Children’s mental health when experiencing multiple adversities: Practice skills for effective conversational maps

Family and relationship services understand that children’s mental health issues occur in the context of social divisions and hierarchies across multiple dimensions, drawing attention to both the complexity and diversity of experiences of trauma, conflict, bullying and family separation (Wendt, et al., 2023; Our Watch & Women with Disabilities Victoria, 2022). Given that no individual practitioner can be a specialist in all issues experienced by children, practitioners have focused on developing robust conversational maps, rather than providing ‘expert’ advice. The skilful use of conversational maps helps children and families describe the context of their problems, as well as the active steps they have taken to overcome the effects of problems on their lives. To develop these conversational maps, family and relationship practitioners have become adept at listening to stories outside the scope of their speciality or expertise. Trauma informed practice, for example, has developed in part from the experiences of non- specialist practitioners listening to stories about childhood sexual, physical and emotional abuse (Moss & Klapdor, 2022). This does not mean that all family and relationship practitioners are experts in the assessment or diagnoses of neurobiological or psychological effects of trauma. Instead, they utilise skills to help children describe their active steps in keeping themselves or others safe or resisting the effects of violence in their lives (Emerging Minds, 2022). These skills provide new interpretations of past events for children that help them move beyond self-blame (Carey, 2017).

Children invariably describe a raft of challenges in their everyday lives that extend beyond a singular issue or diagnosis (Azar et al., 2020). Family and relationship services recognise that not all families have the means or support to attend multiple appointments with the specialist services who can respond to each of their adversities (Radez et al., 2021; Herbert, 2021). But what are the generalist skills and conversational maps that are needed by family and relationship practitioners to attend to the varied and complex stories of children? How can practitioners attend to children’s mental health when they are affected by multiple issues? How do they ensure that children’s safety is prioritised when they discuss painful or co-occurring experiences such as trauma, bullying or parental separation?

The five practice perspective shifts are a set of positions taken up by practitioners who want to prioritise children’s ability to tell their stories in their own ways, using their own language (Emerging Minds, 2019). This paper examines the history and development of these practice perspective shifts and how they can be used in work with children and families who present to services with a broad range of experiences. The authors have used the common practice examples of childhood trauma, bullying and parental separation to examine how practitioners employ generic skills to support children to tell their stories.

Family and relationship services in Australia have a rich history of ‘no wrong door’ practice that has evolved in recognition of the multiple, co-existing disadvantages faced by many clients. Perhaps the clearest example of this has been the evolution of ‘marriage guidance’ services which were originally established to provide newly married couples advice on how to live with each other for the first time but over time broadened in response to regular presentations of family breakdown and gendered violence, spawning the creation of specialised family violence services, family mental health services and children’s contact services.

As family and relationship services evolved in Australia, they have become well practiced in providing responses to a raft of adult adversities and mental health issues that are exacerbated by family conflict, gendered violence, historical child abuse, poverty, disadvantage and substance use. Although not all services worked directly with children, child-aware practice frameworks were developed in recognition of the effects of parental adversity on children’s social and emotional wellbeing (Price-Robertson & Hunter, 2014). An example of this has been the groundbreaking work of Relationships Australia South Australia in screening for childhood safety risk in every parent who uses their post-separation services (Wells et al., 2018).

In more recent times, services have been created to work specifically with children about the effects of adversity on their lives and a skilled and cost-effective child-specific workforce has developed in family and relationship services (Centre for International Economics, 2023). Family and relationship services are uniquely placed to provide services to children in Australia because they operate outside of the broader child protection or mental health systems that most often require notification or diagnosis to facilitate service engagement (Centre for International Economics, 2023).

The diagnosis of specific, individual mental health issues in children has never been more common, with the development of tools such as the diagnostic and statistical manual of mental disorders reinforcing these practices (Epstein, Weisner & Duda, 2013). While diagnosis for many children leads to essential professional or medical support, social services data show that children most often present with multiple, interactive issues that affect every element of their daily lives (Dalgliesh et al., 2020). Long waist lists for diagnosis can also mean that children and families need to access family and relationship services while they await specialised mental health treatment (Radez et al., 2021).

It is common for children to present to services while awaiting a diagnosis, or having a current diagnosis, and family and relationships practitioners have learned to both listen to the contribution the diagnosis might make to the child’s life, while catering for more than just the effects of children’s mental or physical conditions (Price-Robertson & Schuurman, 2019). Where children have disabilities that affect their learning or communication development, family and relationship practitioners have actively resisted ‘diagnostic overshadowing,’ which can disqualify a focus on the whole child and view the child only through the prism of their diagnosis (Kanne, 2018).

