Dr Arnon Bentovim Hello, I am Arnon  Bentovim, a Child and Adolescent Psychiatrist,   and my presentation will be on “The  Evolution of Child and Adolescent   Mental Health Services from 1960 to 2010”  and influences on our practice today. I now want to come onto another important  stream that really began in the 1960s and   it’s very interesting that the development  of the Bateson project just before the 1960s   on understanding the way in which mental health  disorders can be associated with family context   and was not just a biological phenomenon, was  the identification of maltreatment in the 1960s. A key was the recognition of maltreatment,  was the publication in 1962 of Henry Kempe’s   “Battered Child Syndrome,” focusing the thinking  of child health practitioners worldwide. And   as the most recently appointed Consultant at  Great Ormond Street, I was given the task of   trying to understand the role of the “Battered  Child Syndrome” within a paediatric hospital. Henry Kempe described the identification of  different forms of maltreatment in a sequential   way, first describing physical abuse, burns,  fractures, bruising, a child deserving punishment   and the appearance of children with a whole  series of harmful inflicted forms of injuries. Another important description was the – was dis –  in neglect and failure to thrive. The unawareness   of the needs of the child and the failure to  give adequate nutrition, educational – education,   support, clothing, living in a context of  poverty, not necessarily associated with the   context. Emotional abuse, rejection, scapegoating,  perceiving the child as deserving criticism and   harshness, and then, of course, the awareness  that exposure to devi – of – to violence,   domestic violence and abuse, was a form  of harm equivalent to physical abuse. Sexual abuse, sexual interest and exploitation  of the child and young person was very much   described in the 70s and the – very much the  awareness of sexual abuse within the home,   exploitation and these forms of abuse which,  of course, is of current concern, of sexual   abuse online. The development of ideas that verbal  abuse, harsh criticism, bullying, victimisation,   might be seen as separate categories, and of  course, the more recent description of symptoms   falsified, factitious illness, Munchausen  by proxy, non-accidental poisoning. One of   the elements of a parent being with the child in  hospital all day was the importance for the parent   of having a child perceived as having an illness  state and the positive value for themselves. Epidemiological research has emphasised the  under-reporting, the unawareness of the degree   of physical, emotional harm to children and  young people and their long-term impact on   physical and mental health. The text, “The  Maltreated Child,” edited by Jan Carter,   was the text which we contributed to from our team  at Great Ormond Street and from our recognition   of children who’ve been maltreated, who’ve been  admitted without awareness. The centre is the   classical image of “The Battered Child” in the  Helfer and Kempe text, now, many, many additions   later, and the “Physical Signs of Child Abuse”  by Chris Hobbs and our colleagues from Leeds. I want to say something more about the recognition  and treatment of sexual abuse and this occurred in   the UK in 1981. Remember the gradual recognition  of different forms of abuse and neglect. So,   I was approached by Patricia Beezley Mrazek, who’d  worked with Henry Kempe and was doing an elective   year in the UK, and she said she’d like to do a  survey of professionals working with children,   to ask them how many children who’d been  sexually abused they were seeing. And indeed,   we noted that there was really quite an  incidence, perhaps three per thousand,   but it was being perceived as a  crime, not a child protection issue. Subsequently, Esther Rantzen, in TV programme  “That’s Life”, individuals who’d suffered   sexual abuse in silence, spoke about their  persisting traumatic experiences. Childline,   for children to be able to link, received 55,000  calls in the first year that it was established.  We were asked by some of the teams that we’d  surveyed in the earlier professional survey,   whether we would begin to see some children  with se – who’d been sexually abused that they   were seeing in their services. And we began  to establish a family and group treatment   and research programme at Great Ormond Street  Children in 1981, to diagnose and treat children,   male and female victims. And we began a group  programme for children and young people,   protective mothers and abusive young  people and even abusive parents. Eileen Vizard, our colleague, saw male  parents in the hospital boardroom and we   began to see groups of parents, and on a Thursday  evening, we would have a whole network of groups,   colleagues invited from other services to  come and work with us. And we really began   to see the way in which we could work  with and support children and families. We made a Horizon film, Prisoners of Incest,  in 1984, to demonstrate the approach in which   we could use a family systemic approach to  help begin to understand what had happened   in the family and begin to see whether  it was possible, even for individuals   who’d been imprisoned, to begin to work  therapeutically, to began to put right   and to deal with the trauma and process  of abuse within the family context. Research on treatments demonstrated the  effectiveness of a groups and family approach   and we published “Child Sexual Abuse Within the  Family Assessment and Treatment.” We contributed   to Patricia Beezley and Henry Kempe’s “Sexual  Abuse in the Family,” and we developed research   with the Institute of Child Health,  Elizabeth Monk, looking at the   effectiveness our – of our approach. So,  very significant development in the 1980s. Subsequently, there were developments of  young offender services acro – in the UK in   the 1990s and we did – were able to do some very  interesting research on what were the risk factors   for sexually harmful behaviour? And we were able  to do a cross-section study, with a large number   of young people, to look at factors which were  associated with the development of sexual harmful   behaviour, and we were able to do a significant  longitudinal study of children and young people   that we had treated at Great Ormond Street and  were able to follow them up into adult life.  And what we noted was that it was an exposure  to intra-familial violence was a significant   risk factor associated with rejecting –  rejection and neglect. Seeing a parent,   a mother being abused, and a violent –  treated violently, and a young person   who’s been sexually abused would develop a model  of violence themselves, sexual harmful behaviour. Young offenders services were established  in 1998, special schools, youth courts and   residential care, but in 1993, two vulnerable  11-year-olds were tried in an adult court for   the killing of James Bulger, a toddler. Children  were perceived as evil and devious, and even   though myself and Eileen Vizard had tried to tell  the court that these were vulnerable young people,   who had been highly traumatised by their actions  and were two individuals almost acting as a gang,   the children were perceived as evil and  devious. And attempts to change the age   of criminal responsibility so that ten and  11-year-olds were not perceived as criminal,   having criminal responsibility, has been firmly  resisted. And of course, there are pre-occupations   with gangs, knife crimes, bullying, children  who kill, but fortunately, this sight of two   young – of two children and young people going  to an adult court, beamed all over the world,   has had an impact and children are not  seen in adult courts to the same extent. Of course, there has been a significant public  recognition of child maltreatment over this   period. The tragic case of 1974 of Maria  Colwell, who was killed by her stepfather,   had a very significant public profile.  Social work professionals responsible for   child protection were harshly criticised,  but there – this led to the introduction   of a far more effective system, conference  system, working together, in 1973 and 1988,   where professions across Children’s Services  were helped to work across boundaries,   to work together. However, there have been 30  public inquiries since and the images Victoria   Climbie and Baby P had a very significant  impact on public awareness of maltreatment. Of course, the secrecy and threat associated  with sexual abuse made diagnosis complex and   challenging. In 1986, Paediatricians Christopher  Hobbs and Wynne introduced the observation of a   physical diagnosis of boys and girls, the physical  findings associated with sexual abuse. This had   a very significant influence on the Cleveland  Affair, which occurred in the summer of 1987,   which focused on two Paediatricians trained by  Chris Hobbs and Jane Wynne in the diagnosis of   sexual abuse and 100 children were removed from  families. The physical findings were fiercely   criticised as dubious, and an inquiry subsequently  highlighted the risk of professional intervention   on questionable grounds. The inquiry supported  the rights of parents and really had quite an   impact on those practitioners who were trying  to find a way to amplify the voice of a child. So, implicit in the narrative of overzealous  approaches to protect children