Clinical Child Psychology and Psychiatry

This study examines carer attributes associated with placement stability for teenagers growing up in long term foster care, focusing on unexpected placement success. We explored experiences and perceptions relating to family, belonging and commitment in a group of foster carers providing a stable placement for a young person who had not been expected to settle. These placements showed positive outcome, despite factors in the child’s history that might have predicted otherwise.

Seven foster carers were interviewed following a semi-structured guide, which covered their ideas about their relationship with the child in question, about the foster family, and the child’s sense of belonging in foster and birth family. Analysis of carers’ accounts of placements which had succeeded ‘against the odds’ revealed four major themes, described under the headings My Child—emotional bonding, the carers’ enlarged view of family and their parental regard for the young person; Jam in the Sandwich—working within a ‘compromised space’ between Local Authority and birth family; Repair and Rebuild—the craft of fostering including managing the foster/birth family boundary; Sticking with It—resilience, tenacity and maintaining hopefulness.

The carers’ accounts offer pointers towards the ingredients of successful placements and prompt reflection on how these may be supported and promoted. They also highlight tensions inherent in the foster carer task relating to carers’ parental functioning for young people in long-term foster care.

Over the last 15 years, policy initiatives have aimed at the provision of more comprehensive Child and Adolescent Mental Health care. These presented a series of new challenges in organising and delivering Tier 2 child mental health services, particularly in schools. This exploratory study aimed to examine and clarify the service model underpinning a Tier 2 child mental health service offering school-based mental health work. Using semi-structured interviews, clinician descriptions of operational experiences were gathered. These were analysed using grounded theory methods. Analysis was validated by respondents at two stages. A pathway for casework emerged that included a systemic consultative function, as part of an overall three-function service model, which required: (1) activity as a member of the multi-agency system; (2) activity to improve the system working around a particular child; and (3) activity to universally develop a Tier 1 workforce confident in supporting children at risk of or experiencing mental health problems. The study challenged the perception of such a service serving solely a Tier 2 function, the requisite workforce to deliver the service model, and could give service providers a rationale for negotiating service models that include an explicit focus on improving the children’s environments.

Many young people growing up with HIV are choosing not to disclose their status to others, yet are likely to face difficult decisions and conversations such as explaining school absence, taking medication, coping with physical changes and for many, parental bereavement. This study aims to describe and explore the attitudes and opinions of adolescents with perinatally acquired HIV towards disclosure. Semi-structured interviews were conducted with nine young people aged 13–19 and analysed using Interpretative Phenomenological Analysis. Four themes emerged to illuminate the young people’s attitudes towards disclosure. These were 1) myths and assumptions, 2) the disclosure dilemma, 3) fear and 4) keeping HIV in its place. This study confirms that many young people with HIV are choosing not to disclose. However, it appears that it is a complex decision-making process that changes over time and is influenced by developmental factors and societal attitudes towards HIV. Recommendations are suggested for services to better support adolescents growing up with HIV.

Preventive interventions with parents of infants have tended to focus on mothers. Recent research focused on fathers suggests that their involvement in interventions might enhance effectiveness. One effective approach with mothers is the brief, home-based Video-feedback Intervention to promote Positive Parenting (VIPP). This paper is a report of a pilot study of VIPP with fathers to assess its feasibility.

Five fathers were recruited from an existing longitudinal study of parents. The primary outcome was acceptability, assessed using a semi-structured questionnaire after completion of the intervention.

All fathers completed all sessions of the intervention. Fathers rated the intervention as having had a significant impact on their understanding of their child’s thoughts and feelings, and as having improved their communication and relationship with their baby. Fathers’ feedback was generally positive. The flexibility to conduct sessions at home (or at fathers’ places of work) and the flexible timing of sessions were identified as fundamental to successful delivery.

The results of this pilot study are encouraging, as VIPP with fathers was feasible. In light of the modest sample size, and the use of a non-clinical sample, the intervention must be evaluated with larger, clinical samples to evaluate its efficacy with fathers.

Research into children’s perspectives and understandings of emotional difficulties is limited and methodologically varied. In this paper we explore young children’s perspectives and understandings of emotional difficulties in their peers. We conducted five focus groups involving a total of 25 children. The children, aged eight and nine, were presented with vignettes representing peers experiencing emotional difficulties, and invited to discuss their perspectives on possible causes. We also explored their emotional and behavioural reactions to the vignette characters.

Using interpretative phenomenological analysis we identified three themes: Searching for an Explanation; Empathy versus Blame; and Consequences and Solutions. The children drew on their own emotional experiences in their sense-making, and the extent to which they held the character responsible for their behaviour was particularly important in influencing their responses towards the characters.

In 2003 the New Opportunities Fund (NOF, now known as The Big Lottery) awarded £48 million to 70 home-based care teams to enable them to provide a range of services to allow children with non-malignant life-limiting conditions to be cared for at home. Four grants were made available in Bristol, North Somerset, South Gloucestershire and Bath and North East Somerset to enhance existing children’s palliative care services.

As there is limited evidence about the impact of palliative care services on psychological well-being, this study measured parental stress and the psychological wellbeing of parents of newly referred children with life-limiting and life-threatening conditions. Measures were administered at the point of referral and at 12 months follow-up.

Statistical analysis indicated that there was no significant change at 12 month follow-up. The lack of deterioration in levels of parental stress and psychological wellbeing is viewed positively within this context. It is hypothesised that multi-agency and partnership working was a significant contributory factor in not increasing levels of parental stress and psychological wellbeing through social support.

Some mothers who have recently lost a significant attachment figure may become mentally incoherent and sporadically even enter a trancelike, dissociative state. Such states of mind have been shown to predict infant attachment disorganization. Infants born close to the time of a parental loss are at a greater risk for intergenerational trauma. A background of maternal substance abuse is also known to increase such risk. We illustrate by way of a case study how a mother–infant group psychotherapy programme aimed at substance-abusing mothers may help to prevent the transmission of mother’s unresolved trauma to the infant. Another goal was to discuss how attachment-derived methods (namely, Adult Attachment Interview, Strange Situation Procedure and the Emotional Availability Scales) may aid in understanding the effects of the intervention.

Primary care institutions, including clinics, schools and community organizations, because of their closeness to the family living environment, are often in a privileged position to detect problems in traumatized refugee children and to provide help. In a collaborative care model, the child psychiatrist consultant can assist the primary care consultee and family in holding the trauma narrative and organizing a safe network around the child and family. The consultant can support the establishment of a therapeutic alliance, provide a cultural understanding of presenting problems and negotiate with the consultee and the family a treatment plan. In many settings, trauma focused psychotherapy may not be widely available, but committed community workers and primary care professionals may provide excellent psychosocial support and a forum for empathic listening that may provide relief to the family and the child.

A case is presented of an 11-year-old girl with pervasive refusal syndrome (PRS) who ultimately recovered acutely and completely after an 18-month paediatric hospitalisation. There was an apparent absence of previously proposed important aetiological factors in PRS, such as family pathology and markedly traumatic or abusive experiences, and her recovery was sudden and complete. The authors consider the differential diagnoses of PRS paying particular attention to the possibility of a conversion disorder or catatonia, given the absence of PRS in the North American literature. Consideration of catatonia is important as it has a diagnostic test and responds rapidly to appropriate treatment, in contrast to conventional treatment for PRS and conversion disorder.