Children's health by British Holistic Medical Association

Volume 14 • Issue 1

Spring 2017

JOURNAL OF

holistic healthcare Re-imagining healthcare

Children’s health

Raising children compassionately Parenting in the age of the internet Children’s centres Rites of passage Nurturing childhood resilience Forest schools Educating for health Tackling childhood obesity Child analysis in the NHS Herbal first aid for children Research Reviews

JOURNAL OF

holistic healthcare About the BHMA In the heady days of 1983 while the Greenham Common Women’s Camp was being born, a group of doctors formed the British Holistic Medical Association (BHMA). They too were full of idealism. They wanted to halt the relentless slide of mainstream healthcare towards industrialised monoculture. They wanted medicine to understand the world in all its fuzzy complexity, and to embrace health and healing; healing that involves body, mind and spirit. They wanted to free medicine from the grip of old institutions, from over-reliance on drugs and to explore the potential of other therapies. They wanted practitioners to care for themselves, understanding that practitioners who cannot care for their own bodies and feelings will be so much less able to care for others. The motto, ‘Physician heal thyself ’ is a rallying call for the healing of individuals and communities; a reminder to all humankind that we cannot rely on those in power to solve all our problems. And this motto is even more relevant now than it was in 1983. Since then, the BHMA has worked to promote holism in medicine, evolving to embrace new challenges, particularly the over-arching issue of sustainability of vital NHS human and social capital, as well as ecological and economic systems, and to understand how they are intertwined . The BHMA now stands for five linked and overlapping dimensions of holistic healthcare:

marker of good practice through policy, training and good management. We have a historical duty to pay special attention to deprived and excluded groups, especially those who are poor, mentally ill, disabled and elderly. Planning compassionate healthcare organisations calls for social and economic creativity. More literally, the wider use of the arts and artistic therapies can help create more humane healing spaces and may elevate the clinical encounter so that the art of healthcare can take its place alongside appropriately applied medical science.

Integrating complementary therapies Because holistic healthcare is patient-centred and concerned about patient choice, it must be open to the possibility that forms of treatment other than conventional medicine might benefit a patient. It is not unscientific to consider that certain complementary therapies might be integrated into mainstream practice. There is already some evidence to support its use in the care and management of relapsing long-term illness and chronic disease where pharmaceutics have relatively little to offer. A collaborative approach based on mutual respect informed by critical openness and honest evaluation of outcomes should encourage more widespread co-operation between ‘orthodox’ and complementary clinicians.

Sustainability Whole person medicine Whole person healthcare seeks to understand the complex influences – from the genome to the ozone layer – that build up or break down the body–mind: what promotes vitality adaptation and repair, what undermines them? Practitioners are interested not just in the biochemistry and pathology of disease but in the lived body, emotions and beliefs, experiences and relationships, the impact of the family, community and the physical environment. As well as treating illness and disease, whole person medicine aims to create resilience and wellbeing. Its practitioners strive to work compassionately while recognising that they too have limitations and vulnerabilities of their own.

Self-care All practitioners need to be aware that the medical and nursing professions are at higher risk of poor mental health and burnout. Difficult and demanding work, sometimes in toxic organisations, can foster defensive cynicism, ‘presenteeism’ or burnout. Healthcare workers have to understand the origins of health, and must learn to attend to their wellbeing. Certain core skills can help us, yet our resilience will often depend greatly on support from family and colleagues, and on the culture of the organisations in which we work.

Climate change is the biggest threat to the health of human and the other-than-human species on planet Earth. The science is clear enough: what builds health and wellbeing is better diet, more exercise, less loneliness, more access to green spaces, breathing clean air and drinking uncontaminated water. If the seeds of mental ill-health are often planted in an over-stressed childhood, this is less likely in supportive communities where life feels meaningful. Wars are bad for people, and disastrous for the biosphere. In so many ways what is good for the planet is good for people too. Medical science now has very effective ways of rescuing people from end-stage disease. But if healthcare is to become sustainable it must begin to do more than just repair bodies and minds damaged by an unsustainable culture. Holistic healthcare practitioners can help people lead healthier lives, and take the lead in developing more sustainable communities, creating more appropriate models of healthcare, and living more sustainable ways of life. If the earth is to sustain us, inaction is not a choice.

