even masking their emotions. Although this begins earlier, as children
move to understanding the intentions of others, so they become more skilled at predicting what will bring social success (Rubin 2002). The
development of emotional regulation is dependant on a number of factors, including temperament, brain development and experience. In
terms of the latter;
the outcomes of controlling (or not controlling) emotion
what happens when I control myself?
what happens when I dont control myself?
management of emotion as modelled by others
It is again clear then that as children progress through these
stages, so their infuence on their surroundings increases and
shapes the world in which they live.
1.7 Self esteem
The article by Guerra et al examines the interaction
between context and self concept with particular focus on
bullying, giving an important insight into the impact of the
behaviour of others on the childs self esteem.
In light of the paper, consider a child with whom you are
working and you think may have poor self esteem. Think of the
internal (cognitive and developmental) and contextual factors
which may contribute to the maintenance of their poor self
esteem.
Record you thoughts in your portfolio.
Guerra, NG., Williams, KR., Sadek, S. (2011) Understanding
Bullying and Victimization During Childhood and
Adolescence: A Mixed Method Study. Child Development
82:1, 295
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As we move through this stage, along with the cognitive, social and emotional developments, we see the beginnings of the next phase
of physical development. As children move toward puberty, increasingly friendship groups become desegregated. The onset of the
development of secondary sexual characteristics can vary and this individual variation can, in itself, impact on the individual child although
the impact may be different for boys and girls. Consider what the impact of late puberty might be for a boy, given the social tasks described
earlier. What about girls? How may they be affected by early or late onset of puberty?
Parenting the 8-11 year old
Whilst parents remain the most important fgures in their childs life at this point, the infuence that parents have on their children begins to
change. Relationships with teachers, friendships, interactions with other children and academic success can all have signifcant infuence on
how children feel about themselves, how they behave and how the cope. Parenting a school age child involves being mindful of these outside
infuences and learning how to help children navigate these relationships and experiences as successfully as possible, whilst fostering the
childs independence and self effcacy.
Additionally, the way in which parents manage their children needs to gradually change. Whilst the majority of principles and approaches
that parents have used for younger children are still applicable at this age, parents need to recognise and take into account the changes
in childrens development. Children of primary school age are getting physically bigger and so techniques used with preschoolers, such as
physically removing them from an activity are likely to be no longer possible. Additionally, primary aged children are now better able to think
of their own solutions to problems, and parents need to encourage such problem solving skill development.
With growing independence and abilities, a challenge for parents is managing the balance between frm but fair limits, which still encourage
the development of the childs opinions and values, rather than imposing their own on their child. As such, parents increasingly need to
compromise and seek the childs views. Such fexibility and respectful consideration of others thoughts and opinions by parents models the
very behaviours that children need to start developing themselves. Higher order social skills such as these, as well as the development of self
discipline, and taking increasing responsibility highlight the more complex developmental tasks that children are embarking on in this period,
and upon which, much parenting needs to focus.
Additional reading
Bee, H (1994) Lifespan Development. Harper Collins, New York
Searcy, Y D (2006) Placing the Horse in Front of the Wagon: Toward a Conceptual Understanding of the Development of Self-Esteem in
Children and Adolescents. Child and Adolescent Social Work Journal, Vol. 24, No. 2, April 2007
Smith K, Hart C (eds) (2002) Blackwell Handbook of Childhood Social Development. Blackwell: Oxford.
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Adolescence
Adolescence is often characterised as a period of storm and stress where
the individual, and family, experience turmoil and upset as they begin
the transition from childhood to adulthood. While storm and stress
is a debatable construct, adolescence is certainly a period of signifcant
physical, cognitive and emotional change. Triggered by a combination
of genetic and environmental factors, the young persons body begins
a transformation that will see rapid changes in physical size, a shift in
capacity to understand the world around them, and all of this in a body
and mind that was a child only months before.
Puberty brings with it major physiological changes, such as; the growth spurt, sexual
maturation, growth of pubic hair, sebaceous glands becoming more active (the latter which
can lead to acne or blackheads). Changes in adolescence have often been desctribed as a
phase that young people are going through. In fact evidence is growing that these changes
in mood, emotional upset and risk-taking behaviours may be infuenced by changes in the the
structure of the brain, which in turn is infuenced by changes in the environment.
1.8 Puberty
The physical development characteristic of puberty can vary widely in their onset which in turn has
an impact on the young persons self concept and the way they are viewed by others. This may be
different between individuals and across genders.
Access the developmental literature and consider what might be the impact on the individual of:
Early development of secondary sexual characteristics
Late development of secondary sexual characteristics
Note these in your portfolio
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We know that the adolescent brain is different from the adult and the brain with respect to grey and white
Matter, structural connectivity and neurotransmission (Steinberg 2010). Adolescence is a time when
regions of the brain undergo refnement. Most of the changes take place in the prefrontal cortex, the
area responsible for controlling, planning, organisation and mood regulation. The more developed the
prefrontal cortex, the better able the young person is to control their impulses and make judgements.
In earlier life the volume of Grey Matter increases, at the start of puberty it is subject to thinning
and loss. This is at the same time as the adolescents cognitive abilities develop. Redundant
neural connections are pruned and there are increases in Myelin which increases brain message
transmission. These and environmental changes can result in an increase in risk-taking
behaviours. What this all means is that the changes in young peoples behaviour are infuenced
and, to some extent, controlled by both physical and environmental development.
As these awkward physical changes take place, cruelly, the young person is entering a social
world where the opinion of peers becomes a focus (Coleman, Hendry and Koep 2007).
Increasingly, young people live their lives outside the confnes of the family. However this
new individuation* also requires a secure base from which to explore. The nature of this
base, however is less straight forward than in the early years.
This is a time of identity formation in all its many different forms such as sexual,
educational, vocational and spiritual. As the young person seeks to become
incorporated into their peer group, they may associate with various subgroups, some
less socially acceptible than others, before being, and feeling, accepted. This may be
a time of risk taking, and experimentation where young people are often exposed
to and may partake in mind altering substances. At the same time young people
may be more vulnerable to the long term effects of substances such as alcohol and
drugs.
*Individuation the process through which a person becomes his/her true self, whereby the innate elements of
personality, the different experiences of a persons life and the different aspects and components of the immature
psyche become integrated over time into a well-functioning whole. Individuation might thus be summarised as the
self-formation of the personality into a coherent whole.
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These challenging, confusing and sometimes distressing experiences can for some bring
more extreme diffculties. This period of development is particularly associated with a
number of psychological difculties which arise from the combination of physiological,
social and emotional development and the social context within which they occur. In
particular with puberty there is an increase in the incidence of:
Depression
Self Harm
Social anxiety
Eating disorders
Conduct disorder
Relationships and sexuality are an important aspect of adolescence. It can be bewildering,
working out your sexuality. Most young people are fairly secure in their sexuality,
they might experiment early in adolescence, but manage this developmental task with
comparative ease, resulting in a sexual identity which is comfortable to themselves and
others around them. Others struggle with their sexuality and have diffculty deciding what
their sexual identity is. Young people who are lesbian, gay, bisexual and transgender have
a particularly diffcult journey through adolescence, they are often bullied and ostracised
and it can be diffcult for them to talk about their feelings with all but their closest friends.
Sometimes as professionals we may inadvertently compound these issues by assuming
that everyone is heterosexual.
What are your recollections of the transitions that took
place during adolescence?
Who was there being supportive?
How did they do that?
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Table 1 (from Camhs in Context) Major stages of brain development in children.
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1.12 The Cultural Context of the Family
Over the centuries and decades, the role of the child within the family has
changed. In Britain we have moved from the child as a source of income,
to a consumer of income. We have moved from child labour as the norm
through be seen but not heard to European Convention on the rights
of the child
Note down how you think the rights, roles and responsibilities of the child
have changed in response to the dominant cultural ideology in the last
hundred years
Key issues to consider would be:
The cost of childhood
Role (and purpose) of education
Expectations of the child (what would be described as a good
child)
Given that this is not static, how do you think it may change in the future
in response to, for example the dominant fnancial state of affairs?
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The development of the family
Introduction
This unit will discuss the role of the family in children and young peoples development. The family has changed
signifcantly over the last three decades as has the expectations, roles and tasks of the individuals within the
family. The shape and function of the family is closely bound up with the cultural context within which it lives
and grows.
While some children are raised in a nuclear family,
others will be raised in families which have changed
and reconstituted with more complex relationships.
The profle of the family is probably not particularly
important to a childs development. The key is that the
family network meets the developmental needs of the
children for which it is responsible. It is helpful to think
in an inclusive way about the family; in a way which
respects diversity. Thinking of the ideal normal family
is probably unhelpful as Walsh (2003) states:
Notions of normality sanction and privilege
certain family arrangements while stigmatising and
marginalizing others.
(Walsh 2003: 4)
While most people grow up in families, a number of
young people do not. As you study this section you
should refect on this issue, i.e. how might young people
who do not grow up in families experience the issues
under discussion? Whilst it is true that most people
grow up in families, each individuals experience of family
life will be different and may even be different within
each family.
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Whilst all children do not grow up in nuclear families, the
nuclear family can be a useful focus in thinking about the
roles, relationships, rules and boundaries which affect a
childs development. Families are complex systems which
are constantly changing; as members grow older, new
challenges are develop. Furthermore, the family is more
than the sum of its parts. Frunde described it as having
emergent properties: characteristics which do not mirror
any one individual exactly but are some function of how
the family members come together. . The metaphor of an
organism has often been used in the literature. The idea is
that the family has the following characteristics:
Internal structures and processes
Permeable boundary with the outside world
Is part of but distinct from environment
Grows and develops
As time passes, the family must create a context for the
development of all of the individuals within the family. This
Make notes in your portfolio of your understanding of the family.
Having completed the above task, refect on the following:
What Family means to you:
In your personal life?
In your work life?
Makes notes of what you regard as the main tasks of the family.
What do you think gets in the way of a family functioning well?
Make a list of all these factors in your portfolio.
Consider the development of children not raised in a family environment,
such as children who are accommodated and looked after. How are
networks formed around these children and developed to provide
the optimum level of care and nurturing for the child? What are the
particular challenges faced by looked after and accommodated children?
is further complicated by the fact that those same individuals contribute to the context. Their personalities form and develop. Their own life
stage changes and their expectations of themselves, the family and the world change.
Barker (2007) sees the functions of families as including:
The provision of basic necessities of life for its members.
The rearing and socialisation of children.
Provisions for the legitimate expression of the marital couples sexuality.
The provision of mutual comfort and support for its members.
Reproduction and continuation of the species.
This is no mean feat for a group of individuals coming together, where often there is little recognition or discussion of the goals or how they
may be achieved.
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1.13 Family tasks
Using the previous defnition, Barker (2007):
Outline what you see as the strengths and weaknesses of this approach?
Are there families who might be excluded by this defnition? Who might they be?
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In an attempt to capture the developmental tasks of the family, Carter and McGoldrick (1999) developed a model outlining the phases of the
family lifecycle.
Table 2: The Family Lifecycle (Carter & McGoldrick, 1999)
Stages of the Family Life Cycle Task
Leaving home: single young adults.
Young adults need to separate from their parents and become independent young
adults.
The joining of families through marriage.
Families have to accommodate and come to terms with the needs of other families
across different generations.
Becoming parents: Families with young children.
Families have to adjust to the needs of a new infant and make space in the parental
relationship to allow this to happen healthily.
The transformation of the family system in
adolescence. The rules and roles that previously worked are challenged and adjustments have to be
made to allow the young person to have greater freedom.
Families at midlife: launching children and moving on. Letting go of children and adjusting to live together after children leave.
Families in later life.
Adjusting to being a grandparent and a new relationship with children and
grandchildren adjusting to the change in health status.
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Like many other commentators on the family, Carter and McGoldrick (1999) envisage a journey through which most families pass. Each
stage represents a transition; a challenge which must be met and negotiated. The manner in which they negotiate these changes will vary
both between and within families, however meeting the needs of family members means fnding some satisfactory resolution. The families
approach must adapt to the developmental levels and capacities of the individual members. For example, as the child develops, strategies
used by parents to manage problems in an earlier developmental period may no longer be effective, or may even be detrimental, when the
child is older or the family is facing a new and different challenge.
As families move through their life cycle, smoothly or otherwise, there may be times when they do not have the resources, knowledge or
experience to mange any given situation. Once off course, maladaptive patterns of behaviour or emotional distress may further
contribute to the diffculties. The role of therapy is to help the family re-establish their own momentum. There are a number
of key concepts, which are important in the life cycle:
The family life cycle
Consider how Carter and McGoldrick construct
the family life cycle do you agree with the
outline of the stages? How else might the family
life cycle be constructed what are your thoughts
about their view of the family life cycle?
The family is seen as a system moving through time
Families naturally face transitions as they grow and develop. The needs of the
family (which is some function of the needs of the individual family members)
will change over time as will their capacity and need to interact with their
context. As the individuals grow and develop, their personalities, behaviour
and attitudes will be shaped by the family behaviours, attitudes and problem
solving strategies, but will also exert some infuence on those same family
belies and behaviours over time.
The three-generation life cycle model
This model emphasises the connectedness between generations and the fact that family members dont have the option of choosing not
to be a part of the family. We all receive family attitudes, taboos, expectations and so on. This is the hand we are dealt. What we do with
this hand is an issue for us all. Crisis during the life cycle, such as the addition or loss of a family member, causes stress and can give rise to
symptoms of dysfunction.
This life cycle model makes use of the idea of a horizontal axis (the here and now, as the family deals with problems, stresses and family
tragedies) and a vertical axis (family history, which includes family patterns, myths and taboos). For example, if the family of origin of one
or other spouse had diffculty in dealing with the birth of the frst child, there may be problems at the same life cycle stage in the next
generation. Where problems on both axes converge, a quantum leap in stress takes place. The addition of social or political stresses, for
example poverty, will increase stress levels even further. Families may lack a temporal perspective when they are experiencing problems and
the use of a life cycle model in therapy is about restoring this perspective of movement through time.
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1.14 The family life cycle
Read the case study on the Campbell family and
consider the following:
At what stage of the family life cycle is the
Campbell family?
Note it may be that different members of the
family are at different stages discuss this with
your mentor or your online group.
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The changing family life cycle
The family life cycle in the late twentieth and early twenty frst century differs considerably from earlier versions. For example, the empty
nest phase is relatively new and has come because people live longer. Previously the child-rearing phase took up the entire adult life span.
Women now have a young adulthood independent of family, where previously they moved directly from family of origin to marriage. More
recently there are young people who are unable to leave home because of fnancial constraints. This has an impact on expectations and
attitudes across generations and family members adjust to new norm and more.
Major variations in the family life cycle
Divorce, separation and remarriage obviously change the ways that families function and there are a number of situations when emotional
pressure peaks such as:
When the decision to divorce is made.
When it is announced to family and friends.
When money and custody issues are discussed.
When the separation or divorce are acrimonious.
When physical separation takes place.
When actual legal divorce takes place.
When there is contact about money or children.
When each child graduates, marries, has children or is ill.
As each spouse remarries, moves, becomes ill or dies.
Mourning and dealing with hurt are a major feature at each of the
above stages. As in other transitions, complete cut-offs are harmful.
Therapy involves enabling those involved to successfully face and
negotiate the challenges of each transition. Cultural variations need
to be taken account of and the therapist must encourage families to
carry out the transitions appropriate to their ethnic background.
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There are different ways of constructing the challenges families face. Dallos and Draper (2000) see the family as developing and managing
three interwoven areas these are:
1 The social, cultural and spiritual the customs, rituals and laws which make up a society. What is acceptable in a society, how society is
organised.
2 The familial how decisions are negotiated in families this will be based partly on the culture which the family are in and through the
familys own shared beliefs.
3 The personal each family has its own experiences and beliefs which are brought in part by parents through their experiences in other
families and develop as a result of experiences outside the family.
As mentioned earlier families are complex and it can be a challenge in thinking about with whom one should work. The Campbell family are
used in the next activity to help you refect on working with this family.
1.15 The Campbell Family
Relationships in the Campbell family are quite complex with both parents entering new long term relationships. The
children have to manage these new relationships, as well as managing their feelings about the parental separation. This
will clearly have an effect on Stephanie and these relationships may have to be considered as part of the assessment. The
following people are involved in the family: Mum and Dad, and their partners, Stephanie and her brother and sister.
Who would you invite to the initial meeting?
Would you involve other members of the family if yes, who and when?
If you would not involve other members of the family - why not?
Discuss with your mentor the advantages and disadvantages of your chosen approach.
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The Campbell family
The Campbell family are; Mum Sara, her new partner David; Dad Craig and his new partner Fiona. There are three children; Stephanie who is 14
years old, Kara (13) and Ross (5) who are all the biological children of Sara and Craig. Sara and Craig separated 5 years ago just after the birth
of Ross and divorced two years later. Both Sara and Craig have new partners with whom they are cohabiting. All the children spend weekdays
with Sara their mother and her partner David and weekends with their father Craig and his partner Fiona. The children have reacted differently
to the parental separation. Stephanie found the separation particularly diffcult. At primary school she was described as looking sad and
withdrawn, at age 11 years she stopped mixing with other children for a while and was noticed to have scratches on her arms. She gradually
started mixing with friends again as they made an effort to involve her in games. She played football for the school team and seemed to really
enjoy this. Kara appeared to manage the separation well and seems to be coping well at school. Ross has been having diffculties at school
and there is concern that he may be on the autistic spectrum or that he has conduct disorder. He appears not to listen for brief periods of
time. Ross has diffculty interacting with other children preferring to play on his own. He has development delays in his speech and language
comprehension and he becomes upset and angry when he is asked by adults to do something he does not want to do.
Kara managed the transition to secondary school very well. However Stephanies transition from primary school was diffcult. She found the
large secondary school an overwhelming environment and started refusing to go to school. She began complaining of stomach-aches and
would refuse to get out of bed. Mum has diffculty in asserting her authority and feels unable to persuade her to go to school. Mums new
partner David works early shifts and is not at home when Stephanie is due to leave for school. If Stephanie is home when David returns in the
early afternoon he becomes very angry. At school Stephanie has few friends, partly because of her persistent absence. Her guidance teacher
has asked for a consultation from the Primary Mental Health Worker attached to the school. The school has concerns that Stephanie is self-
harming she always wears long sleeves and a teacher noticed cuts on her arm. She is often absent from physical education classes and if she
does attend she always has a note from her mother excusing her from taking part.
Sara describes her daughter as changed and has taken Stephanie to see their G.P. He considered she may be depressed and has asked for a
CAMHS assessment. Her mood does appear to be lower. She complains of diffculty in getting off to sleep, has lost contact with her friends at
school and seems very unhappy. Sara is also worried about the effect Stephanies behaviour is having on Kara who is asking why she should
have to go to school if her sister doesnt have to. Her father Craig says he hasnt noticed any major changes in Stephanies behaviour he
agrees that shes more sad than usual but thinks its just down to being a teenager. Craig also thinks Stephanie should be with him during the
week so that he can ensure she gets to school he is very worried about her schooling and feels she is missing out because her mother has no
authority over her.
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Module 2: Engaging with Children, Young
People & Families
Child & Adolescent Mental Health Services | Module 2: Engaging with Children, Young People & Families |
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Engaging with Children, Young People & Families
Setting the Context
Working with Emotions
Cultural Competence
Working with Risk
Clinical Risk Management
Interagency Working
Refective Practice
Supervision & Other Staff Supports
ILOs
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Ability to communicate with C&YP of
different ages, developmental levels and
backgrounds
Ability to engage and communicate
with children, young people and their
families/carer signifcant members of the
system in therapeutic relationships
Ability to foster and maintain a good
therapeutic alliance, and to grasp the
clients perspective and world view
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ILOs
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Ability to deal with the emotional
content of sessions
Ability to manage endings and
transitions
Ability to work with difference
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Engaging with Children, Young People & Families
Young people and families attend CAMH services for a variety of reasons and with a range of diffculties. For
some the purpose may be diagnosis as discussed later in module 3; for others they may be seeking longer term
support for signifcant mental health problems; while for others, the aim may be reassurance that, given the
diffculties they face, they are doing all they can. There are however many steps to be taken before families can
achieve these goals, some of which are within the remit of CAMHS and some of which are not. We will begin
this module, therefore, by briefy looking at the clients journey to and through CAMH services, giving some
consideration to the barriers they face and the expectations they hold.
From here we will go on to look at the ways in which CAMHS clinicians can enhance the value of the work they do with families. While there
are continual developments in therapeutic models and treatment modalities, key to all of these is the way in which the individual clients
engage in these processes. We will explore the key skills required to engage children, young people and families in the care that a CAMHS can
provide and the importance of establishing positive therapeutic alliances in order to make a positive difference in their lives. We will consider
how the basic assessment and therapeutic skills and tools can be adapted for the developmental range, before going on to discuss some of
the challenges in working with family groups and the therapeutic process itself.
If we consider the therapeutic relationship to be a signifcant factor in therapeutic change, then it would be remiss of us to consider only the
thoughts, beliefs and emotions of the client. As clinicians we too carry a world of personal beliefs and experiences which inevitably impact
on our thoughts behaviour and relationships. During this module, therefore, we also examine the role of the clinicians experience, values and
beliefs in forming and maintaining therapeutic relationships. Faced with the emotional stresses and strains of therapeutic work, these values
and beliefs can be stretched and tested. Key to the maintenance of a positive relationship, not to mention effective therapeutic work, is the
capacity of the clinician to refect on these experiences and their impact on practice.
However the therapeutic relationship does not exist in isolation. There will inevitably be other agencies involved in the familys life and the
clinicians relationship with theses services will impact on the therapeutic alliance. The CAMHS clinicians contribution to the work of these
services, whether it be sharing information, reframing perceptions or direct input to their plans and activities, will have an impact on the
experiences and perceptions of the child and family and therefore on their perception of the relationship. We will therefore briefy look at
interagency working and its impact on engagement.
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Furthermore, it is unlikely that this particular path is the only
one the family have travelled since their diffculties arose. The
consequences of mental health diffculties in young people
often reach far beyond the family environment. For the young
boy displaying challenging behaviour, there is often school
and community involvement. The family are likely therefore
to have had support and advice from a range of services and
professionals including Public Health Nurse, G.P., education
staff and perhaps even the police.
In time, the journey may become more integrated for families
and, as services become more client centred and practice
becomes more values based, it may also become less arduous.
Either way however each service, and individual clinicians
within each service, has a signifcant role to play in engaging
with all families. If the development of a positive therapeutic
alliance is an end goal, the formation of this relationship with
the individual begins even before the frst meeting.
Thinking about the journey
Where Does it Begin?
The day a family arrive at the door of your CAMH service may be the beginning of a new experience. It may
mean they have access to a range of highly skilled professionals who can offer support and guidance which,
ultimately, may bring about signifcant change in the quality of their lives and the relationships in their family.
However, for the family, this is unlikely to be the frst step on their journey; rather, it may seem like the last leg of
a long and arduous trek for them.
2.1 Accessing Services
Imagine you or a member of your family is worried
that their child is developing a mental health problem.
Where would they go for help or advice?
Who would they speak to?
Who would help them fnd the appropriate
resources?
Think of the path they would need to take to arrive at
your service. Also consider the kinds of experiences
they might have which your service would be able to
help with.
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The First Steps
Have you ever wondered what it is like to arrive at your service as a client for the frst time? What kinds of
feelings might this engender? For most families, the frst appointment will be a new and anxiety provoking
experience. There will undoubtedly be expectations of the types of people they will meet there, such as doctors
and nurses, and the roles they fulfl. There will be speculation about what is expected of them and about
outcomes. There will be beliefs about the reason for being there, the source of the diffculties and there may be
worries about who is to blame.
Furthermore, almost every initial appointment will be attended by a number of family members, each of whom has their own set of concerns
and perspectives. The clinician has to balance and address these fears and allow each family member to feel included, valued and ultimately
engaged.
You may have attended a CAMHS yourself as a service user at some point in the past. If so, you will have a rich vein of experience to help
think about meeting new families. If not, you may have had similar experiences elsewhere. For example, attending somewhere new which
involved meeting someone you perceived to be in authority. It may have been a new job; it may have been the childrens headmaster; or it
may have been the bank manager. In all of these situations, there is an inherent power imbalance; an inequality that may impact on how you
feel, what you say and how you behave. Remember how you felt? How it impacted on how you interacted with this person. How it affected
what you said; how you spoke; how you reacted to their questions.
Potentially this could be equally true for families attending a CAMH service. However, as we will see, these imbalances are likely to hamper
progress as the relationship with the families. Therapeutic work is predicated on open and collaborative relationships which offer safety,
security and predictability.
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Some families may have attended CAMHS before. While
this familiarity may reduce some of these anxieties, their
previous attendance is likely to impact on their current
interactions: what were their previous experiences? How
did the attendance fnish? Did their attendance prove
helpful? Were they happy with their experience? While
such families may appear familiar with the process, their
beliefs and perceptions may similarly create barriers to
the engagement process.
However, as we noted earlier, the familys relationship
with your service begins long before that frst visit. In
many ways the relationship with your service begins at
the moment the G.P. suggests referring the family. This is
when their vision of your service begins. Take some time
to think about how children and families are welcomed
into your service by doing Activity 2.2.
Hopefully this exercise will help you consider the
impact of your service on the children, young people
and families who come along. All of these factors set
the context before any attempt to develop a working
relationship can be made. Further issues you might
like to consider would include access e.g. if you had a
disability how easy would it be to negotiate access? If
you had a learning disability how accessible is the written
information about your service?
2.2 Welcome
Put yourself in the position of a family arriving at your service.
You can do this by sitting in reception and observing how a real
family are welcomed. You can also physically try it by leaving
your home and imagine attending an appointment and following
the steps you would need to take. When you are observing
in the waiting room, think about the experience of each of
the family members. You should address the following areas:
preparation for the appointment, travel, being welcomed.
How were you invited to attend the service?
What information did you receive about the service?
How would you actually get to the service drive, by public
transport, walk?
How would you know when you were there - is the place
well signposted?
How are you welcomed by reception?
What is the atmosphere in the reception area?
How is confdentiality and privacy maintained what might
this feel like for the family?
How do the professionals you are meeting speak to you
how might that make you feel?
Make some notes in your portfolio and discuss your fndings
with your supervisor.
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Clearly, within any service there are factors which are diffcult, if not impossible to change. The structure and location of the building, or the
regularity of public transport are often immutable, however the interactions with the service, both written and verbal, are important factors in
setting the scene for the developing relationship. At a service level, one approach could be to involve users in the design and development of
this function of the service, however each individual clinician can have a signifcant impact on the familys early experience
It seems clear therefore, that the familys journey to the frst assessment session is neither simple nor easy. There may be many barriers to
engagement some of which you, as a clinician, have infuence over and some not. However, the next step in the journey for the family is
sitting down with you in their frst session. Depending on the service in which you work, this may have a variety of names. It may simply be
called the assessment session, it may be called a choice appointment or it may be a triage session. Either way, the function is similar; to
engage the family in the process of describing their current diffculties with a view to establishing whether and how you and your service can
be of help.
2.3 Getting it right for Every Visitor
When you engaged in the previous exercise, were you struck by
any particular strengths or weaknesses in your service?
How much time and investment does your service spend in
getting that frst meeting right?
How would you address any issues you have identifed?
Based on your experiences, are there any things you as a
clinician could do to improve the experience for families?
For those areas where you feel you have little infuence, are three
things you could do in the frst meeting to reduce the impact?
Are there any ways in which you feel the service could improve
the overall experience?
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The Initial Meeting
While the aim of this frst session is to gather information about the familys diffculties, the history of those
diffculties and, perhaps more importantly, the familys beliefs about their diffculties, fundamental to the success
of this process is the development of a positive working relationship, or as Carr (2006) notes, all other features
of the consultation process should be subordinate to the working alliance.
As we saw there can be many barriers and anxieties for families which are likely to impact on the way they communicate with us as clinicians,
and ultimately the way in which they make use of our service. The frst task therefore is to set the groundwork for developing a sound
working relationship or therapeutic alliance with the family.
Transparency, honesty and consistency are key issues in the development of these relationships. There may be some diffcult challenges
during the course of the relationship but modelling openness from the outset will allow these challenges to be acknowledged and examined.
2.4 The Taylor Family
Four months have passed since Alison was
referred to your service. The family
have all come along for the frst session. Although
little has changed, Alison continues to express
that she feels she does not need to be there. She
believes her behaviour is normal.
In these circumstances, who would you
consider to be the client?
How do you consider the goals of treatment;
whose goals do you use?
How might Alisons goals differ from her
parents?
Discuss with your supervisor whether they have had
similar experiences. What did they do?
Although it may be a family group who attend together and sit with you in your
clinic room, each member will have their own feelings and beliefs about the
diffculties and about attending. Each family member needs to be included and
involved in the process in a way which allows them to participate to the best of
their capacity. They key to the change process is empowerment. Each individual
must develop the sense that they have the capacity and means to make any
changes being asked of them. Family members who feel undervalued or excluded
from these initial processes are likely to reject any later recommendations made by
the therapist, or alternatively are likely to simply drop out of the process.
While the views, motivations and goals may be very different for each of those in
the room, we can still begin by valuing each of their contributions equally. Indeed,
motivations and expectations my be conficting and appear, in the frst instance,
irreconcilable, however by respectfully listening, summarising and checking your
understanding of their contributions we can start to develop an environment where
people can begin to share views in a non-judgemental and respectful manner. The
authority carried by any single member of the family may be important for the
processes in the family, but our aim is to consider how each of the members feel
and think, and to try and capture a glimpse of their individual world view.
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Case study: The Taylor family
Mr and Mrs Taylor have two children; Alison is 14 years old
and David is 9 years old. For the past year or so they have
found it increasingly diffcult to deal with Alisons behaviour.
Although Alison has always been a diffcult child more recently she has
become increasingly defant. Over the past few months she has been
staying out past her curfew. Most weekends she is away all day Saturday
and Sunday and on several occasions, her parents have been unable to
contact her. They have attempted to ground Alison, however she has run
away a number of times; one of which involved jumping out of her frst
foor bedroom window. Mr & Mrs Taylor are also concerned about the
impact Alisons behaviour is having on David.
While Mr & Mrs Taylor have found this a struggle, they are more concerned
about two instances of what appear to be deliberate self harm. Alison has
twice cut her fore arms with a craft knife. When confronted after the frst
episode, Alison said she was just seeing what it was like because some of
her friends did it. She assured mum it would not happen again, not least
because it was painful. After the second incident, Mrs Taylor took Alison
to the G.P. who met with Alison alone. Alison reported to him that she was
feeling fne. There were no worries at home, other than mums constant
nagging and while there had been some bullying going on at school,
this had stopped when she started hanging about with this new group of
friends. She commented that she was behaving no differently to her friends
and that she wouldnt have to run away if mum and dad werent so uptight.
He discussed a referral to CAMHS with the family and while Alison didnt
think it was necessary, the G.P. felt Mr & Mrs Taylor were really struggling to
manage and would beneft from the support your service can offer.
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However valuing contributions equally does not necessarily mean everyone giving equal contributions. Furthermore, young children may
contribute through play or behaviour. Encouraging contribution is important, but respecting the choice to withhold contribution is equally
so. Particularly in the early stages of the relationship, some family members may wish to wait and see what happens. How do you, as clinician,
deal with information? What expectations do you have? How do others view you? By remaining open, warm and respectful to everyone and
creating opportunities for their contribution should they choose, in time even the most reluctant contributor may fnd a voice.
Joining with a family such as the Taylors can be
a trying process. We inevitably bring our own
feelings and beliefs about families, children and
behaviour to our work. How easy do you think
it would it be to balance Alisons views with the
distress of her parents?
How do you think you might feel toward
Alison in these circumstances?
How do you think you may feel toward Mr. &
Mrs. Taylor?
How may these feelings make you behave?
How would you know if you were behaving
this way?
It may be worthwhile discussing these answers
and feelings with your supervisor. Learning to
acknowledge and respond to these thoughts and
feelings is the beginning of engaging with families
in open and honest ways and of developing a
clearer understanding of their world.
Inherent in valuing the individual is valuing their role in the
process. While you undoubtedly carry a great deal of knowledge
in relation to services, mental health and psychology, families
and their individual members are the experts on themselves and
their lives. They carry knowledge of their family functioning,
their development and their diffculties as well as their individual
experiences, hopes and beliefs. The story (or formulation) which
will fnally emerge will be an integration of these two bodies of
knowledge and experience which explains the familys experiences
and makes sense within both realms, offering choices about how
things can change. This can only be achieved with a collaborative
approach which shares responsibility for the whole process, while
acknowledging respective strengths and limitations.
Through all of this engagement activity, it is worth remembering
that children and young people often fnd it diffcult to be referred
to a CAMHS at all, perceiving it as a threat to their social identity;
many may even be there under duress. Research has shown their
experience in CAMHS can be stigmatising and there is a risk that
the experience of CAMHS interventions recreate the sense of
powerlessness young people can experience when adults take
charge of decision making for them (New to CAMHS, 2006). Having
said that, respect must be paid to particular circumstances, and
young people also want adults in their lives who are powerful
enough to make things happen on their behalf.
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The Next Steps
As was noted in the discussion of the therapeutic alliance, increasingly research is suggesting that the quality of
the relationship and the progress of the therapeutic task are interlinked. Throughout the course of the families
attendance at your service there may be threats to both progress and the relationship itself.
Within the clinic room, many facets of the discussions may be perceived as challenging by clients. Some aspect of the therapeutic process
may even be perceived as threatening. Refecting on ones own history or current behaviour can be diffcult However the therapies in which
we engage take place in rooms and much of the work that is generated for families occurs out in the real world. Inevitably we will be asking
them to make changes in their daily lives; changes which may be diffcult or even uncomfortable. Some may lead to success; however some
may end less positively.
2.5 Threatening Factors
Can you identify factors which may threaten
the quality of the relationship during the
course of a familys attendance at your service?
Try to think of factors which may impact
During session
Out with sessions
Discuss with your supervisor
How you might spot these threats
How you might deal with these threats
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The continued quality of the relationship, while potentially threatened
by these challenges, is the primary means of supporting clients through
those same changes. Alongside monitoring progress and change, the
clinician needs to maintain the integrity of the relationship, ensuring
that threats, or even ruptures, are aknowledged and repaired. Once
again empowering the client to address their concerns and creating an
open and honest space for their discussion can reduce their impact.
Perhaps the one aspect of the therapetic relationship which
differentiates it from other relationships is that the primary objective of
the relationship is that it will, at some point, come to an end.
Refecting on relationships
Consider a family or young person with whom you
have been involved. Were there times when the
relationship appeared strained?
How did this feel?
Did it have any impact on how you thought
about or related to the client?
Did it resolve?
Do you think you had any role in the strain?
