‘The Solihull Approach in North Tyneside ’A collaboration between the PMHW service , Health visiting and Public Health

School Nursing ServiceFacilitators Rhian Davies PMHW CAMHS, Liz Brown Health visitor & Kate Swinburne Public Health School

Nurse

• To provide an overview of the Solihull Approach to promote healthy brain development, emotional well being & positive parent / child relationships.

•To share the North Tyneside PMHW’s experience in developing the approach in partnership with the health visiting and public health school nurse services.

•To illustrate how the approach fits with the current governmental Transforming CAMHS agenda & the best available evidence.

•To provide an overview of the role of the PMHW in facilitating clinical supervision to support the approach in universal practice.

• To identify the challenges & opportunities to created between universal & targeted CAMHS services.

Aims & objectives of the session

Key research & policy messages …

•Promoting resilience, prevention & early intervention

•Interventions to be based on ‘best available evidence' to strengthen attachments , avoid trauma, build resilience & improve behaviour.

•Integrated partnerships and seamless access across agencies

•Support systems built around the needs of the child, young person & family

•The universal workforce to be trained & confident in children's mental health

• For all professionals to know what to do & where to go if they are worried DOH (2015) Future In Mind

Early intervention : our shared vision

The Thrive Model & The Solihull Approach

Background

• Its origins in joint working between psychotherapists and health visitors in 1996 Solihull

• The approach is an early intervention , prevention & promotion of positive mental health among children & their families.

• An integrated model of working for professionals working with babies, children , teenagers & their families

• The framework helps parents & fosters carers to understand their child's behaviour

• Considers the development of children's emotional well being within their family relationships (parent –child interactions) and practitioners interactions with families. (Douglas 2010)

• Developed into a 2 day training programme and resource pack for professionals working with families with children with difficulties (Douglas 1999)

The Solihull Approach

The Solihull Approach

THE RESEARCH BASE

• Psychoanalytic attachment theory, brain development and behavioural theories into a practical framework.

• Focus on listening to parents, observing interactions & families identifying their own goals for change.

• The approach is based on 3 core concepts :-

• Containment –the process where one holds and understands the others emotional content without feeling overwhelmed , and effectively conveys this ( Bion, 1959)

• Reciprocity –an attuned and appropriate form of interaction (Brazelton et al, 1974)

• Behavioural management (Skinner, 1938)- a consistent response techniques that foster safety and encourage self control (Douglas, 2010)

The structure of the Solihull packs

• The theoretical research base supporting the Solihull approach• The baby, child & teenage brain development• The parent/child relationship –attachment patterns • Infant ,child & adolescent development • The Solihull approach in practice

Issues in the early or school years:-

• Case studies• Assessment tools • Specific advice leaflets & handouts• Intervention plans• Triggers for referrals to specialist services

Available PackagesThe resource packs and trainers manuals include ….• The ante natal journey to parenthood• Breastfeeding supporter • The first 5 years • Early years foundation stage • The school years • The fostering & adoption approach• Whole schools approachThe Solihull Approach plus manuals include ….• Attachment seminar• Brain development• Refresher • Trauma & childrenGroup facilitators manuals include….• The antenatal parenting group• The post natal parenting group• The post natal plus group• The parenting group• Workshop for parents of young school children• Workshop for parents of adolescents• Foster carer group

The mental health issues addressed for the first 5 years

The pre-school programme supports with …..

• Playing• Safety• Weaning & feeding• Sleeping• Toileting & soiling • Behaviour issues

The mental health issues addressed for the school years• The school age pack addresses ….

• Autism, loners & different children• Bullying• Chronic fatigue syndrome• divorce & separation• Eating disorders • Hyperactivity disorder (ADHD)• Loss & bereavement• Mood disorder & depression• Obsessive compulsive disorder• Panic attacks & stress• Post traumatic disorder• School phobia & school refusal• Self harm• Sexual health & sexuality• Sleep disorders• Temper tantrums and anger management• Toileting –soiling & wetting

The empirical evidence base

Themes identified :-

• Increased numbers of health visitors reported feeling more positive in their jobs• Increased confidence and knowledge concerning children’s problems• Enhanced consistency of practice• The promotion of more holistic assessments (Douglas and Ginty 2001) • Resulted in a reduction of referrals to CAMHS (Douglas and Ginty 2001) • Improved health visitors views of their work and partnerships with other

professionals• Development of a shared language (Whithead and Douglas (2005)• Better outcomes at 3 month follow ups (Milford et al (2006) • The relationship focus and links with attachment theory and strengthening

relationships for meaningful change (Douglas ,2007)

The journey so far in North Tyneside

• 2009 North Tyneside Health Visitors reviewed policy and current practice• A need highlighted to enrich the quality of support to children and young peoples

emotional wellbeing• NMET funding and support via NHCT enabled Solihull training plan for all staff • Service recognised need to involve a mental health professional to support the

initiative• PMHW service approached to provide support• More formal clinical supervision systems & processes developed from CAMHS • 2014 public health school nurse service agreed to replicate the established models

with school age pupils.