The application of conversational maps and frameworks that transcend singular diagnoses with children creates possibilities for increased curiosity about every aspect of life, rather than only the identification and modification of one specific problem. This allows for greater flexibility in service delivery and a recognition in the increased interconnectivity of issues that affect children’s mental health (Azar et al., 2020).

Emerging Minds has worked with a range of stakeholders – including many family and relationship practitioners – to develop five practice perspective shifts that can be utilised in any circumstance with children to help them tell their stories. These perspective shifts come from feedback from children who describe what they want from interactions from professionals (Carson et al., 2018; Moore, 2017; Griffiths-Cooke & Fenn, 2017). They are also influenced by practitioners’ descriptions of the need to help children to tell their stories, which are so often silenced through experiences such as family and domestic violence, trauma, bullying, family breakdown and isolation (Moss & Dolman, 2018; Emerging Minds, 2020).

The practice shifts reflect an interest in the social context of children’s lives and a commitment to encouraging children’s participation and are accountable to their experiences. They are designed to support practitioners to engage with both parents and children in ways that notice, acknowledge and build on children’s strengths, skills and know-how. In situations of family breakdown and parental separation, the practice shifts support practitioners’ curiosity to enquire about and make more visible the ways the child has been responding to the impacts of the separation in their life and relationships.

The five practice perspective shifts are:

Passive to active

The passive to active perspective shift assumes that no child is a passive participant in their experiences of adversity and that they have already drawn on skills and know-how to navigate their circumstances. By maintaining curiosity in children’s responses to adversities, practitioners can help children and families develop cracks in the dominant or problem stories, which so often underestimate the strategies that children implement to minimise or overcome the effects of problems (Carey, 2017). This shift also reinforces the need for children and families to contribute actively during professional engagement, rather than passively receive ‘expert’ advice on how to live their lives.

When children become used to considering only the problematic parts of their lives, they can become isolated from their preferences, intentions, skills and know-how (De Mol, D’Alcantara & Cresti, 2018). The passive to active perspective shift calls for practitioner curiosity into multiple aspects of children’s lives, rather than only those aspects affected by adversity or their diagnosis. It prioritises attention to children’s acts of response, protest or resistance to their experiences of adversity (Vermeire, 2022). It pays close attention to the small actions that they have made and what these actions say about what they give value to in their lives (Emerging Minds, 2022).

Naïve to knowledgeable

A naïve to knowledgeable shift considers the language that children use, and how they interpret and describe events, objects and relationships. It does not seek to correct their ‘faulty’ descriptions or explain these descriptions as the effects of their diagnosis. Rather, the naïve to knowledgeable perspective shift genuinely attempts to see the world through the eyes of the children they meet with and the circumstances that are specific to them (Johnson, 2018; Marsten, Epstein & Markham, 2016). Children possess knowledge about the issues they are facing. They can define and describe these problems by drawing their own understandings, meanings and language, and deserve to be provided with the opportunity and space to do so.

Parents or carers might come to family and relationship services with a list of problems in relation to the child and the sense that nothing seems to be changing (Vermeire, 2022). This can position the practitioner as expert and centred, and the child as a problem that needs to be corrected (Vliegen, Tang & Meurs, 2022). Where children’s behaviour is causing immediate safety concerns, they might be positioned as naïve, or lacking the maturity to look after themselves appropriately. Practitioners might feel a sense of urgency to correct the child and their behaviour. Where practitioners can avoid invitations to coerce children through immediate behaviour management, stories of the child’s behaviour might become more accessible. Children who act out in the classroom or at home, for example, might be actively resisting a practice that they view as unfair. In this situation, having conversations with children about what they know about fairness is potentially more generative than imposing immediate correctional imperatives (Emerging Minds, 2021).

Recipients to contributors

The recipients to contributors perspective shift supports children to join with adults to co-research solutions to the problems that affect their lives. It invites children to co-generate knowledge that can contribute to new perspectives about the events in their lives (Manion & Nixon, 2012). When practitioners begin to view children and their families as co- researchers, it becomes less necessary for them to have all the solutions. This de-centred perspective assumes that children attend therapy with a history of finding solutions to their problems. These solutions may not have always been successful, but in the retelling of the experience, children are able to demonstrate their resilience, attempts at connections with others, and the things that they most give value to in their lives (Vermeire, 2022).