It may be worth discussing these experiences with
your supervisor. Threats to the relationship can
manifest in many ways and can be experienced
as personal. It is often helpful to be able to think
about these openly outside the relationship with
the client
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Setting the context
(for working together with children and young people)
Being able to work with children and young people depends on the skills, values
and qualities of the practitioner. In this section we will look at some issues
which need to be considered when working closely with children and young
people. Walker (2003) argues that the success of any intervention depends
on how perceptive and insightful the practitioner is. Walker suggests the
following areas should be considered:
Providing a suitable setting the setting should be welcoming, with age appropriate
materials which the child may explore in the interview. He advocates sitting alongside the child
as the child may fnd this less intimidating.
Planning the session consent and confdentiality issues need to be resolved. Here the focus
should be on enabling communication.
Setting boundaries working out the ground rules from the practitioner and childs
perspective, what the child can expect. The child should be encouraged and supported to
contribute to this process. How long sessions last and how frequent will they be.
Listening and Refecting - close attention should be paid to non-verbal communication.
Listening and acceptance is the preferred stance. Part of this process is reframing what you
have understood the child to be communicating and refecting this back to the child.
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Youngminds, a leading Voluntary Organisation, carried out a consultation with a range of CAMH service users, asking what they considered
important in a clinician. While there was variation, some key characteristics and behaviours did emerge. They noted that they found it most
useful when clinicians:
Listen; Let us speak dont ramble
Kind
Respectful not patronising
Thinks about people frst we are not an illness
Treats you as a person; takes interest in our other interests and doesnt see us as an illness
Give us time
knows when to put their foot down
Asks the patient how they are feeling
doesnt tell them!
Communicates; tell us what you are doing
Non-judgemental
Prepared to journey together
Committed
Follows through with plans and support.
At one level these may seem relatively easy to achieve,
however there may be individual or organisational barriers
which prevent you from providing the optimal service.
2.6 What children want
Consider your reactions to the list
Do you have concerns about any of the statements?
Why is that?
What do you think infuenced these concerns?
What would the most challenging aspect be for you?
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The interpersonal or attachment relationships that children
and young people have with their main carers are both a
source of comfort and a model for the relationships they
develop elsewhere. Their view of adults, and therefore you as
a clinician, as being safe and helpful (as opposed to unhelpful
or even threatening) is likely to be some function of their
attachment experiences. The nature of these relationships is
likely to have an impact on and manifest in, how they relate
to staff. Children may need to have their main carers close by
to offer a sense of security.
Adolescents may also wish parents to be present initially,
until they themselves are comfortable with the situation.
Separation may cause additional stress or discomfort and
have a negative impact on the therapeutic relationship.
Reluctance to separate may also simply be a function of
the adolescents belief that they do not need to be there.
However, as noted in Module 1, adolescence is a time of
identity formation and growing autonomy. Young people
may be happy and willing to separate, although the capacity
to engage in the subsequent therapeutic conversation may
depend on a variety of factors, including cognitive and
emotional maturity.
As clinicians, for each child or young person, we need to
evaluate their capacity to self-report strengths and diffculties
objectively and we may draw on parents or carers in
developing a rounded clinical picture. Doing so can also
help clarify the different expectations young people and
their carers may have about therapeutic outcomes, a process
which, skilfully done, can itself go a long way to building a
good therapeutic alliance.
Adolescent engagement
Suzy is a 14 year old girl who has been referred because
of a recent increase in anxiety in social situations. She has
become withdrawn from her peer group and her parents
have noticed an increase in confict within the house on
those occasions when they encourage her to go out. Suzy
herself said to the GP that she had experienced more
anxiety, even at the thought of going out sometimes. Suzy
is a bright, if very shy girl, who is functioning well in most
other aspects of her life.
On the second meeting, she agrees to meet with you on
her own for half of the session, but fnds it quite diffcult to
talk.
How might you approach Suzy and begin to develop
rapport?
What role might you fnd yourself playing or what
behaviours might you fnd yourself exhibiting?
(based on Suzys presentation) that may later prove
unhelpful?
How would you know you were beginning to fulfll
these roles?
What thoughts and feelings may you experience,
which could potentially infuence the way you
interact with Suzy? How could these impact on the
therapeutic alliance?
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Adapting sessions
Depending on age and stage of emotional and cognitive
development, children and young peoples capacity for
language and self-reporting my impact on their ability
to engage in the kinds of conversations which take place
during talking therapies. As we saw in Module 1, the
capacity to think about others, to tolerate alternative
perspectives and to access thoughts and feelings varies.
Strategies for addressing this issue include;
clinicians adapting their own language accordingly;
developing hypotheses about thoughts and emotions
the child may be experiencing based on observation and
understanding of behaviour including interactions with
others, play, problem solving
checking those hypotheses directly with the child or young
person.
Therapeutic sessions can be structured creatively, with non-verbal methods
incorporated as appropriate, such as drawing or painting, or playing with
toys. While there is a general expectation that sessions will be of one hour
duration, this may prove too long for some children, depending on their
developmental stage and their capacity to concentrate. It may also be
essential to include carers in part or all of any intervention offered, and, as
a minimum, to regularly check-in with them to obtain and all-round view of
progress and identify what problem areas to address next.
2.7 Adapting Language
Matching language with the clients
understanding is vital for maintaining
communication, reducing confict and confusion
and ensuring shared goals. Consider how
you might explain the purpose and process of
attending CAMHS to:
A 5 year old who has been referred because
of behaviour diffculties
An 11 year old who has been referred for
school anxiety
A 16 year old who has been referred for self
harm
Role play each one with your supervisor.
How did you adapt your language
(vocabulary and structure)?
How did you accommodate their differing
cognitive capacities?
How did it feel trying to express yourself at
each of the levels?
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It is also important to consider the things children and young people say within a
developmental context. For example, an adolescent saying he or she has not seen their
friends for ages may mean something very different from an adult using the same
phrase. Here, the key is to obtain as behaviourally specifc as possible an understanding
of information like this. Does ages mean months, weeks, or days? It is also crucial not to
dismiss or diminish the signifcance of the response should it carry a different signifcance
for us in our own lives. It is worth being mindful too, that a friend, a group of friends, or a
peer group can be found (and sometimes lost) on the internet as well as in everyday life.
Perhaps what is more important however, is what this means to the young person.
Adolescence can be a period of time in which young people experiment with new ideas
and ways of being and learn to take risks. This may happen in ways which are bold or
dramatic - and sometimes challenging to the adults around them. Simultaneously, even
the most apparently robust young person can be acutely sensitive to the behaviour and
reactions of signifcant adults in their lives; and that includes clinicians. The skills required
to manage this include a sense of openness and kind curiosity towards the young persons
behaviour, attitudes and emerging world view. As staff, we also need to be able to discern
between healthy adolescent development and psychological problems, and work with
both throughout treatment. These are key skills and represent some of the pleasure and
challenges which go together with with working alongside children and young people;
not to mention the challenge.
Communication
Remember, communication is not simply a process of speaking
and listening, but a process in which the outcome is a shared
understanding i.e. checking out that what you hear is what is
meant and what you say is understood as it was meant to be
understood. Perhaps what is more important however, is what
it means to the young person; what are the thoughts, feelings
and behaviours that are associated.
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Working with Emotions
As CAMHS clinicians, you will spend much of your time steeped in the strong, often uncomfortable, emotions
of the children, young people and parents you meet. Supporting clients to understand and manage these
emotions is pivotal to the work we do. There are a number of terms commonly used to describe how young
people manage emotions and our ability to work alongside them. Emotional Intelligence, emotional literacy and
reciprocity are such terms. The following activity asks you to consider these terms and how they may be helpful
in your practice.
2.8 Working with Emotions
What do you understand by the term emotional literacy?
How might being emotionally literate help a young person?
How could you promote emotional literacy?
What do you understand by the term emotional intelligence?
Is it different from emotional literacy?
How might being emotionally intelligent help a young
person?
One of the fundamental aspects of working alongside children and
young people is the concept of reciprocity.
What is your understanding of the term reciprocity?
With the help of your mentor, your colleagues or your team,
identify examples of reciprocity in your service.
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Emotional Containment
Anxiety, anger, guilt, hopelessness are but some of the strong and often aversive emotions that can be evoked in the course of a therapeutic
session. Creating space for those attending to experience, examine and process these emotions in key to the change process. Briggs (2008)
proposes that, within the therapeutic relationship, we must create a place of safety which will allow people to tell us directly how they think
and feel, and which also allows them to project on to us any thoughts or feelings which may be too painful for them to tolerate for the time
being. They use the metaphor of dissolving salt into a glass of water: if you drink that mixture it may well taste terrible. If you pour the
mixture into a larger vessel and add more water, the salty taste diminishes and the drink becomes more tolerable. They argue that therapists
task is to be that larger vessel.
Being the larger vessel means, by defnition,
holding onto and dealing with the strong
emotions of others Since, generally speaking,
CAMHS staff are, by their nature, sensitive,
empathic and attuned this can lead to strong and
uncomfortable emotional experiences. These can
be confusing and intense, particularly for new
staff who may fnd themselves carrying thoughts
and feelings they do not recognise as their own
and are uncertain as to where they came from
(Rose 2002: 36). Staff may even fnd themselves
behaving in ways they fnd surprising, such as
avoiding contact or taking sides. Understanding
the meaning and function of these emotions is
as important for the clinician as it is for the client.
In the section on Refection and Supervision, we
will discuss ways in which the clinician can think
about their own thoughts and emotions, how
to recognise them and what function they may
serve.
The idea of creating a safe space relates in many ways to the concept of secure
base described by Mary Ainsworth in her work around attachment. Paul Gilbert
(2007; 148) describes how the safe space requires not only physical safety and a
sense that the discussions are safe (i.e. they are not being judged by the clinician
and the content is in safe hands), but also a sense that the clinician themselves
is safe; they are robust enough to deal with whatever may come and can emerge
from the other side. Only in experiencing this sense of safety (secure base) will
the childs attachment behaviour system subside suffciently to allow the young
person to explore the content of sessions. Depending on theoretical orientation,
developmental stage and the nature of the diffculties, that content may range
from developing reward charts through to exploring the meaning of relationships
and identity; whichever level you are working at, all these tasks will require the
young person to expose themselves to some level of emotional distress and this
unlikely to occur without a secure base from which to explore.
Siegel (1999) also describes ways in which clinicians can work skilfully with
attachment. He notes that secure therapeutic relationships are based on
continuous collaboration and communication in which the various parties are
sensitively attuned Therapy involves refecting on meaning from the young person
or childs perspective so they can then learn from the experience of being in
therapy and that when there are disruptions to therapeutic relationships, or the
communication within them, these must be addressed and repaired (Siegel 1999).
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Emotional containment in
different settings
Modern CAMHS work takes place in a wide
variety of other settings too, including: GP
surgeries / practices, informal settings such as
a caf, college or gym and children and young
peoples own homes. Discuss with your mentor
or colleagues what you think the different issues
are in terms of emotional containment in these
settings.
What challenges might the different
settings present?
What do you think the advantages of each
setting might be frstly for children, young
people and their carers and secondly for
you as a member of staff?
We have examined some ideas describing how staff
can understand and help young people contain diffcult
emotions. The families that we see in our services have
of course often been managing to do this long before we
began to be involved in their lives.
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Case study: Alley
Alley Watson is 14 and has been given a diagnosis of anorexia. She is signifcantly
underweight for her height and age as a result of restricting her food intake and
exercising. She lives with her parents, James and Mary and her brother Tom, aged 9.
James runs his own IT business and Mary is a primary school teacher. Alley is a keen
pupil at her secondary school and has performed well academically so far. She is also in
the school drama club and swimming team. She is busy socially too, both on internet
social network sites and face-to-face social contact. Very recently Alley has been advised
by medical colleagues that unfortunately she needs to rest more due to the physical
consequences of her anorexia, which means she is to be off school and not to exercise.
Alley is very upset and anxious about this, and does not believe she can manage without
those things in her life.
2.9 Working Alongside Alley
Even though you only have limited information here, use the Integrated
Assessment Framework described in Module 4 to build up a holistic picture of Alley
and her family.
Consider how you could help the family cope with this crisis. What strengths do the
various family members have that could help them? Are there things that might
need to change in the family for now? What role might different family members
take in helping Alley with her distress?
Discuss your fndings with colleagues- would they do anything different?
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59
Cultural competence
The diversity of service users, carers and families we encounter in all areas of health care highlights the
importance of cultural competence for individual practitioners as well as for services and organisations. There is
no single defnition of cultural competence, but at the level of the individual practitioner, the various defnitions
usually refer to knowledge, attitudes and skills that allow the practitioner to understand and appreciate cultural
differences, and to the capacity to provide effective health care which takes into account peoples cultural beliefs,
behaviours and needs.
This raises an important question: what is culture? A commonly quoted defnition of culture is from Chamberlain (2005, p.197): who defnes
culture as the values, norms, and traditions that affect how individuals of a particular group perceive, think, interact, behave, and make
judgments about their world. While this is a useful starting point, it is important to remember that culture is not a homogenous or static
entity. It is also not the same thing as ethnic identity. Anthropologist and physician Arthur Kleinman suggests that we should think of culture
as a process of making meaning (2006, p. 1674). This is a dynamic process, and it is shaped by differences in age, gender, social class, religion,
ethnicity, or even personality. Thus, culture is not a list of traits or beliefs shared by a social group, but it is fundamentally about how people
make sense of experience.
We all participate in multiple cultures which are linked to our ethnicity, nationality, social class, and other aspects of our identity like gender,
sexual orientation or religion. Culture shapes the way we think, feel and experience our lives. We are also shaped by organisational and
professional cultures. Cultural competence is also about understanding how culture infuences the way we think and act, the things we value
and our understanding of health, illness, personhood, recovery, etc.
Developing cultural competence is not a process of learning lists of facts about other cultures. It is about learning to understand and work
with service users from a range of diverse cultural and social backgrounds. A key part of this is learning to be refective about our how own
culture infuences our assumptions and the ways we work.
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Models of Cultural Competence
There are a variety of models of cultural competence which are
used in the health services. They often break cultural competence
into domains, including awareness, knowledge, sensitivity, skill. One
example is the model developed by Papadopoulos, Tilki and Taylor
in CAMHS services. Campinha-Bacotes (2003) model, which was
developed in nursing, lays out fve constructs: cultural desire, cultural
awareness, cultural knowledge, cultural skill and cultural encounters.
Seeleman et al (2009) proposed a conceptual framework for cultural
competency in medicine based on the following:
Knowledge of epidemiology and differential effects of
treatment in different ethnic groups;
Awareness of how culture shapes individual behaviour and
thinking:
Awareness of the social context within which groups live;
Awareness of ones own prejudices and tendency to
stereotype;
Ability to transfer information in a way the patient can
understand;
Ability to adapt to new situations fexibly and creatively.
Cross et al (1989) also proposed a continuum, which was originally
designed to assess an organisations level of cultural competence,
but has been adapted on the next page to help you think about your
own level as a practitioner.
2.10 Cultural Biography
Write a cultural biography refecting on
how your own culture has infuenced and
shaped your beliefs and professional practice. There
are a number of ways you could approach this. Here
are some suggestions to get you started:
How do you defne health, mental health, youth,
recovery, well-being? Are these ideas important
to you and, if so, why?
Do your personal defnitions (that is, your
defnitions when thinking about yourself)
differ from your professional defnitions (the
defnitions you apply at work)?
Who or what infuences the way you think
about these concepts? Where did you learn the
attitudes and knowledge?
Do you act in accordance with these defnitions?
Why or why not? What factors infuence the
way you put your knowledge and beliefs in to
practice?
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Competence level Practitioner characteristics
Cultural profciency Holds culture in high esteem
(Advanced competence) Adds to knowledge base by doing research, developing new approaches based on culture,
publishing results of demonstration projects.
Seeks advice and supervision from specialists in culturally competent practice.
Advocates for competence throughout the system.
Cultural competency Has acceptance and respect for differences.
(Basic competence) Engages in continuing self-assessment regarding culture.
Makes adaptations to service models in order to meet client needs.
Seeks advice and consultation from minority communities.
Cultural pre-competence Appreciates own weaknesses in serving minorities and attempts to make specifc improvements.
Tries experiments; explores how to reach clients, seeks training on cultural sensitivity, recruits minorities
for boards and advisory committees.
Has commitment to human rights.
May feel a false sense of accomplishment that prevents further action.
May engage in tokenism.
Cultural blindness Believes that colour or culture make no difference; were all the same.
Believes helping approaches used by dominant culture are universally acceptable and universally
applicable.
Thinks all people should be served with equal effectiveness.
Ignores cultural strengths and blames clients for their problems.
Follows cultural deprivation model (problems are the result of inadequate cultural resources).
Cultural incapacity Takes paternal attitude toward lesser groups and communities.
Discriminates based on whether clients know their place and believes in the supremacy of dominant
culture helpers.
May support segregation as a desirable policy.
Gives subtle not welcome messages.
Has lower expectations of minority clients.
Cultural destructiveness Holds attitudes, beliefs and practices that are intentionally destructive to a cultural group.
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Working with Diversity
We have already noted that culture is a dynamic process, rather than
a static entity, and that there are cultural differences within as well
as between groups. We have also realised that developing cultural
competence is not just memorising a list of characteristics attributed
to particular groups; indeed, that sort of approach leads to the risk
of stereotyping. We have also considered different models which will
help us to understand the idea of cultural competence. The question
is, how can we take this forward in practice?
2.11 Models of Cultural Competence
Investigate models of cultural competence using the
resources listed previously or other resources available through
the Knowledge Network. With a mentor or colleague, discuss
which models you fnd helpful in refecting on your own
attitudes, knowledge, skills, and practice. What is the most
important learning point for you from this discussion?
Kleinman (2006) offers a practical approach which is based on the anthropological method of ethnography. Ethnography is about
engagement with others. In a clinical context, ethnography is about learning from patients, carers and family members about their
understanding and experience. He notes that the clinician, as an anthropologist of sorts, can empathise with the lived experience of the
patients illness, and try to understand the illness and how the patient understands, feels, perceives and responds to it. (p. 1674).
Kleinman suggests a process which is a six-step mini-ethnography. This is based on his explanatory models approach and is a revision of the
Cultural Formulation included In the DSM-IV (2006:p. 1674-1675). The process is as follows:
Step 1 Ethnic identity. Ask about ethnic identity and whether it matters for the patient.
Step 2 What is at stake? Evaluate what is at stake for patients, families and others in an episode of illness.
Step 3 The illness narrative. Using a series of open questions, develop the patients explanatory model questions. This can be a way of
opening up a conversation about different cultural meanings which may have implications for care.
Step 4 Psychosocial stresses. Considering ongoing stresses and social supports.
Step 5 Infuence of culture on clinical relationships. Clinicians need to be able to refect on their own culture, and how this impacts their
expectations of the relationship.
Step 6 The problems of a cultural competency approach. This is about effcacy does the intervention actually work in this case? How
useful is the focus on cultural difference? Are there issues here which cultural competency alone cannot resolve?
One of the advantages of this approach is that it supports the delivery of person-centred care, as well as the engagement of service users,
their cares and their families in their care. It also provides the clinicians with a way to refect on their own explanatory models.
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Although these models and techniques have been developed in relation to such things as cultural diversity and disability, the principles
involved are similar to the ideas expressed elsewhere in this resource. Key to supporting change in children, parents and families is developing
a shared understanding of the meaning and relevance of their diffculties and the circumstances surrounding them. One could consider each
and every encounter as a trip into cultural competence, where understanding from the clients perspective is the aim, and ultimately will be
the catalyst for insight and change.
2.12 The Explanatory Models Approach
Compare this approach to existing assessment processes in your service.
To what extent do your existing assessments enable you to consider the
aforementioned issues outlined?
Think of a time when you were ill. Using the explanatory models approach,
construct your own illness narrative. How do you think your cultural
background infuenced this narrative? Did your narrative differ from those of
the healthcare practitioners who were treating you? If so, how did that make
you feel? Did it affect the way you were involved with your treatment?
Practice the explanatory models approach with a service user (regardless of
specifc cultural background) and refect on the process. Were the questions
easy to ask? Were you surprised by the results? Did you learn anything
which made you reconsider your practice/care for that individual? What
was the service users experience of the process? Did it improve the clinical
relationship or not?
The Explanatory Models Approach
What do you call this problem?
What do you believe is the cause of
the problem?
What course to do you expect it to
take? How serious is it?
What do you think this problem does
inside your body?
How does it affect your body and your
mind?
What do you most fear about this
condition?
What do you most fear about the
treatment?
(from Kleinman, A 1988, The Illness
Narratives: Suffering, healing and the human
condition. NY: Basic Books).
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Working with Risk
The term risk, in general refers to the current, or future, probability of the occurrence of a negative or positive
event (Morgan 2000)). In this section we will examine aspects of risk within the therapeutic setting.
Working with risk and managing the anxious feelings that are created by and within the young person is important, however managing the
anxious feeling within ourselves is key if we are to work alongside young people who are at risk either to themselves or others. We will begin
by considering the concept of risk and how it manifests in CAMHS work before going on to look at a range of models which support the
assessment and management of clinical risk and how to support young people who present with elevated risk. We will also look at challenging
behaviour and how this can be managed within the context of CAMHS.
2.13 Risk taking in context
Depending on your own life stage, consider either:
Your own experiences as an adolescent, or
The experiences of an adolescent you know
During adolescence, were there behaviours that you/they engaged in
which others considered risky?
Did you/their peer group engage in risky behaviours?
What were the views of the adults around you/them?
How did these views contrast with yours/theirs?
How were these differences resolved?
What are your/their views now?
Use these thoughts to discuss with your supervisor your thoughts about
developmentally appropriate risk taking behaviour. Is there such a thing,
or should we act to mitigate all risk?
Risk is an everyday part of life. There are risks in
crossing the road, risks in cooking our dinner and,
emotionally, risks in many of our relationships. In the
daily practice of living, many of us have learned to
manage these risks. Generally speaking, we do not
avoid them, nor do we ignore them; rather we fnd
a way to mitigate risk where possible (i.e. cross at a
crossing) or tolerate the discomfort caused by the
thought of risk, usually with an eye on the outcome
(when you applied for this job, there was a risk of
rejection; with little means of mitigating this risk you
clearly found a way of tolerating your discomfort
and completed the application). Within our work
in CAMHS, we will encounter many kinds and levels
of risk which need to be mitigated, managed and
tolerated, all with an eye for the outcome.
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Clinical Risk Management
Although relatively rare, there are particularly areas of risk associated with the mental
health diffculties we encounter in CAMHS. For example a young person with low
mood, experiencing hopelessness may be at risk of attempting suicide; a person
experiencing command hallucinations may also be at risk of self-harm or causing
harm to others; a person with an eating disorder may be malnourished and their
immune system compromised.
External risk factors, that is, those caused by other people or situations, include abuse (which can be sexual,
physical or emotional) and the consequences of neglect.
Inevitably, there is an interrelationship between external risk factors and psychological distress, with, for
example, abuse leading to low self-esteem and low mood, potentially culminating in self-harm. There may
also be other signifcant diffculties in a childs family which do not necessarily involve immediate risk to
the child, but which nonetheless heighten the level of risk and could impact on their psychological health.
Domestic spousal abuse and parental or carer drug and alcohol misuse are examples of this.
2.14 Risk Management
Consider a family where one parent is engaged in chronic drug misuse.
Can you think of ways in which this may increase risk to:
The three year old daughter
The 12 year old son
Discuss this with your supervisor. Find out if hey have had similar
situations with families they have dealt with.
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Regardless of the nature of the risk, the task in clinical risk management is to identify the actions and strategies which will deliver the best
outcome for the child; balancing risk management strategies with ongoing psychological treatment (Flewett 2010). Flewett (2010) argues that
the term risk management was coined by American Insurance companies and has become associated with a culture of blame and litigation,
both of which are anxiety provoking for staff. He also notes that clinical staff are under increasing scrutiny and simultaneously society has
become more risk-averse. While it is reasonable that clinicians are held accountable for their actions, this has the potential to create a vicious
cycle in which staff, anxious to avoid blame and punishment, become more conservative in their decision making. This can result in poorer
outcomes for service users. Indeed, in recognition of the value, and requirement for appropriately managed positive risk taking as a tool for
therapeutic progress no.9 on the list of Essential Shared Capabilities reads:
Managing Positive Risk
Try and identify a young person or
family with whom you have worked
where clinicians have encouraged
some level of positive risk taking.
This may have involved engaging in
some activity outwith the therapeutic
session, for example going out with a
group of friends.
Who identifed the risk factors?
What did it feel like to
encourage this activity?
How did you manage:
Your own perception of risk?
The young persons
perception of risk?
How did you know the risk was
reasonable?
ESQ NO.9: Promoting Safety and Positive Risk Taking. Empowering the person
to decide the level of risk they are prepared to take with their health and safety.
This includes working with the tension between promoting safety and positive
risk taking, including assessing and dealing with possible risks for service users,
carers, family members, and the wider public.
In the adapted 10 ESC for working with Children and Young People, this translates into:
Keep me safe; help me grow: Believe in my participation in my life.
Part of the growing up process is achieved through making mistakes and learning
from them. Therefore having the opportunity to make mistakes, to fail in tasks, is
a signifcant feature of development in young people. This involves taking risks
and this descriptor is about the relationship between keeping children and young
people safe and supporting appropriate risk taking that can help children and
young people (and their families and carers) learn and grow.
Depending on ones perspective, these issues are made more worrying or are beautifully
contextualised by Carson and Bain (2008). They state that the occurrence of a harmful
event does not necessarily indicate that clinical risk was poorly managed and just
because nothing harmful happened does not mean that the clinical risk was managed
well.
Nonetheless, risk must be acknowledged and actively managed by all who are involved
with the family. This topic will be discussed in Module 3.
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Interagency working
Introduction
As we noted in Module 1, children, young people and families will often have come into contact with a range of
services before fnally arriving at the CAMH service. Almost all will have had sustained contact with education
services and many will also have had extensive contact with Social Work services. Some may have worked with
the voluntary sector, sometimes referred to as third sector. Some may have been involved with the police and
criminal justice system. Finally some may have had contact with all of the above.
In this section we will consider some of the key aspects of interagency working before going on to explore the main barriers. You will begin to
gather information about the kinds of services which operate locally and to think about how these services could be useful in your day to day
interactions with families.
Networks and sharing information
Increasingly Scottish Government expects agencies to work together in the best interests of the child and family, fnding ways to ensure all
aspects of health and well being are taken into consideration (GIRFEC). There is a long list of inquiries and newspaper headlines which would
bear testimony that a failure to work together can have a detrimental effect on a childs care and in the worst circumstances can end with
tragic consequences. In practice, however, ensuring communication between such an extensive group of professionals with differing priorities,
work loads and resources, can be a task in itself.
It may become obvious at your frst meeting with a family that they are currently involved with a whole range of services. Typically, the young
person will be attending school, therefore education is involved. There may have been Social Work involvement in the past for a number of
reasons, for example parental drug misuse or child protection issues. Additional information from these agencies is likely to be an important
part of your assessment process, offering a variety of perspectives on the functioning of the child and the family in a range of settings.
It is also worth remembering that the family will have developed relationships and histories with these agencies. Some may be good and
some less so. Either way, you may be about to step into the middle of these relationships and it is important that we as clinicians keep this in
mind as a context for new developing relationships.
Alternatively, during the course of your work with a young person or family, you may feel that schooling or housing, for example, are having a
signifcant impact on their mental well being. You may want to contact a local voluntary organisation who provides structured out of school
activities which may help a young person reintegrate into their peer group.
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In any of the above examples, there would be clear beneft in making contact with these organisations and giving or gathering information,
with a view to either enhancing your assessment or intervention. There does remain, however, a question about what information can and
should be shared. If, with the familys permission, you have contacted school for some additional information and the school head asks for
a summary of the work you are doing and your fndings, how do you respond? If the voluntary organisation asked for a bit of a history to
allow them to understand the young persons diffculties, should you offer one?
As is always the case in working with families the key is collaboration. The information you hold is the familys information and as such they
should remain the guardians of its use. What can and cannot be shared should be discussed openly and honestly and the reasons for sharing
the information with other services should be made clear and explicit. Even on the rare occasions where, based on clinical risk, you have
decided information needs to be shared with which the young person or family disagree, the process should be explained to, and discussed
with, the family.
2.16 Sharing information
Establish what the local protocols are for the sharing of information.
How does your service deal with the confdentiality issues related to
sharing information in this way?
Services may use an Integrated Assessment Framework (IAF) or a
Common Assessment Framework (CAF) to share info across services. If
so:
How and when would you access such a system?
Does it apply to all families/young people?
How much information can you access?
Ask your supervisor if they have had particularly diffcult instances where
families have asked for information to be withheld. How did they deal
with it?
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Roles and responsibilities
We began by discussion the sharing of information because it is a key consideration of any interagency work, however, before we proceed, it
may make sense to establish who the main organisations are operating in your area.
It is important to have a sense of what these organisations can offer families and to have a sense of the limits of what they offer. By far the
best way to achieve this is to make contact with them personally. The key to good interagency work is often the relationships that develop
between professionals. Perhaps more important, however, is that you develop a sense of the scope of the service in which you work. Discuss
with your supervisor the limits of responsibility of your service. Once you understand these, then understanding the roles of others will be
easier.
2.17 Other organisations
Use your portfolio to list the following details for each of the main
organisations in your area. Start with the statutory ones such as
education and social work before moving on to others which may
be voluntary or social work funded.
Organisation Name Contact Name
Contact Telephone Target Group/Restrictions
Key Roles & Responsibilities Resources Available
Discuss with your supervisor their experiences of jointly working
with these agencies
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So now that we have some sense of whom these agencies are and what they do, how do we work with them? In examining the literature
around CAMHS interagency working, Worrall-Davies & Cottrell (2009) noted that in order to promote good working relationships between
individuals in different organisations, the organisations themselves need structures and confgurations which are conducive to these activities.
Commonly recognised prerequisites for effective interagency work
Commitment to joint working at all levels of the organisations from senior managers to grassroots practitioners.
Strategic and operational joint planning and commissioning.
Service level agreements and clear inter-agency protocols cutting across procedural bureaucracy.
Clear, jointly agreed aims, objectives and timetables for the service.
Delineation of roles and responsibilities for all staff and clarity of line management arrangements
Good working relationships at grassroots level.
Mutual trust and respect between partner agencies and staff.
Recognition of the constraints others are under.
Good systems of communication.
Clear paths for information sharing, including databases.
Commitment to consulting with and acting on user carer views.
Its clear from the list above that many of the prerequisites are likely to be outwith the individual clinicians control. Few clinicians will have
access to strategic and operational joint plans nor will they be able to infuence service level agreements, however there are some keys
aspects which, if shared by all services will allow effective communication and joint working. Joint working is a dynamic process requiring
open, effective communication, clear goal setting and continual updating.
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While tasks remain important, the best interests of the client (rather than the agency) must remain paramount and professionals must act as
advocates for the client in all their communication with other services, using their expert knowledge to help shape others understanding of
the problem. Where one agency begins to fall behind in their input, it is the role, indeed the responsibility, of the partner agencies to fnd a
way to re-engage the service in a positive and constructive way.
Where there are conficts and misunderstanding, the role of the professionals involved is to resolve these, again in the young persons best
interest, but to do so in a way that will allow and encourage future joint work to take place. This is no easy task and Worral-Davies and Cottrel
(2009) also noted a list of signifcant barriers:
Commonly recognised barriers to Inter-agency work
Previous history of confict between individuals and organizations.
Competitive relationships between services.
Bureaucratic need to follow agency procedures may lead to stifed creative planning.
Accountability issues - lack of clarity about who takes responsibility in each agency. Dysfunction at both operational and
strategic levels for multi-agency working to be effective.
Professionals and disciplines insisting on undertaking particular parts of assessments and therapeutic work.
Interdisciplinary power struggles.
Lack of a common language.
A fairly long list, again some of which are outwith individual control, however some relate directly to experiences and beliefs about ones own
profession and other professions and agencies.
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2.18 Barriers to interagency working
Discuss with your supervisor some of the barriers to
interagency working they have experienced locally;
How did they overcome the barriers?
How did this impact on future encounters?
What was the outcome for the client?
How was risk management factored into the thinking?
Note down in your portfolio some of the key aspects of
dealing with these conficts and barriers
Some of the recognised barriers to interagency working involve the
preconceptions and experiences of the professionals involved. Consider your
own views of the main agencies involved and how they my impact on the work
you may do with them.
For each of Education, Social Work and the Voluntary Sector consider the
following questions:
How do you consider the work they do?
Particularly in relation to child protection.
What are your feelings about the way the organisation is run?
Do you feel there is overlap between their remit and that of CAMHS?
Is there any way in which these thoughts or feelings may impact on the way
you work alongside these agencies.
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As a fnal activity for this section, consider the following case example:
Case study: Craig
Multiple Perspectives
Craig is 12 years old and has just started secondary school. He is new to the area and his school have
yet to get to know Craig and his family very well. He can be disruptive in class and appears to fnds it
diffcult to concentrate. The teacher is forever catching him chatting to his neighbours and he has had
detention several times. On a number of occasions Craig has left the school premises, during school
hours, without informing anyone.
Craig lives with his mother who has a problem with alcohol. She is often in bed when Craig leaves for
school. Craigs father left home several years ago and only visits occasionally. When he does he is often
violent towards Craig.
Craig has recently been caught stealing CDs to the value of 200 from HMV and has been charged by
the police. The school knows about his stealing but not about his home circumstances. Consider the
way in which Craigs behaviour might be viewed by:
His teachers at school.
The Police.
His mother.
A CAMHS school liaison worker who has been asked to advise on his behaviour.
A social worker.
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Additional reading
Bailey S (2002) Violent children: a framework for assessment Advances in Psychiatric Treatment, 8:97-106.
Bouch J, Marshall J, (2005) Suicide risk: Structured professional judgement Advances in Psychiatric Treatment (2005), vol. 11, 8491
Carson, D and Bain, A (2008) Professional Risk and Working with People,
Jessica Kingsley. Elsevier; Chestwood.
Flewett T (2010) Clinical Risk Management: An Introductory Text for Mental Health Clinicians
Garcia, J A, Weisz, J R (2002) When Youth Mental Health Care Stops: Therapeutic Relationship Problems and Other Reasons for Ending Youth
Outpatient Treatment Journal of Consulting and Clinical Psychology , Vol. 70, No. 2, 439443
Gilbert P (2007), Psychotherapy and Counselling for depression; Third edition. Sage: London (to go in references)
Hawley K, Weisz, J (2005) Youth Versus Parent Working Alliance in Usual Clinical Care: Distinctive Associations With Retention, Satisfaction,
and Treatment Outcome Journal of Clinical Child and Adolescent Psychology; 2005, Vol. 34, No. 1, 117128
Hawley K, Weisz, J (2005) Youth Child, Parent, and Therapist (Dis)Agreement on Target Problems in Outpatient Therapy: The Therapists
Dilemma and Its Implications Journal of Consulting and Clinical Psychology 2003, Vol. 71, No. 1, 6270
McLeod, B (2011) Relation of the alliance with outcomes in youth psychotherapy: A meta-analysis Clinical Psychology Review 31 (2011) 603
616
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Refective Practice
Clinical work in CAMHS is a challenging process and workers often come into contact with children, young
people and families who cause them to experience situations, emotions and feelings that may be new or
uncomfortable. This requires that workers in CAMHS have, at their core, the capacity to refect on their practice
and develop knowledge and skills through experiential learning and support in clinical and professional
supervision.