was a criticism of   social welfare and the 1980s were characterised by  an increasing disillusionment, a rise in violence   and a decline in social discipline. An alternative  individualised concept of relationships and   market forces was advanced, shrinking the  state. The family was a private domain. The thinking underpinned the establishment  of The Children Act in 1989, stressing the   importance for families and establishing  criteria for children being at significant   risk to justify removal. At the same time,  the United Nations Convention on the Rights   of the Child was established to ensure that  services should be provided, children should   participate in society, have a voice and be  protected from violence and exploitation. From the 1990s to 2010, there was very much  a period of consolidation of mental health   services. The period was marked by the last  phase of Thatcherism, extending marsh – market   rationalities, focusing on the individual, rather  than governing through society. New Labour,   from 1997 to 2009, espoused a third way, combining  individualism and egalitarianism, personal   self-realisation, autonomy and membership and  community. But despite very significant investment   in this period, there was no full-scale attempt  to reduce social inequality. More than one million   children were lifted out of poverty, but the final  year saw the re-election of a Conservative-Liberal   Democratic coalition, with the introduction of  austerity and the reduction of public services. One of the important developments at that  time was the introduction of the Sure Start   Children’s Centres, which were established in  1999, which supported health, parenting support,   childcare and parental employment of families  with children under the age of five. By 2010,   there were over 3,000 Sure Start Centres, but  spending fell, centres closed, scaled back   and integrated into – currently into Family Hubs.  There was a greater access to Sure Start initially   and this increased hospital admissions of children  at the age of 12-months, presumably because of   increasing awareness of the harmful interactions  and relationships within families. But the   longer-term effect was the reduction of hospital  admissions in childhood and adolescence, positive   parenting and family relationships, particularly  having a large effect of boys in poorer areas. There was an important introduction  of a four-tiered framework of CAMHS,   Child and Adolescent Mental Health Services,  as a health service, replacing Child Guidance   in 1995. Tier one, early intervention and  prevention by schools, children’s centres,   Health Visitors, School Nurses, GPs, early health  and targeted services. Tier two, responding to   the generality of child guidance. Tier three,  specialised CAMHS, eating disorder services,   and tier four, inpatient provision. So, very  much revolutionising the approach to child and   adolescent mental health and perhaps beginning to  understand the child and adolescent mental health,   positive or negative, was a response to context.  Not a biological entity, but a vulnerability,   but responding to the context in which  children and young people were living in. By the 90s, child and adolescent  mental health had a much higher profile   in public and professional worlds. There were  more Academic Chairs, training, accreditation,   research developed across the fields and there  was tremendous on – tremendous development   of controlled trials of different  forms of mental health interventions. The NHS organisation, NICE, National  Institute of Clinical Excellence,   was established to recommend the most  effective approaches. And it’s important   to say that C – the CBT approaches I  described earlier, was in – was found   to be some of the most effective ways  of delivering mental health services. The IAPT, Improving Access  to Psychological Treatments,   Adult Services in 2008 and Children’s  Services in 2011. Mind-Ed training was   developed to complement the IAPT, online  training in emotional and behavioural first   aid and essential therapeutic skills across  the field of services who needed to develop   mental health skills to work with children and  young people seen across different services. I want to just describe one qualitative systemic  review that emerged from that period, which was   the use of art as a resource in recovery from the  impact of sexual abuse. And this is an example   of a qualitative systemic review, systematic  review, which developed over this period. Creative   activities, reducing stress, mood disturbances  and depression, artmaking can function as a   refuge or a distraction from intense emotions,  a state of being, meditation, mindfulness,   autonomy, living vividly in the present, sense of  self-strengthening on emerging from a flow state. There were 16 studies identified through a  systemic research protocol, and it showed,   across the field, that artmaking was a  voice for experiences that were silenced,   empowering, making new discoveries,  coherent self-narratives, integrating   dissociated aspects of experience.  Communication, countering secrecy,   private to self-communication to a more public  communication. And this gave an i – gives an   idea of the developing therapeutic approaches  which developed over this fer – over this frame. In 1989, there was the establishment of a gender  identity clinic at the Tavistock Clinic. There was   a growing number of children and young people who  raised significant doubts about their gender over   this period. We had always seen children and young  people who were uncertain. Boys who were attracted   by the femininity and the beauty and ways of  – feminine ways of being. Girls who very much   valued a more male identity, and we began – even  saw at the Children’s Hospital, children and young   people who had hormonal disorders which resulted  in a misassignment at birth and the emergence of a   different gender during adolescence. So, the whole  ways of working with children and young people,   helping them make a decision about whether  they wanted to transition to a different   gender or to a cer – or to see this as a passing  phase was an important element in our work. The service, developed by Domenico  Di Ceglie, grew exponentially.   Several thousand children and young people were  referred to the only service, and a deeply held   controversy emerged, whether the deeply held  wishes of young people should not be supported   and whether they should be helped to deal with  a phase until they reached adulthood, or should   there be respect for the emerging individuality  and autonomy of the young person to help   transitioning, rest prubi – puberty and help them  choose to take on the role of the opposite sex? This proved to be highly controversial and  a report by Hilary Cass, in recent years,   noted that the rapid increase in the number  of children requiring support and the complex   case mix meant that a model with a single  national provider was not sustainable.   She felt that we needed to know more about  the population and the outcomes and she was   concerned that there hadn’t been sufficient  routine or consistent data collection. She   felt that there was a lack of consensus and  open discussion about the nature of gender   dysphoria and therefore, about clinical  – appropriate clinical responses. The   design had not been subject to normal  quality controls and a whole range of   different outcomes is now being advocated,  and we’ll see how this works out in practice. I want to talk about an important development, the  Assessment Framework in 2000. So, the Assessment   Framework was the Framework for the Assessment  of Children in Need and their Families, and I   want to speak about the establishment of our own  Child and Family Training organisation in 2000. The Sieff Foundation, founded by Elizabeth  Sieff, in the name of her husband, Michael,   Founder of the – Manager of Marks & Spencer’s,  was founded in 1987, and this brought together   the tremendously valuably – valuable of  professionals concerned with the whole   question of children in need, of child  protection, from law, from medicine,   from social work, from government, to really look  at the issues. And there was a very significant   awareness that child protection was focusing far  too much on the event and not the context. It was   important to look at parenting, individual,  family and systemic and community influences. And there was an introduction of an ecosystemic  Assessment Framework in the Year 2000 and we   established Child and Family Training to develop  evidence approaches to help practitioners   across different fields, not just in  CAMHS, but in social care and education,   to work with this broad-based approach  to assessing children and families. The Triangle, the Framework, a map  of relevant data to be collected,   and you can see that there is a focus on  children’s developmental needs health,   education, emotional and behavioural development,  their identity, relationships, how they presented   themselves socially and self-care. And the  context of parenting care, safety, warmth,   stimulation, guidance, boundaries and stability.  