It is possible that the efforts that children have gone to in an attempt to make things better for themselves or those around them have never been acknowledged by anyone. It is also possible that the child themselves has never considered their own attempts at finding solutions. When a practitioner demonstrates curiosity about every aspect of the child’s life, their relationships, interests and values, their meaningful contribution becomes more possible (Manion & Nixon, 2012).

When practitioners genuinely consider the place for contribution of children’s stories in their own professional (or personal) lives, all sorts of learning can be derived from children’s experiences. These contributions not only help children to consider their stories in more hopeful and generative ways, but it provides practitioners with opportunities to become more effective in what they do (Marsten, Epston & Markham, 2016).

Categories to context

A child who has experienced misuse of power or adversity may present with ambivalence about the adults in their lives, even if those adults have not been responsible for their adversity (Vermeire, 2022). Therapeutic interventions with these children might locate their distrust or withdrawal from family members, educators or friends as an outcome of their disorder or as an effect of their adversity. These perspectives can risk positioning the child’s internalising or externalising behaviours as dysfunctional responses to their current circumstances.

A focus on the context of children’s lives considers how children make relational decisions according to the environment that surrounds them (National Scientific Council on the Developing Child, 2020). It is the non-judgemental curiosity about the decisions that children make that can shift practice emphasis from categorising or pathologising to an interest in their everyday experiences (Emerging Minds, 2019).

Learning how children make sense of their relationships can uncover much about what children hope for (Rupert, 2017; Yuen, 2018). If they are withdrawn or cautious with adults in their lives, this may reflect a protection mechanism that has helped to keep them safe. Children who are withdrawn or cautious with adults in their lives can sometimes be categorised as ‘dysfunctional.’ A categories to context perspective shift helps practitioners to focus on the active decisions children have made in withdrawing from relationships or exercising care. These decisions might actually say much about what children give value to in their lives, safety, self-care and judgement.

Top-down to bottom-up accountability

Services and practitioners can shift from a solely ‘top-down’ way of working towards incorporating a ‘bottom-up’ view of accountability. Whilst hierarchical top-down accountabilities to the practitioner’s agency, funders and salient evidence-based literature remain important, this shift prioritises understandings and practices of accountability towards those less powerful. This shift calls for practice approaches that are accountable and answerable to the child, as well as their parents and other concerned adults – in other words, to those most affected by the problem (Sargeant & Harcourt, 2012; Lambert & Glacken, 2011).

Bottom-up accountability might mean paying active attention to the small cues that a child’s play, body language, or facial expressions can provide. The practitioner can become curious about why a child becomes animated, distracted, withdrawn, or even angry, when specific topics are raised. Children’s responses can therefore be seen as feedback to the practitioner regarding the effectiveness of the conversations they are facilitating. Rather than assessing responses as evidence of children’s developmental or cognitive functioning, a bottom-up accountability shift positions children as experts and co-researchers in the conversational frameworks and strategies that best help them in their lives (Emerging Minds, 2020).

The recent Australian Childhood Maltreatment study reaffirmed the strong links between economic and social disadvantage, multiple experiences of maltreatment and negative outcomes for children’s long-term mental health (Haslam et al., 2023). The link between childhood trauma, mental health and other childhood adversities is now so clear that it is impossible to conceive of a service where responses to trauma are not viewed as core business.

Family and relationship practitioners are extremely familiar with working with children who are up against multiple challenges, and who are likely to have experienced at least one form of trauma in their lives (Moss & Klapdor, 2022). These children are often brought to practitioners because of immediate worries such as school refusal, risk-taking behaviour or relationship breakdown. For good reason, adults are motivated by their hope for immediate change in these children’s behaviour that facilitates less risk and more positive engagement. The immediacy can have practitioners using more didactic approaches with children that can disqualify story, particularly where children are up against multiple problems in their lives (Moss & Dolman, 2018). Where children come to services with negative experiences of adult relationships and institutions, immediacy can serve to reinforce their withdrawal, or their assumption that they are a problem to be fixed (Brown, 2018).

The passive to active practice shift helps practitioners to practice patience in their engagement with children and their families who face multiple challenges in their lives. This is not to say that an exploration of the effects of the problem should be ignored, but practitioners can also glean much from children’s stories of resistance to the problem (Carey, 2017).