Refective practice is more than a short period of self-refection or informal chat considering a situation that has just occurred. True refective
practice requires time, support and an engagement between a clinician and supervisor to challenge actions or inactions openly and honestly
with a view to understanding and learning. Refective practice and critical exploration of practice are central to the process of analysing
practice based problems and crucial for CAMHS clinicians in their day to day work.
The concept of the refective practitioner and the development of skills, knowledge and expertise from the exploration of practice was
presented by Schon in The Refective Practitioner (REF). Schons work was underpinned by an assumption that competent practitioners often
know more than they can say about their practice and the underpinning knowledge. Schon introduced the concepts of refection-in-action
later defned as
To think about what one is doing whilst one is doing it; it is typically stimulated by surprise, by something which puzzled
the practitioner concerned(Greenwood, 1993).
and refection-on-action
The retrospective contemplation of practice undertaken in order to uncover the knowledge used in practical situations,
by analysing and interpreting the information recalled (Fitzgerald, 1994pp67)
which Schon suggested provide a foundation for practitioners to cope with the uncertainty and conficts of practice which often arise.
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The problems with these views of refection on action are that they do not take account of the importance of refection before action. This is
when we plan out before we act what we want to do. Refective practice is constituted then by three inter-related concepts
Refection before action
Refection in action
Refection on action
There a number of frameworks (Gibbs 1988 , Bortons 1970, Johns 1995 for example) that have been developed to support workers in
healthcare and other felds to participate in a process of structured refection to support learning, development and clinical expertise.
While each of these methods is presented differently they all have common elements which are useful to support the worker in developing
refective practice
1 Developing self awareness by the worker on the practice being explored
2 Describing the detail of the practice event and the questions arising from it
3 What infuenced the workers practice
4 What could have been done differently
5 What has the worker learnt from the experience
CAMHS workers should be consistently engaged in a process of refective practice and use models that support this in informal and formal
supervision procedures. Developing self awareness and a capacity for critical and honest self refection will ensure that, as a CAMHS worker,
you are maximising your potential.
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2.19 Refective Practice
Access at least two of the refective frameworks listed previously.
After reading, consider how you may have used this process in the
past. It may be that you did not use the term refective practice,
but there may have been occasions where you reviewed practice
retrospectively, with or without the support of a supervisor.
How did you fnd that experience. If there was someone else
involved in the process (e.g a supervisor), how did you fnd this
conversation?
Do you think there are any limits to the utility of this approach?
Where is the client in the process?
How reliable may the recollection be?
How does this relate to client outcomes?
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Supervision and Other Staff Supports
A crucial part of developing as a refective practitioner is the use of supervision to aid refection. In todays
mental health services, most, if not all staff, are familiar with the concept of supervision, although models of
supervision and how it is implemented can vary between health care professions and across different areas of
practice.
Clinical supervision is a process that supports practice and allows for staff to work with an experienced or trained supervisor to engage in
structured refection. The purpose of supervision is to ensure that the clinicians (or supervisees) professional and personal development is the
most crucial part of the process.
Proctor (1986) suggested an interaction model of Clinical Supervision which has been widely adopted in healthcare practice especially in the
clinical and professional supervison of nurses in practice. Proctors model suggest three interactive dimensions which together interrelate and
overlap to frame the supervision process
Proctor Model
Normative The quality control and risk management element of supervision. The supervisee takes responsibility for maintaining
effective practice through refection, self monitoring and self assessment.
Formative This area is focussed on personal and skill development. The supervisee understanding and abilities are enhanced
through refection on and preparation for work with patients
Restorative A formal means of support to the Supervisee to help identify and cope with the specifc stresses of clinical work.
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Models of Supervision
In practice you may participate in a variety of approaches to supervision. The most common and perhaps most useful for personal
development is the 1:1 supervisory model. This model is based on a close relationship forming between a clinician and their supervisor
through regular individual meetings that facilitate refection and development.
Other models may be used as an adjunt or an alternative to 1:1 supervision and these may include the following
Triadic Supervision: An expanded 1:1 model were the supervisor is assisted by a consultant to work with the supervisee
Group Supervision: More than 1 supervisee receive supervision from one clinical supervisor (common in inpatient settings)
Peer Group Supervision: All participants offer mutual support and supervison with no main supervisor selected.
Team Supervision: All the supervisee work as part of a clinical or professional team and receive supervision together
While each of these models offer a great opportunity for developing skills, refection and support when new in CAMHS it is most likely that
you will begin the supervision process with an identifed 1:1 supervisor.
2.20 Supervision
Identify and evaluate (with your supervisor,
peers or colleagues) the relative advantages and
disadvantages of the supervision and staff support
arrangements in your service.
From your experiences of supervision to date,
what are 3 benefts and 3 challenges you have
experienced in supervision? What could you, or
your colleagues, or your service, do about these
challenges.
Supervision is clearly important for staff to refect and process
work with children and young people and their families. It is an
opportunity to understand and make sense of conscious and
unconscious communication. Being able to separate what belongs
to you and what belongs to the child or young person is an
important part of this ongoing process.
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References
Borton, T (1970) Reach, Teach and Touch. Mc Graw Hill, London.
Fitzgerald M (1994): Theories of Refection for learning IN Refective Practice in nursing, A Palmer and S Burns (eds). Blackwell Scientifc, Oxford.
Gibbs G (1988) Learning by doing: A guide to teaching and learning methods. Oxford Further Education Unit, Oxford.
Greenwood J (1993): Refective practice a critique of the work of Argyris & Schon. Journal of Advanced Nursing 19 1183-1187
Johns C (1995) Framing learning through refection within Carpers fundamental ways of knowing in nursing. Journal of Advanced Nursing 22
226-234
NHS Greater Glasgow and Clyde (2010) Nursing Clinical Supervison Policy and Framework, Internal operational policy.
Proctor, B (1986) Supervision: A co-operative exercise in accountability, cited in Marken, M and Payne, M (Eds.) Enabling and Enduring,
Leicester, National Youth Bureau/Council for Education and Training in Youth Work and Community Work
Schon DA (1983): The Refective Practitioner. Basic Books, New York.
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Module 3: Mental Health of Children
and Young People
Child & Adolescent Mental Health Services | Module 3: Mental Health of Children and Young People |
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Mental Health of Children and Young People
The Determinants of Mental Health
Risk and Resilience
Diagnosis and Classifcation
Developmental Psychopathology
Mental Health Challenges
Mental Health Problems and Disorders
Mental Health - Introduction
Module 3: Mental health of Children and Young People
ILOs
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Knowledge of mental health presentations in children, young people and adults
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Introduction
Mental health, mental illness and mental well being are all phases in
common use by clinicians, politicians and the public alike. However
their meanings can often be confused and their validity as
concepts remains contested in some areas. Misinformation and
incomplete knowledge help create myths and fear which can,
in turn, generate attitudes of prejudice and intolerance. It is
important, therefore, to gain some clarity about the language
and concepts relating to mental health and mental illness.
We will begin this unit by exploring the concept of mental
health, as distinct from mental illness. We will briefy
consider the determinants of mental health before going
on to consider mental health in the child and adolescent
context.
In moving on to look more closely at the concept of mental illness,
we will consider the language and classifcation systems used
within CAMHS. This will be followed by a brief insight into
the more common presentations that attend CAMHS, before
thinking about the impact these diffculties have on children,
young people and families.
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While, at one time, positive mental health and mental illness would have been
considered as opposite ends of a continuum, in recent years there has been
increasing recognition that mental health consists of more than simply the
absence of symptoms of mental illness. Indeed, as is evident form the World
Health Organisations defnition, positive mental health refers to the individuals
capacity to recognize and make use of their strengths and resources, as well
as those available to them, in order to cope with every day life and to develop
both as an individual and a contributing member of society.
It is also clear from the defnition offered by the Health Education Authority (1998) that mental well
being is a subjective state which rests, not only on positive affect (or happiness), but also on our
capacity to encounter diffculty and to grow, psychologically, as a result. While there are almost
as many defnitions as there are authors in the feld, the progression has been toward recognition
that there can be positive mental well being in adversity and conversely, one could report poor
mental health in otherwise apparently positive circumstances. Across the defnitions, some of
the key themes appear to be the capacity to develop psychologically, the opportunity to take
part in community and society and a sense of autonomy or control.
Mental health is defned as a state of well-being in
which every individual realizes his or her own potential,
can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a
contribution to her or his community.
WHO 2010
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The Mental Health foundation has offered a description of [the circumstances of] a mentally healthy child:
Develop psychologically, emotionally, socially, intellectually and spiritually.
Initiate, develop and sustain mutually satisfying relationships.
Use and enjoy solitude.
Become aware of others and empathise with them.
Play and learn.
Develop a sense of right and wrong.
Resolve problems and setbacks satisfactorily and learn from them.
3.1 Defnitions of Mental Health
Consider the defnitions above contrast the
child defnition of mental wellbeing with the adult
orientations
In what way are they different and is this difference
helpful? Make notes in your portfolio.
Mental health or mental well being, then refer to a subjective state
which includes a sense of coping, being valued and control. The
terms Mental ill health or mental health problems, however are
generally reserved to describe psychological distress. Ranging from
the more prevalent diffculties such as anxiety or depression, through
to those conditions more commonly known as mental disorders
or mental illness, such as schizophrenia or bipolar disorder. These
terms denote the presence, at some level, of particular clusters
of symptoms of distress. We will discuss mental illness and the
classifcation thereof in greater depth later.
One approach in understanding mental health is to consider it as a
discrete entity, like physical well-being, which exists on a continuum.
As we move through life, experiencing the normal range of traumas
and challenges, our position on the continuum moves up and down
from good mental health to poor mental health.
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Figure 5: The mental health continuum

NES 2010 (adapted from Tudor 1996)
Has a diagnosis of serious
mental health problem but
copes with life well and has
positive mental wellbeing
No diagnosable mental
health problem and positive
mental wellbeing
MAXIMUM MENTAL
HEALTH PROBLEMS
MAXIMUM MENTAL
WELLBEING
MINIMUM MENTAL
WELLBEING
MINIMUM MENTAL
HEALTH PROBLEMS
Has a diagnosis of serious
mental health problem and
poor mental wellbeing
No diagnosable mental
health problem but poor
mental wellbeing
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This array can be developed further by considering mental illness on the horizontal axis (see Diagram 4). Now it is possible to consider the
way in which an individual who experiences mental health problems may have a good quality of life and experience good mental well-being
despite their express mental health diffculties. They may have a sense of connectedness and inclusion, they may feel like they can cope with
their condition and they may function well in their lives. Others, who do not experience mental health problems may report poor mental well-
being. Despite the absence of a mental illness, for reasons of socio-economic status, physical health or isolation, they may feel powerless,
unfulflled and as a result function poorly within their lives. As individuals over time we may all move along both continua and, depending on
personal and social circumstances, may take up position in any on of the quadrants above.
It is clear, therefore, that while mental illness may affect mental well being, they are neither synonymous, nor is their relationship linear.
Indeed this idea of the relative independence of these two concepts has had a signifcant infuence on the way we consider supporting those
with mental health problems. Indeed this forms the basis of the idea of recovery*, rather than cure, as a goal for sufferers of mental illness.
3.2 Mental Wellbeing
Before you read any further, think of an individual with whom
you are currently working. Jot down a few notes about where
you would place the child or young person on the continuum
model.
What characteristics of their current functioning led you to
place them here?
How do you imagine things would be different if they were
further along each of the continua?
Go to the Well Scotland website to discover more about the
mental health continuum.
*Recovery is being able to live a meaningful
and satisfying life, as defned by each person,
in the presence or absence of symptoms. It is
about having control over and input into your
own life. Each individuals recovery, like his or
her experience of the mental health problems
or illness, is a unique and deeply personal
process.
From the Scottish Recovery Network website
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The Determinants of Mental Health
Defning mental health in this way enables us to broaden our thinking about the factors which may infuence
mental health and well being.
3.3 What infuences mental health?
Returning to the young person you considered above.
What factors do you think have infuenced outcomes for this
young person?
What contextual factors do you think impacted on their
development?
What social factors?
What political factors?
What community factors?
What personal factors do you think impacted on their
development?
What family factors?
Were there personality factors?
Were there genetic factors?
Chose one from each of the six categories and describe ways
in which you believe they may have impacted on this young
persons well being. Some may have a direct impact, while some
may shape structures or beliefs which impact less directly.
Discuss with you supervisor the impact of the socio-cultural
factors on the well being of young people and consider how you
and the service may mitigate (or magnify) this effect.
However Coppock and Hopton (2000)in their Critical
Perspectives on Mental Health have suggested that mental
health professionals tend to function within a narrow range of
theoretical constructs of mental health (and ill health); often at
the expense of awareness of different models. These usually
relate to professional discipline or background training. Lester
and Glasby (2009: 6) on the other hand, consider it important
that all perspectives are considered as each has something to
offer as the origin of the mental health problem will inevitably
represent a confuence of factors.
It is perhaps worth giving some brief consideration to those
factors which may infuence mental health outcomes.
It is clear that a young persons capacity for mental well being
is subject to a wide range of factors. Depending on their
age and stage, they have little or no capacity to infuence
these circumstances. For younger children, their experience
is entirely dependant on the context their carers create. Even
as they reach adolescence and moving outwith the family,
there are educational and social contexts over which they may
feel they have little control. Since one core aspect of positive
mental health, as described earlier, is an [appropriate] sense of
autonomy or self determinism, one can perhaps understand
why this period of rapid cognitive and emotional development
may lead to a poorer sense of well being.
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Risk and Resilience
Within CAMHS the ideas described above are captured in what has become known as the risk and resilience
model. Initially described by Rutter (1985), risk and resilience is understood to be both a tool for assessment
and an approach for managing therapeutic interventions. The Health Education Authority (1998) also favoured
the resilience theory by defning mental health as the emotional resilience which enables us to enjoy life and
to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our
own, and others dignity and worth. (Health education Authority 1997:7). Joubert and Raeburn (1998) defned
it as a dynamic and human concept to cope with and bounce back from challenges. An individuals ability to be
resilient is infuenced by factors pertaining to the individual, the family and the community.
The concept of resilience was further developed by Gilligan (1999 and 2001) who discussed the concept particularly in relation to school
children and looked after children and young people. Here resilience is viewed as dynamic rather than static elements that are malleable to
external infuences and events. Luthar (2003) defnes resilience as the:
Patterns of positive adjustment in the context of signifcant risk or adversity.
(Luthar 2003:4)
It is important also to be clear about the difference between risk factors and risky behaviour which is arguably an essential part of adolescent
development, before considering whether interventions are effective. For example, the likely effectiveness of just say no to drugs for example
is questionable if (as research suggests) between 30 and 40% of young people experiment with drugs at some stage of adolescence. The
table on the next page outlines some of the risk and protective factors within individual and social domains.
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Table 4- Examples of risk and protective factors
Domain Protective Factors Risk Factors
Individual
Positive sense of self
Good coping skills
Attachment to family
Social skills
Good Physical health
Low self esteem
Low self effcacy
Poor coping skills
Insecure attachment
Physical and intellectual disability
Social
Positive Early Attachment
Supportive family
Robust social relationships
Sense of social belonging
Community participation
Experiences of abuse and violence
Separation and loss
Peer rejection
Social isolation
(Taken from: Barry and Jenkins 2007)
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Gilligan (2001) in Bright Futures (Mental Health Foundation 1999) also makes slightly more contentious claims about factors of risk and
resilience. For example, he states that being a boy rather than a girl increases vulnerability and that holding a religious belief is a factor that
increases resilience. Similarly, the comparative weighting of elements are seen to have variable levels of infuence on existing vulnerability
or resilience depending on the period of development in which they occur (Masten and Powell 2003). All agree that, in general, risks are
cumulative - the more risks the individual experiences the greater the likelihood of a poor outcome in the longer term (Appleyard et al 2005).
Acute periods of stress are likely to do less harm than long exposures to chronic stressors that may present in the form of family dysfunction,
economic poverty or social disadvantage, although this will also depend on the nature of the acute stress.
Newman (2004) suggests a number of strategies for all professionals to promote resilience:
Applying risk and resilience to practice
In what ways do you think young people and
children might understand the concept of risk
differently from adults?
Think of a family with whom you are currently
working. What do you perceive as their strengths
and their difficulties? Do you know how they
managed earlier challenges?
Which of the strategies described by Newman above
do you see as being effective with a child or young
person with whom you are currently working?
Consider physical well-being alongside mental health. For example
a child or young person with a mental health issue may beneft
from a nutritional based intervention as well as a therapeutic
intervention. Breakfast clubs in schools for example, have made
great strides in improving the well-being of vulnerable youngsters.
Interrupting the chain reaction of negative events, for example the
provision of safe meeting places for children whose parents are
experiencing an acrimonious separation.
Provide opportunity to have positive experiences to build self
esteem and develop relationships.
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Diagnosis and Classifcation
Introduction
A differential diagnosis is a tool for describing accurately the diffculties with which a child or young person
presents. It should be viewed as just one element of describing and understanding, or formulating, a childs
diffculties. A formulation is a succinct description of a childs diffculties, placing the differential diagnosis
within the wider context of that childs risk and resilience factors including; family factors; developmental factors;
and wider systemic factors such as school. The formulation then acts as a guide to developing and delivering
the best possible intervention. Throughout this section the example of Depressive Disorders will be used, but
the principles under discussion apply to all mental health problems in children and young people.
3.4 Classifcation and the use of language
Think about the different ways in which a phrase such as she is
depressed is used.
Can you think of examples when it is used to describe a normal
state of a young person being unhappy about something?
When is it used to describe somebody who is no fun to be with?
When may it be used in a technical sense to describe a teenager
who has a mental health disorder?
What may be the differences between such children or teenagers
and those who have a mental health problem or mental distress?
In your thinking, try to make a distinction between the use of he or she
is depressed to describe somebody experiencing a normal range of
emotions, a young person or child with a mental health problem, a child
with a mental health disorder, and a child with a mental illness.
Classifcation systems
One of the skills of a child mental health practitioner
is to be able to recognise and defne normal
and abnormal psychological distress in children.
Classifcation systems are tools to help us to make such
distinctions. When child mental health practitioners
use words to describe a childs condition, they need to
communicate very precisely and reliably, with patients
and families and with each other, and therefore need
to use a technical language to do so. The role of such
a language is to provide a succinct account of a childs
diffculties in a manner that is standardised and has
the same meaning for different practitioners, allowing
clear communication. However, a diffculty arises
when words used in a technical sense may also have a
common usage.
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When a word such as depression is used in a technical sense, it means
that the child fulfls diagnostic criteria for a Depressive Disorder, as
defned by a classifcatory system of either DSM-IV or ICD-10. It needs to
be remembered, however, that this is merely a very accurate description
of a childs symptoms and behaviour, and does not describe either all of a
childs life and being nor does it imply an underlying abnormality, such as
a clearly identifed brain abnormality or enzyme defciency. Such careful
descriptions are helpful in that they allow us to identify children and young
people whose diffculties follow a predictable path over time, and allow us
to see what sorts of interventions work for what sorts of children. Thus,
to stick with depression, if a young person fulfls the diagnostic criteria
for a Depressive Disorder, this identifes the child as one who, reports a
particular cluster of symptoms and behaviours, is likely to be helped by
particular forms of psychotherapy (e.g. CBT) and, in more severe cases,
very specifc types of anti-depressant medication. Further more, if they do
not get therapy (Bhardwaj & Goodyer 2009), it is likely that they will still
be suffering from a Depressive disorder a year later and have recurrent
episodes of Depressive Disorder throughout their lives.
Systems of classifcations of mental health disorders are tools for thought. An ideal system would aim to aid communication by being;
unambiguous; comprehensive; acceptable to users; an aid to guiding evidence based interventions; and accurately refect nature. Being tools,
there are different classifcation systems for different purposes. There are two dominant systems of classifcation being used within CAMH
services in Scotland currently. The Diagnostic and Statistical Manual for Mental Disorders: fourth edition, commonly referred to as DSM IV,
and International Classifcation of Diseases which is in its tenth revision, commonly referred to as ICD-10.
3.5 Classifcation systems
What might be some of the problems associated with using a classifcation system for understanding and managing
emotional and behavioural diffculties in children and young people? How might you address such problems?
3.6 Diagnosis Depression
Try to locate copies of the two main classifcation
systems.
What are the diagnostic rules for diagnosing a
Depressive Disorders in DSM-IV and ICD-10?
What are the differences in the rules for
diagnosing Depressive Disorder between these
two diagnostic systems
Do you think there is just one form of
Depressive Disorder or
might there be several sorts of Depressive
Disorder?
might here be other conditions which may
manifest as depression?
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Refecting on diagnosis
Think about a child with whom you are working who has received a formal diagnosis.
What impact do you think the diagnostic process had on:
The young person
The family
The therapeutic process
What happened when the diagnosis was eventually given?
Was there a positive impact on any of the above
Was there a negative impact on any of the above
Discuss with your supervisor your thoughts and experiences of this process and how you
feel it impacts on the therapeutic relationship and family dynamics.
3.7 Depressive/Generalised Anxiety Disorders
Some researchers have argued that children and young people often do not present with a neat and tidy picture of a
Depressive Disorder, and that such children often have a combined picture of, for example, both anxiety and depression.
What might the differences be between a young person having a Depressive Disorder and a Generalised Anxiety Disorder?
Is there evidence that there an association between these two Disorders?
Could the symptoms and behaviours all be part of the same disorder?
How might this thinking affect your clinical practice?
Discuss how you might think about this with your supervisor.
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Developmental Psychopathology
There are many ways of understanding mental health problems in children and young people including;
behavioural models; cognitive models; psychodynamic models; family therapy models; and in terms of
underlying biological factors. Each of these various ways of making sense of a childs diffculties has a
contribution to make to our overall understanding, but it is rare that a single model is able to fully account
for why a child may present to a CAMHS clinic. One way of resolving this is to adopt a bio-psycho-social
understanding, which allows us to incorporate insights and evidence from each of these various ways into our
overall understanding.
For example, if a young person presents with a Depressive Disorder, there may be:
biological (genetic) factors (e.g. a strong family history of Depressive Disorder in close relatives)
early relationships factors (e.g. child has lost its mother in early childhood)
current environmental factors (e.g. the child is being bullied at school)
cognitive factors (e.g. the child has a negative self-image and low self-esteem)
behavioural factors (e.g. the child is not going out of the family home, and as a result is not meeting up with peers)
family factors (e.g. the members of his or her family are not good at tuning in to each others feelings and there is a culture in the family
of bottling up feelings and not talking about them).
Each of these factors may, or may not, be contributing to the young persons Depressive Disorder. Most presentations of children and young
people to a CAMHS clinic require the therapist to understand the child in a number of different ways at the same time and to consider how
each of these domains may be infuencing the diffculties, and in turn consider which factors need to be addressed if the diffculties are going
to improve.
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However, whichever of these factors prove to be important in considering any individual case, there is one aspect which is ubiquitous among
our client group. Each and every one of the children and young people who attend the CAMH service are immersed a maturational process.
Somewhere on the pathway from conception to independence, adulthood or whichever state one considers the endpoint of development,
CAMHS clients will present a unique story of how that trajectory has interacted with biology, family and nature to bring them to their current
situation.
As discussed in Module 1, from conception children are not passive recipients of development. Physiologically and psychologically, their
relationship with both the developmental process and the context within which that development occurs is reciprocal.
To offer a behavioural example, imagine a young child who displays their frustration at not being allowed a toy by having a temper tantrum.
Generally, the child will be helped to cope, by their parents, in a way that is not overtly punitive. They will eventually learn to tolerate
frustration and have their needs met by more acceptable methods. However, if the same child repeatedly experiences having his needs
met by engaging in temper tantrums, they are likely to begin to use this method more often. Parents may then respond by becoming more
punitive e.g. by taking toys off the child for bad behaviour and the child may respond by having more severe, and frequent, temper
tantrums, alongside developing a sense of not being very loveable. However, the childs development is not stationary. As they mature
3.8 Developmental Psychopathology
Choose a child or young person with whom
you are currently working.
Can you identify factors in the childs
history, from the day of conception
onwards, which may have led to the
child or young person developing a
serious mental health problem?
What factors may have helped to
make that child stronger and more
able to cope with mental distress?
and seek increasing independence, the lack of tolerance may well have
an impact on their capacity to develop other relationships. In reaching
adolescence they may fnd they never learned the skills of negotiation
to get what they want; as a result they may have few if any good friends
which, in turn, feed back into their sense of not being liked/loved. This
schema may shape the way the child perceives others; threat perception
may be high and tolerance low. Their behaviour and attitude may put
them in confict with teachers (shoring up their negative sense of self and
reaffrming their sense of others). This disapproval may lead to truanting
from school, and ultimately the only people who will tolerate their
behaviour are other, similarly disenfranchised young people. This affnity to
deviant groups may lead to criminality and substance abuse.
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This idea could be applied to a range of mental health disorders including
Depressive Disorders, Eating Disorders and even Psychosis. In considering
this developmental pathway, it would be diffcult to pick out particular factors
which could be considered the cause of the eventual outcome: was it the
childs temperament; was it the childs behaviour; was it the parents response.
Similarly, it would be diffcult to pin point when the diffculties began: were
the tantrums abnormal; was the childs early self perception abnormal; were
the childs social relationships abnormal. Further more, would another child,
in similar circumstances, have developed differently with vastly different
outcomes? Indeed, one may even suggest that the young person in the
previous example is simply displaying adaptive behaviour; fnding ways, within
their range of skills, to manage the environment and their development.
It is important to recognise, however, that not all children who have tantrums
which are poorly managed end up in prison; nor do all criminals have parents
who managed their tantrums poorly. This trajectory is neither pre-determined
nor inevitable. Cicchetti & Rogosch (1996) use the terms multifnality and
equifnality. Equifnality refers to the observation that many developmental
pathways can lead to the same outcome, whereas multifnality refers to the
concept that similar pathways can lead to differing outcomes.
3.9 Risk/Resilience Factors
Use the readings below to help you think about the
following questions:
What evidence is there to say that something
is a risk or a resilience factor in developing a
mental health problem?
What sorts of studies would give us more
evidence?
How might such evidence shape our
intervention strategies?
For instance, is there evidence to suggest
that a depressive disorder beginning in a
child before the age of 12 should be treated
differently from a depressive disorder first
beginning at age 18?
Suggested readings:
Maughan, B. and Rutter, M. (2008).Development and psychopathology: a life course perspective. In: Rutters Child and Adolescent Psychiatry. (Ed.
Rutter, M. et al), Blackwell Publishing Limited: Oxford.
Collishaw, S., Andrew Pickles, A.,, Julie Messer, J., Michael Rutter, M., Christina Shearer, C., Maughan, B. (2007) Resilience to adult psychopathology
following childhood maltreatment: Evidence from a community sample. Child Abuse & Neglect, Volume 31, Issue 3, Pages 211-229.
Bhardwaj, A., Goodyer, I. (2009). Depression and allied illness in children and adolescents: Basic Facts. Psychoanal. Psychother., 23:176-184.).
Ciccheti D, Rogosch F (1996) Equifnality and multifnality in Developmental Psychology. Development & Psychopathology 8(4); 597-600
Harrington R, Rutter M, Fombonne (1996) Developmental pathways in depression: Multiple meanings, antecedents, and Endpoints Development and
Psychopathology, 8, 601-616
WHO (2010) Mental health: strengthening our response WHO factsheet no. 220 available at:http://www.who.int/mediacentre/factsheets/fs220/en/
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If, as suggested, children can move in and out of these abnormal
developmental pathways, it would seem useful to be able to identify
which factors infuence this movement. A great deal of high quality
research has been carried out looking at the factors which infuence
these trajectories and outcomes. These so called risk and resilience
factors are thought to be key in determining whether a child or young
person develops a serious mental health disorder (Harrington, Rutter
& Fombonne (1996)). Much of this research has involved very large
longitudinal follow-up studies. In these, a large sample of children is
assessed and followed up over time, looking at the infuence of a host
of social and individual factors on the onset of mental health problems
including; family history; genetic markers; school performance; social
class; exposure to violence; parenting styles; housing; lifestyle; and so
forth. For a good introduction to the feld you should look at some
of the current longitudinal follow-up studies such as the Dunedin
Longitudinal Study in New Zealand and the Avon Longitudinal Study of
Parents and Children (ALSPAC) in the UK.
Applying risk and resilience to practice
Think about your own life and growing up. Can you
identify points in your own history where upsetting things
happened?
How did you and your family deal with them?
What impact did these things have on you?
Could things have been done differently?
How would that have helped?
If you had not had the help and support that your
family, school and friends offered you, would things
have turned out differently for you?
When looking at a childs history, it is important to look at both risk factors i.e. factors that make it more likely that a child develops a
mental health problem and resilience factors i.e. factors that in some way help the child to overcome adversity and do well. However, it
is important to remember that aspects which, for one child act as a risk factor by adding to that childs diffculty may, may in fact prove to be
a resilience factor for another child who is already quite resilient,. For example, a child with low self-esteem and living in a family who have
diffculty with social problem solving or being assertive, or perhaps struggle with discussing and managing upset feelings, may respond very
badly to being bullied at school. However, a child with high self-esteem, living with empathic parents who will help them to think about good
solutions to social problems, may fnd that successfully dealing with a school bully will further enhance his or her sense of being able to cope
with the vicissitudes of life.
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Mental Health Challenges Faced By Children And Young People
In the last section, we introduced the terms multifnality (and equifnality)
to describe the ways in which children and young people on similar (or
different pathways) can and up with different (or similar) outcomes. We
noted that there may be many factors along the way which infuence
these pathways both positively and negatively and that these factors
can become a key element of any intervention plan. We will now go on
to think about some of the main mental health problems that manifest
through childhood and adolescence.
DSM IV and ICD 10 were mentioned earlier and you will fnd a full list of disorders in these
volumes, however it is important to note that children and young people in CAMHS may not
present with such clearly delineated diffculties. Childrens problems are often complex and
while a diagnostic approach provides a picture of what is happening at a particular point in
time, the whole of the childs experiences and supports need to be taken into account.
Children and young peoples mental health diffculties occur at different developmental
stages. It is more likely that a child will develop anorexia after the age of 10 and similarly a
child is more likely to develop a psychosis in their teenage years, rather than earlier in their
development. Some problems occur in childhood and cannot develop at a later phase, e.g. a
child cannot develop ADHD or Aspergers syndrome in their teenage years. These problems
are present in early childhood and continue throughout the lifespan. Of course childrens
diffculties may go unnoticed and not be diagnosed until a child is in their teenage years.
However, this is not the same as the problem frst occurring in adolescence. The following
table provides an outline of the approximate developmental phase when some mental health
problems frst occur. The colour green indicates the approximate age at which the diffculty
may start.
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Types of diffculties
Developmental Phase in which diffculties are more likely to occur
Infant to 5 years Children 6 to 12 years Young People
Anxiety
Attachment disorders
Separation anxiety
Obsessive Compulsive
Disorder
Phobias
Depression
Self Harm
Suicide
Bulimia
Anorexia Nervosa
EDNOS
Conduct Disorders
ADHD
ADD
Autistic Spectrum
Disorders
Psychosis
Tourettes syndrome
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Child and Adolescent Mental Health Problems and Disorders
Introduction
This section gives an overview of mental health problems / disorders and assessment questions. It cannot
possibly cover the range of information necessary for a specialist practitioner and we have assumed many of
you will already have covered these areas in your professional training. If you have joined your service without
training in these areas, we hope this section will help you identify the gaps in your knowledge and competence
and help to inform your continuing professional development. A useful introduction is the BMAs (2006) guide
to mental health problems in children and young people. There are a number of textbooks which are good
introductions to mental health problems in children and young people. These are listed in the recommended
reading section.
Children and young people present at specialist
CAMHS with a variety of possible problems and
disorders. Very often they have more than one
diagnosable problem. This is referred to as
comorbidity. Sometimes it is diffcult to give the
child or young persons diffculty a name, as it may
ft more than one description or diagnostic category.
Added to this, some practitioners are reluctant to
give children and young people a label as some
labels, such as Schizophrenia, are stigmatising.
Assessing mental health problems in children and
young people is not straightforward and can be
contentious. The main mental health problems
and disorders of childhood and adolescence are
given on the next few pages. They relate with a few
exceptions to the diagnostic categories used in the
two widely used manuals, DSM-IV and ICD-10.
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The following information is taken from CAMHS in Context, with a few adaptations.
Anxiety, worries, fears and phobias
Many things worry and frighten children, but these change with age. Symptoms are more likely to be expressed in unfamiliar circumstances
or when the child is tired or ill. Young children often express isolated fears like fears of monsters or the dark. Some fears may be diffcult to
uncover.
Assessment questions:
Would you expect any child of a similar age to be anxious in the same circumstances?
To what extent is the anxiety causing the child distress or interfering with his / her everyday functioning?
Is the child showing other symptoms like depression, weight loss or gain, conduct problems?
Are parents or others unknowingly reinforcing the fear or anxiety by being overly concerned, giving too much reassurance, or giving in
to it?
Treatment: when anxiety symptoms are age and situation appropriate, reassuring parents / carers may be all that is necessary, but they may
need help in managing their own anxiety before they can manage their childrens. Parents / carers should be warned that the childs anxiety
may worsen when it is confronted, but as the child becomes better able to tolerate the object of fear, the anxiety will lessen. Generally, the
child is exposed to the feared situation gradually, with pictures, role play, or at a safe distance, with the parent and child negotiating each stage.
Sometimes this can be done all at once, depending on the fear. Very occasionally low doses of medication are prescribed.
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Separation Anxiety Disorder: refers to excessive anxiety concerning separation from home or from a major attachment fgure, with the level
of anxiety beyond that expected for the childs age, lasting at least 4 weeks and accompanied by 3 or more of 8 separation-related symptoms:
1. Recurrent excessive distress upon or anticipating separation.
2. Worry about losing or harm befalling major attachment fgures.
3. Worry that an untoward event will lead to separation.
4. Reluctance or refusal to go to school or elsewhere because of fear of separation.
5. Fearful or reluctant to be alone without major attachment fgures at home.
6. Reluctance / refusal to go to sleep without being near major attachment fgure or to sleep away from home.
7. Repeated nightmares involving theme of separation.
8. Repeated complaints of physical symptoms (headaches, stomach-aches, nausea or vomiting) when separation from major attachment
fgure occurs or is anticipated.
These symptoms must cause signifcant distress and/or impairment in social functioning.