And the family/environmental factors history,   functioning, the wider family, housing,  employment, income, social integration   and the resources in the community. A very broad  way of trying to understand the context that a   children was living in and when there was an  identification of concern about their harm. So, to help practitioners make an  evidence-based assessment of needs,   capacity in family, we developed a series of  tools and training across all Children’s Services,   the importance of broadening out mental  – child and adolescent mental health,   beyond CAMHS, to a whole range of practitioners  concerned with children and young people. So,   we developed the Family Pack of Questionnaires and  Scales, screening for emotional and behavioural   difficulties, providing in – evidence  for best interest planning for children,   questionnaires and scales for screening,  emotional and behavioural difficulties,   parenting problems. Economical and  effective ways of gathering information,   gauging children and parents, useful in monitoring  the effectness – effectiveness of interventions. So, you can see the list of tools here. Strengths  and difficulties, which looks at the range of   mental health responses for children and  young people. Parenting daily hassles,   the hassles of dealing with – or the everyday  problems of children and young people,   gives an idea about the degree of stress the  parents feel. The conditions of the home,   adult wellbeing, anxiety, depression have played  such an important role. The wellbeing of young   people, recent life questionnaires about events  that have happened, the lives of the family and   their ongoing impact, activities that families  are able to share with children and of course,   an alcohol scale. We found this quite difficult  to judge because we were all looking at our own   alcohol use and say, “Well, where are we on  this scale?” So, important set of stools which   were – tools which were made available across the  whole field of Children’s Services, so important. This is just an example of the Adolescent  Wellbeing Scale for children 11 to 16. You   can see how it works. “I look forward to things  as much as I did most of the time, sometimes,   never.” “I feel like crying most of the times,  sometimes, never.” “Get stomach aches, energy,   I enjoy my food.” We advocated that  practitioners need to sit with children,   doing – filling out this scale and then  go through it and say, “Well, you said you   felt like crying sometimes. Well, why is that?  What’s the situations which leads to that?” So,   very valuable ways of being able to  engage with children and young people. An important tool was the introduction of  The HOME Inventory, developed by colleagues,   Tony Cox, Stephen Pizzey, Stephen Walker, and  it’s a practice tool designed to support the   implementation of the Framework. Assessing the  quality of parenting in the home environment,   a one-hour, semi-structured interview in  the home, assessing all aspects of the home   environment, the nature of children’s day-to-day  experiencing, parenting capacity, other aspects   of the child’s world, and available for children  at different age groups and for disabled children. And I’m going to show you an example from  our training videos about – which introduces   the HOME assessment of the environment. And  it’s about a family, and these are actors,   child and parent – adult actors, so they don’t  have the same concern about confidentiality.   It’s based on one of our cases, but they – and  we gave them some ideas about the issues. And   they developed the script from their – from having  done family roleplays, the, sort of, ways which we   had trained ourselves in family therapy, we used  as a way of getting the family into action with   these adults and child actors. And this is the  family of Michael, and you can see his mother,   Moira, sitting next to him, Ian, his stepfather  on the right, and Laura, his older sister. And the con – and so, let’s play you  this video and you’ll hear about the   family and see the interview in action by  Professor Antony Cox, Tony, in the interview,   who initiated this 24-hour clock way of looking  at the experiences of children and families   through directly examining what actually  happened yesterday, what’s happening today. [Video commences] Moira Ward [Walks to stairs] What  are you sitting out here for, Mike? Michael Ward [Curled up] Nothing. Moira Ward [Sits down] What’s the matter? Michael Ward [Pushes mum away] I don’t want… Narrator Meet our first family, the Wards. Moira Ward [Puts hand on Michael’s  forehead] Are you feeling alright? Michael Ward [Turns away] Yeah, leave me alone. Narrator Social Services have  been asked to see mother, Moira,   and Michael, because of the  school’s recent concerns… Moira Ward If you don’t tell me what’s  wrong, I’m not going to know, am I? Narrator …over his persistent  lateness, his anxious behaviour… Moira Ward Yeah? Narrator …and his exhausted  and neglected appearance. Michael Ward I miss my dad. I miss him.. Narrator The family consists of Moira… Moira Ward I know, but things change, don’t they? Michael Ward [Closes his eyes]. Ian What time did you get home last night? Laura Ward Does it matter? It doesn’t matter. Narrator …her new partner, Ian… Ian Tell me what time. Laura Ward It’s nothing to do with you. Narrator …and Michael’s  14-year-old sister, Laura. Ian What time did you get home? Laura Ward Half past 11 [music]. Professor Antony Cox You may  remember when I came last week,   it was – I’d come because the  school were bothered about Michael,   but actually, you seemed to be much  more concerned about Laura, I remember. Moira Ward Well, yeah, she’s the one  giving me all the trouble, but that… Narrator As you watch… Moira Ward There’s nothing wrong with Michael. Narrator …try to score as many items as possible… Moira Ward I don’t see  what all the fuss is about. Narrator …on the Middle Childhood Inventory. Professor Antony Cox Well, I think nevertheless… Narrator The glossary in The HOME manual… Professor Antony Cox …because the school’s… Narrator …contains detailed notes… Professor Antony Cox Well, I know… Narrator …for scoring individual items… Professor Antony Cox …how  you feel about it and clearly… Narrator …in each subscale. Professor Antony Cox …we need to  pay attention to that. But because   the school have expressed this concern,  I think we’ve got to try and understand   Michael’s situation a bit more.  It – are you expecting him back? Moira Ward Well, yeah, he should be home  by now. Just running a bit late, I suppose. Professor Antony Cox What I think I  also said to you was that a helpful   way of trying to understand what’s happening  for you and the family is to go through a,   sort of, fairly typical  school day. So, if we think   about today is Thursday, what about yesterday? Moira Ward What, like what did I do and that? Professor Antony Cox Well, was it a, sort  of, fairly ordinary [bang] school day, really? Moira Ward Well, yeah [Michael walks in]. Hello. Michael Ward Hello [drops bag on floor]. Moira Ward This is Tony. Do you  remember I said he was coming? Michael Ward Yeah. Professor Antony Cox Hello, Michael. Michael Ward [Throws coat on floor] Hello. Moira Ward Don’t leave your bag  there. Someone’s going to trip on it. Michael Ward Hmmm hmm [picks bag up]. Moira Ward Don’t throw your coat down. Hey,  hold on a minute, what have you done to your top? Michael Ward [Looks at arm]  I’ve got a bit of dirt on it. Moira Ward God, the state of you. Michael Ward [Takes drink from fridge]. Moira Ward Come and sit down. Michael Ward Going to watch  TV. I want to go and watch TV. Moira Ward Come and sit down a minute, I said. Michael Ward Alright [sits at table]. Professor Antony Cox So, Michael, the  school say you’re pretty hot on computers. Michael Ward Yeah. Professor Antony Cox Is that right? Michael Ward [Nods head]. Professor Antony Cox So,  what do you think about that? Moira Ward Yeah, he’s really good.  I mean, he loves it, don’t you? Michael Ward [Nods head]. Moira Ward I mean, Ian tries to get  him to play football and all that, but… Professor Antony Cox Hmmm. Moira Ward …you’re not really built  as a footballer, are you, Mike? Michael Ward [Shakes head]. Professor Antony Cox So, just remind  me, how long have you been here now? Moira Ward About 15 months.  So, we did this Council swap,   ‘cause I didn’t want any  reminders of Gary, you know. Professor Antony Cox Right. Moira Ward And we came down to live here  and Ian moved in about, well, a year ago now. Michael Ward February the 19th. Professor Antony Cox Gosh, you’ve  got a good memory, haven’t you? Moira Ward My little brainbox, aren’t you? Professor Antony Cox Yes. So, let’s think  about yesterday. How did the day start? Moira Ward Well, Ian got up, went to work. Professor Antony Cox Just a moment, did  you hear him wake – did you hear him get up? Moira Ward Me, no. Professor Antony Cox Really?  What about you, did you…? Michael Ward I heard him have  a go at Laura in the bathroom. Moira Ward Hmmm, they’re  always arguing, him and Laura. Professor Antony Cox What sort of time was that? Michael Ward 7 o’clock. Professor Antony Cox Right,  and what, in fact, woke you up? Moira Ward Well… Michael Ward I woke you up. Moira Ward Yeah, Michael woke me up yesterday. Professor Antony Cox Right. Moira Ward I was a bit  tired, you know, overslept. Professor Antony Cox Hmmm, have  you been having a hard time? Moira Ward Well, yeah, I’m  just tired lately, you know. Professor Antony Cox Really? Hmmm. So, how often  has that happened this last week that he’s…? Moira Ward Hmmm, well, it’s just this  week I’ve been oversleeping, you know. Professor Antony Cox Right. So, what happened  about breakfast and having something to eat? Moira Ward Well, he’s nearly nine. He  went downstairs and got his own breakfast. Professor Antony Cox I see,  and what do you have, Michael? Michael Ward Yesterday I had a bun. Moira Ward A bun for breakfast? Michael Ward Yeah. Moira Ward Well, that’s no good for  you. What about cereal or something? Michael Ward There weren’t  none. I told you to get some. Moira Ward Got – Michael,  you’re old enough to know. Michael Ward Yeah, I know, but I told  you to get some with the shopping. Moira Ward Right, I’ll get some. Professor Antony Cox So, what were you  doing when he was having his breakfast? Moira Ward Well, I was getting  rea – myself ready, you know. Professor Antony Cox Right.  