“The Journal of Holistic Healthcare… a great resource for the integration-minded, and what a bargain!” Dr Michael Dixon

Humane care Compassion must become a core value for healthcare and be affirmed and fully supported as an essential

Three issues each year – £48 for full BHMA members. On-line members £25/year including access to all past issues.

JOURNAL OF

holistic healthcare

Contents

ISSN 1743-9493

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Published by

Update. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

British Holistic Medical Association West Barn, Chewton Keynsham BRISTOL BS31 2SR journal@bhma.org www.bhma.org

Raising children compassionately. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Reg. Charity No. 289459

Whatever happened to Sure Start?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Editor-in-chief

Marshall B Rosenberg

The internet stole my children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Mike Fisher

Donna Gaywood and Heidi Limbert

David Peters petersd@westminster.ac.uk

Crossing the threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Editorial Board

Nurturing childhood resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Peter Donebauer Ian Henghes Dr William House (Chair) Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

Luke Harrison and Terri Harrison

Transformative learning in nature An educational pilot programme at Hazel Hill Wood . . . . . . . . . . . . . 25

Production editor

Hugh van’t Hoff

Edwina Rowling edwina.rowling@gmail.com

Partnership for change in Newcastle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Advertising Rates 1/4 page £130; 1/2 page £210; full page £400; loose inserts £140. Rates are exclusive of origination where applicable. To advertise email contactbhma@aol.co.uk Products and services offered by advertisers in these pages are not necessarily endorsed by the BHMA.

Design

Gabby Hollis

Louisa Clark and Daniel Körner

Educating children for health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

David Stobbs

Children and psychosomatic disorders: perspective from a child psychotherapist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Angele Wallis

Herbal medicine in paediatric practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Dedj Leibbrandt William House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

karenjigsawdesign@gmail.com Cover illustration Ben Peters severedhp@hotmail.com

Printing Spinnaker Press

Volume 14 ● Issue 1 Spring 2017

Unless otherwise stated, material is copyright BHMA and reproduction for educational, non-profit purposes is welcomed. However we do ask that you credit the journal. With this exception no part of this publication may be reproduced in any form or by any other means – graphically, electronically, or mechanically, including photocopying, recording, taping or information storage and retrieval systems – without the prior written permission from the British Holistic Medical Association. Every effort is made to ensure the accuracy of material published in the Journal of Holistic Healthcare. However, the publishers will not be liable for any inaccuracies. The views expressed by contributors are not necessarily those of the editor or publisher. 1

Editorial The child is the father to the man The courage to creatively explore the world is an untapped resource for humanity. If we don’t work together to solve some of the world’s most pressing problems with the help of adolescent minds, then we’re not going to do so well. Dan Siegel, founder of Interpersonal neurobiology (2013)

Our children are adults of the future. How we raise them and help them walk the firepit of adolescence will shape the destiny of our species. In the early 20th century, people with radical ideas about child development formed new kinds of school and different approaches to raising children. By the 1970s Montessori, Steiner and AS Neil’s free schools had taken root in the wider culture: child-centred education and compassionate child-raising were recognisable signs of a changing consciousness; complementary therapies, new expressions of spirituality, and growing ecological anxieties became badges of allegiance worn by those seeking a new order. Though seemingly unconnected, these movements delineated a worldview steeped in interconnectedness, holism and hopes for a better future. That we now need to wrest our children back from the internet, tackle a childhood obesity epidemic and compensate for nature deficit disorder all tell us something about the world our children are emerging into. What can the family and the (counter-)culture do to neutralise trends such as these? Innovations in this issue of JHH express an urgent concern to raise the next generation more consciously and with grace: forest schools, non-violent communication, making exercising fun, nurturing individuation, setting realistic health expectations, and creating social organisms that support better parenting. These too are signs of the times. This issue has no space to take in what happens to our children next: adolescence, leaving the home cave behind, taking risks and facing hardship. Yet every generation has to explore new ways of thinking and doing. If not, human progress would hit the buffers as everyone simply accepted what the parent generation knew and passed on. And if the young didn’t move away our species’ gene pool would be too shallow for evolution to have enough space for new options. As the adolescent brain rewires it gets easier for teens to take risks unthinkable in childhood, and face the challenges of independence. Yet their energy and thirst for new experiences leads many young people into harm.