When family and relationship practitioners broaden the scope of curiosity beyond just the effects of the problem, children can be supported to consider their relationship preferences and values. This provides the catalyst for meaning-making conversations with children which might lead to small differences in the ways they remember adverse events. Rather than only focusing on what they did not do and reinforcing self- blame, children might start to consider the responses they made in the face of adversity, even if these were small (Carey, 2015). Small acts of resistance or protest can be remembered for the first time and these acts can reshape how a child interprets the events of their lives (Carey, 2017).

Helping children to focus on the actions of protest or resistance they have taken throughout their lives may contribute to a minimisation of the effects of secrecy or self-blame on their mental health (Emerging Minds, 2022). It is important to note that the passive to active shift does not necessarily mean that children will disclose past trauma, or that family and relationship practitioners will enquire about trauma. There are ethical, safety and legal considerations for all non- specialist trauma practitioners (Guy, 2020). However, practitioners who use a passive to active perspective are more likely to hear multiple aspects of children’s story from the point of view of their preferences, values and intentions. This has been supported by the implementation of trauma-informed practices in family and relationship services over the past decades.

Given the increasingly wide reach of bullying due to the growth of communications technology, childhood bullying no longer exists only within the confines of the school environment (Dale et al., 2014). Family and relationship practitioners are increasingly working with children whose mental health is being negatively affected by bullying around the clock (Rollbusch, 2023).

Extended exposure to bullying – whether the child is experiencing or engaging in the behaviour – can reinforce children’s negative views of themselves (Rollbusch, 2023). For children who are already facing adversity in their lives, bullying can serve to reinforce the deficit-based assumptions they have made about themselves. For some children, pre- existing experiences of adversity and disadvantage can impede their peer relationships in educational settings and increase the likelihood and effects of bullying (Tippet & Wolke, 2014).

Positive connections with family and peers, and within schools and other institutions, have been consistently demonstrated to be the most protective factors both for children who are experiencing and/or engaging in bullying behaviour (Bayer et al., 2018). For children who are already isolated and do not have access to the social supports that can help them make meaning of their bullying experiences, psychological effects are likely to be heightened. This can include higher rates of depression, anxiety, eating disorders, self-harm and suicidal ideation (Wolke et al, 2014).

Children who experience bullying behaviour are also more likely to have worries at school or avoid school resulting in poorer academic outcomes (Wolke et al., 2013). These children may then be incorrectly categorised as ‘anxious,’ ‘naughty,’ ‘lazy,’ or ‘withdrawn.’ These categories can attach themselves to negative identity conclusions that further exacerbate children’s mental health issues. The repetitive element of bullying makes negative messages more impactful and erodes children’s self-worth. A child who views themselves, or who is categorised as a ‘victim,’ may come to view themselves as powerless or fragile (Moore et al, 2017).

The categories to context perspective shift helps to divert practitioners away from categorising children’s experiences of bullying. Exploring the context of a child’s experience in the classroom, online, or in other social settings helps provide a sense of the internal messages that are developed through the negative messaging the child is receiving.

Through exploring the meaning behind bullying behaviour, children can move away from feelings of self-blame. In making meaning, children can begin to understand that the messages they are receiving are not about them personally and are more likely a reflection of how the child engaging in the bullying is feeling. This work can begin by supporting children to understand the dynamics of bullying. That is, why bullying happens. Bullying is considered a goal- oriented behaviour for the children engaging in it (Sansom et al., 2022). It may be that they are trying to fit in socially or attempting to increase their feelings of power and control.

The recipients to contributors perspective shift is particularly relevant when working with children who are engaging in bullying behaviour. These children might see their bullying behaviour as reinforcement of their negative identity, which might have been developed through other adversities in their lives. We know that bullying behaviour can stem from several environmental influences that children have little control over (McLory et al., 2017).

When practitioners assume that children who engage in bullying behaviour are doing it because they are malicious or ‘bad,’ they can become recipients in coercive or rectifying therapy which might reinforce children’s already negative beliefs about themselves (Emerging Minds, 2023a). Practitioners can work alongside children who engage in bullying behaviour to be curious about what is happening for them and explore their values and how these differ from their present behaviour. This type of practice ensures children are contributing to the therapeutic relationship and allows them to understand themselves and the bullying behaviour in a different way.