Generalised Anxiety Disorder: (Overanxious Disorder of Childhood) is characterised by excessive and persistent worry, which the child fnds
hard to control and is not focussed on any one object or situation. This worry must be experienced more days than not over a period of at
least 6 months, cause signifcant distress or impairment in functioning, and be accompanied by one of the following symptoms in children:
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Diffculty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance diffculty falling or staying asleep or restless unsatisfying sleep.
Specifc (or Simple) Phobias: describe marked and persistent fear of circumscribed objects or situations lasting at least 6 months. Such
fears are usually transitory, and a diagnosis is not usually made unless there is excessive distress or impairment in social functioning.
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Post-traumatic Stress Disorder (PTSD)
PTSD is linked with an extreme traumatic stress or involving direct personal experience of an event that involves actual or threatened death or
serious injury to self or someone close. The event is re-experienced in one or more of the following ways: fashbacks to the event, nightmares
related to the event, re-enactment through play, intense emotional arousal, numbness around memories or reminders of the trauma, and
physical symptoms such as tummy aches and headaches.
In addition, there are at least 2 of the following symptoms of avoidance:
1. Persistent avoidance of thoughts, feelings or conversations associated with the trauma.
2. Avoidance of activities, places or people associated with the trauma.
3. Inability to recall an important aspect of the trauma.
4. Diminished interest or participation in signifcant activities.
5. Feeling detached or estranged from others.
6. Limited or restricted expression of feelings.
7. Limited sense of future.
Finally, there are at least 2 symptoms of increased arousal:
1. Diffculty falling or staying asleep.
2. Irritability or outbursts of anger.
3. Diffculty concentrating.
4. Hyper-vigilance.
5. Exaggerated startle response.
Assessment: it is suffcient to obtain a brief history of the trauma in order to understand the type of emotional upset being expressed. It is
important to know whether there are legal proceedings pending and to establish whether it is an adult rather than the child who wishes to
establish the severity of the symptoms. Go through the list of PTSD symptoms, noting symptoms associated with re-experiencing the event,
then any nonspecifc changes in behaviour, increased arousal, and / or any new fears.
Treatment: parents / carers can help children deal with their memories and emotions by talking about the trauma. Thoughts and feelings
tend to recur unchanged until they can be understood and tolerated. Following the childs cue for discussion is the best strategy, pressuring a
child right after a trauma has occurred can make things worse.
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Obsessive Compulsive Disorder (OCD)
Children are comforted by a predictable sequence of events. OCD must be distinguished from normal childhood rituals and concerns
persistent obsessions, compulsions or both. Compulsions are repetitive behaviours aimed at preventing or reducing distress or preventing a
dreaded event or outcome. However, the behaviours are not realistically connected with what they are designed to prevent or neutralise.
Assessment: parents / carers may be unaware of the extent of a childs compulsive behaviours, so questioning the child about the nature of
the thoughts and behaviours is important. Asking him / her to keep a diary can be very useful. As with other worrying conditions, knowing
the childs family circumstances is important since, for example, the childs symptomatic behaviour may be designed to bring quarrelling
parents together.
Treatment: if OCD symptoms are time-consuming, distressing and interfere with the childs normal routine, then she / he should be referred
for specialist treatment as soon as possible. Cognitive behavioural therapy with family therapy is most effective. Medication may be
prescribed, but not in isolation.
Attention-Defcit Hyperactivity Disorder (ADHD)
ADHD is characterised by pervasive lack of attention, impulsivity and hyperactivity across situations and settings at home, school, and in
public which began before age 7, persisted for at least 6 months and is associated with behaviour that is maladaptive and inconsistent with
developmental level.
Assessment: there is debate about whether ADHD is a discrete diagnosis and whether the interests of parents and teachers rather than the
interests of children are being served in diagnosing and prescribing medication to treat it. If suffcient numbers of symptoms are present,
and impaired functioning is directly related to the symptoms, the diagnosis is made. Associated features often include: defance, aggression,
disinhibition with adults, conduct problems, low IQ, dyslexia, clumsiness & history of developmental disorders.
Treatment: ADHD uncomplicated by behaviour problems can be seen in children up to the age of 7 and early intervention can prevent
the development of commonly associated problems. Multifaceted interventions are recommended, including work with the school and
parents. Where there is signifcant impairment, medication can improve attention and reduce physical restlessness. It does not improve other
behaviours such as oppositional behaviours.
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Conduct / Anti-social Disorder
This disorder is characterised by persistent failure to control behaviour and breaking of age appropriate socially-defned rules, defance and
anti-social behaviour that persists for 6 months or more and impairs every-day functioning. Symptoms include aggression to people and
animals.
Assessment: complaints about childrens behaviour problems are among the most frequent to CAMHS professionals. The frst consideration
is whether such behaviour is age appropriate. Up to the age of 5, children are likely to be active and boisterous, test limits, experience
diffculties in occupying themselves and demand more adult attention than parents / carers are prepared to give. Such behaviour may persist
after age 5, but tends to subside with age.
Treatment: once a distinction is made between normal naughtiness and behaviours that cause distress or impairment, professional
intervention can be helpful. However, treatment is likely to be most effective before a child is eight years old since anti-social habits will be
less ingrained and he or she is unlikely to be part of a deviant peer group. Whatever the underlying causes, multiagency co-operation is
especially important in dealing with conduct problems, since health, education and social work can make valuable contributions to helping
these children and their families.
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Major Depression
Sad mood, tearfulness, loss of interest, and social withdrawal are common among children with unhappy life experiences, but may not be part
of a syndrome of either major depression or dysthymia a persistently low mood that lasts for a year or more. These rarely occur before age
6 years and are uncommon before adolescence when rates increase markedly. Major Depression refers to one or more periods of depressed
mood or loss of interest or pleasure, lasting at least two weeks and accompanied by at least four symptoms including:
Change in appetite or weight loss or gain.
Disturbed sleep.
Physical agitation or retardation.
Fatigue or loss of energy.
Feelings of worthlessness or inappropriate guilt.
Diffculty concentrating or indecisiveness.
Recurrent thoughts of death or suicide.
Assessment: Interviewing the young person alone as well as with a parent / carer is recommended, since parents may be unaware of how
their child is feeling. Open questions about mood, participation and enjoyment of usual activities, relationships with friends and family and
feelings of self-worth are generally asked frst and then additional questions about associated symptoms, such as change in sleeping, eating,
and suicidal ideas or intent, as well as recent life events, stressors and losses
Treatment: A useful starting point is explaining to the parents / carers with the consent of and in the presence of the young person how
the child is feeling. Treatment should be tailored to the young person and family and may include social and psychological interventions and
medication.
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Bipolar Disorder
Bipolar disorder or a manic episode is defned by a distinct period of abnormally and persistently elevated, expansive or irritable mood lasting
at least a week and accompanied by symptoms of infated self-esteem or grandiosity, decreased need for sleep, more talkative or pressure to
keep talking, fight of ideas or racing thoughts, distractibility, increased activity or agitation, excessive involvement in pleasurable activities with
high potential for painful consequences.
Assessment: depending on the presentation, issues of self-harm and child protection may require an urgent assessment of risk.
Treatment: with social supports, the acute phase of a manic episode can be managed at home. However, if the mania is moderate or severe,
inpatient care is likely to be most appropriate. Medication typically is used both acutely and once the mood has stabilised.
Disorders of Attachment
Attachment disorders are those that describe children who are excessively inhibited or excessively disinhibited in their social interactions as a
result of known parental separation, abuse and / or neglect.
Assessment: disorders of attachment are primarily seen in children who come from highly dysfunctional families and have histories of
parental abuse and neglect. Many will have been taken into care and some have had multiple placements in foster care or childrens homes.
Such children fnd it diffcult to trust or interact closely with adults or children and are at risk of a range of mental health problems.
Treatment: psychological treatment is unlikely to be successful in the absence of a stable care arrangement. Because of the diffculty in
achieving such stability, some therapists have begun to provide support and advice to foster carers, staff of childrens homes and other
professionals to help them understand and cope with the complex needs and behaviours of such children.
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Autism
Autism has an early onset, often picked up by Health Visitors before age 3. Three types of impairment are always present referred to as the
Triad of Impairments:
1. A lack of social reciprocation with 50% not reciprocating at all, others display little or no response to commands and little or no empathy;
2. Poor communication with 50% with no useful speech and others with echolalia, pronoun reversal, use of idiosyncratic phrases, invention
of words, and/or use of stock phrases
3. Restricted and repetitive activities, resistance to change, following set routines and / or stereotyped behaviours such as hand-clapping.
Assessment: Autism is a pervasive developmental disorder and behavioural syndrome that arises from abnormalities in central nervous
system development, probably in the foetus. There are serious impairments in social functioning and interaction (which may be poor to
nonexistent), in language and non-verbal communication and in play, which tends to be unimaginative, repetitive, ritualistic or obsessional.
Autism is often associated with moderate to severe learning diffculties and sometimes with hyperactivity, severe temper tantrums, self injury
and phobias.
Treatment: Psychological treatment programmes can help parents / carers in modifying childrens behaviour, enabling them to cope with
specifc diffculties and ensuring optimal schooling. Helpful advice to parents is that it is more effective to change the environment around the
autistic child than to attempt to change the child.
Aspergers Syndrome
Aspergers syndrome is a developmental disorder that is sometimes considered to be on the milder end of autistic spectrum disorder (ASD).
Assessment: Aspergers Syndrome is characterised by impairment of social interaction, social communications and restricted interests and
activities.
Treatment: an educational statement can be helpful if desired by parents/carers who are aware of the childs diffculties and wish for more
sensitive educational input, especially at secondary school level where the childs diffculties with empathy and subtlety of language are likely
to lead to feelings of frustration and lower marks.
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Tourettes Syndrome and Tic Disorders
Tic Disorders can be transient or enduring and may involve a number of behavioural manifestations such as hyperactivity, OCD symptoms,
impulsive behaviour and disinhibited speech. These disorders can be very distressing for the child or young person. The most severe of these
disorders is Tourette Syndrome.
Assessment: level of overall functioning; identify the degree of impairment and distress. Level of family support. May be useful to use the
Yale Global Tic Severity Scale (YGTSS).
Treatment: educational and supportive interventions. May be helpful to use pharmacological interventions.
Psychoses
These are rare in children and adolescents, but may involve transient states or short episodes of delusions, hallucinations, disorganised
speech, or grossly disorganised or catatonic behaviour. Such states are more likely to be associated with substance misuse. Some episodes of
psychosis may be recurrent and may lead to long-term problems
Assessment: children commonly experience hearing voices. These questions and the answers help decide when the voices are cause for
concern follow.
Where is the voice? If outside the head, as if someone else is really talking. Whose voice is it? If a frightening or unknown being. How
many voices are there? Several. Who are the voices talking to?
Treatment: episodes of suspected psychosis should be referred to and treated by CAMHS. Treatment of psychosis in young people usually
involves the use of medication such as atypical antipsychotic medication and psychosocial interventions such as Cognitive psychotherapy in
early psychosis (COPE) or Family Interventions such as Behavioural Family Therapy (BFT).
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Eating disorders
Eating disorders are a signifcant problem in young people, in young women in particular and to a lesser extent in young men. There is an
ever-present concern about the effect of the media on young girls self-image and the infuence of size zero models. The factors which lead
young males and females to develop eating disorders are however more complex and involve different vulnerability factors.
Anorexia
Anorexia is characterised by a refusal to maintain a minimally normal body weight, intense fear of gaining weight and signifcant disturbance
in perception of own body shape or size. In anorexia starvation becomes an addiction.
Treatment: before referral or while waiting for a specialist appointment for anorexia, three steps might be taken.
1. Help parents / carers face the potentially life-threatening nature of the problem and encourage them to come up with ways that might
encourage the child to resume eating more normally.
2. Engage the young person in externalising the problem something that can take people over and hurt them.
3. Encourage the young person and parents to keep a food intake diary, setting a target for weight and weekly or fortnightly weighing to
monitor progress.
Bulimia
Bulimia is characterised by binge-eating and purging and maintaining adequate body weight is found more commonly among older
adolescents. In bulimia binge eating is a habit that is hard to give up.
Treatment: Bulimia sufferers are more successful at keeping their problem secret and reluctant to seek help, but if they do, cognitive-
behavioural therapy or interpersonal therapy can be effective.
Eating disorder not otherwise specifed (EDNOS); and binge eating disorder (BED): young People with EDNOS have an eating disorder but
do not meet all recognised diagnostic criteria for anorexia or bulimia, and young people with BED are people who engage in the bingeing but
not the purging behaviour seen in bulimia.
Treatment: self-help and supportive family approaches may be helpful.
Cognitive-behavioural therapy or interpersonal therapy can be effective. Similar approaches to those used with anorexia or bulimia may be
helpful if the problems prove longstanding.
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Suicidal Behaviour and Self-Harm
These are both rare in children under 12 years. The decision to attempt suicide often is a hasty one- following arguments with family, friends
and partners. Those who fail in their attempts often regret their actions, but all attempts should be taken seriously. Self-harm without suicidal
intent takes many forms and can be seen as a way of dealing with diffcult feelings that build up inside.
Self Harm working alongside the young person using a supportive uncritical approach, working with the young person to uncover the
meaning of the self-harm. A harm minimisation approach may help with young people where self-harming has become a way of coping in the
medium to long-term.
Suicide - putting in place suicide prevention strategies may have some success. Such strategies raise the profle of suicide risk in the
community, so that people are more able to recognise that suicide is a risk.
Learning Disability
Learning disability is a diagnosis, but it is not a disease. Nor is it a physical or mental illness and so far as we know it is not treatable.
Internationally three criteria are regarded as requiring to be met before learning disabilities can be identifed:
Intellectual impairment
Social or adaptive dysfunction
Early onset
Intellectual impairment
IQ is one way of classifying learning disability:
50-70 mild learning disability.
35-50 moderate learning disability.
20-35 severe learning disability.
Below 20 profound learning disability.
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However, there are problems with using IQ alone. Measurements can vary during a persons growth and development. Also, many of us have
individual strengths and abilities which do not show up well in IQ tests. However, IQ is important to take into account as well the degree of
social functioning and adaptation.
Onset in childhood - the third criterion is that these impairments can be identifed in the developmental period of life. They are present from
childhood, not acquired later as a result of an accident, adult disease or illness, or dementia (BILD, 2010).
Causes: among people who have a mild learning disability, in about 50% of cases no cause has been identifed. A number of environmental
and genetic factors are thought to be signifcant, although clearly diagnosed genetic causes have been found in only 5% of people in this
category. Research increasingly points to organic causes, such as exposure to alcohol and other toxins prior to birth, hypoxia and other
problems at the time of birth and some chromosomal abnormalities.
However, where there is a known condition it can be helpful to understand as much as possible about the condition and how it affects the
child with disabilities. This understanding can help families and professionals make sense of behaviour and develop positive and effective
strategies. Some of the more common conditions and where you can fnd more information are shown below.
Prevalence - just as there is no consensus on terminology, there are no offcial statistics that tell us precisely how many people there are
with learning disabilities in the UK. The information we have comes from a number of population studies which have focused on measuring
prevalence rates. On a statistical basis 2.5% of the population should have learning disabilities. In fact, prevalence seems to be lower at about
1-2%, giving a total of between 602,000 and 1,204,000 in a UK population of 60.2 million. Partly this is because mortality is higher among
people with more severe forms of learning disability than in the general population. Also in part it is due to not all cases of mild learning
disabilities being identifed (BILD, 2010)
Websites
Royal College of Nursing Children and Young Peoples Mental Health Its Everyones Business
Royal College of Psychiatrists: Young People
National Service Framework for Children Young People and Maternity Services: Medicines for children and young people: Standard 10
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Child & Adolescent Mental Health Services | Module 4: Assessment and Formulation |
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Assessment Themes
Planning for Assessment
Introductions and Engagement in Assessment
Presenting problems
History Taking
Family Observations
Individual Sessions with Child/Young Person
Agency Working
Measures
Risk Assessment
Specialist Assessments
Assessment in the Scottish Context
Formulation
Intervention Planning
Introduction
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ILOs
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Ability to undertake a comprehensive, developmentally appropriate assessment
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ILOs
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Ability to undertake a risk assessment Ability to Formulate the C/YPs problems
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Introduction
Assessment, formulation and treatment planning are the core of clinical work in the CAMHS setting. The
aim of this module is to help you think about the key aspects of all three processes and begin to think about
ways to engage in these activities with the young people and families who come along to your service. As
we will see, all three activities are dependent on the knowledge and skills outlined in modules 1 to 3 and on a
sound understanding of knowledge of therapeutic models and interventions as described in module 5. After
discussing broad assessment themes, and the Scottish context, this module will move through different stages of
an holistic assessment process. With reference to relevant theory, the module will attempt
to explore with the reader both what should be assessed and how. Towards the end of
the module a few commonly used specialist CAMHS assessments will be described.
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The Assessment Process
The core task of an assessment is to help the family develop an understanding of the problems which have prompted them to seek help,
and to encourage them to identify specifcally what help they want. Members of the family may well have very different beliefs about what
constitutes the presenting problem. They may also have different expectations of you, the service and ultimately the kind of help they are
looking for.
Assessment is not a one off event. It continues as an ongoing part of the intervention or treatment approach. The assessment process can
also in itself be therapeutic, and for example can lead the family to make previously unacknowledged links between the presenting diffculty
and family life events. The following defnition and description of assessment are used by the Scottish Government in Getting it Right for
Every Child:
An ongoing process of gathering information, structuring it and making sense of it, in order to inform decisions about the
actions necessary to maximise childrens potential.
(Scottish Executive 2005: 32)
Assessment needs to take account of all infuences on a childs life and should be rooted in understandings of child development. Assessment
involves systematic analysis and evaluation, recognition of alternative explanations and interpretations for the purpose of planning. All those
who are signifcant in a child or young persons life should refect on and review what is known about them and their circumstances before
planning the most appropriate action. The aim is to support assessment and action, which respects rights and needs, seeking the earliest, most
effective and least intrusive responses.
(Scottish Executive 2005: 3)
In practice, the level of detail, and theoretical slant of an holistic assessment can be infuenced by a number of factors including:
Child/young person and family factors such as the developmental stage of the child/young person, and the presenting problems.
Practitioner factors such as preferred theoretical models and training.
Service factors such as Tier of CAMHS service, use of service protocols, expected speed of assessment process etc.
However there are a number of important themes which transcend therapeutic models and should be considered throughout the assessment
process
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Assessment Themes
Assessment of child within multiple systems
A major theme of work with children and young people is to try and understand their development, psychological problems and emotional
distress within the context or systems which they live. These systems can include: the family, school or place of work, peer groups, the
social and community setting, the professional network supporting the family, the cultural setting and the socio-political environment. These
different contexts are connected and are likely to interact, so that a change in one systems can have a knock on effect on other aspects of the
child/young persons environment.
A simple diagrammatical illustration of the child within multiple systems is used in the Getting it Right for Every Child (Scottish Government
2005) assessment approach.
The diagram shows the GIRFEC Assessment Triangle which describes three domains, in each of which the practitioner needs to obtain relevant
assessment information. These are:
The childs developmental needs.
The capacity of parents or carers to respond to
developmental needs.
Wider family, social and environmental factors.
Scottish Executive (2005: 13)
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Risk and Protective Factors for well being
Module 3 detailed the importance of examining a range of factors that are either risk factors for mental ill health or are factors which promote
resilience in the child/young person. This theme of identifying both risk and protective factors runs through every stage of the assessment
process and can be identifed in different assessment methods such as history taking, observation and measures. Goodman and Scott (2005)
believe that risk factors can be further subdivided into predisposing, precipitating and perpetuating factors. Carr (2006) explains these factors
as:
Predisposing factors are those which make it more likely that a child develops a mental health diffculty in the frst place e.g. genetic
factors, birth injuries, insecure attachment to caregiver, caregiver marital diffculties
Precipitating factors which trigger the onset or a marked exacerbation of psychological diffculties e.g. acute life stresses such as
illnesses or bereavements, or developmental transitions such as starting school
Perpetuating (maintaining) factors that develop and keep problems going once they have started e.g. poor coping strategies,
inadvertent reinforcement of problem behaviours.
Carr (2006) also defnes protective factors as:
Protective factors that can guard against mental health diffculties and prevent further deterioration e.g. high IQ, good family
communication, high parental self-effcacy.
Looking out for these risk and protective factors throughout the assessment process, will help you and the family to formulate the reason for
the childs current diffculties, and develop an appropriate intervention plan.
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Child Centered
Another key theme throughout the assessment, formulation and intervention planning process is to take into account the views of children/
young people both in whole family interview situations and individual interviews. This theme around listening to childrens views and
involving them in decision making has been endorsed by a number of legislative and policy drivers in Scotland - Childrens Scotland Act,
1995; Scottish Needs Assessment Programme (SNAP, 2003); The Mental Health of Children and Young People: A Framework for Promotion,
Prevention and Care (Scottish Executive 2005); Getting it Right For Every Child (GIRFEC, Scottish Executive 2005) .
Listening to the views of young children and thinking about their needs, not only involves thinking about what they say verbally but also
refecting on their behaviour and what message it may be communicating. Within family sessions and sessions with the child, the practitioner
faces the interesting task of monitoring not only what is said, but also the behavioural and emotional communications of the child and other
family member
4.1 Views of Children and Young People
A recent study of young peoples views on assessment and therapy
has just been conducted by Young Minds (2011) for the Increasing
Access to Psychological Therapies (IAPT) Initiative in England.
Look at the summary of their views on the Young Minds website
and think about how they apply to your service.
Make some notes in your portfolio.
Other reading
UN Convention on the Rights of the Child Summary Sheet
Needs Assessment Report on Child and Adolescent Mental
Health (SNAP 2003)
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Multidimensional
Given the need to understand the child within multiple systems or contexts, practitioners will often carry out a multidimensional assessment
which is:
Multisource this will include information from the child, family, school as well as other sources of particular relevance to an individual
family.
Multimethod this will include information from interviews, observations and measures as well as any other method which seems
appropriate to the particular family. Using a multimethod approach acknowledges that using a single method to obtain information will
only give a partial picture of the familys functioning.
Multilevel Information about a range of areas of functioning including: emotional, cognitive, physical, and social development, along
with cultural, social and spiritual infuences on the family.
As noted earlier the length and level of detail of an holistic assessment can vary because of a number of factors. Usually an initial meeting is
held with the family to determine: the presenting diffculties, the goals for contact with the service, and what the family might expect following
the assessment. A number of sessions are held to complete the assessment and may involve meeting the child individually for interview,
as well as meeting the whole family and the parents separately. Other meetings may involve: the school, extended family, other involved
professionals, the clinical team, professional networks, case conferences. Detailed records need to be taken of these meetings and written
consent obtained from legal guardians.
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Planning for Assessment
Purpose of the assessment
Assessment of the child/young person and family begins with the initial referral into the CAMHS clinic. From the referral letter the clinician
can begin to make initial hypotheses or explanations about the presenting problem and the purpose of CAMHS assessment and possible
further intervention. A group of CAMHS clinicians will usually make a joint decision about whether the referral meets the criteria for the
CAMHS service. Sometimes decisions cannot be made on the basis of the information on the referral letter, and follow-up telephone calls
or initial meetings with involved agencies need to be made to obtain further information. At other times an initial screening or choice
appointment is offered.
Who to invite
After a decision is made about the appropriateness of the referral and the aim of a CAMHS assessment, the clinician then has to decide on
who to invite to the initial assessment and how to invite them. In many services there will be a standard default position where for example,
all family members living at home will be asked to the initial assessment appointment. This assumes that the carers at home have parental
rights and responsibilities and can give consent to assessment and intervention work. However, some children/young people live in more
complex care arrangements such as in informal kinship care arrangements or are looked after and accommodated. In these circumstances
in particular, it is useful to conduct a network analysis which involves analyzing who is involved with the problem and the role that they play
in respect to it. You may remember from module 2, our discussions about the importance of recognizing who is in the family and who is
considered the client. In particular it is useful to obtain clarity on:
Who are the primary carers (e.g. parents, foster parents, residential childcare staff).
Who has parental rights and responsibilities (e.g. parent, family member, social work department).
What professionals and agencies are involved with the child/young person (e.g. school, social work, youth justice)
Who is the main customer who has the most concern about the childs behaviour and has triggered the referral (e.g. parent, school,
social work etc)
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An initial meeting or telephone calls with other involved agencies can help to clarify the caring network, and the most appropriate people to
invite to future assessments. Carr (2006) emphasizes the importance of planning the assessment, including the network analysis, in his four-
stage model of contact with the family which includes:
Stage 1 - Planning (including a network analysis).
Stage 2 - Assessment and Formulation.
Stage 3 - Case Management.
Stage 4 - Disengagement or re-contracting
4.2 Read the following referral letter to CAMHS and answer the following questions
CAMHS Services, East Sector
Dear Dr Klein,
Re: Referral of Robert Smith, D.O.B: 25/12/2000 Urgency of Referral: Soon
Please see this pleasant young man who came to my surgery today with his mother. He has been displaying aggressive behaviour at school
and at home, and has recently been suspended from school. His mother said that the school has not referred to him educational psychology
and suggested a referral to CAMHS. She said that he is behind in his school work. At home he can sometimes be tearful and says that he
misses his father. During my surgery today he was quiet and subdued.
Roberts father died two years ago and since then his mothers alcohol use has become worse. I understand that he now resides with his aunt
during the week, and he sees his mother at weekends. He has a social worker, and a befriender whom he sees every few weeks. His mother has
an addictions worker. I have also had the aunt down at my surgery who is struggling to cope with Roberts behaviour. He does not do anything
that she asks, is rude and aggressive at home and recently punched a hole in his bedroom door. I have referred her onto a Triple P parents
group.
Please can you offer assessment and bereavement counseling to Robert.
Yours sincerely
Dr Green
Discuss the referral with your supervisor, mentor, or online group
How would you determine who has parental rights and responsibilities?
Who would you invite to an initial consultation meeting about the case?
What information would you like to obtain from a consultation meeting?
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Planning the assessment environment.
You may remember the exercise in module 2 which encouraged you to think about what it was like for a family coming along for the frst
time. You will recall that it can be a daunting process. In order to settle the family in, increase the likelihood of engagement and maximize the
chance of obtaining good and appropriate assessment information, it is worth taking some time to plan the frst meeting.
Think about where you offer the initial appointment. This issue will be particularly relevant when a family/young person may have diffculty
accessing a clinic environment. What options do you have? Which of the options would best meet the needs of the family? If necessary, plan
for using interpreters and advocates when appropriate, allowing time to meet and brief them in advance
As with all appointments you should be aware of safety planning. Think about the environment of the clinic and the accessibility/visibility of
clinic rooms. Plan the best seating arrangements and access to doors and panic alarms. If there are indications that safety issues may be of
particular relevance to a particular case then consider offering an appointment jointly with another clinician.
Put yourself in the shoes of a family member and ask yourself these questions about the clinic room:
Would you yourself be happy to be interviewed in it?
What could be the effects of 1 way mirrors or video cameras?
Are there age appropriate toys and games available for children?
What effect will the seating and toy arrangements have on the interview process? e.g. if all the toys are placed at the back of the room
far away from the other chairs what message could this give the child?
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Introductions and engagement in assessment
Introductions and settling the family
Think about a six year old child coming for an initial
assessment at CAMHS. Consider what assessments they might
have experienced in the past in health, education, social work etc.
What worries might they have about the initial meeting?
Does your service send out pre appointment information about
CAMHS written for parents to read to their child?
What information might be helpful to them in the initial meeting?
How would you explain your job role to a young child?
Introducing the service
Young children can have all sorts of worries/fantasies about coming
to a CAMHS service e.g. that they are going to get an injection, that
they are going to get a row for being naughty, that their parents are
going to leave them at the clinic etc. Indeed some children may not
have been given any information from their parents/carers about
why they are attending. For these reasons CAMHS practitioners
usually spend some time at the start of the session describing the
purpose of the service and their role. Parents/carers can often
be poised to fre off a list of concerns, so providing them with
information about the length of the initial assessment session and
follow up assessment opportunities can reassure them and help with
the pacing of the interview.
Family introductions
At the start of the initial assessment practitioners ask the family to introduce themselves. The practitioner may take particular care to try and
engage the child/young person at this stage. Often what the child/young person has to say in the general introduction is of great interest to
the parents/carers. In addition, some practitioners will spend a little time checking basic details such as contact phone numbers, a process
which can also help to settle the family.
Practitioners may ask introductory questions to the family such as:
Would you like to say a bit about yourself? e.g. what is your name and age, what are your interests? Do you go to work/school/college?
How does every one feel about coming along today?
Does everyone know why they are coming along today?
Mum/dad would you like to explain to child x why they are coming along today?
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Consent and Confdentiality
Issues of consent and confdentiality are usually a concern for children and families and should always be addressed at an early stage in
contact with them. Issues around confdentiality can often centre on:
What information given by the family is shared with other agencies such as the referrer, school etc.
What information given by the child/young person in an individual session is shared with the parents/carers.
During an initial session with the family and at other important points, practitioners will often discuss confdentiality and its limits. In addition,
practitioners can decide with the family on who should receive a copy of a letter summarising the assessment information.
4.3 Confdentiality
Stephanie is referred to your service and as part of the initial assessment is seen
with her parents - then on her own for an individual meeting. During her meeting
Stephanie says that she does not want what she talks about in these meetings to be
shared with her parents. What would you say to Stephanie? Discuss your answer
with your mentor. Make some notes in your portfolio.
While it is important to maintain
confdentiality it is also useful to keep
parents on board throughout assessment
and intervention work. By guaranteeing
confdentiality to a child/young person (except
when there are serious child protection or
safety issues when confdentiality must be
overridden) the parents may feel sidelined.
Some of the session with children/young
person can focus on agreeing what is fed back
to the parents/carers, which may be around
broad themes. The feedback can be done by
the practitioner or the child/young person
in the practitioners presence. However, it is
important to remember that children/young
people under the age of 16, who are deemed
capable of giving consent, have the same
right to confdentiality as an adult. (Offce of
the United Nations High Commissioner for
Human Rights. Conventionon the rights of the
child, 1989)
Consent and Confdentiality
How do you address issues of consent and confdentiality in an initial assessment
meeting? What are your main issues and concerns about obtaining consent?
What forms of words do you use to talk about consent and confdentiality? Do you
have written guidelines on consent and confdentiality? How does a member of staff
new to your team fnd out about the management of consent and confdentiality
issues?
How do you or your team ensure that you take account of children and young
peoples views?
Make a note in your portfolio.
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Assessing competence and determining a childs ability to give
consent can be a challenge. In Scotland a young person is
considered to be competent to make decisions about their treatment
(i.e. give informed consent) if she or he is able to understand (in the
opinion of a medical practitioner) the nature of the intervention being
proposed.
Valid legal consent to an intervention is composed of three elements:
The person being invited to give consent must be capable of
consenting (legally competent)
The consent must be freely given
The person consenting must be suitably informed.
It is also important to know that obtaining consent is an ongoing
process throughout contact with the family, and it is usual to revisit
this issue when introducing specifc aspects of an assessment or
intervention. A child/young perons capacity to give or withhold
consent is not absolute, and varies with the complexity of the
intervention and perceptions of risks versus benefts (e.g. a young
person may be judged able to consent to relaxation training but not
an admission to an in-patient unit)
In Scotland parents who have parental responsibility can also give,
or withhold, consent to treatment parents who were named on
the birth certifcate after 4 May 2006 are assumed to have parental
responsibility. Before that both biological parents were required
to be married (either at the time or later) and named on the birth
certifcate. Before 4 May 2006 only the mother is automatically
assumed to have parental responsibility, although the father may
acquire it.
4.4 Consent and Confdentiality
The British Medical Association has a useful toolkit
which looks at issues of consent for adults and
children. Download the BMA consent toolkit and
discuss cards 2, 3, 4, 5, 7 and 10 with your mentor or
your online group.
Think about a child, young person or family where
the issue of consent has been complex and / or
diffcult discuss with your mentor or online group
how this was resolved. If you are new to working
with children and young people, you might want
your mentor to outline an example for you both to
discuss.
Other online references:
CAMHS competence framework map: Knowledge
of, and ability to work with, issues of confdentiality,
consent and capacity
Paul, M (2004). Decision-making about childrens
mental health care: ethical challenges Advances in
Psychiatric Treatment 10, 301311
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Presenting problems
After initial introductions, the clinicians next key tasks are to determine the presenting problems from the point
of view of all the family members present, and to try and establish whether the familys needs are best met by
the CAMHS team and/or another service.
It is useful to start the interview with fairly broad open ended questions such as Would you like to tell me what has brought you along today?
Who would like to begin telling me about what is worrying the family? The interviewer can then follow up the presenting diffculties in more
detail. In order to facilitate engagement in the assessment process and obtain information on both risk and resilience factors, it is useful to
intersperse periods of questioning around problems, with discussion of possible protective factors. Throughout the assessment process, the
clinician has to remain mindful of the impact of the discussion on the feelings of the child/young person in the room.
4.5 Diagnostic considerations
Recognition of whether there is evidence of a mental health problem such as depression or anxiety or a
neurodevelopmental condition such as ADHD or Aspergers syndrome, is a central part of the assessment process. One in ten children
aged 5 to 16 years have a clinically diagnosable mental health problem, including depression, anxiety or psychosis (Green et al 2005) A
diagnostic assessment is underpinned by knowledge of mental health conditions and the ICD or DSM criteria (see module 3) However,
especially for staff new to CAMHS, it is good practice to involve other members of the CAMHS team when assessing and diagnosing
mental health conditions. Indeed for some conditions such as ASD, the SIGN guidelines recommend that a range of professional groups
are involved in the assessment process as they may identify different aspects of the condition and aid accurate diagnosis (SIGN no 98,
2007 page 10)
It is arguably the case that most if not all, emotions and behaviours displayed by CAMHS children are experienced by all children and
young people to some degree and at different times. If a mental health condition is to be diagnosed it is necessary to fulfll the DSM-IV
and ICD-10 impact criteria, which include consideration of the level of:
1. Social impairment the childs ability to function normally in the following areas is signifcantly compromised:
a family life b classroom learning c friendships d leisure activities
2. Distress for the child
3. Disruption for others
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Range of problems
Usually families report an array of presenting diffculties and
it is helpful to begin by making a simple list. Scott (2005)
highlights that presenting diffculties usually fall into four
very broad domains which include:
Emotional symptoms such as anxiety and low mood
Conduct problems such as defant behaviour,
aggression and destructiveness, and antisocial
behaviours such as stealing, fre setting and substance
abuse.
Developmental delays in areas such as: speech,
academic functioning, play, social skills, motor skills,
attention and activity regulation, and in bladder and
bowel control.
Relationship diffculties with peers, family members
etc.