David Peters Editor

The resilience that can protect them depends greatly on emotional anchors laid down in childhood. In these years of incessant brain-building children are sensitive mirrors of relationships and environments that shape them psychologically and physically. The adolescent brain’s burst of accelerating neuroplasticity, which rewires connections faster than ever, gives teens outstanding abilities for learning and memory, but its flipside boosts vulnerability to stress and negative emotion. During the teen years, the emotional mid-brain more easily kicks in and takes over because the forebrain – the most recently evolved headquarters of good judgement and impulse control – fully connects up last of all, often only in the early 20s. Until then the internal information highways running deeper in the brain, linking up different parts, function at only about 80% of their adult capacity (Siegel, 2014). Evolution has made the teenage instinct to break way from parent figures strong, yet in the turbulence of adolescence young people sometimes need a trusted adult to turn to. In our society (unlike in tribal groups) parents are often the only adults available, though the lucky ones might run into an inspirational teacher, or an informal mentor at work. Mentoring schemes aim to make this less random, so do men’s and women’s circles, but are we doing enough to nurture our emerging adults? And where are new social forms that bring young people and elders together to share creativity, vitality and wisdom? The teenage years are fraught with risk so that new breakthroughs are possible. In our ever more hazardous millennium the risks are huge but the potential for human flourishing has never been greater. If we are in the wild adolescence of our species, then we should ponder how to make sure humankind grows up safely. To make it through to planetary adulthood we need to both harness the fabulous daring and creativity of this adolescent era, and manage the crazy risk-taking that is inviting the evolution equivalent of a teenage car crash. These planetsized challenges demand that the generations come together to save us all from harm. The planet urgently requires a better version of the human adult, and (to misquote Wordsworth) our children are fathers and mothers to the men and women we have been waiting for. Siegel DJ (2014) Brainstorm: the power and purpose of the teenage brain. London: Scribe. Siegel DJ (2013) Q&A: Daniel J. Siegel, neuropsychiatrist, on the power and purpose of the teenage brain. Available at: www.zdnet.com/article/qa-daniel-j-siegel-neuropsychiatrist-on-thepower-and-purpose-of-the-teenage-brain (accessed 27 February 2017).

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UPDATE

In memory of George Lewith I am dedicating this issue of JHH to my friend and colleague George Lewith who died suddenly and unexpectedly while on a skiing holiday in March.

George Lewith 12 January 1950–17 March 2017

George was a powerhouse of ideas and achievements: few of us could match his intellect or keep up with his outputs! A qualified physician and general practitioner with wide-ranging interests in research, the commercial world and clinical medicine, in all three areas he pursued successful careers. After retiring from his busy, eclectic complementary clinical practices in London and Southampton in 2012, George worked as a university researcher and teacher. He is perhaps best known for his extensive publications in the field of complementary medicine, but George was in fact an internationally top-rated researcher in primary care and integrated medicine who, for the last 35 years, held a senior role in the Department of Primary Care at the University of Southampton. He took a visiting chair at the University of Westminster’s Centre for Resilience (where he was a vital driving force behind its developing research programme) and also worked closely with the Beijing University of Chinese Medicine.