Family conflict, separation and violence can mean that children and parents can present to services with a diminished sense of connection or trust in their relationships. This might mean that children and adults present to services with a sense of frustration or hopelessness that might manifest as anger or conflict.

For children that have experienced family conflict, violence or trauma they have often had many expectations placed upon them: at home, at school, and in either their biological families or in out-of- home care. Often, children can be judged according to their inability to live up to adults’ expectations of them (Emerging Minds, 2020).

A shift from top-down to bottom-up accountability is about tailoring your support to the child’s individual needs and preferences. These needs are seen as integral to every child, rather than evidence of the child’s deficits. This shift assumes that careful and patient practice can challenge secrecy for all children.

Family and relationship practitioners have developed skilled and nuanced family-centred practice which supports the rebuilding of trust and relationship confidence after adversity. This often begins with a negotiation with children and parents regarding what they hope for from professional engagement. This conversation immediately shows children and parents that the practitioner is accountable and answerable to the child, as well as their parents and other concerned adults – in other words, to those most affected by the problem (Yuen, 2018; Rupert, 2017).

When children and parents can be supported to describe their hopes for engagement, invariably they will want similar outcomes: better relationships, happier times and less conflict. Once these joint goals are named, the child, adults and practitioner can set to work on negotiating therapeutic processes that will track progress against these goals. This negotiation can be seen to pave the way for shared processes that are accountable to the preferences and values of the child and adult (Emerging Minds, 2023b).

The practice shift from a naïve to knowledgeable perspective can be particularly supportive of practitioners engaging with children and their families in the context of parental separation.

When engaging parents in conversations about their children’s wellbeing, concerns about the child or their behaviour can overshadow many aspects of the child’s experience. This can lead parents and practitioners into rigid interpretations about the child’s behaviour and generate misunderstandings about the child’s view of the problem and its impacts on them. This can make it more difficult for parents to notice how the child is trying to respond to the impacts of the separation on their life, or adjust to their new circumstances in some way.

However, children invariably do take steps to lessen the negative impacts of separation on themselves, their parents and siblings. These responses act as a protective factor from the negative consequences of separation (Sorek, 2019).

These sometimes small, unnoticed steps that children take to lessen the impacts of the separation on themselves or those around them can provide a portal into a world of children’s knowledge. This knowledge, performed and embodied or expressed in language most available and meaningful to them, reflects their insights and understandings about the difficulties they are facing. But more than that, it reflects their creativity, imagination and hard-won learnings about what is required of them and others to find a way through the impacts of the separation the family is facing.

Inviting parents to reflect on and describe what they have noticed about their child’s responses to the separation provides them with an opportunity to consider, perhaps in a different way, what the child ‘knows’ and how the child views and makes sense of the problem.

These conversations re-position children as knowledged – as generators and safe-keepers of perspectives and understandings about their experiences of separation. It is no wonder that children navigating parental separation want opportunities to effectively participate in conversations and decisions that affect their lives (Carson et al., 2018).

Positioning children as knowledgeable can make a difference to how parents respond to the child. It can open up possibilities for alternative understandings and responses by the parent, including increased collaboration between the parent and child.

This also paves the way for more detailed descriptions in future conversations with children about their skills, know-how, capabilities and interests that they can summon to contend with the unhelpful impacts of separation on their life and relationships.

‘Where do I start with this family?’ is a familiar question posed by practitioners when presented with the multiple co-existing issues faced by children and families (Moss & Dolman, 2018). When practitioners start to ask these questions, it is more likely that stories of hopelessness overwhelm both them and the children and families who they meet. Amidst this hopelessness, practitioners may stop listening for evidence of hopes, preferences, strengths or even concerns. This may lead to more direct and expert practice that fit with the assumption that children access services to be ‘fixed’ by an adult professional who knows more about their life events than they do. This paper has been inspired by the many family and relationship practitioners and services who actively take contrary positions and have developed maps for more generative, hopeful and bottom-up conversations. The family and relationship services sector continues to find innovative and creative ways to help children to tell their stories in whatever form this takes, and Emerging Minds has developed the five practice perspective shifts to support these practices.

Acknowledgement

This paper was originally published as Moss, D., Dolman, C., & Rollbusch, N. (2024) Family and Relationship Services: Valued now and into the future

Emerging Minds acknowledges the excellent work of FRSA in co-ordinating the peer review process and for significantly contributing to the quality of this paper. It was a pleasure working with Robyn Clough and the team of reviewers at FRSA.

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