4.6 Assessing Presenting Problems
Investigate how your team assesses mental health conditions
such as depression, ADHD and ASD by:
Observing any specialist assessment clinics within the team or
wider service
Observing assessments conducted by clinicians with a specialist
interest/training in that feld
Follow the links below and consider how close your teams assessment
is to that recommended in the guidelines:
Sign guideline on ASD
Nice guideline on ADHD
SIGN guideline on assessment of ADHD
Nice guideline on Depression
Detailing the problems
Families can often talk about problems in quite vague terms e.g. hes a Jekyl and Hyde character who isnt getting on at school or with his
pals. The clinician then has to work to understand the meaning of the descriptions by, for example, eliciting specifc concrete examples of the
presenting diffculty. It can be helpful to ask the family to describe the most recent occurrence of the diffculty. If the occasion is still fresh in
the familys memory, this can produced of wealth of meaningful information, beliefs and emotions.
Obtaining an idea of the frequency, intensity and duration of the problems is also critical to the assessment process. Questions focused on
the duration of the presenting problem sometimes naturally reveal an obvious precipitating factor such as a traumatic incident. However, on
other occasions families may struggle to recall the duration of the problems. It can help to prompt them by asking them if the problems were
present around memorable times such as Christmas, start of school term and so on. It is helpful, early on in the assessment process, to ask
about what prompted the family to seek help at the time they did. This can begin an exploration of factors that may be helping to maintain or
exacerbate problems, and open up a conversation about the familys beliefs and explanations of the presenting diffculty.
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Current functioning
The family may not spontaneously mention all the areas where the diffculties have an impact. It can be useful to check out, systematically, the
child/young persons current functioning in terms of their physical health including possible somatic symptoms, sleep pattern, diet, exercise,
social relationships and use of drugs and alcohol. It can be useful to obtain a step-by-step description of a typical day as some conditions
such as anxiety or depression can cause the child/young person to restrict the number and type of their daily activities. Depending on the
type and severity of symptoms, a formal Mental State Examination may a useful adjunct to the process. There may be specifc members of
your CAMHS team who are particularly experienced or qualifed in conducting an MSE
Often parents/carers, schools and children/young people will have different perceptions and opinions of the presenting diffculty. For
example, a young person may report feeling anxious in social situations, whereas a parent may be of the opinion that their child is confdent
when talking to adults. Post modern therapies such as narrative therapy, would regard each viewpoint as equally valid, and would not
privilege one viewpoint over another. Conversely, the process of diagnosing a condition does require a degree of convergence on one
particular truth. Teasing out whether varying reports are due to the effects of different environments on the child/young person, or lack of
awareness on the part of one of the respondents, can help to explain varying reports.
Attempted solutions
During the discussion about the presenting problems, it is helpful to obtain an account of how the family has tried to solve the problem in the
past, and whether the family thinks that their attempts were successful/unsuccessful. Sometimes the very way that families are attempting to
deal with a problem is helping to perpetuate it. This idea is explored in depth by many models of therapy e.g. cognitive behavioural therapy,
and strategic family therapists who try to disrupt the patterns of perpetuating behaviours and use of solutions which have previously failed.
Exceptions
Another important theme to consider when analyzing the presenting problems is to ask about times when the problem did not occur. The
aim would be to identify what the family was doing differently when the problem did not occur e.g with the case example detailed below
the therapist might want to explore the time when Ryan went to school without anxiety when both mum and dad walked him to the school
playground. There may also be particular settings where the problem does not occur e.g. a young persons anxiety about leaving the house
may not be present on holiday. The search for exceptions to the problem is an approach that is elaborated on in many forms of therapy
including Brief Solution focused family therapy.
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Function and meaning of the behaviour
Children are sometimes unable to communicate their distress verbally, and instead communicate their distress through their behaviour
e.g. by somatising their distress or by displaying disruptive behaviour. Throughout the assessment process clinicians will try and gain an
understanding of the function and meaning of a childs behaviour. There will be an attempt to identify the relationships between clinically
relevant behaviours and factors in the environment which select, infuence and maintain them. During the interview there will be an attempt
to look at the situational factors, family interactions, and chain of events which occurred before the behaviour which may have triggered it,
and the events and reactions which occurred after the behaviour which may be helping to reinforce it. A more detailed functional analysis*
approach can be carried out through using a variety of methods including interviews, structured observations, diaries and questionnaires.
Strengths and resilience factors
As discussed earlier the practitioner needs to identify protective factors and strengths displayed by the child and family. You may want to
explicitly ask about what the parents think their child is good at, and highlight strengths that the parents have demonstrated in the session
or talked about in the initial interview e.g. the care that they have taken to look up a particular condition on the internet. In relation to the
presenting problem specifcally Goodman and Scott (2005) discuss how it can be useful to identify the presenting problem as the opposite
side of the coin to a valuable strength. For example, a child showing very active behaviour could be discussed as having high energy levels
which is a trait that may be useful later in life.
Summary
Goodman and Scott (2005) provide a useful mnemonic (SIRSE)
as an aide memoire to think about the general areas to be
covered in an assessment:
*Functional analysis focuses on the identifcation of variables that infuence problem behaviour and is a hallmark of a behavioural assessment. By doing this it aims to
determine the reason or purpose of the behaviour. It usually involves interviews, direct observations of the behaviou , as well as experimental manipulation of the factors
thought to infuence the behaviour. For further reading see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC12858983.pdf
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History Taking
Developmental and School History
Purpose of developmental history
Obtaining a developmental history is crucial for obtaining information on risk and protective factors for the current presenting problem, and
to detect any delayed or unexpected developmental processes. You may recall the discussion in module 1 about developmental pathways;
having a comprehensive developmental history allows us to think about how, when and why some of the current diffculties may have arisen
in the frst place.
A thorough developmental assessment should cover all areas of a child/young persons development such as: physical, social, psychological,
intellectual and moral development. The different areas of child development interact, so for example if a child experiences a language
delay this can affect their social development. When a practitioner asks about the child/young persons development, their ability to focus
questioning effectively and understand the signifcance of the parents report, is heavily dependent on the practitioners knowledge of normal
child development and mental health and neuro-developmental conditions. For example, if a child presents with suspected Aspergers
Syndrome, more time would be spent on questioning of the childs: communication skills, social skills, play skills and signs of rigidity exhibited
from the infancy stage onwards. In this way, the content and direction of the assessment is guided by:
the clinicians understanding of development
the clinicians understanding of developmental psychopathology
the information offered by the family
To some extent, the developmental history can merge with the family history. It can be helpful to ask about parental mental health
experiences at key stages in the childs development such as during the pregnancy and post birth. Some practitioners ask about key family
life events and transitions at each developmental stage, whereas other practitioners would include this in the family history section. The
practitioner continually monitors evidence for the interaction between parental behaviours and the childs development.
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Case study
Stephanie Campbell was referred to CAMHS age 14 years presenting with
low mood and self harm behaviour. Read the following extract detailing her
early developmental history and consider the questions below:
Stephanie was a premature baby, born at 35 weeks, she weighed 2.2 kg. She was in an incubator
for 24 hours and received phototherapy for jaundice for a couple of days. Her mother Sara
experienced postnatal depression for which she received Fluoxetine 20mg daily for the eight
months following Stephanies birth. Sara had experienced several episodes of depression since her
teenage years for which she received SSRI treatment. Sara had diffculty bonding with Stephanie
in the frst few days following the birth; she was tearful, low in mood and withdrawn. With the
help of her midwife she was able to nurse Stephanie and developed a good bond. Stephanie was
fed with formula milk for the frst few days and after that was breast-fed.
Sara was supported at home by her Health Visitor and attended a local mother and baby group.
Stephanie developed colic which continued for 3 months. She would cry most evenings and nights,
and her parents had diffculty helping her to sleep. Sara and dad Craig took turns in trying to
soothe Stephanie, but the disrupted sleep pattern affected their relationship and there were often
arguments. Stephanie had slight delays in reaching some developmental milestones, she started
to crawl at 10 months and she was nearly two years old before she started to walk.
Stephanie attended nursery from the age of two and Sara went back to work. Stephanie stayed
at nursery until she started school. She played well with other children and made a number of
friendships with other girls in the nursery. These friendships continued with some of the children
into primary school. At school she managed her early years very well until primary 3l and was
popular with her teachers and fellow pupils.
1 What are the risk and protective factors detailed in the case study
2 Are there other areas of Stephanies development that you would want to fnd out about?
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Taking a Developmental History - How to do it
The developmental history should be a venture of joint enquiry, where both professionals and family are active participants in trying to
identify signifcant events in the childs development. As with other areas of the history taking process it is useful to notice not just what
the parent recalls but also how much or little detail is offered about specifc periods in the childs life. Some parents will spontaneously offer
explanations of their poor recall e.g. that they were depressed around that period and noticed fewer changes in their childs development.
Sometimes the parent will not immediately see the relevance of particular question and will be reassured by an explanation of why you have
posed it e.g. that you are asking about the mums mental health after the birth because post-natal depression is a common experience.
A developmental history can be organised around the different stages of childhood beginning with the pregnancy and moving through to
adolescence ( pregnancy and perinatal, 0 to fve, 6-12, adolescence). Module 1 offers an outline of the key stages of development and there
are a number of other helpful sources such as Sheridan (2008) and the NHS choices website.
A parents recall of their childs development may be hazy for a number of reasons, and it can help to tell them in advance of the assessment
session that you will be asking about their childs development. Some parents like to bring along baby books which have recorded their
childs progress. As in the presenting problems section it is useful to start by asking broad open ended questions before using specifc
prompts. It can be helpful to aid the parents recall by asking about the childs development around memorable events e.g. if the child was
saying anything by their frst birthday.
The history taken from the parent/carer can be supplemented by that obtained from child health records or other involved professionals such
as health visitors, social workers nursery nurses, or school teachers. When working with families where the child/young person is looked
after either formally or by kinship carers, the practitioner will have to rely more heavily on obtaining the history from other professionals and
written records.
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Taking a Developmental History - What to ask
The following table summarises question areas to cover from pregnancy to adolescence. The question areas can be elaborated further or
summarised, depending on the presenting diffculty. Some services use problem specifc developmental histories.
Generic Developmental History Expandable Table
Pregnancy to Perinatal period
Mothers health
during pregnancy
Alcohol/Drug use? Smoking? Physical/Mental Health? Stresses? Diet? Supportive relationships?
Progression of pregnancy Any problems? Planned pregnancy?
Birth Birth Weight? Born at how many weeks? Type of birth? Birth complications?
Baby hood to School (0-5 years) evidence of strengths and diffculties
Mothers Health Post Birth Physical/Mental Health? Stresses? Supportive relationships?
Baby and childs Health Special Care? Support? Other health diffculties/illnesses?
Signs of Bonding and Attachment Who were the baby/infants signifcant attachment fgures? How was the baby soothed? Reactions to
separations/reunions?
Infant Temperament (Comparison with
parental temperament)
Descriptions of child as a baby/infant How did you view x as a baby? contented? active? Fretful? cohlic?
Basic Body Functions: Feeding, Sleeping,
Toileting, Growth as baby and child
Breast/Bottle fed? Any worries over feeding? Sleep pattern and routine? When slept through the night? Growth?
Any worries over toileting? When toilet trained during day and night? Growth concerns?
Language development Any concerns? babbling? pointing to comment? pointing to get things? frst word when? First two word phrases
when? Any concerns over language expression? Any concerns over language comprehension?
Motor development Any concerns? Sat up when? Crawled/bottom shuffed when? First steps when? Running? Pedalling trike when?
Fine motor skills?
Cognitive development Any concerns? Sustaining attention on tasks that interest him/her? Play skills? Ability to complete age
appropriate jigsaws and games
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Social development Any concerns? Reports from nursery (council nursery begins age 3). Adjustment to nursery.
Emotion regulation Concerns over tantrums? How were they managed?
Primary School age (5-11 years) evidence of strengths and diffculties
Track the progress of any diffculties highlighted in the earlier developmental phase (0-5 years).
Health of child Any signifcant health concerns or illnesses? Amount of exercise? Diet?
Transition to primary Transition to primary any concerns? Attendance problems?
Transition between school years? Adjustment to new routines?
Academic development Any concerns? Levels achieved when? Concentration diffculties? Concentration on homework? Concentration
on activities that interest the child? Following instructions?
Social development Any concerns? Social skills? turn taking, sharing etc
Behaviour towards strangers- signs of overfamiliarity? Friendships? Peer problems? Bullying? Attendance at
extracurricular activities/clubs?
Emotion regulation Tantrums? Anxieties? Low mood?
Conduct/Behaviour Following rules? Conduct problems? Impulsivity ability to stop and wait? Sense of danger? Road safety?
Activity levels? Experimentation with drugs or alcohol?
Daily life skills Any problems with organising and sequencing tasks? Ability to get ready in the morning? Helping with
household chores?
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Secondary School age (11-18 years) evidence of strengths and diffculties
Track the progress of any diffculties highlighted in the earlier developmental phase (5-11 years).
Health of adolescent Any signifcant health concerns or illnesses? Amount of exercise? Diet? Adjustment to puberty?
Transition to secondary Transition to secondary any concerns? Attendance problems?
Transition between school years? Adjustment to new routines?
Academic development Any concerns? Levels/grades achieved when? Concentration diffculties? Concentration on homework?
Concentration on activities that interest the adolescent? Following instructions?
Social development Any concerns? Social skills? beginning, maintaining and ending conversations appropriately?
Behaviour towards strangers- signs of overfamiliarity? Friendships? Sexual relationships? Peer problems? Gang
membership? Bullying? Attendance at extracurricular activities/clubs?
Psychological symptoms Anxieties? Low mood? Problems with eating pattern? Psychotic symptoms?
Conduct/Behaviour Following rules? Conduct problems? Activity levels? Use of drugs or alcohol? Risk taking behaviours? Contact
with legal services?
Daily life skills Any problems with organising and sequencing tasks? Ability to get ready in the morning? Helping with
household chores?
4.7 Developmental History
Video tape/record a history taking session with a family and discuss with your supervisor/mentor
or
Work in a pair with a colleague and practice taking a developmental history of yourself/a sibling/child/friend.
What areas of development did you focus on and why?
What were the strengths and diffculties highlighted in the developmental history?
How do you think that any weaknesses in one area of development e.g. language may have effected other areas of development?
Discuss how one of the developmental theories highlighted in Module 1 (Piaget, Erickson, Bowlby) informed your thinking about
the developmental history.
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Medical History
Obtaining a medical history can also provide information on risk and protective factors for the presenting diffculties. In addition, if you would
like to refer the child/young person on for further more specialised testing e.g. of their language or learning abilities it is necessary to rule out
basic hearing or visual problems frst.
A basic medical history should include information on:
immunisations, infections, allergies, illnesses, operations
prescribed and non-prescribed medications
fts/faints, loss of consciousness, head injury
hearing and vision problems
contact with hospitals and specialist child health services.
Family And Social History
Purpose of Family History
A family history is obtained in order to build up a picture of family membership and support structures, and to help identify possible genetic
and environmental risk factors for problem development, and any potential protective factors. These environmental risk factors can include
the familys behaviours, beliefs, and problem solving strategies as well as the familys socio-cultural context. As highlighted in Module 1, the
childs personality, beliefs and behaviour will be shaped in part by the behaviour, beliefs, and problem solving strategies of family members,
but will also exert some infuence on those same family beliefs and behaviours.
It is useful to begin taking a family history by obtaining clarity on family membership either by listing family members, or by drawing a family
tree or genogram*.
*Genogram A genogram is a pictorial display of a persons family relationships and medical history which goes beyond a traditional family tree by allowing the user to
visualise hereditary patterns and psychological factors that punctuate relationships. It can be used to identify repetitive patterns of behaviour and to recognize hereditary
tendencies. They can be used for personal records and/ or to explain family dynamics to the client.
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Diagnostic slant genetic and environmental risk factors
Parents can often present to CAMHS with a query about whether their child has a specifc mental health condition e.g. ADHD. It can
sometimes make most sense to these parents to continue the family history taking process by exploring the history of mental health and
medical conditions experienced by the parents and other family members. You might want to ask about:
The history of mental health, physical health, addictions and learning problems on mums side of the family
Whether anyone had extra support from school, health services etc?
These questions can be repeated for dads side of the family. If a genogram is constructed, it is possible to illustrate visually, patterns of ill
health and functioning across three generations of family members.
Parenting factors
Part of a holistic assessment involves assessing the parents ability to meet the needs of the child (see assessment triangle). It is also helpful
to think about the parenting style of the parents/carers. Parenting style can vary according to the degree of warmth and control that parents
show their children. The practitioner can gain information on the parents parenting style from observations of, and enquiring about:
How child care is organised, shared and supported
How the physical, emotional, intellectual and social needs are met by the family e.g. how the child shows their distress? How the child
likes to be comforted when upset?
What are their expectations for the child?
How they reward their child for good behaviour?
What they like doing together as a family or parent/child? (Do they play with their child?)
How do they discipline their child? If the child does something they are not meant to what do the parents do? (Do the parents lose
control?) Do they agree on rules and how discipline should be applied?
Limit setting e.g. managing bedtimes? Do they follow through with commands or instructions if the child does not comply?
Exploration of the parents own experience of childhood and being parented themselves, can facilitate a discussion around the infuences on
their parenting approach. However, some parents do not immediately see the relevance of describing their own parenting history, so you may
want to give them an explanation. How would you explain the relevance of taking a parenting history to parents? You may want to highlight
that parents are affected by how they were parented themselves, and that some parents consciously try to manage their children in a different
way to that adopted by their own parents.
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Case study
Read the following short case study and refect on the parenting styles
Seven year old Ryan was referred to CAMHS for school refusal problems and separation anxiety.
Ryan lives at home with his mother and father and two year old sister Millie. In the session Ryans
mother Maggie and father David talk how they manage Ryans behaviour at home. Maggie works
full time within the home environment looking after the children. She describes how she tries to
do her best for Ryan, giving him everything that he needs. At home he likes to have his meals
in front of tv, and will throw a tantrum shouting and throwing things, if he does not get what he
wants. Maggie feels that she will give into his tantrums on most occasions as she is worried about
the noise that he makes and that he might disturb the next door neighbours. On school mornings
he complains of feeling unwell and cries when they are due to leave for school. Maggie says that
this makes her feel terrible and she cuddles him until he feels better.
David works long hours at his job, and comes back late in the evening. If the children are still up
when he returns from work, he will sometimes lose his temper and shout at them to get to bed.
He expects Ryan to do what he is told. Ryan and Maggie share a bed with their parents and the
parents do not have plans to change this arrangement. At the weekends David likes to take the
family for a drive into the countryside or they travel to visit their grandparents.
What additional questions would you ask the parents when thinking about their parenting
styles?
What might inform your judgments about parenting?
Are you aware of how your own experiences of parenting/being parented may bias/
infuence your judgments?
How would you fnd out about the relevant cultural infuences on parenting practices?
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Systemic Factors
Relationships
During the family history taking process family relationships can be explored. Using the genogram it is possible to look at relationship
patterns across three generations of family members. The clinician and family members can work together to look at patterns of closeness
or distance, and structural patterns such as separation and divorce. At a basic level this can help to identify support systems within the
family, and alliances and coalitions between specifc family members. Module 1 highlighted that the family can be seen as a system with
boundaries. Structural family therapy (Minuchin, S, 1984) also looks at the subsystems that make up the larger family subsystem. Examples of
these subsystems can be the parental and child subsystems, male and female subsystems etc. These subsystems may also be explored using
the genogram.
Goodman and Scott (2005) suggest the following questions for exploring
the parental and sibling relationships:
how do the parents get on together?
do they support each other?
how do the children get on together?
who is close to whom?
who gets into most or least trouble?
how are the children treated differently?
Family life cycle and Life events
Module 1 outlined Carter and McGoldrick (1999) family lifecycle model. During the history taking process clinicians can think about the
developmental stage of the family. How would you determine this? You may want to think about the developmental tasks that the family is
faced with and how it is coping with them? What transitions is the family going through?
The family may have experienced unexpected life events such as traumas or unexpected losses which can sometimes precipitate wider
changes within the family and the presenting diffculties. It is useful to explore the impact of these life events on the family, and any reactions
to anniversaries of trauma or loss.
4.8 Family History
Think of a family that you are about
to work with.
How would you ask about parental and sibling
relationships?
How would you word your questions?
If you had some emerging concerns that there
maybe parental relationship problems which
included domestic violence how would you ask
about this?
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Social and Cultural Context
A number of social factors have been shown to exert stress on families and have an impact on child development and behaviour. For example,
extensive research shows that children who grow up under conditions of poverty are more likely (relative to more affuent children) to be less
successful in school, less productive as adults in the labor market, have lifelong health problems, and commit crimes and engage in other
forms of problematic behaviour (Holzer et al, 2007) The clinician can obtain some idea of the social pressures that the family is under by
asking about employment, debt, housing, overcrowding, safety of the neighbourhood, problems with neighbours, gangs, contact with services
such as social work etc. Again it is useful to look for signs of family resilience factors in the face of environmental stressors and highlight these
factors to the family during the assessment process. Potential protective factors in the familys social environment may include good social
support, proximity to extended family or access to community resources. When it comes to the treatment planning stage of the process
it may be that the clinician can adopt a practical approach to dealing with some social risk factors. For example, they may be able to direct
families to supportive agencies which can for example give advice on beneft maximization.
Asking about cultural and religious practices can sometimes reveal important support networks. At a broader level enquiring about the
familys cultural, racial and religious background can also help you understand the infuences on family beliefs and behaviours, gender roles,
parenting practices and family values. It is important to be aware that you may hold your own racial, cultural, or religious stereotypes which
may be inaccurate generally, and in relation to the particular family you are working with. Rather than relying on your own beliefs about a
particular culture, it is helpful to ask the family about their understanding and perceptions of cultural or religious practices that are important
to them.
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Case Study - Social and cultural context
Deniz Elmas is a 13 year old girl who was referred to CAMHS by her GP with a query over low mood and
possible depression after being brought to the GP surgery by her mother. She lives at home with her mother
and father, older sister Pinar (15 years of age), and younger brother (Ali who is nine years of age). The GP letter
also mentioned that the family is struggling to manage Alis aggressive behaviour displayed at home.
The family who moved from Turkey fve years ago are living in a deprived part of Glasgow in a 3 bedroom council house. Denizs father has
been working in the hospitality sector whilst her mother stays at home to look after the children. Her mother suffers from symptoms of
anxiety and depression and is attending a counsellor at the local GP practice. The family has experienced neighbourhood harassment from
local youths. Mrs Elmas reported that her children have been called names by these youths whilst out walking in the street, and are now
anxious about going outside. The family have written and phoned the council on several occasions to request a house move. The family
attends the local mosque, although Deniz has recently been expressing reluctance about attending. They have also formed friendships with a
couple of Turkish families in the local community.
Deniz has been attending secondary school over the past year and a half. A school report obtained from the deputy head teacher indicated
that she is in the lower groups and has been struggling to fnish work and concentrate. The deputy head assumed that her language abilities
may be affecting her performance, but has referred her to the educational psychologist for further assessment. She does not attend any
school related extra-curricular activities such as sports or arts activities. In class and in the play ground she appears to be a quiet shy girl who
has only one girl friend who attends the local mosque with her. The deputy head has not raised this as a concern with the family assuming
that Denizs choice of activities and friends are culturally infuenced. Towards the end of the phonecall, the deputy head mentioned that Mrs
Elmas attended a couple of sessions of a parents group run by the schools educational psychologist. During this group Mrs Elmas said that
she expects her children to do what they are asked, and she sometimes smacks Ali when he misbehaves. The group leaders did not feel that
this issue needed followed up at the time.
As you were reading the case study which highlighted some social and cultural infuences were you able to identify any risk and resilience
factors for the family?
Denizs school appears to have been making some assumptions about the infuence of her cultural background on her presentation within this
setting.
How would you avoid making such assumptions?
What questions would you ask to explore the familys cultural and religious beliefs and practices and how they affect the family?
Ask your supervisor if they have experienced a similasr cultural issue.
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Constructing a Genogram
Genograms are a useful way of representing family structure in a clear and
easily understandable format. They can be used in two main ways, either as
a tool for the worker to think about families, or as a therapeutic intervention
carried out with the family focused on helping them increase their insight of
patterns of behaviour and relationships.
It is easy to work together with the family to create the genogram and it
can be an engaging way to involve children and young people. Genograms
range in their complexity from images which signal the gender and age of
the family member, to more complex representations which represent issues
such as sexuality, and quality of relationships. They can highlight information
that may be sensitive to some family members, so for this reason it is helpful
to give the family some warning that you want to construct one, especially
if you plan to cover more complex representations. It may be the case that
parents would not want to talk about some of the information in front of
their children. If you are new to creating genograms you might want to start
off with the more basic structure before moving onto the more complex. If
you are unfamiliar with constructing a genogram consult your supervisor, you
might also want to look at the genogram symbols on the following page. It
is usual practice to draw a circle around the family members living at home.
4.9 Draw a Genogram
a Try drawing a genogram of your own family.
You can draw the genogram by hand or use a
Word Processing programme. Make sure you
start drawing the genogram with the document in
landscape orientation they are easier to construct
this way. It is usual to depict three generations of a
family.
how easy was it to recall details such as names,
ages, relationships?
how did you feel when using the genogram
symbols to depict potentially sensitive
information such as deaths, or health problems?
discuss your reactions with your supervisor or
mentor
b Consider a family you are currently working with
and create a genogram.
What issues would you want to explore with
them? You may want to think of resilience and
vulnerability factors within the family. Discuss
with your mentor or online group how you plan
to negotiate carrying out the genogram with the
family.
Make notes in your portfolio on the process.
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Family Observations
The presentations of different family members, and observations of the interpersonal interactions between
them, provide further information on the risk and protective factors infuencing the presenting problem. These
direct observations can be compared against the history provided by family members. There are a number
of structured observational methods for observing the behaviour and interactions of children and families.
Examples include:
time sampling in which the frequency of the problematic child behaviour is recorded within a specifed time frame.
parent/child game assessment (Jenners 2008) in which the frequency of different types of parent child interactions can be recorded
within a specifed time frame.
However, in the clinic most observations of family members are conducted in a fairly unstructured manner during the course of interview and
play sessions. Practitioners usually begin their observations of the family when they frst meet them in the waiting room and will continue
them throughout the assessment process. Broad observation areas may include:
how the child separates from parents for an individual session and reunites with them afterwards
mood and presentation of all family members present
the degree of sensitivity and warmth shown by family members to each other
the degree of criticism shown by family members to each other
whether there are particular alignments or hierarchies within the family
the language family members use to describe one another
the ways in which parents monitor their child and set limits, and the ways in which the child reacts to limit setting.
how family members react to the childs behaviour.
Observing family members whilst taking a history is a challenging task, and is important to be aware of the risks of over-interpreting single
instances of behaviour. The familys behaviour can of course be affected by the interview environment, and parents of small children showing
disruptive behaviour in a session may need explicit encouragement to manage their child as they would at home. During an interview it is
useful to try and record concrete descriptions of behaviour or statements made by family members rather than recording your interpretations
of them. Knowledge of the familys social and cultural background may infuence how you interpret your observations.
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An additional area to observe and refect on is your emotional reactions during the sessions, particularly if you fnd yourself reacting in an
unusual way e.g. with feelings of anger, anxiety or disgust. Refecting on your emotional reactions by yourself or in supervision, can provide
useful information on the verbal and non-verbal communications and dynamics present in the room, and on whether particular information
discussed by a family member has resonated with one of your own life experiences.
4.10 Refection on a session
Read the following extract from a session and think about:
the different forms of observation made by the clinician
how the observations should inform your formulation of the presenting problems.
whether other forms of information are required
Tracey age 10 was referred to CAMHS with anxiety problems, frequent headaches and school refusal. After meeting
with the family together and seeing the parents separately the clinician decided to meet with Tracey individually.
Half an hour before the appointment was due to start the clinician was informed by the teams secretary that the
family had arrived in the clinic. When the clinician went to meet Tracey at the scheduled time she observed her
sitting close to her mother in the waiting room. Her mother was sitting on the edge of her seat and appeared tense-
chewing her lips, with her limbs crossed. After initial greetings the clinician reminded the family that todays session
was for Tracey to talk by herself. At this prompt Tracey stood up and smiled shyly. Her mother also jumped up and
looked concerned stating are you sure you will be o.k Tracey? Shall I come too, as you were feeling worried in the
taxi on the way here?
After separating from her mother Tracey sat down in the clinic room with the practitioner. They began talking about
what Tracey enjoyed doing at home, and Tracey spent a long while making animal fgures out of play-doh. Towards
the end of the session, the practitioner noticed that she had not asked Tracey about her school refusal problems and
she felt wary of doing so. She decided that they had probably covered enough in todays session anyway, and that
she would schedule a second individual session with Tracey to discuss the school refusal problems then.
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Individual Sessions With Child/Young Person
Individual time/sessions with the child/young person allow the practitioner to observe the child/young persons
behaviour, mood, activity levels, attention, social interactions, language and play in a different setting separate
from their parents. The session(s) can encourage the child/young person to talk about their view of the
problems. At the start of the session you may want to remind the child/young person of the purpose of the
session and confdentiality issues (see confdentiality section).
Goodman and Scott (2005) recommend that for children under fve it is best to focus on observations and play and to use fewer directed
questions. For children over fve who are by then at school, you can ask them more directed questions. Beginning with a drawing or
questions about the childs interests is often a way of engaging the child in the session. Carr (2006) suggests that a simplifed child-friendly
genogram or lifeline can be constructed with the child. Further areas to be considered are the childs account of any problems/symptoms and
ways of coping, friendships and bullying, school performance, wishes for the future, and capacity to engage with any proposed interventions.
In addition, Goodman and Scott (2005) feel that it is worth asking a general question about undisclosed abuse or traumas. However, care
needs to be taken with the wording of such questions. They suggest the following wording: sometimes nasty or frightening things happen to
children, and they fnd it diffcult to tell anyone about it. Has anything like that ever happened to you?
4.11 Close Relationships
As children become young people they often struggle to come
to terms with their sexuality and sexual identity. Most young people will
develop opposite sex relationships while a signifcant number of young
people will develop same-sex, or bisexual relationships and some young
people will transgender because they are so unsettled by their assigned
gender.
Asking girls if they have a boyfriend assumes that they are heterosexual,
which may not be the case.
What forms of words could you use to ask a young person about their
close, intimate or sexual relationships in an inclusive way?
During sessions with a child aim to use simple words
and short sentences with open questions that allow
the child to provide a wide range of answers and
descriptions. Closed questions that ask for specifc
pieces of information such as a yes/no answer or a
number can be used as follow up questions. It is
advisable to try and avoid using leading questions
which directly suggest an answer, as children are
particularly likely to answer in a way that they think is
expected. An example of a leading question might be
well you seemed to enjoy todays session didnt you?
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Agency Working
Diagram 3 Assessment Timeline
As can be seen from the timeline, different professionals will be involved at different stages of a childs life.
The timeline illustrates the minimum number of people and professionals who may be involved in a childs
life. Some families presenting at CAMHS may have a much wider network of professionals involved including:
child health staff such as peadiatricians, specialist educationalists such as educational psychologists and SEN
assistants, adult mental health services, social services, and services from the voluntary sector who may provide
services such as befriending.
Carr (2006) suggests making a list of:
all involved agencies
the duration of their involvement
the reasons for their involvement
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The Scottish Government have made collaboration and integrated working a priority. Interagency working is to be encouraged but it is not
without barriers which may include: institutional/systemic factors such as power struggles between agencies, conficts of interest, lack of trust
between professionals, and lack of clarity about who takes responsibility in each agency (see CAMHS Competence Framework interagency
working section)
When obtaining reports from other agencies during the assessment process, consent to obtain information, and if required, consent to share
information has to be sought from the family (unless there are child protection concerns which may override this principle). Many services
now have their own written consent forms designed for this purpose.
With most CAMHS cases, practitioners will obtain a nursery/school report on the child/young person from the head/deputy teacher and/or
class teacher, as a childs behaviour at school can vary markedly from that displayed at home. The type of questions asked will vary according
to the presenting problem, but general areas of interest usually include the history of:
school attendance
academic achievement
social skills and relationships
emotional/behavioural problems
school management of problems and support provided
parent/school relationship.
Depending on the presenting problem, the CAMHS clinician may follow up a school report with a direct observation of the child within the
school setting.
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Measures
Questionnaire measures are often used in clinical practice to obtain a lot of information on the child/parent/
teachers views on a topic quickly. Standardised measures have been tested on a normative sample of
the population which should have similar characteristics (age, gender, nationality etc) to your clinical cases.
Standardised measures have undergone several rigorous tests. For example a standardised measure of
depression should have been checked for its construct validity i.e. that it is really measuring depression and not
some other concept such as anxiety. It should also have been checked for its internal reliability to make sure
that all the questions hang together and are measuring the same concept.
When a carer/child/teacher completes a standardised measure, their ratings can be infuenced by many factors such as their understanding
of the wording, perceptions of their child, motivations for the assessment etc. With children it often helps to read through the questionnaire
with them to check their understanding of questions. The manual for the measure will provide guidelines on the qualifcations required to
administer, score and interpret it.
There are a range of different types of measure including those which can measure:
The child/young persons functioning (e.g. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA))
The parent/carers functioning (e.g. General Health Questionnaire (GHQ))
Symptom-specifc measures (e.g. Childrens Depression Inventory (CDI))
Family functioning (e.g. Family Assessment Device (FAD))
Service satisfaction questionnaires (e.g. Experience of Service Questionnaire (ESQ))
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At present in Scotland, there is a drive to use measures to evaluate service outcomes. Some areas of Scotland are using the CAMHS
Outcomes Research Consortium (CORC) measures and protocols for evaluating outcomes. CORC uses the following measures which are
thought to be sensitive to therapeutic change and take into account the perspectives of the practitioner, parent and child:
1 Strengths and Diffculties Questionnaire (SDQ) This measure which is completed by older children and parents covers both positive
and negative behaviours and also assesses the impact of the diffculties on the child and family. It is administered before the frst
meeting and at 6 months after frst appointment. It is available in a range of languages using the hyperlink above.
2 Commission for Health Improvement (CHI) Experience of Service Questionnaire (ESQ) This asks young people and their parents about
how they found the service.
3 The Childrens Global Assessment Scale (CGAS)
The CGAS is completed by practitioners for all age groups after the frst meeting and 6 months later. The practitioner rates the extent of
child and family diffculties on a 100 point scale.
In addition some services are using: The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Goals Based
Outcomes Measure (GBO).
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Risk Assessment
Introduction
Module 2 began the discussion around risk, and explored normal and
abnormal risk taking, as well as discussing aspects of risk within the
therapeutic setting. This section will consider assessment of risk of harm
which is an ongoing process in contact with families. However, it is beyond
the scope of Essential CAMHS to consider every type of risk and to provide
the child and adult protection training, which should be received by public
health care workers as core and mandatory annual updates. It is also worth
noting that as Bailey (2002) suggests, risk management does not equate
to elimination of risk; and while the Mental Health (Care And Treatment)
(Scotland) Act 2003 makes provision for the detention of young people
considered at very high risk, this would be a position of last resort.
