Strengthening children's emotional and mental health wellbeing: being awarded the Margaret May Blackwell Travel Study Fellowship enabled Plunker nurse Maria Turner to observe a number of innovative nursing practices making a difference to vulnerable children.

An interest in services for women with postnatal depression and in those aiming to meet the emotional and mental health needs of children led New Plymouth Plunket clinical leader Maria Turner to Hawaii, Britain and Denmark earlier this year to observe nurse-led practices focused on vulnerable children. The experience has proved invaluable and has really energised her own practice, she says.

Awarded the 2005/2006 Nursing Education and Research Foundation's Margaret May Blackwell Travel Study Fellowship, Turner set out to examine a range of innovative practices seeking to make a difference to vulnerable child populations, including those with parents with a mental illness, those living in poverty and those from chaotic and detrimental environments. Her other interests included language and speech development projects/programmes and obesity interventions.

In applying for the fellowship earlier last year, Turner wrote an exemplar about an adjustment to parenthood programme, jointly run by Plunker and the Waikato District Health Board's maternal mental health service. "This programme offers a service for women suffering from postnatal depression. Being involved in this group has made me think more about the mental and emotional wellbeing of children, as well as mothers. As nurses we are very good at attending to people's physical health but we sometimes overlook what might be lying behind the physical problems, ie the emotional troubles centered in our minds. Put simply, mental health is about the strength and wellbeing of our minds."

Preventing child abuse in Hawaii

Turner's two-and-a-half months' travel began in mid-March in Honolulu, where she observed first hand the Hawaiian Healthy Start (HHS) programme. Now about 20 years old, this programme is specifically aimed at preventing child abuse and neglect, and has evolved into a systemic and comprehensive family support service for environmentally at-risk families. "Hawaii has the highest cost of living in America," said Turner. "Many families are financially stable only with both parents working full-time. These social and economic conditions are having a negative effect on many of Hawaii's youth. A school readiness assessment programme in 2004 found that, on average, only six out of ten children entering kindergarten were prepared and Hawaii's poorest children start school one to two years behind.

"I spent time with several different workers within the programme, including a nurse. My first visits were to the maternity hospital where I shadowed a social worker who visits new 'moms'. The purpose of the hour-long, early identification interview was to assess the parent/infant relationship and observable risk factors. This interview, attended by partners and grandparents, occurs within 24-48 hours of a baby's birth. Questions asked included: What was the relationship between the mother and father of the baby like? How were they disciplined as children? Did mother/father of the baby ever witness domestic violence between caregivers? Did the parents take drugs? The mothers were encouraged to engage the HHS programme and information from the interview was forwarded to the service deliverers."

Reducing parental stressors

The HHS programme offers support services within a family's natural environment to reduce the likelihood of child maltreatment by reducing parental/environmental stressors. Parents faced with environmental hardships tended to be more punitive and less warm in their parenting techniques, resulting in children who were more likely to act out. Family support workers are the primary contact with the family, although a team of professional specialists work closely with the workers to strengthen the family. Clinical specialists, for example, work with parents with substance use (including smoking), those experiencing partner abuse and those with mental health issues.

White in Hawaii, Turner also attended a community meeting called to address the issue of homelessness on the island (numbers of homeless people are increasing daily) and met up with clinical social work and author Beverly James. Her book Handbook for Treatment of Attachment-Trauma Problems in Children (1) describes her work with sexually abused children, the goals of developmental play therapy and the importance of touch as a means of initiating attachment. At the end of April, Turner attended the 8th annual conference of the Northern Ireland Community Nursing Network in Belfast, where she presented a workshop about her work with Plunker. Of particular interest to her was a presentation by Cardiff University research fellow Lisa Cotes on designing a professional and parent toolbox for preventing serious injury to babies. The toolbox is designed to be used in mainstream services and to reach the most vulnerable groups, especially male carers, to assist them to prevent accidental and non-accidental head injuries in babies.

The Solihull Approach

In Solihull, just south of Birmingham, Turner spent a week with members of the Solihull Approach team. This includes psychologists, nurses, administrators and child psychotherapists. The Solihull Approach was developed to aid hearth visitors working with pre-school children with sleeping, feeding, toileting and behavioural difficulties. It now includes a school years' programme. The model brings together three well-developed concepts--containment, reciprocity and behaviour management. Containment describes the process whereby the parent is able to help the child process intense emotions and anxiety, rather than being overwhelmed by them. Reciprocity is fundamental to the acquisition of language and involves the parent and infant actively developing their interaction to be in tune with each other. Behaviour management is about parents using reinforcement to achieve desired behaviour in their children.