George was an energetic and generous collaborator and an inspirational mentor to a generation of PhD students. He travelled very widely – most recently in Sri Lanka – and had worked in Canada, Australia and China. Proof, if any were needed, of George’s pre-eminence in the field can be found in over 350 peer reviewed papers, several books and the many substantial grants he won from charities and major UK medical research funding bodies. He was a swimmer, a walker, a choir member and had a daily practice of meditation. George was married for 40 years to his artist wife Nicola. We send her and their three children Tom, Emily and Henry and his three grandchildren our deep condolences for their loss. David Peters, Editor in Chief, JHH

Doctors call for national diesel reduction initiative to protect public health Emissions from factories, power plants and traffic is linked to asthma, heart disease, cancer, diabetes and dementia. Levels of air pollution are above legal limits in 25 British cities. 300 doctors, nurses and other health professionals from across the UK, including more than 100 doctors in London, have signed a letter to Theresa May calling for government action to remove the current fleet of diesel vehicles from the roads as soon as possible. Doctors Against Diesel is a group of doctors, nurses and health professionals campaigning for greater awareness of the health impacts of diesel emissions. www.medact.org/about

The answer to the NHS crisis is treating its staff better You may have missed GP Margaret McCartney’s forthright article in a February New Statesman (http://bit.ly/2lbJDmj). In it she chastises the government for depending for too long on staff goodwill and vocation to mop up funding shortfalls and bad policymaking. ‘Working in the NHS should be joyful, a matter of love. But for too long the government has allowed goodwill and vocation to mop up funding shortfalls and bad policymaking. These are now chasmic.’ Treat the staff better, and patients will be treated better too.

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A daily mile ‘The aim of The Daily Mile is to improve the physical, emotional and social health and wellbeing of our children – regardless of age or personal circumstances.’ www.thedailymile.co.uk Almost a quarter of reception children and a third of year 6 in the UK are now obese. Physical activity in children can contribute to a healthy weight and it has numerous other health benefits such as improving bone strength, physical fitness and improved sleep. It is also linked to improved academic performance. In August 2016 the government issued its plan to reduce England’s rate of childhood obesity within the next 10 years. The Coppermile, inspired by The Daily Mile initiative, was a 12-week pilot project with year 5 and 6 students from Coppermill Primary School. They did a 15-minute run (or walk) 3 times a week – averaging about 1 mile initially. Their average fitness percentile increased from 37% to 64%. Students reported some improvement in self-esteem, wellbeing and satisfaction. Teachers noticed the children were more focused in class and behaviour was generally improved and this was particularly noticeable in those who had had previous problems with motivation. Most interesting of all perhaps was how well the students performed in their SATs with results up to 25% above average for the area and nationally (year 6 students completed the ‘daily mile’ daily before their tests).

ROSENBERG

Raising children compassionately Marshall B Rosenberg Founder and director of Educational Services, Center for Nonviolent Communication

Nonviolent communication training evolved from Marshall Rosenberg’s quest to find a way of rapidly disseminating much needed peacemaking skills. The Center for Nonviolent Communication emerged out of his work with civil rights activists in the early 1960s. He worked worldwide offering nonviolent communication training to promote reconciliation and peaceful resolution of differences. Marshall Rosenberg died in 2015.

I’ve been teaching nonviolent communication to parents for 30 years. I would like to share some of the things that have been helpful to both myself and to the parents that I’ve worked with, and to share with you some insights I’ve had into the wonderful and challenging occupation of parenting. I’d first like to call your attention to the danger of the word ‘child’, if we allow it to apply a different quality of respect than we would give to someone who is not labeled a child. Let me show you what I am referring to. In parent workshops that I’ve done over the years, I’ve often started by dividing the group into two. I put one group in one room, and the other in a different room, and I give each group the task of writing down on a large paper a dialogue between themselves and another person in a conflict situation. I tell both groups what the conflict is. The only difference is that I tell one group the other person is their child, and to the second group I say the other person is their neighbor. Then we get back into a large group and we look at these different sheets of paper outlining the dialogue that the groups would have, in the one case thinking that the other person was their child, and in the other case, the neighbor. (And incidentally, I haven’t allowed the groups to discuss with the other group who the person was in their situation, so that both groups think that the situation is the same.) After they’ve had a chance to scan the written dialogues of both groups, I ask them if they can see a difference in terms of the degree of respect and compassion that was demonstrated.