Where was Laura at this time? Moira Ward Oh, she’d gone by then. Professor Antony Cox Had she? Moira Ward Yeah. Professor Antony Cox Right, I see.  So, what? I was trying to think,   ‘cause he heard them about seven and then, he  came to you about half past seven and then,   what sort of time would she have gone off? Moira Ward Well, about… Michael Ward [Struggles to open drink]. Moira Ward She was gone when I got up, so, like… Professor Antony Cox Right. Moira Ward …couple of minutes before that. Professor Antony Cox Right, I see.  Okay, so I’m just trying to get the   picture. There he is, he’s having his bun,  you’re getting dressed. What happens next? Moira Ward Well, I came down, made a cup of  tea and we watched a bit of telly, didn’t we? Michael Ward Yeah. Moira Ward And then, I had to  remind him to get ready for school. Professor Antony Cox Right, so what happened? Moira Ward ‘Cause he takes  a – for ages, don’t you? Michael Ward Hmmm hmm, only  ‘cause I can’t find any clothes. Moira Ward I think he’s old  enough to get his own clothes,   right, and Ian agrees with me. In fact, it was  Ian’s idea. Now, he went upstairs, he couldn’t   find any clothes. Shouting down at me and I’m  trying to watch, it’s the game bit, you know? Professor Antony Cox What about  washing, did you wash yesterday? Michael Ward [Rubs eyes] Hmmm. Professor Antony Cox What happens about  that? You say he’s expected to do things? Moira Ward Yeah, I mean, he’s nearly  nine. He’s able to wash himself. Professor Antony Cox Right. Moira Ward I mean, I can’t do  everything. That’s probably why   I’m so tired, running after you all the time. Professor Antony Cox You’re saying  he’s expected to do quite a bit now,   so thinking about his room, is  he expected to keep that tidy? Moira Ward Uh-huh, well, I ain’t  touching it, it’s a right tip. Professor Antony Cox Right. Do  you ever go in and sort it out? Moira Ward Well, no, I mean,  it’s Michael’s room, innit? Michael Ward [Clears throat]. Moira Ward He’s old enough  to be doing it himself now. Professor Antony Cox So, what about  making the bed, that sort of thing? Moira Ward Well, you only have to  lift the quilt and shake it. I mean… Professor Antony Cox Right, so… Moira Ward …he’s able to do that. Professor Antony Cox So, did  you do that yesterday, Michael? Michael Ward No, I don’t usually do it. Moira Ward Well, he just does it before   he goes to bed. Professor Antony Cox Right. So,   actually getting him organised for  school was a bit of a hassle, really? Moira Ward Well, he’s meant to do it himself,   but I have to remind him and  hurry him along, you know. Professor Antony Cox Right. Moira Ward So, it’s like I’m doing it anyway. Professor Antony Cox Right. So, how much  does he get under your skin over that? I mean,   did he get to the point of shouting yesterday? Moira Ward Well, yeah, because, like,  he’s always late and that and they’re   always complaining, trying to  give him detention and stuff. Professor Antony Cox So, how many times this last   week have you – has he got  you to that sort of pitch? Moira Ward Well, every day  he’s been – well, I mean,   I don’t know what’s wrong with us this  week. He’s been running late every day. Professor Antony Cox So, when did you actually  – when did he actually get off yesterday? Moira Ward Half eight was it, Mike? Michael Ward Hmmm, 20 to. Moira Ward 20 to. Professor Antony Cox So,   when you got into school, what happened then? Michael Ward We had to sign  the late book, then I went… Moira Ward Again. Michael Ward Hmmm, again, then I  went to class and the Teacher had   a little moan saying how I’ve been  late, and then, I just, sort of… Moira Ward I mean, he’s… Michael Ward …just sat down. Moira Ward …always late and it’s  not my fault because he should get… Professor Antony Cox No. Moira Ward …his stuff ready the night before. Professor Antony Cox Hmmm. Moira Ward So, he’s late for school,  the school get onto me and it… Michael Ward Ian. Moira Ward Michael, you know, you’re really  going to get it if you don’t buck your ideas up. Professor Antony Cox So, what do  you mean when you say ‘get it’? Moira Ward He’ll get a really good telling off. Michael Ward He hits me. Professor Antony Cox Hits you? Moira Ward Well, he doesn’t hit him hard. Professor Antony Cox What, Ian? Moira Ward Well, yeah, it’s just  like a little smack on the back   of the legs or something, you  know, just disciplining him. Professor Antony Cox And how often  is that sort of thing happening? Moira Ward Well, a lot lately. I mean,  what with all the letters and that,   it winds Ian up, you know, and then he’s  – he has a word with Michael. I mean,   because we have to knock it on the  head now. We have to discipline… Michael Ward Mum, I want… Moira Ward …him now. Michael Ward …something to eat. Professor Antony Cox So, when was the last time   that he actually gave him a  clip for this sort of thing? Michael Ward Sunday. Professor Antony Cox So, what was that all about? Michael Ward I wanted to go out. Moira Ward He wanted to go out,   right, but he’s always late for school  and we know he’s always late for school,   so he was grounded and he wasn’t allowed out. Professor Antony Cox Right, so it was to do with  school, but he wasn’t being allowed out for…? Moira Ward Yeah, and he – Michael starts pulling… Michael Ward I’m hungry. Moira Ward …funny faces and then,  Ian thinks that’s being cheeky,   so he gives him a clip. I mean,  he don’t hurt him or nothing. Professor Antony Cox So, what was  – what were you doing at that time? Moira Ward Well, I just  couldn’t stand it anymore. Michael Ward I’m hungry. Moira Ward I mean, it was really  building up in my head and I just – like,   Ian’s standing there, Michael’s standing… Michael Ward Mum. Moira Ward …there and I just sat down  in this chair, here, and I just lost it. Michael Ward I’m hungry. Moira Ward I started  crying. I couldn’t handle it. Michael Ward I’m hungry… Professor Antony Cox So, it’s… Michael Ward …mum. Professor Antony Cox So, it’s pre… Moira Ward And I felt so much  better afterwards, do you know? Professor Antony Cox Hmmm. Moira Ward Just to let it out. Michael Ward Hmmm. Professor Antony Cox So, how often have you  had something like that in this last month? Moira Ward Well, all the time. Professor Antony Cox What, like every day, or…? Moira Ward No, not every day, but  I don’t know, often, quite a lot. Professor Antony Cox Hmmm, like every  weekend or two or three times a week, or…? Moira Ward Yeah, I’d say  two or three times a week,   but it’s – you know, we’re going to sort it out. Professor Antony Cox Right, well, that’s  one of the reasons you know why I’ve come,   to see whether there’s anything we can do to help. Moira Ward Hmmm hmm. Professor Antony Cox Hmmm. Moira Ward Do you fancy a cup of tea? Professor Antony Cox Well, I  would. Yes, that would be nice. Moira Ward Yeah. Professor Antony Cox Do you think  while you’re doing that it’d be okay   if Michael showed me his room and  his things? Would that be alright? Moira Ward You’re brave. You want to go in that… Professor Antony Cox Right. Moira Ward …tip? Professor Antony Cox Right,  come on Michael, let’s have… Michael Ward Okay. Professor Antony Cox …a go. [Video ends] Dr Arnon Bentovim   This video, brilliant interview by Antony Cox,  who’s a real master of interviewing, demonstrates   a degree of Mi – the neglect of Michael’s  care, no breakfast cereals, no clean clothes,   there is hitting and there are also moments  of warmth. Further interviews establishes the   degree of family tension, episode of domestic  violence, conflict with Ian, concerns about   Moira’s drinking expressed by Laura, who spends  a lot of time out of the house with friends.  A crisis occurred during the assessment  process, Michael found wandering the streets,   following a harsh punishment by Ian when  he brought a letter from school concerned   about his continuing lateness and an emergency  placement was arranged. But the idea, you can see,   of an initial interview, when there’s concern  about a child expressed, an interview in the home,   looking at the, literally, the last 24 hours,  really brings forth the elements of relationships   within the family, which enables the  practitioner to be able to intervene. The other tool which I want to mention is  The Family Assessment, based on the work   that we did at the Institute of Child Health,  which Liza Bingley Miller and myself developed   in 2002. And this features a systematic,  evidence-based approach to assessing family   life and relationships, including family  dynamics, family adaptability, parenting,   how families communicate, handle feelings, relate,  approach crucial issues of identity and of course,   looks at the impact of family history.  