The scale of delivery in North Tyneside

The population of children in North Tyneside :-

Children 0-4 11,700 (5.8%) Children 0-19 44,700 (22.1%) www.chimat.org.uk

Current health professionals involved in the Solihull approach to support infant , school age & teenage mental health

Universal professionals Health visitors (64) & Public health school nurses (34) Targeted professionals CAMHS PMHWs (6), CAMHS Clinical psychologist(1) & Trainee

Clinical psychologist (1)

The wider workforce

All professionals across the North Tyneside workforce have been trained in the approach.

• Health – CAMHS PMHW s & psychology, health visitors, public health school nurses & nursery nurses

• Local Authority - children's centre staff , Troubled families family partner teams, statutory social workers , fostering & adoption teams (10 week parenting programme to parents & a 12 week programme to foster & adoption carers)

• Education –pastoral school staff, learning mentors, school inclusion managers, teachers (10 week parenting programmes )

• Private sector -nursery staff and playgroups

A demonstration of an infant mental health case within health visiting practice

Importance of Solihull supervision• Supervision as a process of embedding the Solihull Approach

• Crucial role in maintaining the use of the Solihull Approach its principles and ethos.

• It provides the emotional containment for professionals (Douglas and Ginty 2001)

• It enables practitioners to have a deeper understanding of the Solihull Approach , the central importance of a ‘partnership approach’ and promotion of ‘reflective parenting’ (Open university 2014)

• Permission for protected time to ‘reflect on practice

Organizational performance & governance • Senior management agreement across the 3 services

• Trained facilitators identified across CAMHS, health visiting & PHSNs to deliver supervision

• Frequency of sessions agreed as follows:-

Monthly 2.5 hour sessions with health visitors & nursery nurses Every term (6 weekly sessions) 2.5 hours with school nurses & nursery nurses

• Agreed contracts of expectation for facilitators & attendees

• 8/10 Maximum attendees agreed , booking in plans agreed

• 2x sessions per annum expected to be attended for professional development

• 8/10 Maximum attendees agreed , booking in plans agreed

• 3 monthly facilitators meetings with management to discuss operational issues & process supervision with a CAMHS clinical psychologist

• Updates provided at CAMHS departmental meetings & locality meetings for health visitors & public health school nurses.

Role of the supervision facilitator

• To deliver a restorative model of group supervision model (Kolb's reflective cycle)

• To establish a non threatening supportive space

• To support reflective practice to develop reflective parenting

• To create space for the therapeutic relationship to develop

• To use stories to develop shared understandings

• To provide permission to explore feelings for clinicians, self and parents

• To model the key principles of the programme (containment, reciprocity, behaviour management)

• To provide an opportunity to share CAMHS clinical knowledge into primary care practice

Structure of the supervision session

See copy of pre –supervision prompt sheet

• Case summary & genogram• Discussion on the experience• Reflection of feelings during the contact & developmental expectations of the child.

• Analysis of family strengths & weakness on rating scale to measure …• The containment , identifying the ‘containers’/’those unable to contain’• The reciprocity (attuned & sensitive to child's cues) within family• The behaviour management (positive strategies &limit setting )

• Action Plan identified with focus on Solihull approach resources - to enhance parenting capacity on 3 above areas

A demonstration of a school age mental health

case within public health school nurse practice

Evaluating outcomes :Quality Improvement Development of pre & post in session evaluation & one month follow up questionnaire

• Pre session Qs –• How do you feel prior to supervision ?• What do you think may be contributing to how you are feeling?• How contained are you feeling ? (scaling Q) • How confident to you feel about applying the Solihull Approach in with parents ? (scaling Q) • What do you think are the barriers ?

• Post session Qs –• Same as above 3 • How would you rate the session in contributing to your effectiveness, skill & confidence ? (scaling Qs)• What was it that made you feel that way?• Is there anything the Solihull training/supervision can do to support with these feelings?• Any additional training needs ,eg infant mental health ?

• One month Follow up• On reflection how helpful was the session/advice?• What was helpful?• Has the advise changed the management of the case ?• How has it changed your practice• Permission sought to share with colleagues ?

Key evaluation themes• Benefits a clear clinical supervision structure, sharing of practice, discussing

similar cases, good explanations of behaviour issues, the importance of listening not doing , learning from colleagues, off loading, understanding brain development better, importance of exploring feelings, building trust within the professional team , developing a shared language

• Barriers challenge of time, approach may not work for all families

• Opportunities more sessions . Additional training on ADHD,ASD, parental separation & divorce , bereavement & impact on children. More sessions. Information to be shared between the 2 packs.Infant mental health training . A refresher session

Objective 1: To investigate whether there are changes to participants’ confidence after supervision.

