Randolph Beresford Early Years Centre is a local authority setting in west London, serving a hugely deprived and ethnically mixed population. Following long-standing input from the Child and Adolescent Mental Health Service, part of the West London Mental Health NHS Trust, the centre invited CAMHS to set up the nursery-based child psychotherapy service in March 2008. Its aim was to promote the mental health and emotional well-being of children and, specifically, to support children, parents and staff at the centre.
I am employed two days a week, which I spend mostly at the centre, where I have a designated room. I work closely with head teacher Michael Pettavel and the deputy head teachers. About once a month, I visit my NHS base, the Hammersmith and Fulham CAMHS, for management, consultation, liaising and training.
In the nursery, I regularly attend staff meetings and end-of-day discussions to consider children who are causing concern. Because practitioners have an ongoing relationship with families and see the child two to five days a week, they are often able to identify the need for support early on, which facilitates an early psychotherapeutic intervention.
The child may then be referred to me by the head, deputy head or SENCO. Some parents refer themselves by requesting support. Families can usually see me the next day or next week, which contrasts sharply with typical NHS waiting times. Staff can book a time to talk about work or personal matters and can usually see me the next day or the following week. Worthwhile discussions also occur spontaneously over lunchtimes in the staff room.
My involvement with a family usually begins with an observation of the child in the nursery and by speaking to their practitioner. If there is a Child in Need or Child Protection plan, then considerable information is available about the child's environment and difficulties.
Next, I usually meet with the child's main carers. This can lead to an assessment, followed by short-term work (four to six sessions at weekly or monthly intervals) or longer-term work (weekly sessions). The work may involve the parents/carers or parent and child (see box), if the relationship needs support. I also see some children weekly, for individual psychotherapy.
VULNERABLE FAMILIES
Many of the families are vulnerable; about 50 per cent of the children in my current caseload have a Child Protection or Child in Need plan. There are significant levels of domestic violence (35 per cent), drug and/or alcohol misuse (25 per cent), and parents with a criminal record (10 per cent) or a known mental health diagnosis (25 per cent). Some families have suffered trauma, dislocation and hardship and their stories are very moving.
The children typically show attachment problems, sibling and social problems, anxiety and impulsivity, aggressive and oppositional behaviour, eating and sleeping problems, soiling and wetting, and developmental delay, including delays in speech. Usually, a number of problems co-exist.
Working with this age group is very rewarding, because of the significant changes that one can see. Young children's brains and minds are malleable and developing in response to their environment. Parents are the child's first environment and, consequently, the parents' thoughts and behaviours significantly influence the child's developing mind. Because they are still developing, young children are particularly open to psychotherapeutic intervention.
The intervention could focus on the child, the parent and/or the parent-child relationship. The child's natural developmental thrust accelerates the intervention and the nursery practitioners' approach of being consistent, and setting clear boundaries supports and reinforces the therapeutic intervention.
The service is well regarded, and continued funding is currently under negotiation.
EVALUATION
Tamar Karni writes: During the first year of the service, the West London Mental Health NHS Trust invited me to assess parents' and early years practitioners' perception of the service.
For the evaluation, I interviewed mothers of eight children attending the nursery and ten staff members. The interviews were audio-recorded, transcribed, then analysed, using a Content Analysis for the mothers (because of their fairly brief responses and often poor English) and a Thematic Analysis for the practitioners (because of their more elaborate answers) (Smith, 2003).
MOTHERS' NEEDS
The mothers felt the service met their need for a 'solution' to the difficulties they experienced with their child. For instance, one mother said of her toddler and infant, 'Still my son and my daughter sleep with me, but this is for me, I don't want to separate ... because I feel safe. I feel comfortable. She (therapist) helped me to separate.'
Mothers spoke of the changes that they noticed. One mother said of her two-year-old son, 'When I first came to the session ... he won't listen to me. Now he listens to what we are saying.'
Another mother said, 'So now there is a different bond between us. He (child) can express himself. He (child) is more open with me.' One mother said of her toddler, 'I started to understand better the reason he (child) was reacting like that.'
In particular, mothers reported that when they started to see positive changes in their child, or in their relationship with the child, they felt hopeful and they applied at home what they discussed in the meetings.
All the mothers stressed the convenience of the service. As one mother said, 'If she (therapist) made an appointment outside the nursery, then maybe I wouldn't come.'
PRACTITIONERS' VIEWS
Practitioners felt that the meetings with the therapist allowed them 'a space to think' and enabled them to function better in the nursery. Sub-themes included 'being more reflective', 'thinking about the context' and 'confidentiality'.
One practitioner said, 'I noticed that with all the staff members ... we are even more reflective. She (therapist) makes me think more and have an even more open and reflective view of children.'
Staff reported that they felt understood and contained by the meetings, which enabled them to be understanding and containing of the children and parents in the nursery.
One practitioner said, 'We are having more insights about the families, which I think is helping us understand why a child is behaving the way he does or even why parents are behaving the way they are. She (therapist) is helping us to understand them better.'
Another practitioner said that the meetings 'clarify for us what is happening to us with regard to the children and the families'.
On confidentiality, one practitioner said, 'It was very important to us to have someone to talk to confidentially', while another said, 'It was also good to know that it was confidential and that we can tell her (therapists) anything.'
Practitioners felt that the service was beneficial to the children, parents and staff, and crucially important was that it was based in the nursery. They felt that this made it easier for staff to approach the therapist, for the children to receive therapy and for the more vulnerable and hard-to-reach parents to access therapeutic services.
One practitioner said, 'Lots of parents who come from this estate ... this centre is the first place where they get a sense of belonging; they are not feeling they are being judged. If I sent them by referral forms to a public clinic, they would probably never get there. It's scary to walk into another setting that you have never seen before, never met the people before. They see (the therapist) walking around the building, so it's not threatening.'
CASE STUDY: LONGER-TERM PARENT-CHILD WORK
Brian (not his real name) was referred, aged two years and five months, because his mother and the nursery staff were struggling to manage his aggressive and impulsive behaviour. His language was delayed and he lashed out at others when thwarted. After an initial assessment meeting with Brian's mother (who has a mental health diagnosis), I offered them weekly parent-child psychotherapy sessions, which continued for one and a half years until Brian started primary school.
In the early sessions, when Brian lashed out, his mother tended to recoil or freeze and give in to his demands. I modelled and supported her in remaining calm in the face of his aggressive outbursts and helping him calm down afterwards.
His mother's increasing capacity to contain his outbursts, together with his growing self-regulation and language development, resulted in a significant improvement in his behaviour in therapy, nursery and at home. Over time, his capacity to play symbolically and reciprocally improved and he started making friends at nursery.
Nursery staff supported Brian's transfer to primary school by accompanying him and his mother on a number of visits. Three months after starting school, the mother said he had settled well at school and she trusted his teachers. He had apparently thrown a few big tantrums, but on the whole, things were going well.
REFERENCES
- Hammersmith and Fulham Childcare Audit, 2005/06
- Karni, T (2009) How do parents and staff members at an early years centre perceive the consultation service offered to them at the centre? MSc thesis, University College London, Library of the Anna Freud Centre
- Pretorius, I-M and Karni, T (2009) Report for the West London Mental Health NHS Trust on the audit and evaluation of the child psychotherapy outreach project: The consultation service and the Randolph Beresford Early Years Centre
- Smith, JA (2003) 'Qualitative Psychology: A practical guide for research methods', in Smith, JA, Validity and Qualitative Psychology. London: Sage Publications