And it provides a model of understanding,   describing and assessing family strengths  and difficulties in family competencies,   adaptable to a – suit a range of purposes and  again, a range of professionals trained across   the field of social care, well, in child and  adolescent mental health, residential treatments,   offending. A whole range of contexts where  a family assessment is a valuable component   to an overall holistic assessment. Giving all  families a voice and promotes reflective practice. So, I’m going to show an interview that I  carried out with a family, the Fletcher family,   which included Ray, the father, in the middle,  June. Concern about David, sitting on the left,   with extremely disruptive behaviour, and  Michaela, the nine-year-old, very much a   provocateur, and Paul on the right-hand side,  who we’ll see has a, very much, a parenting,   caring role. And mother has, for some months,  had a problem of a neurodevelopmental condition   herself, which needs a lot of support, but where  there’s a lot of concern about its nature. So,   I’ll show you this video because  this gives a contrasting tool,   which we trained, a Family Assessment verse  the – versus the parenting assessment. [Video commences] Michaela Fletcher What are you looking at? David Fletcher You. Ray Fletcher Pack it in,  will you? I’m fed up with it. David Fletcher What? Narrator So, let’s look in detail  at our first family, the Fletchers. David Fletcher So, what? I… Ray Fletcher I said leave it, now. David Fletcher Not doing anything. Narrator The family consists of Ray… Ray Fletcher The pair of you. Narrator …a self-employed Builder, daughter,  Michaela, who’s nine and 12-year-old David. The   third child, Paul, is 14. Mrs Fletcher, June,  has been using a wheelchair for the last six   months. She suffers from fibromyalgia, a  painful muscular condition, associated in   some cases with depression. June has asked her  Social Worker from the local Disability Team… Ray Fletcher Are you coming? Narrator …for help with David. David Fletcher [Shakes head] No. Narrator She’s been called  into school because he’s   started truanting and getting  into serious fights. At home,   he’s become stroppy and uncommunicative [music]. Dr Arnon Bentovim What we’ll be doing this   morning is a number of different things.  I’m going to talk about the, sort of,   problems, the way they’ve developed, what  the concerns are, trying to understand... Narrator Having got the Fletchers altogether… Dr Arnon Bentovim I’m also  going to spend a bit of time… Narrator …and explained the  purpose of the assessment… Dr Arnon Bentovim …to find out how... Narrator …the most useful next  step is likely to be exploring… Dr Arnon Bentovim We’ll also ask  you to done one or two things… Narrator …the problem that’s brought them here. Dr Arnon Bentovim …together, as well as talking. Narrator At this stage, we’re trying to find out… Dr Arnon Bentovim We’ll be talking about... Narrator …exactly what’s considered… Dr Arnon Bentovim …[inaudible – 4545]. Narrator …a problem, by whom… Dr Arnon Bentovim And then,  we’ll see you every week and… Narrator …and what sequence  of events or behaviour… Dr Arnon Bentovim …what you saw… Narrator …typically underlies it. Dr Arnon Bentovim …and who causes problems. Narrator Look out for a pattern in the  way the family tackles the questions. Dr Arnon Bentovim Is that yourself, David, or  Paul, who did people get worried about first? June Fletcher David. Dr Arnon Bentovim About yourself,   David, and do you know what worries did –  got reported about you, then, do you know? David Fletcher Teacher says that  I was truanting and fighting. Dr Arnon Bentovim You were  truanting and fighting, right,   and how long ago was that, then, that  they first realised this was happening? David Fletcher About six or seven months ago. Dr Arnon Bentovim Right, ‘cause do  you think they’d have said this is   a guy who’s very good at truanting and  fighting, or would they have said, no,   he used to be pretty reasonable in school  and used to be there pretty regularly? David Fletcher Don’t know. They  wouldn’t let me in the meetings. Dr Arnon Bentovim They wouldn’t let you in  the meetings, but do you think if I was talking   to your Teacher and I said, “Well, is David  somebody who used to do quite well at school,   did he used to, you know, be there  usually, get on with people?” David Fletcher Yeah, probably. Dr Arnon Bentovim Is that right? Would that  be correct? And what do you think, Mr Fletcher,   have things gone reasonably well, still difficult,  from your perspective, as David’s father? Ray Fletcher I don’t think that it’s as  big a problem as people are making it out. Dr Arnon Bentovim I see,  so you’re not so sure, so…? Ray Fletcher I think they’re making it  all ten times worse than it actually is. Dr Arnon Bentovim I mean, has anybody   else in this family been truanting or  got involved in fighting? Who’s next…? Ray Fletcher Well, I used to be  near enough the same at one point. Dr Arnon Bentovim I see, so you think this  is a, sort of, what, passing phase and…? Ray Fletcher Yeah, did – I mean,  didn’t you truant or anything? Dr Arnon Bentovim So, you’re a bit concerned  that they’re making too much of this? Ray Fletcher Yeah, and I think  they’re making it ten times worse. Dr Arnon Bentovim And I understand, Paul, there  have been some concerns about yourself and being   at school, too. Is that right? Paul Fletcher [Nods head]. Dr Arnon Bentovim Do you  want to – what’s come up? Paul Fletcher Well, it’s just that I think  right now, that mum needs me in the house   and she needs me there for her, you know. She’s  very dependent and she has – she’s not capable   of doing what a woman should do around the  house, doing – just going to the toilet,   she’s not capable. She’s dependent on me  and I think that she needs me in the home. Dr Arnon Bentovim Yeah, well, I’m sure  that’s very helpful, but do you think if   I asked mum would she really prefer you to be  at school, what do you think she would say? Paul Fletcher She probably  would prefer me to be at school,   but I would like to be at home. I feel safer  when I’m with her and I know that she’s safe. Dr Arnon Bentovim Okay. What’s your opinion about  this, Mr Fletcher? What do you think about it? Ray Fletcher Well, I think  he should be at school. June   obviously doesn’t do half what she can do. Dr Arnon Bentovim Right, right. Ray Fletcher It’s like she’s given up. Narrator As the interview progresses, a pattern  within the family is already beginning to emerge. Dr Arnon Bentovim What’s your opinion,  Mrs Fletcher, because I don’t know how much   the children really understand about your  problems with all – I mean, obviously,   we may need to have a separate discussion, but  what do you think they understand is the reason   that you’re having to use a wheelchair  and are quite disabled at the moment? June Fletcher I don’t think they  understand at all, least of all Ray. Dr Arnon Bentovim Hmmm. June Fletcher I think Paul’s the only  one that makes the effort to understand. Dr Arnon Bentovim Yes [David and Michaela  look at each other]. So, if I asked him   what he thought the problem was, you think he’d  probably have the best idea and understanding? June Fletcher Yeah. Dr Arnon Bentovim So, what do think…? Narrator The pattern of family interaction that   triggers David’s truanting and oppositional  behaviour is repeated again and again. Dr Arnon Bentovim When it gets really  difficult and out of hand at home… Michaela Fletcher [Looks at David]. Dr Arnon Bentovim …how does it usually begin? June Fletcher [Sighs] Generally,  with Michaela winding up David. Michaela Fletcher Huh [shrugs]. Dr Arnon Bentovim And what way do you think  she – what way does she wind you up, David? David Fletcher She calls me stupid. Michaela Fletcher Liar. David Fletcher Don’t call me a liar. Michaela Fletcher ‘Cause you are. Paul Fletcher And can you just stop? David Fletcher I’d like to  shove my fist down your throat. Ray Fletcher Oi. Paul Fletcher [Shakes head]. Dr Arnon Bentovim So, what happens  when Paul tries to come – to, you now,   to come in and try to calm the situation  down? What happens between you and he? David Fletcher Just makes it worse, then  it gets into a fight between me and him. Dr Arnon Bentovim And you two have a fight? Paul Fletcher Well, yeah, starts off I try  and talk to him and reason with him and just… David Fletcher Yeah, right, then you just throw… Paul Fletcher …try and tell him to… David Fletcher …threw your fists around. June Fletcher David. Paul Fletcher …quieten down  a bit and it never works. So… Narrator It shows itself in the  way the Fletchers answer questions. Ray Fletcher And I’ve just given up. Narrator In the way they  communicate. In how they align… Ray Fletcher I tell them,  they behave when I tell them. Narrator …with or against each other. Ray Fletcher I can’t see there’s a problem. Dr Arnon Bentovim Hmmm, yeah. Ray Fletcher I tell ‘em to do something  and they’re normally quite good. Dr Arnon Bentovim So, how does that make you  feel when Ray says, “I don’t have a problem”? June Fletcher He doesn’t have a problem  ‘cause he’s never around when it goes on. Dr Arnon Bentovim Hmmm. June Fletcher And the kids  behave differently around him. Dr Arnon Bentovim Hmmm hmm. Ray Fletcher Why? June Fletcher It’s nothing to do with how I talk  to him. It’s nothing to do with how I talk to them   or how I discipline them. It’s the kids knowing  they can get away with murder with their dad. Ray Fletcher But they don’t. June Fletcher They do. Ray Fletcher They behave in front of  me, so why do they misbehave for you? June Fletcher No, fine. Dr Arnon Bentovim Hmmm. [Video ends] Dr Arnon Bentovim And I hope you note that I was  using some of the ways of working with the family   that I described earlier, circular questions  and, “What would happen? What does your dad   think? What do you – what does your mum think  about this?” to really try to get an idea of   what’s going on in the family, and the, sort of,  family that you – interaction that you noted. We   find it very helpful to make a systemic model to  understand what’s actually happening and also, to   think about what’s going to happen if things don’t  change in the family and where we can intervene. So, of course, what we’ve seen here, looking  at hea – children’s health and development,   David is angry, oppositional at home and at  school, truanting, fighting, failing. Paul,   bright, academic, not attending  school, focused on maternal care,   oppositional with his dad. Michaela,  quite neglected, angry, provocative,   high level of sibling and child-parent conflict.  