The broad types of harm assessed for include:
1. Risk of harm from others.
2. Risk of harm to self including suicide risk, and self harm without
apparent suicidal intent.
3. Risk of self-neglect
4. Risk of harm to others (e.g. violent and challenging behaviour)
4.12 Child Protection Policies and
Training
Risk is affected by the developmental stage of the
child or young person. Children because of their
vulnerable nature are at risk from others. Child
protection categories in Scotland include: physical
abuse, emotional abuse, sexual abuse, neglect and
non-organic failure to thrive. Signs of abuse and
neglect presented within the CAMHS setting can be
subtle and mixed, and it is essential that practitioners
are up-to-date with local and national training and
policy.
After completing your local mandatory child
protection course(s) check your knowledge against
the ability to recognise and respond to concerns
about child protection section of the CAMHS
Competence Framework
References:
HM Inspectorate of Education (2009) How Well Do We Protect Scotlands Children? A report on the fndings of the joint inspections of services to
protect children 2005-2009 HMIE
Scottish Executive (2005) National Child Protection Training Framework: fnal draft
Scottish Government (2010) National Child Protection Guidance, Edinburgh, Scottish Government
Scottish Government (2010b) Getting It Right for Every Child Evaluation Themed Briefng 6: Green Shoots of Progress
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Assessing Clinical Risk
Before we proceed, however, it is worth noting that emotional
containment within the context of therapeutic relationships can
make a signifcant contribution to managing clinical risk: if a young
person has the space and voice to air thoughts and feelings, they
can perhaps be dealt with well before any action is taken. Similarly
it is important to bear in mind that team work, communication
and mutual staff support, including positive clinical supervision
are invaluable in effective risk management and addressing staff
fears. We can also include children, young people and their carers
in this equation. They are the people most vulnerable to the
consequences of risk behaviour. They are our partners in care and
if from the outset, to the extent that they are able, they are actively
included in risk management they may help provide the solution
we seek (Barker and Buchanan-Barker 2004).
4.13 Assessing Risk
Think about a recent case in which you were involved.
When you were considering risk;
Did you use gut feeling?
Did you count up the risk factors?
Did you look for the risk factors?
Did you look at the protective factors?
Did you discuss risk with the family?
In the end, what factors allayed your fears?
Refect with your supervisor on the aspects of the case
which raised your sense of risk;
How did they make you feel?
Did they have particular meaning for you?
Approaches to assessing risk
There are a variety of approaches to assessing and managing clinical risks within the CAMHS setting which vary in their level detail, and
specifcity to CAMHS. At a basic level all referrals to CAMHS should be screened in terms of clinical need and risk to determine which element
of CAMHS or indeed any other service is most appropriate to deal with the referral.
One of the most frequently used aspects of risk assessment within Tier 3 and 4 specialist CAMHS is the mental state examination (MSE) which
includes judgments about harm to self and others. We will return to MSE further on in this section. Broader more in depth risk assessment
approaches or tools have been developed but are not yet well validated on a CAMHS population. Despite this each of the three approaches
now outlined offers helpful, active assessment and management guidance.
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GIRFEC a shared interagency approach to assessing risks and needs
The Scottish Government Getting it right for every child (GIRFEC) programme (2005) was designed to reform childrens services with the aim
of joining up services around the needs of service users, strengthening accountability and driving up quality and effciency. Within GIRFEC,
a broad framework for assessing and managing risk which can be adopted by a range of agencies within health, education, social work and
the voluntary sector is outlined. It is a wide approach to assessment which aims to look at the whole picture of the childs life including risk
and protective factors. In the GIRFEC paper Assessing and Managing Risk Aldgate & Rose (2009) highlight that many children who are not
meeting their wellbeing indicators have a complex mix of risks and needs. They argue that risks and needs are two sides of the same coin, and
that if a child is at risk in some way that child will have needs related to their wellbeing. In addition they reason that the more complex and
interrelated the risks, the more likely that childrens wellbeing will be affected on several fronts. (Aldgate & Rose, 2009) The GIRFEC approach
encourages practitioners to think about a childs problems not only from their agencys perspective but also to see any risks and needs in the
context of the whole of the childs life.
The GIRFEC model uses 3 tools to gather information about a childs wellbeing and risks and needs which include:
A list of wellbeing indicators which the childs functioning is judged against. The eight headings are: safe, healthy, nurtured, active,
respected, responsible, included and achieving.
The my world triangle
Resilience matrix
The resilience matrix illustrates that inner vulnerabilities may be counteracted by resilience, and adversity may be counteracted by protective
factors (Daniel & Wassell, 2002)
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Following the general GIRFEC assessment approach, a care plan and a risk management plan are developed. The risk management plan
should aim to meet the needs identifed and reduce the risks. Both plans should take into account the views of children, young people
and their families/carers, and should be reviewed on a regular basis. A shared approach to recording information can be used by different
agencies.
Resilience Matrix
Resilience
Characteristics that enhance normal
development under diffcult conditions
Adversity
Life events or circumstances posing a
threat to healthy development
Vulnerability
Characteristics of the child, the family
circle and wider community which
might threaten or challenge healthy
development
Protective environment
Factors in the childs environment
acting as buffers to the negative
effects of adverse experience
(Scottish Government 2008) adapted from Daniel, Wassell and Gilligan (1999) and Daniel and Wassell (2002)
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Structured Professional Judgement (SPJ)
Proposed by Bouch and Marshall (2005) the Structured Professional Judgement model combines an actuarial approach with the skill and
experience of the clinician within a structured framework. The approach places the individual at the heart of the process and has the function
of developing a plan, rather than simply identifying the level of risk. Clinicians are asked to organize their concerns into three risk domains:
Static and stable risk factors: these are fxed or historical and long-term factors. A static risk factor could be, for example, past suicidal
behaviour or physical aggression. An example of a stable factor would be a long-term mental health problem. Static and stable risk factors
only provide a general indication of risk.
Dynamic risk factors: Dynamic and future risk factors capture the more immediate danger and refect changing nature of a young persons
diffculties. These factors may be short term or recurrent and usually have more immediate infuence on the intensity of risk and therefore
could increase the level of risk signifcantly. For example, the experience of hopelessness (a dynamic factor) in the context of depression and
past suicidal attempts, (stable and static factors respectively) could heighten immediate suicide risk. Similarly, falling out with a friend, which
is generally a transient event, may signifcantly increase the risk for a 15 year old who has a history of self harm. Next week, the argument
may be resolved and the disruption may never recur, however for that week, the level of distress may be enough to trigger the behaviour.
Future risk factors: for example, the end of signifcant therapeutic relationships or other important transitions, exam results and changes
in family relationships or friendships.
Emphasis in this model is on understanding risk from a broad perspective, one that incorporates medical, social and psychological
perspectives and therefore risk management maps onto multi-disciplinary functioning and is the responsibility of all mental health
professionals.
Sainsbury Centre for Mental Health
The third model is a toolkit, from the Sainsbury Centre for Mental Health (Morgan, 2000) This was designed for adult services, but offers a
structured and comprehensive risk assessment process, including:
Considering the total network of people that should be involved in assessing and managing risk, ranging from the young person and
their carers to other colleagues and agencies.
Noting past and present risk indicators in terms of suicidal behaviour, neglect, violence, and a catch-all of other risks, such as abuse by
or of other people and the risk of exploitation by others.
Taking into account the individuals current context and presenting problems.
Taking into account resources or positive factors available to the person, both within themselves and those provided by others.
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This information is partly gathered from discussion with and / or observation of a young person, but also in consultation with any signifcant
other person who may be able to shed light on the risks concerned. Once the assessment is complete, a risk management plan is drawn up
and divided into what needs to happen now and in the short-term; what needs to happen longer-term; what are the positive options for
managing risk now and in the future; and who is going to take responsibility for each aspect of the plan, including when it is to be reviewed
and how long it is to remain in place. There is a clear emphasis on the management of risk across the system of care around the young
person, along with individual responsibility.
Although all three systems may have differing foci or emphases there are a number of key aspects they have in common. All place the
individual rather than the problem or condition at the centre of the process and include the young person and family in the risk management
assessment and planning. Each take into account past, current and future factors and recognise that risk is not a stable characteristic.
4.14 Risk Management
What risks can you identify in the case of Deniz?
Which risks, if any, would you want to look into
further and why? Which case do you think is more
concerning and why? Discuss these questions,
and what you would want to do about them, with
your mentor and wider colleagues. Dont worry
if your views differ from others - a key aspect of
risk management is careful consideration of our
sometimes differing thresholds for risk. Sometimes
better decisions arise from differences; the main thing
is to have the courage to express your views and
listen respectfully to each other.
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While assessment of risk is an aspect of all three processes (static,
dynamic and future), the outcome in each is the development
of a risk management plan, based on the circumstances of the
individual and fnally all three recognise that responsibility for
risk management belongs to the system of care around the child
and, through clear communication, must dealt with accordingly.
Sobering reminders of the value of these aspects are not hard to
fnd. Munro (1999), in reviewing 45 public child death or abuse
inquiries, consistently found the following themes; clinicians basing
risk assessments on a narrow range of information; clinicians
tending to consider only information readily available; clinicians
failing to revise risk assessments. Although strictly speaking we
are not comparing like with like here in terms of research subjects,
the principles are transferable and demonstrate the need for
hard work, team work and continuous effective communication
to ensure effective risk management. Reasoned professional
judgment and the use of risk management tools also need to be
complemented by local strategies, policies and training in relation
to lone working arrangements and, in situations of last resort,
management of aggression and violence techniques appropriate to
a CAMHS age range.
4.15 Risk Management: Local policies
Find out what the local arrangements are in your
CAMHS for risk management, including:
risk assessment tools used;
who to contact in an emergency;
what protocols are in place to manage sudden
crises, including the use of medication and
physical restraint;
and lone working arrangements.
Refecting on some or any of these issues can
trigger a range of possible reactions including, but
not exclusive to, fear and concern, or distress that
children and young people engage in such risk-taking
behaviour, which is then sometimes contained by
such extreme-sounding methods. Discuss how this
makes you feel with your mentor, your supervisor,
or a colleague you trust. It would be helpful for
you to attempt to defne your role in managing risk
within a team and identify what training and support
is available to you to do this. Discuss it with your
supervisor and colleagues.
Record this in your portfolio.
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Specialist Assessments
There is a wide variety of specialist CAMHS assessments which may be carried out with children/young people
and families. It is beyond the scope of Essential CAMHS to describe all of them. Some of the model specifc
therapy orientated assessments include: play therapy, psychodynamic therapy, family therapy, cognitive-
behavioural therapy, behavioural functional analysis, and parenting assessments. Many of the themes involved
in these assessments have been touched upon under the holistic assessment section, however, a greater
understanding of a selection of these models can be obtained from module 5 interventions. The following
section details one of the most commonly used CAMHS specialist assessments namely the Mental State
Examination, before describing various cognitive, language, communication, and occupational performance
assessments.
4.16 Specialist Assessments
Explore the range of specialist assessments offered by your CAMHS
team. Where possible arrange to observe a selection of them being
carried out with a child/young person or family.
Consider:
Who offers these specialist assessments?
What are the internal referral criteria for these assessments?
Are there services out-with the CAMHS team that can offer
similar assessments?
What are the similarities/differences between the specialist
assessments?
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Mental State Examination (MSE)
The MSE is an ordered summary of the clinicians observations of the child/young persons mental experiences and behaviour at the time of
the interview. It aims to identify evidence for and against a diagnosis of mental illness, and (if present) to record the current type and severity
of symptoms. It is usually recorded and presented in a standardised format.
The broad topic areas analysed by a MSE are listed below with the method of assessment given in brackets:
Appearance (observation) standard and style of clothing, physical condition, etc
Behaviour (observation) tearfulness, restlessness, distractible, socially appropriate etc
Speech (observation) quality, rate, volume, rhythm, and use of language etc
Depressed Mood (observation and enquiry) questions about the pervasiveness of the depressed mood, biological symptoms of
depression and anhedonia.
Risk (enquiry) questions around thoughts of self-harm including those pertaining to suicidal ideation, suicidal intent and self injurious
behaviour. Questions will also be asked about harm to others.
Anxiety (observation and enquiry) questions around the nature, severity and precipitants of any anxiety symptoms including OCD, as well
as their impact on the child/young persons functioning
Abnormal Perceptions (observation and enquiry) questions focused on whether abnormal perceptions are altered perceptions or false
perceptions. Questions which explore the evidence for different forms of hallucination.
Abnormal Beliefs (enquiry) questions about abnormal beliefs/ideas. Exploration of how these beliefs ft with the child/young persons
developmental stage, family, social and cultural context. Questions would be aim to distinguish between primary delusions, secondary
delusions, over-valued ideas and culturally sanctioned beliefs.
Cognition (observation and enquiry) questions about the childs orientation to time, place and person. Assessment of the childs short-
term memory, concentration, comprehension and use of vocabulary,
Insight (enquiry) questions would focus on the child/young persons insight into their diffculties and what they think is happening to
them.
Further information on mental state examinations can be obtained from:
Semple, D and Smyth, R. (2009) Ovid Online: Oxford Handbook of Psychiatry (Second Edition) at www.ovid.com
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Cognitive Assessments
Cognitive assessments are used to measure a child/young persons intellectual abilities. They are often carried out when there is a query
about the reasons for a child/young persons poor performance/achievement at school, or diffculties with social interaction and poor
functioning at home. A childs performance with their school work can be impaired for a number of reasons including poor concentration,
emotional/behavioural problems, motivational factors, the teaching environment, as well as the ability levels of the child. Using a battery of
tests, a cognitive assessment aims to provide a measure of the childs intellectual ability levels. Commonly used assessments include:
Wechsler Intelligence Scale for Children-Third Edition (WISC-IV) (Wechsler 2004): is a battery of tests which assesses various verbal,
perceptual, working memory and processing speed skills.
Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-III) (Wechsler 2004): is a battery of tests which is a version of
the above designed for younger children up to 7 years.
British Ability Scale- Second Edition (BAS II) (Elliott, 1996): provides measures of intelligence, reading, spelling, arithmetic and various
other cognitive skills.
These measures which are carried out by clinical or educational psychologists can provide an overall IQ score as well highlighting cognitive
strengths and weaknesses. When a practitioner is interpreting the signifcance of the results from these measures they will take into account
factors such as the childs: motivation during testing, concentration and activity levels, emotional state etc. Results of testing will be put into
the overall context of the assessment and will be compared against school and parental reports of the childs functioning.
A generalized learning disability is diagnosed from assessing performance on a cognitive assessment and through assessing adaptive
functioning. Adaptive functioning can be assessed formally through tests such as the Vineland Adaptive Behaviour Scales (Sparrow et al,
1984). Both ICD-10 and DSM-IV defne a learning disability from impaired intellectual ability and adaptive functioning and onset before 18
years of age. Goodman and Scott (2005) state that roughly a third of all children with a mild general learning disability will have a co-morbid
psychiatric diagnosis, as do roughly half of all children with severe general learning disability.

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Occupational Performance, visual motor and sensory assessments
Occupational therapists are specialists in assessing and treating the performance defcits which originate from physical illness, mental illness
or disability. The science of occupation underpins the emphasis on enhancing an individuals capacity for achievement and mastery within
their occupational performance roles. You may consider referral for specifc occupational therapy assessments if a child/young person is
displaying motor or sensory diffculties or is not able to function with their occupational and daily living skills as expected.
A range of OT specifc assessments are used to assess occupational performance including;
Adolescent Role Assessment: used to gather information about the adolescents involvement in occupational roles.
Short Child Occupational Profle (SCOPE): used to determine how volition, habituation, skills and the environment facilitate or restrict
a childs occupational participation.
Child Occupational Self Assessment (COSA): a self report that allows young people to rate their sense of competence and the
importance that they place on everyday activities.
Paediatric Volitional Questionnaire (VQ): describes three levels of volitional development (exploration, competency and achievement).
Canadian Occupational Performance Measure (COPM): an individual client centered measure designed to detect changes in a
persons self perception of occupational performance over time.
Childrens Assessment of Participation and Enjoyment and Preferences for Activities of Children: a comprehensive measure of
various aspects of engagement in purposeful and meaningful activities (CAPE/PAC).
Occupational therapists have specifc competencies in assessing children with co-morbid psychiatric and developmental disorders and
providing differential diagnosis. A range of OT specifc assessments are used to identify neuro-developmental impairments and determine
how these impact on performance roles and core psychiatric pathology in children and young people.
These include:
Sensory profles (adolescent and child) - used to determine the young persons sensory performance and compare with typical profles
for a variety of neuro-psychiatric disorders.
Movement Assessment Battery for Children-2 (Sugden & Henderson 2007) - used to assess gross and fne motor skills in children
thought to have developmental motor impairments.
Developmental Test of Visual-motor Integration (VMI) - screening instrument used to assist in the early identifcation of visual motor
integration diffculties in children and adolescents (Beery-Buktenica 2006).
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Motor Free Test of Visual Perception (TVPS) - used to test children and adolescents visual perceptual skills.
Detailed assessment of Speed of Handwriting (DASH) a detailed assessment used to identify children with handwriting diffculties.
Clinical Observations
Language and Communication Assessments
A signifcant number of children and young people who access CAMHS have additional, often undiagnosed speech, language and
communication needs (SLCN). In a recent review of the literature Benner et al (2002) found that approximately 3 out of 4 children formally
identifed with emotional and behavioural diffculties experienced clinically signifcant language diffculties.
As with the practitioners responsible for other forms of specialist assessment listed above, CAMHS Speech and Language Therapists (SLT)
would use the information obtained in relation to the presenting problems, observations, and history (developmental, family and social,
medical) to assist in identifying appropriate areas for assessment. A range of standardised assessment and informal assessment procedures
would be completed as appropriate e.g. school observation, parent-child interaction and social communication assessments. The fndings
of which would identify specifc SLCN to be considered within the context of the individuals mental health presentation. SLT assessment may
also form part of an assessment of attachment, and/or a neuro-developmental assessment. The information from SLT assessment helps to
formulate differential diagnosis including areas of co-morbidity. Formal assessments may include:
Clinical Evaluation of Language Fundamentals (CELF): a detailed formal assessment of expressive and receptive language skills
considering content form and use.
Expression, Reception and Recall of Narrative Instrument (ERRNI): provides a measure of a persons expressive language and story
comprehension.
Where SLTs are integrated members of the multi-disciplinary CAMHS Team, they take on a specialist SLT role considering the SLCN within a
mental health framework which extends beyond core traditional SLT boundaries. Specialist SLT interventions can also be used to assist mental
health assessments such as the use of Talking Mats (a visual communication framework used by SLTs). This has been used successfully with
individuals with SLCN to complete mental state assessments and provide additional information to other areas of assessment. Many aspects
of mental health can be diffcult to assess in individuals with SLCN, and individuals can often struggle with emotional literacy and expressing
their needs. Input from SLT in such aspects of assessment can be benefcial. SLT input in the assessment of communication presentations
within mental health should be considered, including areas of anxiety, anger, emotional literacy, selective mutism, stammering and pervasive
developmental disorders. SLT discourse analysis can also be used, for example to aid in the differential diagnosis of schizophrenia.
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Assessment In The Scottish Context
Integrated Care Pathways (ICP)
Healthcare Improvement Scotland (2011) have produced standards for the care process provided by Child and Adolescent Mental Health
Services. Using the Integrated Care Pathways Individual teams and services can plan how to measure the care that they provide against the
standards. Healthcare Improvement Scotland (2011) argue that An ICP is much more than a document of care. It encompasses how care is
organized, co-ordinated and governed, and embodies a system of continuous quality improvement.
The Generic core standard No 10 relates to CAMHS assessment.
10a A holistic assessment is carried out with the child or young person, and their parents/carers, where appropriate. Where there is a child or
young persons single plan, information that is already available should be considered. A holistic assessment identifes:
current diffculties and previous mental health history
personal, family and social circumstances
family history
physical and developmental history
current and past interventions used (including outcomes, adverse reactions and side effects )
risk
the child or young persons strengths and aspirations
the needs of the child or young person
the needs of parents/carers, where appropriate
capacity to consent to care and treatment
additional vulnerabilities and/or co-morbidities
educational/ vocational status
partner agency involvement, and
legal and/or looked after status.
10b A target time for completion of the holistic assessment is recorded.
10c Service providers can demonstrate that the views of children and young people are routinely sought and recorded as part of the assessment
process.
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Integrated Assessment Planning and Recording Framework (IAF)
The Integrated Assessment Framework (IAF) is an important component of Getting it Right for Every Child (Scottish Government 2005) and
is based on the assessment triangle. It describes a standardised model of assessment, planning and recording which is followed by a range
of agencies e.g. health, social work, and education in order to promote information sharing. The aim is that the framework helps agencies
to work as an integrated team to be more effective in recognising risks and meeting needs, so that children get the services they need at the
time they need them.
The framework can apply to the assessment of all children. However, CAMHS clinicians are more likely to complete the shared interagency IAF
procedure and forms where needs are signifcant and there needs to be an inter-agency assessment and plan and multi-agency intervention.
Examples are when:
parents, the child and agencies all need to know and understand each others responsibilities and contributions to make sure there are
no gaps or duplication in their efforts;
close monitoring of progress is needed to secure a childs safety and wellbeing or the safety and wellbeing of others; and
compulsory measures of care may be needed. (GIRFEC, 2005)
Principles guiding the IAF
Applies to all children.
Is carried out with the best interests of the child in mind.
Identifes the earliest, least restrictive, most effective response to the needs of the child.
Is informed by the assessment triangle.
Takes account of the childs views and views of signifcant adults in the childs world, and seeks agreement from
the child and family / carers.
Involves professionals and families in ongoing assessment with the aim of providing evidence-based services
which address the child and familys needs.
Takes account of all aspects of the childs life by respecting and taking account of diversity and difference.
The assessment is carried out on the basis of equal partnership.
A lead agency is identifed.
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Formulation and Intervention Planning
Introduction
Through the process of assessment, along with the family, we will have gathered a great deal of information about the family, the child or
young person, the nature of the diffculties and individual views of those diffculties. We will have spent time discussing the familys thoughts
and feelings, and we will have explored the impact and the meaning of the diffculties for all involved. Inevitably, however there comes a
stage where, in order to make sense of all of this information and to work out how to proceed, we need to fnd a way to put the information
together.
As well as understanding what is going wrong currently, families are often keen to know how they have reached this point. Clinicians, on
the other hand, need a coherent picture of how the information gathered from assessment fts together in order that they can plan their
intervention. This coherent picture needs to be one which accommodates the perspectives of all involved, while being rooted solidly
in the clinicians theoretical framework. The process has become known as formulation. In this unit we will look at some of the models
of formulation you may come across in the CAMHS team. We will examine what is meant by formulation and how it can inform your
intervention plan.
Defnitions of formulation and relationship to diagnosis
A formulation is often seen as a provisional explanation or hypothesis to clarify why a child, young person or family are experiencing particular
problems at a particular time. A formulation gathers and attempts to make sense of the information gained through the assessment process.
It can be seen as a working hypothesis. Formulation has been described as:
The Summation and integration of the knowledge that is acquired by this assessment process (which may involve a number of different
procedures). This will draw on psychological theory and data to provide a framework for describing a problem, how it developed and is being
maintained.
(Division of Clinical Psychology 2007: 3)
Formulation may contain a number of provisional hypotheses. There are a range of different ways of understanding what is happening with
children and young people and their families. Formulations have been seen as offering an alternative to diagnosis (Eels 1997). Dudley and
Kuyken (2006) argue that diagnoses are descriptive and atheoretical, historically providing nosologically discrete clusters used to develop
theories of and interventions for emotional disorders and that CBT formulation gives a psychological description of an individuals presenting
problems at a particular point in time. More contemporary approaches see formulation as complementary to diagnosis.
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Rutter and Taylors (2008) diagnostic formulation is generated after a detailed holistic assessment process covering similar areas to the holistic
assessment detailed in the assessment section of this module. If a mental health condition is diagnosed, the practitioner will then formulate
the possible risk factors for that mental health condition as well as the protective factors. The formulation is created after refecting on the risk
and protective factors that are specifc to the individual child and family. The diagnosis and formulation will then inform the intervention plan.
The formulation model described by Carr (2006) is similar to the one discussed by Rutter and Taylor (2008) in that risk and protective factors
for the problem presentation are described. Carr (2006) goes onto detail his formulation process which includes:
making a list of all the presenting problems
recognising and describing all the important risk factors described in the assessment process which may have contributed to the
presenting problems. Protective factors are also listed.
deciding on whether the risk factors are predisposing, precipitating or maintaining factors (see defnitions at the start of the assessment
module)
Reformulation
All formulations can offer a number of different possibilities or
hypotheses to be tested and reformulated. The formulation will have
clear implications for the choice of intervention. Carr (2006) describes
a process of recursive formulation, where the child, family or young
persons diffculties are formulated and reformulated in the light of new
assessment material. He states that the formulation and reformulation
process comes to an end when a formulation has been constructed that
fts with:
signifcant aspects of the childs problems
network members experiences of the childs problems
available knowledge about similar problems described in the
literature.

Make or modify formulation
Plan interview guide and select tests
to check accuracy of the formulation
Conduct interview or administer tests
Recursive formulation, Carr (2006)
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Therapy Specifc Formulation Models
Different approaches to formulation are infuenced by the particular theoretical stance of the professional/s involved. We will examine a few
of these - if a particular theory which informs your practice is not included in the discussion, you may want to fnd out what your particular
theoretical stance says about formulation. First refect on your own and your colleagues preferred therapeutic stance.
Having discussed with your colleagues the particular therapeutic approaches used in your service, we will outline defnitions of some
approaches to formulation.
Cognitive Behavioural Approaches
Using a CBT approach case formulation is the assessors hypothesis about the inter-relationships between the patients presenting problems
and the psychological mechanism underlying these
Persons (1989 cited in Morrison et al 2004: 25)
The presenting problems are developed in CBT from the problem list created collaboratively by therapist and child or young person. The
psychological mechanisms are the rules, schema and core beliefs which inform the young persons life.
Psychodynamic Approaches
Formulation takes into account the current life situation of the young person and relates this to earlier development. It is about thinking
of the young persons problems using a psychological framework. Why this person at this time? All behaviour is seen to have meaning;
uncovering meaning is an aspect of formulation. Collaborative attempts to understand the young persons internal working model are made.
Defense mechanisms are explored. Predisposing, precipitating and perpetuating factors are discussed and attempts made to understand
them. An important aspect of psychodynamic therapy is whether the young person has suffcient insight to be able to use the therapy
(Bateman, Brown and Pedder 2000).
A Systematic Approach
Havinghurst and Downey (2009) outline a systematic approach to formulation using the 4Ps (predisposing, precipitating, perpetuating
and protective factors) as a foundation. They describe a Mindful formulation which has three stages. The frst stage is the completion of
an Assessment Worksheet which covers information including presenting, relationships, developmental history, attachment experiences,
safety concerns, resilience factors and missing information. The second stage is the patterns worksheet identifying the childs strengths and
diffculties and relationships across a range of systems, e.g. family and community. A matrix of affective responses, behaviours and cognitions
are created by examining the childs relationships across family and wider community systems. In the third stage, theory and knowledge from
the assessment are brought together with the patterns and strengths to explain how predisposing, precipitating, perpetuating and protective
factors are used in the formulation.
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According to Dallos and Draper (2006) all formulations:
Summarise the child young person or familys core problems.
Show how diffculties relate to one another by drawing on psychological theory and principles and by using this theory can explain why
the child or young person developed this problem at this time, in this situation.
Give rise to a plan of intervention based on processes and principles already identifed.
Are open to revision and re-formulation.
Dallos and Draper (2006) state that formulations differ because of the particular factors on which they focus such as thoughts, feelings and
behaviour, because of the concepts which drive the theory, e.g. schema or the unconscious, the emphases on refexivity, whether they are
collaborative in their approach, their use of psychiatric diagnosis and whether the formulation seeks to fnd the truth or be useful.
Sharing Formulations with the Family including Diagnostic Information
The process of sharing the formulation with the family and checking out the practitioners hypotheses is recommended practice for a
variety of therapy schools such as interpersonal psychotherapy, cognitive analytic therapy and some forms of short-term psychodynamic
psychotherapy. Some therapy schools place more of an emphasis on actually developing the formulation in partnership with the family e.g.
CBT therapy with children and families (Stallard, 2005). The overall message given to the family by the formulation is that their problem makes
sense, and that there are options for change. However, sharing all aspects of the formulation with the family is not universal practice amongst
all therapy schools. For example some family therapy schools such as the MRI school sometimes deliberately withhold information about the
systemic rationale underpinning their interventions (Carr, 2000, 83).
Discussing formulations with families allows them to fll in missing links, elaborate on details and provide contradictory information that shows
how the formulation can be usefully be adjusted (Butler, 1998), When therapeutic failures have been analysed, one of the reasons for failures
is that the formulation did not ft with the familys belief system. If some form of shared understanding of the presenting problems cannot be
reached, it is unlikely that the family will agree with the intervention planning stage which outlines the tasks and goals of interventions. As
you will recall from Module 2, Bordins model of the working alliance stated that two out of the three contributions to the working alliance
were around reaching agreement on the goals and tasks of therapy. For example if the parents remain convinced that their childs behaviour
problems are due to something wrong with his head, that needs investigated, it will be unlikely that they will engage well with a parenting
group intervention.
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When discussing formulations with the family, you may want to vary the
amount of detail given, according to the familys cognitive abilities and
emotional readiness to accept the information (Carr, 2006). As you talk
about the formulation it is helpful to check regularly whether the family
agree with and understand the different aspects of it. After describing the
presenting problems as seen by different family members, you may then
want to discuss the various protective and risk factors highlighted during the
assessment process. The family may fnd it helpful to receive a written copy
of the assessment information and formulation upon which they can read
and refect. For some model specifc formulations e.g. CBT, the therapist will
construct a very simple diagrammatical representation of the formulation
with the child. The diagram may represent only one or two elements of the
overall formulation.
Sharing the Formulation
Refect on some of the reasons why there may be
signifcant differences between the familys and the
clinicians view of the formulation including diagnosis.
(see CAMHS Competence Framework Ability to
feedback the results of the assessment and formulation
and agree a treatment plan)
Consider how you would discuss the formulation in a
sensitive non-blaming manner?
4.17 Working with the Family
Ask to sit in with a colleague when they are meeting a child or
family to discuss formulation. Make notes in your portfolio about
what you have learnt and refect on the process of learning
A core part of formulation feedback for some families involves
discussing the diagnosis of a mental health condition. If a child/
young person has been diagnosed with a specifc condition
such as ADHD, the child/young person and parents will need
verbal and written information on the condition itself, as well
as the overall formulation that details the various risk and
protective factors specifc to that child. The Royal College of
Psychiatry has produced a range of mental health factsheets
written for parents, teachers and children which are available at
their mental health and growing up website.
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Intervention Planning
During the formulation process you will be thinking about various intervention options. Key questions to
consider with the family might be:
1. Is a CAMHS intervention actually required?
Following assessment, you and the family may conclude that no further intervention at all is required. The assessment process by itself
may have enabled the family to understand and address the diffculties. For example, a conversation assessing parental management may
have been enough to focus mum and dads attention on responding to child tantrums consistently. Another common scenario is that the
process of assessment can reassure parents that certain child problems are actually developmentally appropriate behaviour.
On occasions, assessment will indicate that another service would better meet the needs of the child and family. For example, if your
assessment reveals that marital diffculties are the main perpetuating factor for the childs behaviour problems, you may want to consider
referral on for marital counseling.
2. What CAMHS interventions are indicated by the formulation including diagnosis?
There is an array of possible CAMHS intervention options including direct work with the child/family and/or consultation work with other
agencies. Some broad intervention decisions are based on the intervention evidence base for specifc problem presentations or diagnosed
conditions. In general, when researchers examine which interventions are effective, they apply the intervention to children/young people
with a similar diagnosis rather than formulation e.g. psychodynamic therapy for depression. A summary of the evidence base for CAMHS
interventions can be obtained at the MATRIX
Using a formulation can broaden the scope of your intervention options. For example, if following assessment you felt that a childs
presentation ftted the criteria for Post Traumatic Stress Disorder (PTSD) after a car crash, the diagnostically focused evidence base would
lead you to consider CBT for the child. However, your broader formulation may indicate that a key perpetuating factor appeared to be
mums depression following the car crash and withdrawal from activities in the home. This could lead you to refer on for parallel work in
adult mental health services. An anxious temperament and underling beliefs that the world is a dangerous place may have predisposed
the child to experiencing a prolonged trauma reaction. However, identifed protective factors could be utilised during the therapy process
e.g. good support from father and other relatives who could be enrolled to encourage the child with therapy homework tasks.
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3. Can the family engage with the intervention(s)?
When thinking about intervention options, some therapists will consider the childs ability to engage with a particular intervention. This
decision will be infuenced by factors such as age and developmental level. Although interventions can be adapted to suit the needs of a
particular child, some interventions such as CBT might be more diffcult with children under 7 years (Stallard, 2005, 23). CBT therapy for
trauma in children, or psychodynamic therapy with children, can result in a temporary increase in symptoms. As a result, the practitioner
and family need to consider whether they are able to support the therapeutic process, and what if any additional supports can be drawn
upon.
4. Has the family been fully informed about the intervention options?
The various intervention options should be fully explained and discussed with the family so that they can make an informed choice. They
may want to consider:
the evidence base for the intervention
what the intervention involves
whether there are any side- effects or perceived negatives to the intervention e.g. time away from school, time spent on homework
activities etc.
what wider changes in the family might be brought about by the intervention e.g. if the childs problem improved, what would the
family be doing differently.
what would be the best timing of the various intervention components
You may want to supplement your discussion with written information about the interventions. Try investigating the range of approved
leafets that your service has to describe CAMHS interventions. The Talking Mental Health website can help you to create customized
mental health information sheets.
5. What are achievable goals for intervention(s)?
During assessment you should have gained some idea of the familys goals for intervention. Throughout the intervention planning stage
specifc realistic goals for intervention should be clearly outlined. This maybe a relatively straightforward process when working with one
client, but when working with a family, the priorities and goals of various family members have to be considered and negotiated. During
the negotiating process, you and the family might want to consider the costs and benefts of reaching each of the goals.
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Case Study
Consider the following initial formulation including diagnosis and intervention
plan.
Robert (age 10) presented to CAMHS with overactive and impulsive behaviour with reports that he was
behind in his school work. The assessment at CAMHS involved meeting with the family, the parents
separately, and Robert individually, conducting a school observation, and completing Connors measures.
Following assessment, the two CAMHS clinicians involved in the case concluded that his presentation
met the criteria for Attention Defcit Hyperactivity Disorder (ADHD) with additional oppositional
behaviours. A school report indicated that he has shown a consistent pattern of poor attention,
impulsivity and overactivity since P1, but his problematic behaviours became more pronounced
approximately two years ago.