Every time I’ve done this, the group that was working on the situation with the other person being a child was seen as being less respectful and compassionate in their communication than the group that saw the other person as a neighbor. This painfully reveals to the people in these groups how easy it is to dehumanise someone by the process of simply thinking of him or her as ‘our child’. I had an experience one day that really heightened my awareness of the danger of thinking of people as children. This experience followed a weekend in which I had worked with two groups: a street gang and a police department. I was mediating between the two groups. There had been considerable violence between them, and they had asked that I serve in the role of a mediator. After spending as much time as I did with them, dealing with the violence they had toward each other, I was exhausted. And as I was driving home afterwards, I told myself, I never want to be in the middle of another conflict for the rest of my life. And of course, when I walked in my back door, my three children were fighting. I expressed my pain to them in a way that we advocate in nonviolent communication. I expressed how I was feeling, what my needs were, and what my requests were. I did it this way. I shouted, ‘When I hear all of this going on right now, I feel extremely tense! I have a real need for some peace and quiet after the weekend I’ve been through! So would you all be willing to give me that time and space?’ My oldest son looked at me and said, ‘Would you like to talk about it?’ Now, at that moment, I dehumanised

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ROSENBERG Raising children compassionately

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The label ‘child’ can lead us to behave in a way that’s quite unfortunate

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So I’m not suggesting that we don’t use words like ‘child’ as a shorthand way of letting people know that we’re talking about people of a certain age. I’m talking about when we allow labels like this to keep us from seeing the other person as a human being, in a way which leads us to dehumanise the other person because of the things our culture teaches us about ‘children’. Let me show you an extension of what I’m talking about, how the label ‘child’ can lead us to behave in a way that’s quite unfortunate. Having been educated, as I was, to think about parenting, I thought that it was the job of a parent to make children behave. You see, once you define yourself as an authority, a teacher or parent, in the culture that I was educated in, you then see it as your responsibility to make people that you label a ‘child’ or a ‘student’ behave in a certain way. I now see what a self-defeating objective this is, because I have learned that any time it’s our objective to get another person to behave in a certain way, people are likely to resist no matter what it is we’re asking for. This seems to be true whether the other person is 2 or 92 years of age. This objective of getting what we want from other people, or getting them to do what we want them to do, threatens the autonomy of people, their right to choose what they want to do. And whenever people feel that they’re not free to choose what they want to do, they are likely to resist, even if they see the purpose in what we are

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asking and would ordinarily want to do it. So strong is our need to protect our autonomy, that if we see that someone has this single-mindedness of purpose, if they are acting like they think that they know what’s best for us and are not leaving it to us to make the choice of how we behave, it stimulates our resistance.

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About 80% of American parents firmly believe in corporal punishment of children

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him in my thinking. Why? Because I said to myself, ‘How cute. Here’s a nine-year-old boy trying to help his father’. But take a closer look at how I was disregarding his offer because of his age, because I had him labeled as a child. Fortunately I saw that was going on in my head, and maybe I was able to see it more clearly because the work I had been doing between the street gang and the police showed me the danger of thinking of people in terms of labels instead of their humanness. So instead of seeing him as a child and thinking to myself, ‘how cute’, I saw a human being who was reaching out to another human being in pain, and I said out loud, ‘Yes, I would like to talk about it’. And the three of them followed me into another room and listened while I opened up my heart to how painful it was to see that people could come to a point of wanting to hurt one another simply because they hadn’t been trained to see the other person’s humanness. After talking about it for 45 minutes I felt wonderful, and as I recall we turned the stereo on and danced like fools for a while.