Precipitating trigger factors, mother’s persistent   disability, physical and psychological factors,  evoking a caring, supportive role from Paul,   sceptical and critical by dad. Significant  parental conflict, failing care, emotional   support and conflict, which is reflected in  David’s angry, oppositional behaviour at home   and school. Predisposing factors, both parents had  to deal with highly stressful events in their own   childhood, the loss of paternal grandfather and  maternal grandfathers. Both taking on parental   responsibility, but father a model of oppositional  and rebellious responses and mother, a caring. So, it looks as though, looking at what’s –  what are the harmful maintaining factors? Well,   obviously, there’s continuing uncertainty  about the nature of mother’s disability,   capacities and her needs. Expectations  that children care for parents, as she did,   paternal expectations that children will rebel  following loss, and the failures of the parents   to adjust to mother’s maternal disability  reflected in the angry/caring responses of   the children, sibling conflict, lack of  support, maintaining harmful alliances. We always ask, what are the protective factors?  Well, the parents did survive and overcome major   stressful events. They have – there’s a  history of good care, emotional support,   and educational support and her capacities  to relate, control and manage the children. But what’s clear is that if the pattern continues,  there’s a risk of David developing a conduct   disorder, educational failures for David and  Paul and Michaela’s increasing opposition. So,   from this, we obviously, need to develop a  therapeutic plan, but that’s an idea of how   the different elements, the different approaches  that we took, the different tools to assess,   can actually help begin to formulate  an understanding of family profile   and give one a platform to begin  to develop a treatment approach. We found it very helpful in developing this  work to develop an Assessment and an Analysis   Framework, myself and Stephen Pizzey,  to look at the nature and level of harm,   the risks of re-abuse and the prospects of  successful intervention. We found it very   helpful to develop a seven-stage model of  assessment, analysis and intervention and   published this approach in the text, which  are illustrated, identifying harm, assessing   children’s family needs, the nature and level of  harm, harmful effects, a safeguarding analysis,   what are the risks, likelihood of future  harm? Developing a plan of intervention,   rehabilitation for the child, for example, the  work with the Ward family that you saw earlier,   when Michael had to be separated, what would  be the criteria to return? Rehabilitation,   of the child, moving on, placement of children  when rehabilitation isn’t possible. So,   we try to develop, using the tools, a  model of, really, how – of assessment. And an important theme, of course, is the  communicating with children. And I want to   introduce a tool we introduced, communicating  with children, In My Shoes. A computer assisted   interview for communicating with children and  vulnerable adults, developed by Rachel Calam,   Antony Cox, who we’ve already heard about, and  my colleagues, David Glasgow and Phil Jimmieson   and Sheila Growth Larsen. So, the aim of the In My  Shoes interview is particularly developed to help   professionals talk with children about traumatic  experiences, abuse, neglect, separation and loss.   But it needs a broad-based assessment of  the child’s experiences in their family,   school and elsewhere and their thoughts, feelings  and wishes. Very useful with young or vulnerable   or disabled children, who are often familiar with  laptops, interviewer sitting alongside the child. There’s a whole range of facets, standard symbols  to help children communicate, people, situations,   emotions, thoughts, messages, places, and  you can see the way in which children can   develop a narrative and a conversation using  these images. This is just an example of a   family and the images can be adjusted to the  ethnic context that the child has grown up in,   or the child’s identity. And you can see that  this is a way in which the child can say, “Who’s   in your family?” and the child can pick out the  individuals in the family to make up their family. Then, of course, there’s the emotions.  So, here’s an example of a child on the   swing and you can see the facial  emotion and the child can pick out   from the palette of emotions to say how  they feel about a particular activity. Obviously, very important is the  whole phase of being hurt, harmed,   and you can see here a palette for painful  events, and these are all images which   children have developed themselves to display  how hurt feels, and you can see in – and where   hurt feels and you can see the face and the  feet on the right-hand side. And here’s an   example of a seven-year-old girl suffering from  neglect and you can see here she’s indicated,   “My mum tied me in her dressing gown,” and you  can see the images that they – she’s used to   describe her experiences. And you can have a  throb rating for each of these experiences. Here's another somatic experiences described by a  boy, “Wizzered by Sam.” “Punched at school.” “Wee   started burning.” “Fell on barbed wire.” “Mum  trapped my toe in the kitchen.” “I was hurt   by Sam.” And you can see the indication in the  anal area. Now, this is – this could be Michael.   “Ian kicked me when I kept missing the ball in  football,” and you can see the image of being   kicked. And “When the letter came from school,”  being hit across the – hit across his leg. So, the advantages of a computer medium  in communicating with children and young   people. There’s a clear structural framework.  It’s novel and very appealing, motivating,   gathering information about children’s  experiences. An external focus for attention,   looking together rather than face-to-face.  Controllability of the pacing, empowering,   tamper-proof records, so  you can record the images. Jenny Gray and I organised a conference in 2012 to  recognise the 50th anniversary since Henry Kempe   described child maltreatment. The conference  was called, “Eradicating Child Maltreatment   Evidence-based Approaches to Prevention and  Intervention Across Services.” And you can   see a list of the sort of themes we discussed,  the “Burdensome Consequences of Maltreatment,”   “The Role of Health Services.” Jane Barlow  “Preventing Abuse Getting it Right from the   Start.” Ron Prinz describing “Triple P, the Public  Health Approaches,” used once at University of   Carolina. Bruce Chorpita, the “Development and  Design in the Service Systems.” Our own “Hope   for Children and Family Resources,” which we  developed. “Child Sexual Abuse The Possibility   of Prevention,” and a review. So, we tried to  bring together our thinking about the field. I want to extend this discussion about adverse  experiences to talk about the description of   Adverse Childhood Experiences, a parallel  development to the Assessment Framework,   which I’ve already looked at. Vincent Felitti, in  2000 – 1998, defined forms of Adverse Childhood   Experiences, and what his team did was to describe  the forms of maltreatment emotional, physical,   sexual abuse, emotional neglect, treatment and  violence, together with household dysfunction,   household substance abuse, mental health,  incarcerated household member and parental   separation or divorce. And the more ACEs reported  by more than 17,000 individuals in the USA,   there’s – the more significant  their subsequent health as adults,   their greater the risk of  health-harming behaviour. The image just describes the different forms  of adverse experiences and their way they’re   linked to health issues. ACEs is noted to be a  cumulative risk score across multiple domains   and generations. Lead to an elevated risk, require  significant adaptation and is a cumulative risk   score. So, you can see childhood adversities  abuse and neglect, related stressors in the home,   result in adolescent early initiation of substance  abuse, suicidality, pregnancy and mental health   problems, sexual risk behaviours. Adult outcomes  chronic diseases, substance