Objective 2: To investigate whether there are changes to how participants were feeling after supervision.

Quality Improvement • Monthly data captured across services for commissioning purposes (demonstration of KPIs)

• Senior management across services measuring application in annual appraisals

• Integration in practice reviewed through regular case note audits

• Senior management recognition of ‘containment of staff’ during staffing crisis

• Unicef Baby Friendly audit found health visitors scored ‘very highly ‘ on conversations with mothers on brain development & attachments relationships in responsive feeding

• Feedback informing further staff training needs to be delivered by the PMHW team

Strengths• Early intervention & prevention initiative

• Evidence of a clear framework for supporting children's mental health

• Approach based on facilitating child & family resilience

• Family's as experts of their lives , identifying their own solutions

• Compliance with evidenced based practice & policy guidance

• Provision of supportive ‘protected time’ for clinical supervision

• Joint working and collaboration between CAMHS and universal health providers

• Evidence that practice has become less time consuming

• Establishing a common/ shared professional language

• Normalising behaviours within a developmental framework

• Improved quality of mental health assessments in primary care

• It offers a consistent primary care approach from 0-18 –supporting transitions

Challenges• Initial resistance to change and variation of ‘buy in’, fear of time limits, old v new ideas

• Time & capacity issues for facilitators

• Finding a balance between standardised practice v flexible practice wisdom

• Quality of practice ‘drifting’ during current staffing crisis

• Recognised differences in application between health & social care and co-ordination of interventions between services

• Limited data on improved outcomes for children & parents at present

• Further data needed to monitor direct impact on practice eg, duration of involvement in cases & referral patterns to CAMHS

• Variability of GPs knowledge of initiative for signposting

• Sustainability in challenging times

Future opportunities• Additional PMHWs to be trained to facilitate supervision to ensure sustainability

• Consideration to develop more creative tools in supervision eg use of video, research papers & themed focus

• To plan a Solihull Approach refresher training event for both services

• Possibility of multi agency training / supervision arrangements across the services

• Northumberland area interested in replicating our model (joint training event agreed)

• Some health visitors & school nurses trained to deliver the Solihull parenting programmes

• Service user outcome measures to be considered (to measure resilience & symptom change)

• Facilitating team to deliver training on the approach to commissioners /GPS to raise awareness

• Consideration of a joint research pilot to consider the impact on referral patterns across universal, targeted & specialist services

• Current pathways of care to be developed by the future North Tyneside Transforming CAMHS plans.

Reference List • Bateson, K., Delaney, J., & Pybus, R. (2008). Meeting expectations: the pilot evaluation of the Solihull

Approach Parenting Group. Community Practitioner, 81(5), 28-31. • Bion, W. R. (1959). Attacks on linking. The International Journal of Psychoanalysis. • Brazelton, T. B., Koslowski, B., & Main, M. (1974). The origins of reciprocity: The early mother-infant

interaction. • Brigham, L., & Smith, A. (2014). Implementing the Solihull Approach: A study of how the Solihull Approach is

embedded in the day to day practice of health practitioners. • DOH. (2015). Future in mind: Promoting, protecting and improving our children and young people’s mental

health and wellbeing. NHS England.• Douglas, H. (2010). Supporting emotional health and wellbeing: the Solihull Approach. Community

Practitioner, 83(8), 22-25. • Douglas, H., & Brennan, A. (2004). Containment, reciprocity and behaviour management: Preliminary

evaluation of a brief early intervention (the Solihull approach) for families with infants and young children. Infant Observation, 7(1), 89-107.

• Douglas, H., & Ginty, M. (2001). The Solihull Approach: changes in health visiting practice. Community Practitioner, 74(6), 222-224.

• Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. • Weber, R. P. (1990). Basic content analysis: Sage.• Wolpert, M., Harris, R., Jones, M., Hodges, S., Fuggle, P., James, R., Fonagy, P. (2014). Thrive: The AFC-Tavistock

Model for CAMHS.

Contact details

1. Rhian Davies North Tyneside PMHW team Albion Resource Centre North Shields, North Tyneside, NE290HG . Tel : 0191 2196670. Email rhian.davies@northumbria-healthcare.nhs.uk2. Liz Brown North Tyneside health visiting service Whitley Bay Health Centre ,Whitley Road Whitley Bay Tyne and Wear,NE26 2ND Tel: 0191 238 0106Email elizabeth.brown@nhs.net3. Kate Swinburne Public Health School Nurse Service Albion Resource Centre North

Shields, North Tyneside, NE290HG . Tel: 0191 2196654Email kate.swinburn@nhs.net