The developmental history highlighted several possible predisposing risk factors. During pregnancy
his mother smoked and drank alcohol, and his birth was described as traumatic. She said he had to
be taken to special care for several days after turning blue through lack of oxygen. His birth weight
was low. After the birth, his mother experienced post natal depression, and received frequent visits
from the health visitor who helped her with her concerns about Roberts feeding. His mother reported
fnding it diffcult to bond with him during the early years, and focused on the practical aspects of
childrearing. The family history indicated some other possible predisposing factors. His father who now
has temporary work in the construction industry dropped out of school early. He described getting into
diffculty at school, was always on the go, and found it diffcult to focus on school work. However, he
never received an assessment at school.
Roberts parents separated two years ago, and since then the parental relationship has been
acrimonious. The parental separation appears to have precipitated an increase in Roberts behaviour
problems.
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At home there appears to be several factors helping to maintain Roberts oppositional
behaviour. His mum and dad hold varying beliefs about how to parent which has led to them
communicate different messages to Robert, and different ways of managing his behaviour.
Roberts father believes that Robert should be allowed a bit of freedom and time to burn off
his energy. When Robert stays over at his house, he is allowed to stay up and watch late
night tv, and chat with his father. His mother believes that Robert should do what he is told
without negotiation. His mother has been feeling increasingly exhausted from: working full
time, looking after Robert, and worrying about her brother who has drug addiction problems
and visits the family home frequently. Robert believes that at school there are a lot of boys
who are out to annoy him, and that his teacher is always on his case.
The assessment highlighted several protective factors. Robert presents as a bright intelligent
boy who is in good health. He was happy to talk about his worries during CAMHS sessions,
and voiced a desire to do better at his school work and for his mum to worry less. His school,
also believe that he is very able but is falling behind due to his inattention and lack of care
with his work. His parents receive some support from extended family members who help out
with taking Robert to after school activities and appointments. His mother, is very worried
about how he will do at his secondary school next year if something is not done, and would
like advice on how to manage his behaviour. His father would like him to get into fewer
fghts with his friends in the playground.
What intervention options might you consider for this case?
Are there any potential drawbacks/concerns about any of the intervention options?
If you are considering more than one type of intervention, how would you sequence them?
If you were to consider the above assessment and formulation information from a
particular therapeutic model that you know about e.g. psychodynamic, systemic, or CBT,
how could the case be reformulated?
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Child & Adolescent Mental Health Services | Module 5: Therapeutic Interventions |
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Informal Support
Evidence into Practice
Examining the Evidence Base
The Matrix
A Range of Therapeutic Resources
Parenting Approaches
Systemic Approaches
Prescribing Medication
Key Learning Points
Introduction
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ILOs
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Working with the evidence base relating
to children/young people
Knowledge of a range of therapeutic
approaches
Knowledge of psychopharmacology in
child and adolescent work
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ILOs
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Safe practice and supervision Knowledge of the care environment and its interaction with child/adolescent
development
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Developing Therapeutic Interventions
Introduction
In this unit we will begin to think about the range of therapeutic interventions which are routinely used in
CAMH services. Within your team there is likely to be a range of professions working in an array of modalities.
Our intention here is neither to describe the breadth of these interventions, nor to provide training in any one.
Rather the aim is to offer a brief description of some of the key evidence based approaches such that they are
familiar when you encounter them and to allow you to ask some informed
questions of your colleagues, who are the experts.
We will begin by pausing briefy to considering what supports people already have
in their lives and how they may be considered in our work before moving on
to think about the meaning of evidence base practice. Finally we will
introduce a small range of the therapeutic approaches used in CAMHS
which have an evidence base. These approaches form a basis for
much of the work carried out by CAMHS professionals, however
it is worth noting that clinicians may engage in a whole range
of activities outwith the direct therapeutic work. Indeed in
many cases indirect work with colleagues and other agencies
may constitute the majority of our activity. The context within
which children, young people and families live may be such
a signifcant source of stress that managing this in order to
create a space for therapeutic work is the frst priority of
the network working alongside the family. This may mean
CAMHS clinicians being involved in consultation to a range
of agencies to ensure their approaches are sensitive to, and
mindful of, the psychological state of the family and young
person involved.
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Informal Support: The Ordinary Is Extraordinary
Later in this section we will explore a range of structured psychological therapies which are commonly used in
CAMH services. However, before we consider the value and effcacy of these approaches, it is perhaps worth
considering the way our services engage with the structures and supports which already exist in our clients lives.
Repper and Perkins (2003) argue that mental health services have a propensity, albeit perhaps unwittingly, to reduce people and their lives to
a set of problems or symptoms which can be treated or managed. Similarly, one could suggest that the current evidence based approach
leads us to think about people in terms of the condition or disorder. Indeed this is how many of the intervention guidelines are categorized:
management is dependant on diagnosis.
However for the individual experiencing mental health problems, their mental health diffculties, or symptoms, are only one aspect of a
considerably more complex and rounded whole. For health care practitioners the essence of caring is to attend to that whole person (Barker
and Buchanan-Barker 2005).
Faulkner (2000), highlight this disconnect by establishing that symptom reduction is not always the primary goal for service users. Rather the
things they valued most included:
Relationships with others, including friends and family
A sense of acceptance and shared experience with peers
Finding meaning in their lives
Having choices
Having other people just be there for them.
Kirk (2007) suggests that services for younger people need to provide informal supports and that not all young people can or want to access
formally-structured interventions. Careful consideration should be given to where support is offered. For example staff could meet young
people in public places rather than institutional locations, and support could be provided during or via activities in which the young person
would like to engage.
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It is important to highlight here that we are not proposing that informal and formal interventions are, or should be, in opposition. Rather
we are suggesting that it is important to be fexible and to fnd ways in which different approaches can be complementary, and above all to
listen.
Throughout this pack, we have highlighted that children, young people and their families or carers are our partners in the services we provide.
There is also a theme running through much modern health care literature emphasizing that people are their own experts, not only in terms
of the health problems they experience, but also in thinking about what is going to help. Barker and Buchanan-Barker (2005), for example,
developed their Tidal Model as a philosophy of care in which respect for the experiences of people using mental health services is a central
tenet.
5.1 Values into practice
Review the sections in Essential CAMHS
on the Values Based Practice. Refecting
on those values and the ideas in this Unit,
consider what, if anything, might need to
change about your practice, the service you
work in and wider CAMHS in order ensure
that we do not reduce people to sets of
symptoms or problem lists.
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In the Tidal Model each stage of a persons health journey belongs to them, from the lived experience of precursors; to the current diffculties;
to experiencing distress, such as low mood, anxiety or hearing voices; and to recovery. Recovery is defned by the person; it may mean being
able to live with particular mental health experiences or symptoms, or it may mean health restoration. In order to ensure these ideas are
upheld, health care practitioners are especially advised against just doing things to people, or even doing things for them. Instead we are
urged to care with people- to do what needs to be done now, in order that people can return to living lives that are meaningful to them.
5.2 Recovery and resilience
In this and in previous sections we have
mentioned the recovery approach which
unlike the traditional restorative approach
emphasizes that people may be supported
to a position where they can function
well, while coping with their mental health
diffculties, rather than necessarily seeking
a complete resolution of symptoms. Some
people might argue that when we work with
children and young people the concept
of resilience is more relevant, and that
recovery is more applicable to an adult
context. What do you think about this? Are
the concepts compatible? Discuss this with
others. Is there a philosophy in your service
which relates to either or both of these
concepts?
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In the above activity you may have considered re-engaging
Robert in some of the activities he previously enjoyed. Taking
a stepped approach to helping Robert take part in activities
which promote his physical and mental health can be a helpful
component of an intervention.
5.3 Working alongside Robert
Robert Smith is 15 and is experiencing low mood and
periods of time when he feels very angry. His parents
recently separated and his grandmother, who he was
very close to, died a few months ago. He lives with his
mother, younger brother, John (13) and older sister Jane
(17). He has dropped out of school because he says he
does not have the energy to go at the moment. He has
also stopped playing football in the park with his friends.
He plays computer games in his room long into the night
partly because he sometimes fnds it hard to sleep and also
because he does not have to speak to peers while doing
this. Robert is also very reluctant to go the local CAMHS
service due to worries that he will be seen as mad if he
goes there
What informal interventions could you try in order to get
to know Robert and earn his trust?
What other supports could you see being of beneft in
this situation? What resources are available to Robert
already?
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Evidence Into Practice
Evidence-based mental health practice is a movement that has gained considerable momentum in the past few
decades. Furthermore government policy has increasingly focused on facilitating the effective and effcient
delivery of therapeutic approaches which can systematically demonstrate that, under the correct conditions,
they can bring about positive change for clients.
However the term itself has become so widely used in so many contexts, that its meaning is often lost. In fact, there is no single widely-
agreed defnition of what is meant by evidence-based practice. Indeed, there is considerable confusion and misunderstanding surrounding the
term and related expressions such as empirically-supported treatments and evidence-informed care. In essence however, evidence-based
practice promotes a scientifc approach by focusing decision-making on what can be proven rather than on what is believed to be effective.
5.4 Interventions
Ask some of your CAMHS colleagues how
different interventions came to be adopted in
their service.
To what extent do they describe decisions
that were based historically on accepted
wisdom and popular theories of the time?
To what extent are the services shaped
around the goals children, young people
and families have for themselves?
To what extent has the choice of
interventions been influenced in recent
years by the evidence-based practice
movement?
This has increased the need for CAMHS practitioners to know how
to search, appraise, interpret and understand research. It has also
produced debate around how services should decide what form of help
they offer children, young people and families. Some concepts relating
to evidence-based practice are introduced in the following section. As
you study it, try to use the information and refection points to trigger
aspects of this debate in your own mind.
It is, of course, important to recognise that evidence-based practices
are not necessarily the only ones that work. What distinguishes them,
however, is that they are supported by a body of data from empirical
studies which demonstrate their use can bring about specifc outcomes
for individuals and that these outcomes can be generalized to other
similar individuals.
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Examining the Evidence Base
When any clinician attempts to establish what approach should be employed with any given family, they are
trying to make a judgement based on the available evidence.
As in other aspects of life, however, there are many types of evidence. For example, when you notice that a friend is looking thinner and she
speaks favourably about the diet she has been following, your observation of her size could act as evidence backing your belief that the
diet works. If you then meet several other people who claim to have followed the same diet, and who provide you with further anecdotal
information about the weight they too have lost, your confdence in the effectiveness of the diet is likely to increase. If they then provide you
with a plausible rationale about how the diet works, then you are likely to be even more convinced. Likewise, within a scientifc framework, it is
generally recognised that different types of scientifc studies generate different types of evidence, and that different types of evidence provide
us with different levels of confdence when deciding whether or not something works.
Understanding this hierarchy of evidence lies at the heart of traditional evidence-based practice. Within this framework the quality of a study
is judged both by the strength of its underpinning theory, and by the rigour and appropriateness of its research design. Good studies are
deemed to be those that, for example
have a suffcient number of participants
use well-validated measures of changes ( in knowledge, attitudes or behaviour)
are presented in such a way that they can be replicated by others
use an appropriate type of analysis
show that any gains are maintained after the intervention has been delivered
have been scrutinised by other experts in the feld
provide a high level of confdence that any effects observed are due to the intervention itself by controlling for confounding factors
The gold standard is set by randomised control trials (RCTs). In this research design, participants are randomly assigned to either an
experimental group (treatment) or a control group (no treatment/placebo). When the researchers compare the two groups, after the
intervention, they are able to use statistics to infer whether the intervention (and only the intervention) caused any differences in outcomes
between the two groups.
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Accessing websites and reading individual research papers is one way of
staying in touch with the evidence-base supporting specifc interventions.
When a large number of studies are reported within one topic, it becomes
possible to boil down their fndings using the methods of a systematic review
or meta-analysis. In this latter process, aggregated results from multiple studies
are expressed as an effect size. This enables estimates to be made of the
impact one intervention has relative to another. For example, an intervention
which in a meta-analysis had an effect size of (0.3) would be considered less
effective than another intervention with an effect size of (0.8). In the same
way that the quality of individual research papers can vary depending on a
range of criteria, the level of rigour and quality of analysis applied to these
meta-analyses can vary. There are however a number of well respected sources
which offer high quality.
5.5 Researching the Evidence
Within the NHS, we would often access research evidence
through the various data bases offered by The Knowledge
Network. Have a look at the site and try doing a search
for ADHD. You will fnd there are in excess of 15,000
articles available from this source alone. Clearly it would
be impossible to trawl through this number of articles. Try
adding parent management training. The results are now
down to well under a hundred. From these resources,
try to identify one or two articles which may support (or
otherwise) parent management training as an approach to
intervention for ADHD. Use some of the criteria above to
help you.
Discuss this process, and the outcome, with your supervisor.
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Beyond the evidence: Guidelines and Standards
Both of the methods described above are important and accessing such evidence should be a routine aspect of all clinicians activities.
However there are a number of sources which, rather than simply providing or even analyse the evidence, develop standards or guidelines
for assessment and treatment based on a close analysis of the best available evidence. Perhaps the two best know are NICE (National
Institute for Health & Clinical Excellence) and SIGN (Scottish Intercollegiate Guidelines Network). Both organisations produce guidance and
standards which ensure high quality evidence based treatment in clinical practice and should be a blue print for the clients journey through
services. The Social Care Institute for Excellence is also an excellent resource.
5.6 SIGN
Use the link above to visit the SIGN website. Look for guidelines which relate to the assessment or treatment of ADHD.
How do these differ from the two sets of evidence above?
Discuss this with your supervisor and, between you, think about how your service manages ADHD in relation to he SIGN
guidelines.
5.7 Cochrane Library
Access the Cochrane Library on the internet. This site offers a range of levels of evidence, but perhaps most notably
offers high quality reviews of evidence.
As before, type ADHD in the search box. You will see while they have over 6000 pieces of evidence, they only have around 15 reviews
which mach this search.
Look through the list and identify whether there are any which relate to parent management training. If so read the article and
compare what you found ther with what was in the previous article you identifed.
How do the contents and analyses differ?
How are the similar?
Have a look at the other reviews in this topic. What do you think ar the most appropriate interventions for ADHD in he CAMHS
setting?
Discuss this with your supervisor. Find out how this compares with what happens in your service
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The Matrix
Here in Scotland, NES have developed a document which draws together much of the best available current
evidence in psychological therapies across the whole age range.
The Psychological Therapies Matrix project grew out of requests from NHS Boards for advice on commissioning psychological therapies in
local areas to enable them to plan and provide the most effective available psychological treatments for their particular patient population.
The Matrix: A Guide to delivering evidence-based Psychological Therapies in Scotland (Scottish Government and NHS Scotland 2008)
is a guide evidence-based Psychological Therapies within NHS Boards in Scotland. It provides a summary of the information on the current
evidence base for various therapeutic approaches including matching the type of care delivered to the intensity of the mental health problems
experienced by children and young people
5.8 The Matrix (1)
Access The Matrix document and Read the
introductory sections of the document up to
page 18.
Pay particular attention to the defnitions
of the different levels of intervention and
discuss these with your mentor or colleagues.
Are there any aspects of what you have read
here that surprise you or that are familiar to
you?
Discuss these aspects with others too.
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It is important to be clear that the language used in the Matrix which describes the range of interventions from low to highly specialised,
does not infer an order of importance on clinicians delivering care at these different levels, or on the value of the interventions themselves.
The purpose is to ensure the best match between the intensity of interventions and the needs of service users. As fdelity to particular
evidence-based practice models is directly related to good clinical outcomes, it is also crucial that clinical staff are trained in those models
before applying them.
5.9 The Matrix (2)
Return again to the Matrix document and
read pages 19- 22, summarising the sort of
training and further education required for
different interventions.
It may be clear from carrying out the last activity that all of the approaches
mentioned above require commitment from both the organization and the
clinicians involved. The organisation needs to commit to the development of a
structure which allow the delivery of these evidence based approaches such as;
training and CPD; supervision; access to appropriate research and resources.
The clinicans delivering the interventions, on the other hand must remain
committed to; the delivery of therapies with fdelity; accessing appropriate
model specifc supervision; and continually updating their knowledge and
skills.
In many cases, families with whom we are working will require interventions
which are outwith our individual realm of competence. It is important
then that clinicians have some awareness of the range of evidence based
interventions and the circumstances in which they are most effective. The
Matrix offers an easily accessible source for this information.
5.10 The Matrix (3)
Return again to the Matrix read pages 1
to 6 make notes in your portfolio of the
Children and Young Peoples Mental Health
commitments. Which of these commitments
are relevant to your practice?
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The evidence for the interventions uses the categories of A, B and C which are defned as:
Matrix level
A
At least one meta-analysis, systematic review, or RCT of high quality and consistency aimed at target population
Matrix level
B
Well conducted clinical studies but no RCTs on the topic of recommendation directly applicable to the target
population, and the demonstrating overall consistency of results.
Matrix level
C
That have widely held expert opinion but no available or directly applicable studies of good quality.

5.11 Researching Therapeutic Approaches
The names of three reasonably common therapeutic approaches and
associated websites are given below. If you are interested in fnding out
more about specifc training requirements, follow the relevant web link and
take a note of advice related to training and development for your area of
interest.
Cognitive Behavioural Therapy: an evidence-based approach to a number
of mental health problems, as you will have noted from your study of the
Matrix, and discussed in more detail in Unit 2.2.
Interpersonal Therapy for Adolescents: an evidence- based approach to
treating depression in adolescents.
Behavioural Family Therapy: an approach to family work recommended by
the NICE guidelines in 100% of situations where a person is recognised to be
experiencing psychosis (NICE 2009) (also outlined in Unit 2.3).
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In the fnal activity of this Unit we will be looking at the evidence for interventions for particular mental health problems children and young
people experience. This activity should be repeated a number of times until you have an awareness of which particular interventions are more
suited to which particular problems.
5.12 Evidence for Interventions
From page 79 of the Matrix onwards the Evidence Base for Psychological Interventions is
outlined. Choose the mental health problems you are working with and make notes in your
portfolio about the evidence for the different approaches
Diagnosis Page
Infant Mental Health 124
Disruptive Behaviour Disorders (Disorders of Conduct) 127
Attention-Defcit Hyperactivity Disorder (ADHD) 129
Autism Spectrum Disorders 132
Anxiety Disorders 135
Obsessive Compulsive Disorder 137
Specifc Phobia 139
Post Traumatic Stress Disorder (PTSD) 140
The Impact of CSA 142
Depression 144
Anorexia Nervosa 152
Bulimia Nervosa 154
Schizophrenia / Psychosis 155
Bipolar Disorder 157
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Although the movement towards evidence-based practices has gained considerable momentum in recent years, it has also invited a degree of
scepticism
5.13 Evidence to improve practice
Here are some of the criticisms levied
at the evidence-based movement.
Can you think of some counter-
arguments to these challenges?
1 Evidence-based programmes
do not take into account
professional experience and
judgement of practitioners
2 Evidence-based programmes
and practices do not exist for all
identified needs or for all target
populations
3 Implementing evidence-based
programs can be very expensive
Discuss with your supervisor the pros
and cons of applying evidence based
practice to the CAMHS context
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A Range of Therapeutic Approaches
Introduction
As noted in the introduction to this unit, the aim is not to provide training in the range of therapeutic
approaches offered in CAMH services. There are a plethora of accredited training courses which offer high
quality training and support in developing these skills. Many experienced clinicians undertake years of training
and study before accreditation while others have therapeutic techniques and approaches integrated into their
core professional training. In both cases, accreditation or qualifcation is simply a starting point; the continual
updating of skills is an essential aspect of CAMHS clinicians role as the literature base grows and develops and
as guidelines and pathways are redrawn in accordance.
While this section will offer an outline of the approaches, including some case studies and links to relevant articles and websites, by far your
greatest resource is the colleagues in your team. Sharing knowledge of practice is a vital aspect of CAMHS work. Clinicians will often fnd
themselves working alongside colleagues and having some understanding of their approach invariably allows closer and more integrated
working. Similarly, an understanding of the strengths of approaches other than your own helps think about how the team can best support
any family which attends your service.
There is, however, no single therapy which is helpful for all mental health problems experienced by young people. Individual differences need
to be taken into account and most of the time a combination of therapeutic approaches which encompass a biopsychosocial approach will
be preferred. We must also bear in mind that therapy is not the only function or activity in CAMHS. A very large proportion of the work
undertaken by the CAMH team will be in liaising with, consulting to or even delivering training to other professionals, teams and agencies.
Even when we consider working with any individual family, any or all of these tasks could be an essential part of the intervention plan.
Nonetheless, there will be times when clinicians deliver therapeutic interventions and some of these approaches are detailed below.
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Cognitive Behavioural Therapy (CBT)
In reading the various sections within the Matrix, you will have noted that Cognitive Behavioural Therapy (CBT) is present in some form
in almost all of the conditions within the Child and Family section. CBT is similarly ubiquitous within the adult and older adult sections.
Furthermore, it is listed as a recommended intervention in most, if not all of the NICE and SIGN guidelines for mental health problems and
accounts for a very large proportion of the psychotherapy research that is carried out around the world. It is worth remembering, however,
that CBT is not a single entity; it is, in reality, an umbrella term for a range of specifc models and techniques adapted for specifc problems
and age ranges (Westbrook et al 2007), although all have at their core some common features.
Indeed the term CBT has become so common, that many of the young people and families who attend your service may come looking for CBT
or have engaged in the approach elsewhere. It is worthwhile recapping some of the fundamentals of the approach therefore.
One of the basic tenets of CBT is that our understanding of the world is regulated not by the experience directly, but by the way we appraise
that experience. For example, were we to awake to a bump in the night, our emotional and behavioral reaction to that bump would depend
not on the bump itself, but on what we understood the bump to mean. If we awoke and believed the bump to be the result of our cat
wandering through the house, we would most probably pull the covers up (in mild annoyance!) and go back to sleep fairly quickly. If, on the
other hand, we thought that the bump was caused by a burglar, our emotional reaction may be somewhat different (fear!) and pulling the
covers up may have a very different purpose. Furthermore, our pounding heart, rapid breathing and heightened arousal may make sleep a
very unlikely option.
CBT uses the areas described above as its focus in helping people understand and overcome emotional and behavioral diffculties. Thoughts,
feelings, physical response and behaviour are seen as interdependent; making changes in one area will create changes in the other domains.
Clearly this does not happen in isolation; all take place within the individuals current context. This model is often represented by what has
become commonly known as the hot cross bun (fgure 10)
+Environmental
Issues
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5 areas/ Hot Cross Bun model
The appraisals themselves, while occurring in the present, are considered to
be the outcome of previous experiences, and in particular early experiences.
The understanding of the world, or core beliefs, developed in our early years
lays a foundation for how we will experience life. The child who experiences
threat in their environment comes to expect threat from the adult environment.
Furthermore, based on appraisal, that individual is likely to behave toward the
world in ways which match their appraisal which may in turn prompt particular
reactions which are likely to reinforce their beliefs.
For example, imagine a man at the bar in a busy pub. Someone next to them
nudges him and spills their drink. Their emotional response and behaviour will
depend on their appraisal of the incident and of the intent of the individual
involved. How do you think they would feel or behave if their appraisals were as
follows:
He did that on purpose!
People should be more careful
My its busy in here, accidents happen
Often, in CBT, the key appraisals are those which are self directed. Returning to
the more benign example of the bump in the night: if the initial appraisal is its a
burglar and the resultant behaviour is to pull up the covers and wait until he, or
indeed she, has gone, there is an element of self preservation here. For many of
us, this may seem to be the sensible thing to do. For some people, however, their
reaction may be very different. They may believe that the appropriate thing to
do would be to confront the burglar and protect the house (perhaps thats what
dad would have done; or rather they believe thats what dad, or more generally a
man, would have done). However, if the level of fear they experience at the its a
burglar appraisal is so great they fnd they can do no more that pull the covers
up, what does this mean? Again depending on their core beliefs the resultant
appraisal may be Im weak, Im not a man or Im not worthy, all of which are
likely to impact on mood.
Figure 10
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CBT aims to explore these core beliefs and the appraisals which result. By highlighting where these maladaptive thought processes occur
and helping individuals recognise and challenge them, the aim is to alter the core beliefs and change the appraisals (thereby shifting
behaviour, mood and physical response).
However, as Paul Salkovskis notes:
..the aim is not to persuade persons that their current way of looking at the situation is wrong, irrational, or too negative; instead, it is to allow
them to identify where they may have become trapped or stuck in their way of thinking and to allow them to discover other ways of looking at
their situation. (Salkovskis, 1996: 49).
Implicit in this statement is the sense of collaboration at the heart of good CBT; the therapist hopefully has some helpful ideas and techniques
to draw on, but the person in therapy is the expert of their diffculties and life experience (Padesky et al). One further key aspect of CBT is the
explicit transference of the thinking and skills developed within sessions to the real world. The majority of work in CBT takes place outside the
session: clients are encouraged to apply their new ways of thinking and behaving in between sessions and these experiences then become the
focus of future session. These behavioural experiments allow a trial and error approach to learning new ways of thinking and offer a safe way
to facilitate gradual change.
Common CBT Myths
CBT is brief and only works for mild difcultes: While
CBT is ofen described as tme limited, this refers to the
goals oriented nature rather than defned tme limits. CBT
always begins by setng collaboratve goals which should
be reviewed regularly
CBT is highly structured and can be quite mechanistc:
There are specifc structures and techniques which,
if followed will promote positve outcomes, however
the delivery of these techniques needs to occur within
a collaboratve and exploratory environment. A very
mechanistc approach is likely to be more related to
therapist competence (Westbrook et al 2007)
CBT is simply training in positve thinking: In fact,
CBT aims to help people evaluate thinking realistically,
whether that is positive or negative (Westbrook et al 2007).
Sometimes a negative assumption proves accurate; the task
then might be to learn to deal with the correlates.
CBT is easy to learn: While some CBT techniques
are indeed straightforward, many CBT adaptations are
manualised for widespread use and a number of good self-
help and computerised treatments exist. These things do
not account for the reality and complexity of delivering
a therapy in many of the situations required in CAMHS
and we recommend formal training and CBT clinical
supervision before attempting to do so. We also recommend
understanding and experiences of the broader set of
psychotherapeutic skills
Common CBT Myths
CBT is brief and only works for mild diffculties: While CBT is often described as time limited, this refers to the goals oriented nature rather
than defned time limits. CBT always begins by setting collaborative goals which should be reviewed regularly
CBT is highly structured and can be quite mechanistic: There are specifc structures and techniques which, if followed will promote positive
outcomes, however the delivery of these techniques needs to occur within a collaborative and exploratory environment. A very mechanistic
approach is likely to be more related to therapist competence (Westbrook et al 2007)
CBT is simply training in positive thinking: In fact, CBT aims to help people evaluate thinking realistically, whether that is positive or negative
(Westbrook et al 2007). Sometimes a negative assumption proves accurate; the task then might be to learn to deal with the correlates.
CBT is easy to learn: While some CBT techniques are indeed straightforward, many CBT adaptations are manualised for widespread use and a
number of good self-help and computerised treatments exist. These things do not account for the reality and complexity of delivering a therapy
in many of the situations required in CAMHS and we recommend formal training and CBT clinical supervision before attempting to do so. We
also recommend understanding and experiences of the broader set of psychotherapeutic skills
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The following case study will give a brief description of the application of CBT for anxiety with a young person.
Case study: CBT for anxiety
Alison (41 years) and Mark (43) MacDonald have been married for 15 years and currently live in their own home in the Southside of Glasgow.
They have two children, Alice (12 years) and Tom (9 years). Alison and Mark describe their relationship as solid and feel that they have a very
close family who enjoy spending time together, particularly at weekends when they all engage in activities such as swimming and biking.
Alisons parents live close by and play a large and active part in the familys life. Marks family live in Dumfries and, unfortunately, the family
only get to visit his parents on a couple of occasions a year.
Mark is in sales and has recently taken on a new job which requires him to travel throughout Scotland and involves overnight stays. He enjoys
his job, although the increase in responsibility been an adjustment. Alison works as a receptionist at a local law frm. Although the wages are
low, she enjoys the work and has many friends there.
Alice is in frst year at the local high school and is doing well both academically and socially within school, with no diffculties making the
adjustment from primary. A keen swimmer and dancer, Alice participates both after school and on weekends at local clubs. Alice has a small
group of close friends whom she has known since primary school; they spend a great deal of time in each others houses and have regular
sleepovers.
Tom is in Primary 4 and the school have no concerns about his performance academically, socially or
behaviourally. Tom has a group of friends at school with whom he plays most days and attends clubs
outside of school (football and Scouts) with these boys. He will go to friends houses when asked,
but prefers to have friends come to his home.
Alison and Mark have become increasingly concerned about Toms tendency to worry,
which has been a long standing problem, but has worsened considerably over the past
6 months. Tom has been reporting lots of physical symptoms including headaches and
stomach pains that can last for several hours. This has resulted in frequent GP visits;
however medical investigations have found no physical cause. Following his most
recent appointment at the GP, it was agreed with Tom and his parents that a
referral to the local Child and Adolescent Mental Health Service would be made.
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Meeting the MacDonalds
Following referral from the G.P., the Macdonald family attended an initial assessment appointment. As outlined in the Assessment section, the
aim of this appointment was to; engage with the family; establish their needs; gain a fuller understanding of their current diffculties, including
the history of the diffculties and their management; and to establish whether the CAMHS service could offer the appropriate support.
Assessment
During the assessment it became clear that, not only was Tom a young man with a history of being a real worrier, but that this had worsened
over recent months. It had reached the point where mum and dad felt it was having a signifcant impact on his daily life. In addition to
increasing worries (thoughts), Tom reported that he was often scared and nervous (feelings), particularly when dad was away. He was worried
that he would be in a car crash, now that he did so much driving, and would end up dying in a hospital miles from where they live. He also
reported that, even when dad was home, it wasnt much better. He simply worried about when dad was going away again. He said that when
he was with his friends, particularly at their houses it was often worse because their dads were home and safe. Tom said that the stomach
aches and sore heads (physical response) were getting worse and mum noted that they happened most often on a Sunday night, before dad
left. Mum also noted that Tom was constantly seeking reassurance from his parents, and simply didnt want to leave her side when dad was
away (behaviour).
Despite Tom and his parents combined efforts, including lots of reassurance and attention when he became anxious, and allowing him to call
his father when he is away, their management of the problem had been inconsistent and had not reduced the frequency or severity of Toms
worrying. Generally speaking, the focus of their interactions within the family was being placed on Toms fears rather than the many successful
things that Tom was achieving elsewhere in his life.
Evidence base
As described in the MATRIX, the most effective intervention for mild to moderate anxiety in children Toms age is CBT. CBT has been found
to be a highly effcacious treatment for anxiety in children (Barrett, 1998; Barrett, Dadds & Rapee, 1996; Flanner, Schroeder & Kendall, 2000;
Kendall, 1994; Wood, 2006). Furthermore, the evidence base indicates that, not only is CBT which involves the child and parent superior to wait
list control as a treatment for child anxiety (Bogels & Siqueland, 2006), but the effects of CBT are enhanced by involving parents (Barrett et
al., 1996; Cobhna et al., 1998; Cresswell & Cartwright-Hatton, 2007). Given this evidence, along with Toms age and developmental stage, the
treatment planned involve both Tom and his parents.
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Treatment Plan
Based on a full assessment and formulation and based on the evidence based described, the following treatment plan was developed in
collaboration with Tom and his parents.
The intervention involved Tom and both his parents, who had a signifcant role in both encouraging and supporting Tom in his own efforts to
manage his anxiety, and in learning how they could manage most effectively Toms anxious behaviour; particularly in relation to the amount of
attention and reassurance that they were offering to Tom. Intervention involved a combination of sessions for Tom alone, sessions with Toms
parents by themselves and sessions with them together. Even in the sessions with Tom alone, there would always be at least part of the session
involving his parents, so that they were aware of what had been the focus of the session, and also what Tom would be working on over the
upcoming week.
Tom present Parents present All together
Session 1 Psychoeducation and socialising into CBT
Session 2 Understanding and recognising
feelings
Session 3 Parenting work
Session 4 Worry scale;
Applying the model;
Session 5 Challenging thought distortions
Session 6 Hierarchy;
Exposure tasks
Session 7 Developing rewards
Session 8 Review and develop tasks
Session 9 Review and develop tasks
Session 10 Relapse prevention
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Session 1 Psychoeducation and socialising into the model
For both Tom and his parents, the treatment started with psycho education around anxiety, its causes and treatment, and introduced the
family to the CBT model. The thoughts, feelings, physical reactions and behaviours that Tom was exhibiting during times when he was anxious
were drawn from the initial assessment to inform the discussion around the CBT model. Of particular importance for Toms parents during the
psycho education was to understand the factors that were maintaining Toms anxious behaviour (for example, the attention and reassurance
that he was receiving), why such management of Toms anxiety was unhelpful, and potential alternate response. It was imperative when
providing this psycho education that the family were given realistic expectations about the treatment, including such factors as the likelihood
that Toms anxiety could get worse before it improved; this often happens because we are often asking young people to put themselves in
anxiety provoking situations in order to learn that they can in fact manage.
Session 2 Understanding and recognising feelings
Following on from this initial psycho education was work for Tom on understanding and identifying feelings. This involved a discussion of a
wide range of feelings, not simply the varying forms that anxiety may take. Alongside aiming to increase childrens general emotional literacy,
the aim is also to help children understand that all the feelings we have are ok, that our feelings change in different situations and whilst some
feelings are nicer to experience than others, negative feelings, including fear, are not bad or something of which one should be ashamed. Part
of this discussion focused on identifying the things that worry children - at this stage it was not to identify worries upon which they will focus,
but to help understand that worrying is normal and that everyone has things they worry about. Whilst much of the focus would be on feelings
work, it was important for his parents also to understand that it is normal for children, and adults, to have worries and that different worries
tend to arise at different developmental stages for children. This was designed to help his parents understand that fears and worries are not
necessarily indicative of pathology within the child.
Session 3 Parenting work
Whilst much of the rationale for psycho education around anxiety, understanding cognitive distortions, being able to generate coping
statements and cognitive challenging to thought distortions is in order for parents to be able to support Tom in his efforts to combat his fears
and worries, additionally these elements help parents who themselves may be experiencing their own anxiety, either in general about things
in their life, or specifcally in relation to their child. Here parents can develop skills to combat their fears that, for example, their child wont
cope when put to sleep in their own room, since their fears are likely to be playing a role in the development and maintenance of their childs
diffculties. Even parents who generally cope well may beneft from this work, given that it is likely that their childs anxiety and distress will
increase as they undertake the behavioural experiments. Here, it is helpful for parents to have coping statements for themselves (I know I am
doing the right thing- he needs to face this fear to help him become less anxious, even though it will be hard for him) to help buffer the stress
that they will naturally experience when they see their child become upset.