abuse, obesity, STD,   HIV risk, sexual risk behaviours, mental health,  suicidality, emotional dysregulation and of   course, the impact on parenting and the next gen  – reprise of the next generation with childhood. This model has had an enormous influence  in the huge research looking at how   childhood experiences can affect adult  functioning. Highly controversial,   but a very interesting and challenging field. And  of course, there’s been a significant awareness   that Adverse Childhood Experiences are related  to Adverse Community Environments poverty,   discrimination, disruption, violence, housing,  and the – again, it’s the maternal depression,   substance abuse, physical/emotional  neglect, homelessness and so on. So,   a tremendous development of the field of  adversity, Adverse Childhood Experiences   and Adverse Community Environments. And of course,  the tremendous increase in mental health problems,   over recent years, very much associated  with the COVID as a very significant form   of adverse experience in the life of  children and families, has had a very   significant impact. Again, the whole notion  of mental health as a response to adversity,   depending on vulnerability, genetic factors,  again, demonstrated through this development. A very important piece of research  from the Maudsley, Andrea Danese   and colleagues, has been the longitudinal study of  trauma exposed individuals. The longitudinal study   looked at the exposure to victimisations  at the age of five, seven, ten and 12,   in a longitudinal study. Cumulative information  was gathered exposure to domestic violence,   bullying, physical abuse, sexual abuse, emotional  abuse, and positive mitigating factors. There’s   been a tremendous interest, in recent years,  in the opposing Adverse Childhood Experiences,   is positive in – experiences and the  way that they balance each other out. So, they looked at positive mitigating  factors good relationships with one adult,   supportive school, peer group, and they carried  out a psychiatric assessment at the age of 18.   Trauma exposed individuals had a wide range of  mental health disorders, combination of trauma   and epigenetic factors, and you can see here,  the dark green PTSD, major depression, anxiety,   ADHD, conduct disorders, aggression, alcohol,  cannabis use, psychotic symptoms, self-harm,   suicide. So, demonstrating the importance  and the overlapping mental health responses   associated with adversity, and which is really  what practitioners meet in their everyday work. So, Mark Bellis from the University of Liverpool  and Bangor, stated that “An understanding of the   impact of adversity allows multiple sectors and  agencies to recognise that the issues they see   in people’s lives health, education, social,  criminal justice, are often rooted in the same   childhood adversities, ACEs, forms of maltreatment  and the associated” – those “household stressors,   parental mental health, substance abuse  and violence.” Trauma informed practices   have developed across sectors, recognising  the key role of toxic stress. Evidence-based   models are emerging, but there is a need to  develop more complex models of intervention   to parallel the infinite complexity of  presentations of children and families. I want now to speak about more  recent developments, which is   the idea of transdiagnostic approaches to address  the complexity of the overlapping responses to   adversity and of course, the overlapping  responses which we see across the field of   child and adolescent mental health. And dealing  with complexity is such an important issue today. One model which we’ve used recently, which  we’ve found tremendously useful, is the 4D   Model Dealing With Distress, introduced by Warren  Mansell and his colleagues from Manchester. So,   this is an approach to deal with any forms of  distress and can be delivered to large groups   within school, within communities. It works with  adults, it works with children and young people,   in all sorts of contexts, and is  a very valuable model across the   field of different diagnoses and different  contexts, different children and young people. So, they describe the triangle of –  at the lower part of the triangle,   the importance of distraction. Coping activities  that act as a temporary distraction from distress   remove the experience. We developed modules, which  I’ll talk about a bit later, Ways of Feeling Good.   And these are important ways of distracting  from distress, to allow one – the individual   to gradually begin to develop their capacities  to deal with the distressing context, situation. Dilution, a collection of techniques that enable  young people to circumvent some of the processes   that temporarily exacerbate distress, not to  remove it, but to reduce its intensity while   experiencing some manageable degree of distress.  And I think the tremendous developments that we   see of activities, of exercise, of yoga,  of relaxation techniques, of visualisation   techniques, of mindful techniques, and the  self-soothing of the bilateral stimulation,   are all part of this important focus of dilution.  We’ve found these techniques tremendously helpful   in helping foster carers manage the extreme  responses of unaccompanied asylum seekers. The next phase is to develop, think about and  talk about problems, even though this can feel   distressing, but the importance of managing  the way we feel before we really begin to   talk about experiences. Discovery, the benefits of  speaking one’s problems out loud, to hear them in   one’s or – own voice and develop new perspectives.  Valuable tool that really works extremely well. I now want to talk about an important  development by Bruce Chorpita and John Weisz,   the Match-ADTC, Modular Approach to  Therapy for Children with Anxiety,   Depression, Trauma or Conduct Problems. The  most common problems seen across CAMHS services,   across schools, educational context,  within all the different contexts,   anxiety, depression, trauma, conduct, in  various combinations. So, Bruce Chorpita,   in 2009, introduced a common elements approach  to intervention in the child mental health   field. He and his team analysed over 700  gold standard studies of interventions in   child mental health and defined the common  elements across these different modes of   intervention. There are now over 1,000, which  could be – which he – which they’ve analysed. So, common elements of those which emerge  across different interventions, from a   variety of theories, CBT, systemic, dynamic, and  what was common? What did the – what was – what   were the activities, what was done in these  different interventions, despite them having   a different layer of CBT, systemic, dynamic? And  what was common for interventions for depression,   anxiety, trauma and conduct? And these different  elements were put together into the MATCH-ADTC,   a modular approach, a step-by-step approach, which  included common elements and general factors,   and which was a library which Therapists could use  to pull out, depending on what was the particular   problem with the child, the young person  and family that they were working with. And a young person might present with low  mood and then would – there would be some   significantly challenging behaviour. Rather than  having to go from a sing – manual-to-manual about   how to deal with depression, how to deal  with anxiety, the modular approach enabled   the practitioner to be able to choose what was  necessary for this young person, this child,   at that moment. And this approach outperformed  focal treatment manuals for anxiety,   depression and disruptive conduct. We,  from Child and Family Training asked,   well, was this approach possible to deal  with child maltreatment, to deal with the   impact of significant stress and adversity  and trainable across the professional field? So, we, with support from Bruce Chorpita and  his team, developed the Hope for Children and   Families intervention resources, common elements,  modular, trauma-informed approach. So, the Common   Elements Framework is generic components cutting  across many different treatment protocols,   identifying specific clinical procedures, common  to evidence-based practices. The Chorpita and   Daleidon protocols helped us provide a detailed  step-by-step approach and guidance on how to   meet the changing complex needs of children and  families. And they helped us to do an analysis   of a number of effective ways of dealing with  adversity and trauma and maltreatment. Many   interventions included a variety of elements  common to evidence-based interventions. Specific practice techniques included  psychoeducation for parents and children,   information on different forms of maltreatment and  adversity, behavioural techniques, understanding   and modified behaviour. Systemic approaches  fostering relationships, intervening directly to   prevent harmful interactions. Dynamic/attachment  interventions, managing traumatic re-enactments.   Social econom – ecological interventions,  focusing on community and agencies. Mentalisation   as an integrative framework, to see ourselves, be  aware of our own/others’ thoughts and feelings. And we used the Assessment Framework to develop a  series of guides around the assessment triangle,   engaging and fostering and goalsetting,  training these approaches across a wide   range of practitioners. And, of course,  this is all part of the prevention of mental   health problems of children and young people.  