As well as attending part of the foundation training course, Turner visited a Sure Start pre-school facility in Chelmsley Wood. Sure Start is a government-funded initiative that works with parents and children to promote physical, intellectual and social development of pre-school children, to ensure they are ready to thrive when they go to school

"Sure Start is about fostering emotional development in children at a young age, so they are more likely to settle welt into school, work cooperatively, confidently and independently and to behave appropriately. A child with poor social and emotional development is at risk of poor relationships with peers, academic problems, of later involvement in crime, of developing physical health and adult mental health problems. Key to social and emotional development is the child's early relationship with parents/caregivers. Efforts to support parents in understanding and fulfilling their children's emotional needs can help to provide a secure base from which to grow into well-rounded, capable adults with robust mental health."

In London, Turner made contact with the Queen's Nursing Institute (QNI). This works to influence innovation and best practice in community nursing. As an independent organisation, the QNI does not charge fees for the support it offers to community nurses in developing new health care initiatives and promoting best practice, nor for providing information updates.

Talk, sing and play with your baby

She also met with manager of the Talk to Your Baby programme Liz Attenborough. Set up in 2003, the programme is an initiative of the National Literacy Trust which aims to draw attention to listening as a skill. Its simple message is to encourage communication with babies from birth, thus helping to develop their communication, learning and social skills, and to create solid foundations for literacy later in life. "In my work with Plunket I have noticed increasing numbers of children who are not developing early language skills. Health visitors Anne Hobbs and Alex Dudley work with children with underdeveloped speaking and listening skills. They have produced a CD of traditional nursery rhymes called Sing and Play Every Day to help new parents bond and communicate with their babies. It features a local school choir singing 30 traditional nursery rhymes. The CD is now distributed by health visitors to all new babies in South Western Staffordshire National Health Service (NHS) Primary Care Trust.

"Research suggests that nursery rhymes play a significant part in the early experience of good readers. The ability to recite a nursery rhyme in a child's formative years may be one of the best indicators of future reading skills. An important beneficial effect of parents using rhymes with their children has been seen in the quality of parent-child interaction."

In Redhill, East Surrey, Turner spent time with health visitor Lynda Dawson who leads the Infant Mental Health project focusing on early attachment issues. "During my visit I observed a postnatal depression support group led by a psychologist. I also sat in on a baby massage session for vulnerable children, ie unsettled and/ or fractious babies. The mothers and their babies were referred to the course by their health visitor. The group of ten mothers and their babies enjoyed their bonding session and were growing in confidence as they learnt to relax their babies. There is strong evidence to support the use of massage to reduce anxiety and stress."

Of particular significance to Turner was two weeks in Copenhagen, a city where she once lived and nursed for a year, gaining some facility in Danish. Her mentor for the first week was health visitor/nurse Benthne Hansen. "Her role is similar to my clinical leader position, though in Denmark nurses are also assigned a school as part of their caseload. At a housing estate, we observed two nurses, a childcare supervisor, a translator and several immigrant mums and their children having a discussion, following a video presentation. The mums were sitting on the floor along with the children, who were relaxed and playing happily. Benthe explained that, when they started the programme several years ago, the women did not know how to talk within a group. Now, several years later, the women generally cope much more easily with the Danish way of life and the concept of "hygge". This is about creating a comfortable, relaxed atmosphere in which to promote positive social intercourse. The group begins at 9am with coffee and breakfast, then moves into discussion for an hour. To finish the morning, they come together as a group to engage in song and action routines with the children. This practice brings the focus back to the children, which is what the programme is all about."

In 2003, the National Board of Health in Denmark launched the National Action Plan against Obesity: Recommendations and Perspectives. Funds were allocated to 26 projects, with evaluation on-going and new prevention treatment activities being established. Two projects were aimed at early identification of childhood obesity. Families are visited by a nurse in order to identify children with weight problems, discuss habitual physical activity and diet, and identify motivation and barriers for life style changes. Turner is looking forward to putting into practice many of the initiatives she observed during the study tour and believes she is even more child-centred in her approach than before she went away. Priorities include programmes around healthy sleeping habits and language development. Although admitting setting up her study programme required a great deal of time and effort, she feels very satisfied with what she achieved. "I met some great nurses who were very generous with their time and showed great leadership skills. Although nursing seems to be in the doldrums in the United Kingdom at present, with a freeze on nursing vacancies and budgets, the nurses I met were leading change and working effectively in teams to implement new ideas. There is much New Zealand nurses can learn from their examples."

Reference

1) James, B. (1994) Handbook for Treatment of Attachment-Trauma Problems in Children. New York: Lexington Books.