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Session 4 Worry scale and revisiting the formulation
The next element of the CBT approach was a method to rate the severity of Toms fears and worries, often referred to as a worry scale. Here
the simple rating of 0-10 (0= totally calm, relaxed and having no fear, 10= terrifed and having huge amount of fear) is taught to children. This
simple measure is important for helping children articulate what level of anxiety they feel in a situation (and monitor whether this changes
during behavioural experiments) but also to identify what fears should be tackled in what order when it comes to designing such exposure
tasks. Again, it was imperative that Toms parents were also able to help Tom rate his worries, as the majority of the therapeutic work, both the
cognitive and behavioural elements would take place within the home environment, rather than the clinic setting.
The next step involved a follow on discussion from some of the original issues raised during the assessment and feedback session; looking
at the impact the fears and worries which the child experiences are having on their life, and examining the physical sensations that are being
experienced by the child during times of stress. These issues are addressed for a couple of important reasons. Firstly, the discussion of the
impact of fear on the childs life highlights for the parents and child the restrictions that exist within their family life as a result of the anxiety,
and the subsequent discussion of what the child could do if anxiety wasnt a problem is designed to motivate the child (and parents) to
engage with the therapeutic work. The discussion of the physical symptoms serves as a way for both the child and parents to be alert for clues
that will allow them to identify when the child is feeling nervous or scared. This will be utilized frequently during the behavioural experiments
that will be developed.
Session 5 Thought distortions and thought challenging
Helping children to start recognizing the link between their thoughts, feelings and behaviour was the focus of the next part of the
intervention. Here discussions focused on how the same event can be interpreted in different ways by people, and it is the thoughts
that people have in relation to an event that determine the feelings that are experienced and the behaviours that are undertaken as a
consequence. This is the frst step in helping Tom (and his parents) to understand that there are alternative ways to think about the same
situation, which would become a key strategy utilized both in their thought challenging and coping statements.
Common thinking errors were then explored with Tom, as an introduction to the sorts of cognitive distortions that can accompany people
when they are anxious or scared. This is another strategy to help Tom start to recognize the sorts of thoughts that he was having that might
be contributing to their fears, and was a step toward getting children to develop more realistic thinking about situations. Thought challenging,
or Detective thinking as it is often called within child work, follows on from the work on cognitive distortions and aimed to equip Tom with
strategies for being able to evaluate how balanced and realistic he was being in a situation. It is stressed that the goal is not to get children to
rationalize their thoughts, nor to get them to think positively about events, some of which might be objectively negative. The goal is to help
them to realistically appraise a situation by asking themselves a series of questions, with the ultimate goal of coming up with a more realistic
thought about the event. The expectation is that by thinking more realistically about a situation, the childs anxiety level is likely to reduce. This
cognitive challenging approach was also taught to Toms parents so that they could help Tom with his detective thinking in the home.
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Session 6 Developing a hierarchy
Whilst the cognitive element of treatment is in itself helpful in reducing anxiety in (older) children, for younger children in particular, the
behavioural component of CBT plays a particularly a signifcant role. Whilst older children and adolescents beneft from the thought
challenging that is entailed within CT, children under 12, but especially children under 8 (for whom logical arguments are a not yet reached as
a developmental stage) rely upon the behavioural experiments to change their interpretations of events. As such, the exposure tasks (in order
to fght fear by facing fear) are the next important step in CBT for children.
However, the exercise of getting children to be exposed to the situation of which they are fearful is not a simple matter of just sending them
off to pat a dog, sleep in their own bed, or do a speech in front of the class. One of the keys to the success of exposure tasks is the planning
of these behavioural experiments. This involves multiple steps including: the development of the list of fears that the child wants to work on
(which need to be tasks that can actually be arranged, and that are occurring frequently enough that they are interfering with the child or
familys functioning), choosing one worry to tackle frst, building a hierarchy of steps in order to face the ultimate fear (the construction of the
hierarchy could be a series of steps which include gradually increasing the amount of time that the child is exposed to the fear, or the gradual
withdrawal of factors that make it easier for the child to face the fear), making a plan for undertaking the exposure task (including what the
child and other family members will do when it becomes diffcult for the child), and identifying the rewards that the child will earn when they
have undertaken a task.
Session 7 Rewards
One of the key ingredients to the exposure tasks, particularly with younger children, is the establishment of rewards that the child can earn
for undertaking a pre-arranged activity. These rewards can include; social rewards of praise and affection from their parents, such as hugs,
pats on the back; tangible rewards, such as stickers, sweeties, magazine or some other small items; and experiential rewards such as having a
friend over to stay, getting to stay up late. Developing a reward chart is no easy feat. It requires a good basic understanding of the principles;
especially when parents return saying it has been unsuccessful.
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Sessions 8-9 Review and develop the tasks
It is likely that the hierarchy initially developed will need to be revised at some point following its implementation: sometimes the distance
between steps in the hierarchy is too great and so need broken down into smaller steps; sometimes children make faster progress than
anticipated and so can move on to more challenging tasks more quickly. One of the most important things to consider when developing a
hierarchy for children is to ensure that the frst step on the hierarchy will be achievable for the child. It is disheartening for a family to set off
on a task that is unlikely to be successful. In these instances children, and parents, often want to give up and the failure experience reinforces
the view, often shared by the whole family, that they cannot cope. This will make them resistant to new challenges and reinforce avoidance.
Developing hierarchies is therefore a necessarily time consuming business and it is essential that the clinician manages this development in a
way that is ultimately going to be successful. Sometimes children and/or parents want to attempt activities that are just too hard for the child.
For example, a parent of a child who sleeps with them every night (and has done for some years) might want to have the frst step on the
hierarchy be the child sleeping in their own bed for the whole night. This is an unrealistic goal- if the child has not achieved this for some time;
there is no reason to think that it will suddenly be achieved overnight.
Within the clinic setting, the focus will be on planning these activities, trouble shooting any diffculties and perhaps doing some rehearsal with
the family of an activity. However, it will take more than a couple of exposure sessions to reduce childrens fears, and many of these fearful
situations cannot be rehearsed realistically in the clinic and so the real work is done outside the clinic by the family.
Session 10 Relapse prevention
The fnal two elements of CBT for anxiety focus on what to do when things become challenging; dealing with setbacks. It is an important part
of therapeutic work to prepare families to be aware that setbacks may occur at some point in time. The way to successfully manage these is to
be aware that this possibility could happen, anticipate when they might occur and be prepared for them. It is also important for families to see
setbacks for what they are; simply a setback. It is not helpful if they are experienced as failure. Teaching families problem solving steps will
equip them with skills to successfully navigate their way when any setbacks may occur.
Kendall (1994) developed a successful CBT intervention for children aged between nine and thirteen with generalised anxiety disorder (GAD)
called the Coping Cat programme. Kendalls (1994) programme for individual therapy involved sixteen sessions of treatment and combined a
psycho-educative approach with relaxation training and practice coping with anxiety-provoking situations. There are a range of standardized
programmes and online resources for intervention in anxiety, depression, OCD and PTSD. Information and links are available from The
Playfeld Institute website. There are models for CBT for psychosis in practice for treatment of acute and negative psychotic symptoms.
However this is a complex and highly specialised clinical practice (although training and professional development is essential for the other
models too)
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5.14 Tom: CBT for Anxiety
Having just read about how CBT was applied
as a treatment for anxiety (for Tom and his
parents):
How would the intervention differ if Tom
had depression?
What would be the common elements
for both?
5.15 CBT for Psychosis
The term Psycho-social interventions is
also often used in relation to psychosis.
Find out what this means by reading the
SIGN guidance number 30, available from:
web site or by reading the definition in the
matrix.
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As a treatment modality, CBT is continually evolving. Recent examples of this
include Fairbairns (2008) transdiagnostic treatment model for eating disorders.
This approach is based on the evidence that people with anorexic symptoms
often go on to experience bulimia and vice versa, and that most people seen
for treatment for an eating disorder do not meet full criteria for either anorexia
or bulimia nervosa. Fairbairns sensible proposition is to consider the person
as having one eating disorder with different phase and to aspire to treat those
phases within one approach. Butler et al (2008) also examine the value of a
transdiagnostic perspective in considering the commonalities and differences
between anxiety disorders.
Mindfulness-based interventions are another new dimension in CBT. Mindfulness-Based Cognitive Therapy has been shown to be an effective
intervention for adults with recurring depression and is recommended in the relevant NICE Guideline (NICE, 2009; Segal et al 2002). In
CAMHS, there is currently very little evidence but growing interest, including nascent research efforts (Burke 2010). There are also related
research projects underway into the potential for mindfulness to be of beneft to school teachers, health care professionals working with
children and young people, and of course school children themselves (Cultivating Emotional Balance 2011; Oxford Mindfulness Centre 2011).
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Parenting Approaches
As we saw in Module 4, there are a wide range of factors which exert infuence on a childs development. Within
this broad array of factors, their experience of relationships with their main care-givers, particularly early in life,
emerges as one of the most important. We often refer to this infuence using the general title of Parenting.
Not surprisingly, given its importance in terms of shaping child outcomes, parenting appears in many of the developmental theories guiding
the work of CAMHS practitioners and child care workers. Parenting themes are represented, for example in theories developed by Freud,
Erikson, Bowlby, Skinner and Bandura. These theories all recognise not only how important the primary carer is in childrens development, but
also what a complicated set of activities they perform. Indeed, Freud himself is said to have referred to childrearing as one of three impossible
professions (the other two being governing nations and psychoanalysis!)
Not surprisingly then, Interventions which seek to engage parents and bring about positive outcomes for children and young people, have
become a central focus within CAMHS. These vary considerably however. Some aim to provide psycho-education or support to parents
of children experiencing particular mental health problems; for example a group for parents of adolescents with eating disorders. Others
offer parenting input that acts essentially as an adjunct to the childs intervention; for example, parents of child with a fear of dogs might be
involved in a progressive exposure programme.
Yet other interventions target specifc aspects of parenting behaviour that are known to mediate outcomes for children and adolescents.
Currently, the term parenting is probably most widely used to describe interventions of this latter type. Most draw heavily on the attachment
and social learning theory literature. Several have been developed as manualised programmes, and arguably enjoy the strongest scientifc
support of any psycho-social intervention for children (Parenting/Education Programme). With an increasing push towards the use of
evidence-based approaches in CAMHS, these parenting programmes occupy a very worthy place.
In this section we will consider how these theories inform our work in CAMHS and review some of the structured programmes which have
been developed.
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5.16 Parenting skills
Think of a list of 6 parenting skills you consider
important for childrens wellbeing. Now think
of the mechanisms through which these might
bring about positive development in children.
How, for example, do you think parents having
fun with their child might serve to shape the
childs self-esteem?
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Several decades ago, Diana Baumrind studied variations in normal parenting practices and described
two basic elements: responsiveness and demandingness. From these she identifed three basic
parenting styles authoritative, authoritarian, and permissive. At a later stage, Maccoby and Martin
expanded this work and added a fourth category of uninvolved parenting. This framework is
summarised in the diagram.
The authoritarian parenting style is characterised by high demandingness with low
responsiveness. As such, when parents use an authoritarian style, they might be described as
being rigid, harsh, and demanding.
A permissive parenting style, by contrast, is characterized by low demandingness with high
responsiveness. These parents may be seen to be overly responsive to the childs demands,
seldom enforcing consistent rules.
The authoritative parent is firm but flexible and is also responsive to the childs needs without
indulging them.
Uninvloved parenting is characterised by low demand and low responsiveness, having little emotional engagement with their children.
These parenting styles have been found to be associated with certain child rearing outcomes. Authoritarian parenting styles are generally
associated with children who are obedient and profcient, but who rank lower in happiness, social competence and self-esteem. Authoritative
parenting styles tend to be associated with children who are happy, capable and successful. Permissive parenting is often linked with children
who rank low in happiness and self-regulation. These children are more
likely to experience problems with authority and tend to perform poorly in
school. Uninvolved parenting styles are associated with children who tend to
lack self-control, have low self-esteem and are less socially competent than
their peers.
Research of this nature provides a useful framework from which to begin
thinking about some key dimensions of parenting. However it has some
serious limitations. For example the data was derived from largely middle-
class samples and importantly cannot cast any light on causal connections
between parenting a child experiences and development this would require
a signifcantly more complex design.
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The Changing face of parenting
For a start, we would need to recognise that, as traditional Western models of family life have undergone major changes in recent times, the
core and most intimate tasks of raising children have come to be undertaken, less and less exclusively by biological parents. More than ever,
a range of other key adults - or indeed older siblings - may become a parenting fgure for a child. Moreover, these so-called alloparents
may be around in the childs life only briefy, intermittently, or on a longer term basis. Our thoughts around what we understand by the term
parenting, therefore need to embrace a very generous understanding of the settings and social conditions within which parenting occurs.
We might also want to bear in mind the rich variety of parenting arrangements that arise, for example, when
parents divorce or separate, when different parts of families reassemble,
when lesbian and gay partners raise children, when teenagers versus
middle-aged adults take on mothering and fathering roles, when
adults from another generation become involved in grand-parenting,
and when children are fostered or adopted, or receive alternative
parenting experiences, by virtue of being looked after or
accommodated.
Finally, we would do well also to remember that the duties
with which parents are tasked will vary with the age,
developmental status and gender of the child; that most
parents are raising a number of children who may
compete for their resources; and that very many children
present special challenges for parents by virtue of
disabilities and illnesses.
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One example of a parenting intervention that
explicitly uses attachment theory research is VIPP
(Video-based Intervention to Promote Positive
Parenting) (ref: Juffer Bakermans-kranburg, &
van Ijzendoorn, 2007) As its name suggests, this
approach involves giving parents video feedback
to help them to develop sensitive interactions with
their child. Usually this work is undertaken in the
parents own home and is limited to a short series
of visits. This intervention has a growing evidence-
base that promises to contribute meaningfully to the
early intervention agendas that are also currently
infuencing service delivery models in CAMHS.
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How psychological theories have infuenced the development of evidence-based parenting
interventions
With all of this complexity to hold in mind, it is helpful to know that some robust psychological theories have been on hand to guide the
development of much-needed effective parenting interventions. Many of these have been infuenced by the overarching framework provided
by the discipline of developmental psychopathology.
One of the basic premises of this movement is that every life course, whether healthy or maladaptive, is both driven by some common
fundamental principles and is shaped by experience. Although the quality of a childs relationships will always be a key infuence on
their development, the intimate care offered to them in the early days seems to be especially potent. This is partly why most parenting
interventions target young children.
The Risk and Resilience model which is fundamental to the developmental psychopathology approach has also helped focus attention on key
aspects which may contribute to the formation of particular developmental pathways.
With respect to parenting this has, helped to identify specifc risks and
risk processes associated with sub-optimal parenting experiences. Equally
importantly, it has also highlighted the protective role positive parenting
can play even when other aspects of a childs development may be harmful.
Attachment theory has, of course, always highlighted the central role that
the quality of relationships plays in a childs psychological development,
particularly in early life. Concepts of security, attunement, reciprocity and
goodness-of-ft are all seen to build the platform on which subsequent
aspects of parenting are built.
Many parenting programmes and approaches such as Mellow Parenting
and Solihull have also incorporated these attachment focused constructs
into their interventions as does the very successful Family Nurse
Partnership programme
By far the most infuential theory guiding the development of evidence-
based parenting programmes has, however, been Social Learning Theory.
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This theory, developed initially by Albert Bandura, elaborated some of the core concepts of behavioural theories, by emphasising, for example,
the social and cognitive aspects of reinforcers. For sure, social learning theory recognises that the behaviour of both parents and children
is infuenced by a host of factors such as their own genetic and temperamental biases, the nature of the community in which they live, their
exposure to social adversities such as poverty and unemployment, the cultural and political values which they encounter, the quality of
relationships they have experienced, and even just by chance events. It also draws attention to what are known as bi-directional infuence;
while the environment undoubtedly infuences the childs behaviour and development, the childs behaviour also impacts and shapes the
environment within which she lives.
Picture the scene - harassed mother, Karen, is trying to prepare an evening meal for herself and her three young children, in time for
their father arriving home to take them all out to the swimming pool. They are all feeling stressed and hungry. Josie, age 9, decides this
is just the moment to ask for help with her homework, Liam, age 6, runs in with a bleeding knee. Next, Ben, age 4, begins to whine for
a sweetie while the dinner is cooking. Karen refuses to give him the sweetie, explaining that his dinner will soon be ready. Ben however
has a strong-willed temperament and persists with his whining. Its volume and its persistence levels increase. Still he is refused the sweet.
Eventually, Ben begins to scream and a full-blown tantrum looks inevitable. Eventually, Karen changes tack and gives Ben the sweetie he
craves.
5.17 Contextual Factors
How might this scene be influenced by some of
the contextual factors outlined in the sections
above? For example, how might what happens
be affected;
by Karen being a single parent, with
little prospect of a period of respite from
parenting
by Karens socio-economic status
by the childs age
In this example, it is easy to see how Karens behaviour has impacted on
Ben (in that his whining and screaming have been reinforced by Karen
deciding to accede to his demands). A social learning theory perspective
would expect him to be more likely to display similar behaviour in
the future. Its bi-directional focus would, however, also emphasise
the impact Bens behaviour has had on Karen. This is because she has
experienced the negative reinforcement of the cessation of his whining
(and the positive reinforcement of mastering the production of the
meal and the emotional satisfaction of providing well for her children).
Essentially, Karen and Bens behaviour has reciprocally reinforced the
behaviour of the other.
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Delivering Parenting Interventions
Based on research and fndings in these areas a range of structured programmes designed to impact on parenting practices have been
developed. Many of these programmes have been the subject of research and their effcacy in supporting positive outcomes for parents and
children has been established. Two in particular have been the subject of extensive research in a range of settings with a range of clients and
have consistently demonstrated good outcomes. Both the Positive Parenting Programme (Triple P) and Incredible Years are examples of
what are often called evidence-based programmes. This means that they are backed by high quality scientifc research that has been designed
to demonstrate whether or not they work.
For Triple P, numerous rigorous evaluations, completed in several countries, show that at the end of the programme, parents rate themselves
higher on standardised scales measuring their parenting skills, self-effcacy and confdence than they did when they started in the group.
Conversely, their post- versus pre- programme ratings of their childrens emotional and behavioural problems show signifcant reductions.
Similarly parents who participated in Incredible Years groups, reported increases in their use of positive parenting techniques and decreases
in negative parenting practices. Blind independent observers also rate reductions in the childrens behaviour problems, and increases in their
social and emotional competence levels. These results have been replicated by other independent researchers in several countries. Time and
time again, it has been shown that attendance at an Incredible Years parents group alone can move roughly 2/3 of children with diagnosable
disruptive behaviour disorders into the non-clinical range. Impressively, these improvements have been shown to hold up over many years.
Moreover, results of this order have been demonstrated in real life settings within Britain. Finally, economic evaluations have concluded that
this is a cost-effective intervention.
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Child Psychotherapy
Child psychotherapy is a psychoanalytic mode of treatment underpinned by psychoanalytic theory, attachment research, developmental
psychology research and neuroscience fndings. It considers emotion, anxiety, internal representations and unconscious processes as
determinants for symptoms and behaviour. It is suitable for severe, complex and/or enduring diffculties in emotional development,
personality development, or attachment relationships. It is particularly suited to children and young people who have experienced trauma,
neglect, or abuse in infancy or early childhood. These are typically clinically vulnerable children and young people who are often known to
several agencies.
Child psychotherapy is child-led, non-directive and unstructured, with particular emphasis on non-verbal as well as verbal communication,
focusing on the here and now. It is based on detailed and systematic observation, and on getting to know the child or young person in order
to develop an in-depth understanding of what lies beneath the presenting diffculties.
The objective of treatment is individual emotional growth and development, the capacity to establish and maintain relationships, and the
realisation of potential. It aims at:
an in depth understanding of how an individual sees, experiences and responds to people and situations
modification of fixed and maladaptive patterns resulting from repetition and re-enactment of unresolved emotional and attachment
issues
development of the capacity for mentalisation
greater resilience against recurrence of difficulties
The primary therapeutic tool and medium of change is the patienttherapist relationship. Attention is given to underlying dynamics and not
merely to symptoms. This enables children and young people to transfer developments in therapy to other relationships and situations.
In addition to individual psychotherapy, child and adolescent psychotherapists can offer parentinfant psychotherapy, brief parentchild
interventions with under 5s, work with parents, emotional state assessments and consultation to other professionals both within CAMHS and
in other agencies.
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Case illustration
Referral
Scott was referred to CAMHS for psychotherapy by a social worker in a Fostering and Adoption Team, when he had just turned 4 years of
age. The referral was in relation to concerns within his foster placements, though there were also past reports of severe diffculties with peer
relations while with his parents. Current concerns included acts of aggression towards the previous foster carers baby, diffculty recognizing
emotion or having empathy for others, a need for high levels of structure and close supervision, wanting to be in control. The current foster
carer reported that she did not have a sense of emotional connection with Scott; at the same time, Scott couldnt tolerate her being out of his
sight and he stuck close to her at all times. The long term care plan was for adoption, however there was concern about whether Scott could
form a healthy attachment and dependency relationship with adoptive parents.
Early History
Scott had a history of disrupted care; he spent his frst few months in foster care after birth. Scott then spent a period of 2 years with his
parents. While with his parents, Scott experienced severe emotional neglect and chaotic and inconsistent care; he witnessed extreme confict
and violence between his parents, who had a history of substance misuse. The decision was then taken to receive Scott into the care of the
local authority. Over the next two years, Scott experienced a succession of foster placements, some of which ended unexpectedly.
Assessment for psychotherapy: Presentation
In the assessment sessions, Scott presented as hypervigilant, extremely guarded, and emotionally remote, though at the same time there was
an endearing side to him and he was clearly a bright child. Scott showed an all consuming drive to be in control, and was unable to bear any
uncertainty or not knowing, which he dealt with by becoming dismissive towards the female therapist.
Formulation
Scott seemed to lack a sense of self. The overall picture was of a highly complex presentation of disturbed and impaired emotional and
attachment functioning, personality development and patterns of interaction and relating. Scott showed a complicated mix of avoidant,
anxious and disorganized attachment features, and both externalizing and internalizing behaviours. His presentation seemed linked to the
combination of severe trauma and neglect he had experienced in infancy and earliest childhood, and his history of broken attachments. His
rigid and deeply entrenched psychological defenses were limiting his potential for emotional growth and the forming of healthy attachment
relationships.
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Psychoanalytic psychotherapy treatment objective
Scott was offered long-term intensive 3 times weekly individual psychoanalytic psychotherapy for a minimum of one year. Parallel ongoing
once weekly sessions with Scotts foster carers were an integral part of the treatment package, both to support them as carers and in their
understanding of Scott, and to support the psychotherapy. The non-directive and child led psychotherapy offered an in-depth understanding
of Scotts inner world; and a safe setting to contain, think about and work through his pre-verbal unconscious feelings, anxieties and conficts
linked to past neglect and trauma, as they emerged in the transference relationship. In this way psychotherapy provided the opportunity to
develop a capacity to be in touch with emotions, and for thinking and self-refection. The development of a sense of self, and greater ability for
trust, would in turn enable Scott to make and sustain healthier and more secure attachment relationships.
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Systemic Approaches
Each individual we meet in the CAMHS clinic, whether they are a young child or a grandparent, is a member of a
wider system. Within these systems, or families, are individuals whose lives are interlinked and their behaviours,
thoughts and feelings are interdependent.
In Module 2 we discussed the complexity of the family unit and the variety of possible constellations within a family. We also discussed the
path along which families travel. It is important that we bear in mind, throughout our contact with families, that they make this journey
together. Changes by one individual will inevitably cause ripples for others. Conversely, the ripples being experienced by the individual in
front of you, may originate elsewhere within the family. Before we
examine a range of systemic therapeutic approaches, it is worth
acknowledging the distinction between working as a systemic
therapist and working with the family system. The former will
be the end point of a period of specifc training, which will be
supported by an evidence base. Working with the family system,
and the system surrounding the family, however describes what all
CAMHS clinicians do when they consider the views, needs, goals
and emotions of each member of the family and work sensitively
and collaboratively to move the family forward as a unit. It is also
used to refer to the idea of working with the family within their
context (i.e school, home, extended family, community etc) rather
in isolation from these aspects.
Sometimes families become locked in patterns of managing which
can be inadvertently unhelpful to children and young people.
Thinking about the interdependency of the family members, even
when they may feel there is very little, and working with their
relationships, communications and behaviours is the essence of
systemic working. Helping a family understand how they function
in each of these domains and how that functioning may contribute
to or maintain their current diffculties can make a big difference
to a family.
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5.18 Working with children and families
Listen to the following podcast by Dr. Catherine Ford-Sori
on working with children and families. The podcast is
40 minutes long so make sure you have enough time.
Alternatively you might want to listen to it over several visits.
Make notes as you listen to the podcast and answer the
following questions.
What are the benefts of involving children in family
meetings?
When does Dr. Ford-Sori argue that it is better to meet
parents without the children?
What are the reasons from the research she discusses
that therapists gave for not involving children in
meetings
Write a summary in your portfolio about what you have learnt
from studying this podcast?
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There are a number of therapeutic approaches which have developed the idea of the family as a system and have created a range of ways of
describing families and methods for supporting them. Overall two broad approaches can be delineated:
The Modern approach - where the family therapist is seen as the expert who carries a unique understanding of the ways in which a
family should function best. The expert will offer interventions that encourage families to behave and interact in these ways in order to
resume adaptive functioning
The Post-Modern approach - where therapy is seen as a joint venture of discovery and is a collaborative approach between family and
therapist. The optimal style of functioning will be unique to the family and their circumstances. The role of the therapist is to discover
this optimal level with the family.
These are polarised positions and many therapists may practice somewhere between the two. Family therapy can be seen as offering
intervention based on the way in which proponents of a particular mode of family therapy understand and construct ways in which the family
functions. A few of the main theories are discussed in the section following the activity.
Structural Family Therapy developed by Salvador Minuchin, focuses on solving problems in the here now, rather than the past and is
concerned with problem solving. Structural Family Therapy regards normal families functioning through a set of clear rules and structures.
Problems arise in families when this structure becomes unsettled. The therapist approach is to be active - it aims to uncover dysfunctional
family systems and illuminate the problems therein. It may involve acting out diffcult situations through role play.
Strategic family therapy was inspired by the work of Milton Erickson, who worked with families, parts of families and individuals. Erickson
was known for developing a variety of techniques, some of which could be described as strategic. Major life events such as birth and death
require change of the family. Some families are more equipped to deal with these changes. Problems the family experienced represented
within an individual in the family, as if the person was carrying the family diffculty. The approach sees the family as having core problems
which bring them to therapy. The task of family therapy is to disrupt the patterns of perpetuating behaviours and use of solutions which have
previously failed. The therapist is seen as expert. The approach employs the following stages:
1 Detailed exploration of diffculties.
2 Strategic plan (or formulation) to address unhelpful interactions.
3 Delivery of strategic interventions homework for family.
4 Feedback regarding outcomes of strategies.
5 Reappraisal and continuation or revision of tasks.
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Brief Solution Focused Family Therapy - the name of this therapy indicates a
major aspect of the approach. There are usually between 5 and ten sessions in
this type of therapy. The focus is on the positive and identifying what works well.
It looks for exceptions to the problem, so questions might be about what things
are like when the problem does not occur. The therapists job is to help people
recognise that they have their own solutions to their own problems. The therapists
job is to help them recognise what these solutions are.
Narrative Family Therapy based on the work of Gregory Bateson one of the
important premises is that people make sense of their lives by recounting the story
of their experiences. Stories are informed by culture, religion, gender, social norms
and the family itself. Narrative therapies recognise that people and families are able
to make sense of their experiences by evolving and developing new stories about
themselves. Change is brought about by developing new narratives. Problems are
often externalized rather than being seen as belonging to a child or young person.
Problems are seen as outside and separate, something to be dealt with by the child
and family. The refecting team is an important part of narrative therapy, where
discussions about the family are aired openly in front of the family.
5.19 Podcast
Listen to the podcast on using Solution
Focused Therapy with blended families by
Tracey Ayers. In it she uses the analogy of the
starting a new job to help the family develop
strategies to work together.
How might this be useful in working with the
family you are working with?
Make notes in your portfolio on what you
have learnt.
5.20 Family Therapy
If you work in a service which has a family therapy service, discuss
with colleagues what type of family therapy is used and why?
What is the particular theoretical viewpoint which informs their work?
What are the basic tenets of this approach? How does this fit with
your own view of human behaviour?
Search for literature and find evidence which supports the use of the
family therapy approach. Write a summary of the evidence in your
portfolio.
Behavioural Family Therapy - initially used with young
people experiencing a psychosis. Usually involves
meeting the family for 12 to 20 sessions. The purpose of
the Therapy is to; provide Information to families about
psychosis, help the family recognise early signs, relapse
prevention and develop effective communication within
the family. It works on the premise that the emotional
climate in which the child lives has an effect on recovery.
The therapy involves a combination of education, goal
setting for each family member, video feedback on
how they are managing and the active collaborative
involvement of the family in the family sessions.
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Prescribing Medication for Children and Young People
Medication is used in CAMHS with some young people. It is essential that professionals working with young
people who are being prescribed medication are aware of the effects and side effects of such medication.
Children and young people receive a wide variety of medications; in this section we will cover three main types of medication Selective
Serotonin Reuptake Inhibitors, Typical and Atypical antipsychotics and neuro stimulant medication. Whenever a child or young person is
prescribed medication professionals working with them should make themselves aware of the nature of the effects and ill-effects of the
medication. Although this task usually falls to doctors and nurses, all CAMHS staff should have some knowledge of the effects. Medication
should never be the sole approach; it should be part of an intervention plan which includes education, psychosocial interventions and family
work. Children, young people and their families may have concerns about the prescription of medication. The purpose of the medication,
dosage, effects, side effects and treatment options should be discussed and agreement sought before prescribing medication.
SSRIs
Selective Serotonin Reuptake Inhibitors are used with children and young people experiencing depression, they include fuoxetine (brand
name Prozac), fuvoxamine (Faverin), and sertraline (Zoloft, Lustral). The only drug which is licensed for children and young people is
Fluoxetine and studies indicate this is the most effective SSRI (March et al 2004; 2006; 2007). Parents should be informed that the medication
can take two to four weeks to work, and that their child may have to take the medication for 4 to 6 months after the depression has lifted and
the dosage gradually reduced as the medication is withdrawn. There is some concern over the link between suicidal behaviour and SSRIs in
children and young people and the child or young person must be closely monitored if SSRIs are prescribed. Tricyclic antidepressants such
as amitryptiline are sometimes prescribed for depression, however there is general agreement that they should not be prescribed as their
effectiveness is no greater than placebo with children and young people (Hazell et al 2002; Kutcher 1997). Tricyclics also cause unpleasant
side effects such as dry mouth, sweating and constipation, and potentially fatal cardiovascular toxic effects (Birmaher et al 1998). They are also
very toxic when taken in overdose.
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Typical and Atypical Antipsychotic medication
First Generation antipsychotic (FGAs) and Second Generation Antipsychotics (SGAs) are both effective in the reduction of the positive
symptoms in Psychosis. FGAs are also known as Typical antipsychotics and SGAs known as Atypical antipsychotics. Medication needs to be
carefully and slowly introduced when used as a treatment with young people. Young people should start on a low dose, and small increases
made over time. Multiple drug use should be avoided. Concordance with drug treatment can be a problem, an approach which involves
working alongside the young person and not immediately focusing on medication is more likely to be successful. Medication choice should
be negotiated with the child, young person and family.
It is suggested the SGAs have an improved side effect profle from FGAs. However, some SGAs are more effective than others. Leucht et al
(2009) analysed 150 double blind studies trials. They found four of the SGAs (clozapine, olanzapine, amilsulpride, risperidone) were more
effective overall than FGAs. However there are differences in effcacy within the SGA group. Tyrer and Kendall (2009) concluded that the term
SGAs should be abandoned because the drugs as a group do not warrant the distinction. Despite this conclusion there is evidence that some
SGAs, are effective
Neuro stimulant medication
Methylphenidate and dexamfetamine are central nervous systems stimulants used in the treatment of Attention Defcit Hyperactivity Disorder
(ADHD). Medication is recommended as a frst line treatment for children with severe impairments but not mild to moderate impairments.
The medication does not cure ADHD; rather it makes the ADHD behaviours more manageable for the child or young person, while the
medication is present in the body. The short-term benefts of methylphenidate medication are supported by randomised control trials.
However, the long term benefts are less clear.
The medication should of course be negotiated with both parents and children, the most effective dose should be worked out after careful
consideration of the effect of the medication both at home and at school. The medication should only be given as part of a treatment
package which includes family, behavioural and psychological interventions. Monitoring should include blood pressure, pulse, height, weight
and growth (Jones and Claveirole 2011).
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5.21 Medication
Choose a drug from each of the above categories. Find
out the following:
The daily recommended dosage for children and
young people.
Common and less common side effects.
The frequency of administration.
Identify another drug treatment for ADHD.
When you have completed this activity, complete the
following table which outlines common categories of
medication used with children and young people. You
should complete the missing information an example
is given for Fluoxetine.
You should build up a portfolio of evidence, by copying
and pasting the table into your portfolio.
You should also review the evidence of the effectiveness
of these medications with children and young people.
National Prescribing Centre
Prescribing information
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Medication Name Brand
name
Mode of Action Dosage and
frequency
Contraindications Side effects Pharmacokinetic
Properties
Interactions
Antidepressants
SSRIs Fluoxetine Prozac
Acts by
blocking the
reuptake of
serotonin.
10mg
increased to
20mg over 3
weeks
Once a day
Renal or hepatic
insuffciency.
Poorly controlled
epilepsy.
Nausea,
General GI
symptoms,
headaches,
light-
headedness,
anxiety,
weight loss,
seizure, rash,
urticaria,
fever,
neuroleptic
malignant
syndrome.
Half life of 6 days
of fuoxetine, 16
days of active
metabolite
nurfuoxetine.
Increases
plasma levels of
carbamazepine,
phenytoin and
haloperidol.
Enhances effects
of warfarin.
Psychostimulants
Anxiolytics
Mood stabilisers
Antipsychotics
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Key Learning Points for Module 5
There are a number of different therapeutic approaches can be used with children and young
people. All these approaches require the practitioner to be trained and for ongoing supervision to
be embedded in any work.
CBT is an effective approach when used with children and young people for a number of mental
health problems.
CBT is not one entity; it is in reality an umbrella term for a range of specifc models adapted for
specifc problems and age ranges.
Parent Management Training is an effective intervention in a range of conditions and can have
additional ipact through shifting parents attributions.
Psychodynamic approaches while of longer duration than CBT approaches are an alternative
intervention, particularly with problems which are long standing.
Medication can be an effective approach to the treatment of children and young peoples
mental health problems. Medication should never be the sole approach; it should be part of an
intervention which includes education, psychosocial interventions and family work.
WebSite
The British Association for Behavioural and Cognitive Psychotherapies sets and maintains
national CBT standards and accredits formal CBT training programmes and individual
practitioners in the UK.
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