Modifying abusive and neglectful parenting,   helping parents understand the impact of harmful  behaviour, harmful responses, and looking at their   own sources of stress and hopefully, helping  to manage those. To promote children and young   people’s health and development, understanding  the unfolding nature of speech and language and   locomotion and understanding and doing. And really  promoting and helping, particularly where they’re   children with disability and difficulties in  learning, promoting development and wellbeing. Promoting attachment, integrating the circle  of security and attuned responsiveness,   positive emotional relationships. And of course,  promoting positive parenting, ways of managing   children’s challenging behaviour and managing  – so to be supportive and positive, appropriate   ways of managing – challenging and managing, to  help defeat Mr Temper. Working with families,   interactions, promoting positive interactions,  the sort of approaches which Salvador Minuchin   described, working with families. Addressing  emotional and traumatic responses, all the   elements which Chorpita brought in to deal with  anxiety, depression, traumatic responses, creating   trauma narratives, managing visualisations.  Relaxation techniques, generic and specific for –   that is generic for all children, which is helpful  in terms of their management of their feelings   and situ – and concerns. Addressing disruptive  behaviour and working with child sexual abuse. So, what we tried to do, in this set of  manuals, is to incorporate all that’s   effective across the field of intervention,  bringing together so much that I’ve really   described across the whole of the evolution,  bringing it together in this set of guides.   And each module includes briefings, contents  focusing on children, young people, families,   steps to achieve an evidence-based goal,  scripts to help practitioners understand,   find their own voices, guidance, the background  of the steps, activities, worksheets,   practice roleplay, coaching, handouts for  parenting, worksheets to negotiate steps. The evaluation of the approach, in our views,  could be a transformative approach across   services. The guides, piloting and training,  demonstrate their effective resources across   the field of children’s services. Dealing  with mental health responses, overlapping   responses of anxiety, depression, trauma  and contact where they’re occurring. The   tools to deliver effective trauma-informed  practice, impact on health, behaviour,   multiple adversity. Modifying antecedents,  interrupt processes, support resilience,   social relationships, new lives, coping  capacities and social support. Practitioners   from a variety of services can benefit,  including those who have experience,   but no formal professional training,  to experienced practitioners. So, I want to say something about the internet,  its beneficial and harmful influences. It   was launched in 1989 to 1990 and there was  massive popularity in the mid-90s because of   its instant communication, aid, registering  knowledge and information. And, of course,   the development of online therapeutic work and  training has grown. So much of our training   is now online. Young people embraced the  internet, social networking, communicating,   expanding their interests, enriching,  entertaining, gaming, connecting and learning. Important issues have been widely discussed. Young  people, gender identification as male or female,   the issues of transexual, their responses could  be debated. It’s given a voice to children and   young people. Informal support and advice  about managing specific problems, self-harm,   anorexia, and of course, the growth of online  helping, Childline. There’s a new line being   developed called Shore to help children and young  people who are concerned about sexual feelings   and behaviour and, of course, Parentline. So many  different ways in which people can connect. Recent   papers on the value for indigenous families, for  families who are less well served and of course,   as ways of dealing with the tremendous growth  of mental health problems and concerns. So, the interfa – the internet can have very  beneficial impacts, but of course, there’s   been enormous concern about the harmful impact of  the web, and this has dominated social discourse.   Exposure to inappropriate material, pornographic  material, hate speech, grooming young people,   exploiting them, and the very strongly held  views that children and young people shouldn’t   have access to mobile phones until they’re in  older adolescence. And the concerns about the   way in which self-harm, suicide or anorectic  behaviour may be encouraged online. Sexting,   cyberbullying, harassment, disclosure of personal  information, triggering very significant self-harm   and suicidal responses, and the issue of safety  and control are constant and continuing themes. Childline, established in 1986, has multiple calls  about abuse over the internet. Offenders can break   their addictive cycle and children and young  people need significant support and help and   families need great deal of help to help their  children manage the internet, to promote its   beneficial and negate its harmful influences.  Very important current issue, of course. Some concluding remarks and a summary. Michael  Rutter, in his masterly review of the history of   Child and Adolescent Mental Health, concluded,  “There has been an amazing revolution in child   and adolescent psychiatry. As a consequence, the  body of knowledge and the range of therapeutic   interventions have increased in ways that would  have been scarcely conceivable 50 years ago.” I   hope you feel that this review has confirmed  these conclusions. I’ve tried to focus on the   interface between society and mental health  and the way that there have been developments   in therapeutic approaches and services in  the community. And particularly, my emphasis   on identifying and managing the pervasive and  lifetime harmful impact of child maltreatment   and the growing awareness of the impact of  adversity, both nationally and internationally. And the tremendous importance of empowering  and skilling practitioners with the skills that   have been developed, not for them to be held by a  small coterie of professionals and practitioners,   but to be widely available. And for skills to  be developed through a process of presentation   and coaching, which works very effectively across  services. And if we really are aware that mental   health responses are very much associated  with adversity, they may be a predisposition,   but they’re not a biological inevitable  response. They’re a response to the context   the children and young people are living in, the  importance of compassionate, supportive schools,   of families that are positive in their responses,  positive parenting, positive responses, positive   interactions, managing the intergenerational  effects that they, themselves, have been exposed   to. All these are tremendously live issues which I  hope will continue concerns over our future years. Let me summarise the key points I’ve tried to  make. From the 1960s to the 1980s, in parallel   to societal changes, from welfarism to the  counterculture, the legacy of Child Guidance   movement and psychodynamic approach – approaches,  have given way to more active, transparent and   fast-moving therapies, family/systemic therapy,  cognitive therapy, as an alternative, effective   psychological treatment. But at the same time,  I hope that you’ve seen that the development of   more psychodynamic treatments, art therapy,  educational therapy, drama therapy, has continued   in parallel. I have looked at the different  longitudinal and epidemiological research,   measuring the presence and impact of mental health  problems and of course, we’ve begun to look at   conditions such as anorexia nervosa, self-harming,  neurodevelopmental disorders identified,   and trying to begin to see them not so much as  disabilities, but as varian – variations which   need to be understood and managed differently in  our context of education and social relationships. Despite attempts to shrink the states in the  1980s, there has been continuing recognition   of the hidden, yet pervasive, traumatic  impact of maltreatment. Many children suffer,   enlarged through the recognition  of Adverse Childhood Experiences,   adding exposure to family dysfunction, instability  and the growth of trauma-informed care approaches.   Fostered by investment in social inclusion  in the 1990s, multidisciplinary child and   adolescent mental health services were  established, academic units promoted,   training, research, genetics, neurobiology,  research information on intervention   and best practices. Then, of course, the  introduction of the internet in the 1990s,   beneficial and harmful. The voice of  the child as a person can be amplified,   including the rights to determine gender, safety  and protection, require constant vigilance. So, I hope that the general message is  that we need to be aware of the impact   of adversity within our communities, within our  families, within our world, including, of course,   climate change as the ultimate form of adversity.  And we need to be aware of these and to be paying   as much attention, then, to our context as to the  children and young people themselves. Thank you.