I’ll be forever grateful to my children for educating me about the limitations of the objective of getting other people to do what you want. They taught me that, first of all, I couldn’t make them do what I want. I couldn’t make them do anything. I couldn’t make them put a toy back in the toy box. I couldn’t make them make their bed. I couldn’t make them eat. Now, that was quite a humbling lesson for me as a parent, to learn about my powerless-ness, because somewhere I had gotten it into my mind that it was the job of a parent to make a child behave. And here were these young children teaching me this humbling lesson, that I couldn’t make them do anything. All I could do is make them wish they had. And whenever I would be foolish enough to do that, that is, to make them wish they had, they taught me a second lesson about parenting and power that has proven very valuable to me over the years. And that lesson was that anytime I would make them wish they had, they would make me wish I hadn’t made them wish they had. Violence begets violence. They taught me that any use of coercion on my part would invariably create resistance on their part, which could lead to an adversarial quality in the connection between us. I don’t want to have that quality of connection with any human being, but especially not with my children, those human beings that I’m closest to and taking responsibility for. So my children are the last people that I want to get into these coercive games of which punishment is a part. Now this concept of punishment is strongly advocated by most parents. Studies indicate that about 80% of American parents firmly believe in corporal punishment of children. This is about the same percentage of the population who believes in capital punishment of criminals. So with such a high percentage of the population believing that punishment is justified and necessary in the education of children, I’ve had plenty of opportunity over the years to discuss this issue with parents, and I’m pleased with how people can be helped to see the limitations of any kind of punishment, if they’ll simply ask themselves two questions. Question number one: What do you want the child to do differently? If we ask only that question, it can certainly

ROSENBERG Raising children compassionately

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I’d like to suggest that reward is just as coercive as punishment

Since punishment is so frequently used and justified, parents can only imagine that the opposite of punishment is a kind of permissiveness in which we do nothing when children behave in ways that are not in harmony with our values. So therefore parents can think only, ‘If I don’t punish, then I give up my own values and just allow the child to do whatever he or she wants’. As I’ll be discussing below, there are other approaches besides permissiveness, that is, just letting people do whatever they want to do, or coercive tactics such as punishment. And while I’m at it, I’d like to suggest that reward is just as coercive as punishment. In both cases we are using power over people, controlling the environment in a way that tries to force people to behave in ways that we like. In that respect reward comes out of the same mode of thinking as punishment. There is another approach besides doing nothing or using coercive tactics. It requires an awareness of the subtle but important difference between our objective being to get people to do what we want, which I’m not advocating, and instead being clear that our objective is to create the quality of connection necessary for everyone’s needs to get met. It has been my experience, whether we are communicating with children or adults, that when we see the difference between these two objectives, and we are consciously not trying to get a person to do what we want, but trying to create a quality of mutual concern, a quality of mutual respect, a quality where both parties think that their needs matter and they are conscious that their needs and the other person’s well-being are interdependent – it is amazing how conflicts which otherwise seem unresolvable, are easily resolved. Now, this kind of communication that is involved in creating the quality of connection necessary for everybody’s needs to get met is quite different from that communication used if we are using coercive forms of resolving differences with children. It requires a shift away from evaluating children in moralistic terms such as right/

wrong, good/bad, to a language based on needs. We need to be able to tell children whether what they’re doing is in harmony with our needs, or in conflict with our needs, but to do it in a way that doesn’t stimulate guilt or shame on the child’s part. So it might require our saying to the child, ‘I’m scared when I see you hitting your brother, because I have a need for people in the family to be safe’, instead of, ‘It’s wrong to hit your brother’. Or it might require a shift away from saying, ‘You are lazy for not cleaning up your room’, to saying, ‘I feel frustrated when I see that the bed isn’t made, because I have a real need for support in keeping order in the house’. This shift in language away from classifying children’s behavior in terms of right and wrong, and good and bad, to a language based on needs, is not easy for those of us who were educated by teachers and parents to think in moralistic judgements. It also requires an ability to be present to our children, and listen to them with empathy when they are in distress. This is not easy when we have been trained as parents to want to jump in and give advice, or to try to fix things.

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All human beings, when they’re in pain, need presence and empathy

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seem that punishment sometimes works, because certainly through the threat of punishment or application of punishment, we can at times influence a child to do what we would like the child to do. However, when we add a second question, it has been my experience that parents see that punishment never works. The second question is: What do we want the child’s reasons to be for acting as we would like them to act? It’s that question that helps us to see that punishment not only doesn’t work, but it gets in the way of our children doing things for reasons that we would like them to do them.

So when I’m working with parents, we look at situations that are likely to arise where a child might say something like, ‘Nobody likes me’. When a child says something like that, I believe the child is needing an empathic kind of connection. And by that I mean a respectful understanding where the child feels that we are there and really hear what he or she is feeling and needing. Sometimes we can do this silently, just showing in our eyes that we are with their feelings of sadness, and their need for a different quality of connection with their friends. Or it could involve our saying out loud something like, ‘So it sounds like you’re really feeling sad, because you aren’t having very much fun with your friends’. But many parents, defining their role as requiring them to make their children happy all the time, jump in when a child says something like that, and say things like, ‘Well, have you looked at what you’ve been doing that might have been driving your friends away?’ Or they disagree with the child, saying, ‘Well, that’s not true. You’ve had friends in the past. I’m sure you’ll get more friends’. Or they give advice: ‘Maybe if you’d talk differently to your friends, your friends would like you more’. What they don’t realise is that all human beings, when they’re in pain, need presence and empathy. They may want advice, but they want that after they’ve received the empathic connection. My own children have taught me the hard way that, ‘Dad, please withhold all advice unless you receive a request in writing from us signed by a notary’.

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ROSENBERG Raising children compassionately

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he was getting frustrated because he had a friend waiting for him outside, and he said, ‘Daddy, it’s taking you so long to talk’. And I said, ‘Let me tell you what I can say quickly: Do it my way or I’ll kick your butt’. He said, ‘Take your time, Dad. Take your time’.

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People can often mistake what I’m talking about as permissiveness

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Many people believe that it’s more humane to use reward than punishment. But both of them I see as power over others, and nonviolent communication is based on power with people. And in power with people, we try to have influence not by how we can make people suffer if they don’t do what we want, or how we can reward them if they do. It’s a power based on mutual trust and respect, which makes people open to hearing each other and learning from each other, and to giving to one another willingly out of a desire to contribute to one another’s well being, rather than out of a fear of punishment or hope for a reward. We get this kind of power, power with people, by being able to openly communicate our feelings and needs without in any way criticizing the other person. We do that by offering them what we would like from them in a way that is not heard as demanding or threatening. And as I have said, it also requires really hearing what other people are trying to communicate, showing an accurate understanding rather than quickly jumping in and giving advice, or trying to fix things. For many parents, the way I’m talking about communicating is so different that they say, ‘Well, it just doesn’t seem natural to communicate that way’. At just the right time, I read something that Gandhi had written in which he said, ‘Don’t mix up that which is habitual with that which is natural’. Gandhi said that very often we’ve been trained to communicate and act in ways that are quite unnatural, but they are habitual in the sense that we have been trained for various reasons to do it that way in our culture. And that certainly rang true to me in the way that I was trained to communicate with children. The way I was trained to communicate by judging rightness and wrongness, goodness and badness, and the use of punishment was widely used and very easily became habitual for me as a parent. But I wouldn’t say that because something is habitual that it is natural. I learned that it is much more natural for people to connect in a loving, respectful way, and to do things out of joy for each other, rather than using punishment and reward or blame and guilt as means of coercion. But such a transformation does require a good deal of consciousness and effort. I can recall one time when I was transforming myself from a habitually judgmental way of communicating with my children to the way that I am now advocating. On the day I’m thinking of, my oldest son and I were having a conflict, and it was taking me quite awhile to communicate it in the way that I was choosing to, rather than the way that had become habitual. Almost everything that came into my mind originally was some coercive statement in the form of a judgement of him for saying what he did. So I had to stop and take a deep breath, and think of how to get more in touch with my needs, and how to get more in touch with his needs. And this was taking me awhile. And

So yes, I would rather take my time and come from an energy that I choose in communicating with my children, rather than habitually responding in a way that I have been trained to do, when it’s not really in harmony with my own values. Sadly, we will often get much more reinforcement from those around us for behaving in a punitive, judgmental way, than in a way that is respectful to our children. I can recall one Thanksgiving dinner when I was doing my best to communicate with my youngest son in the way that I am advocating, and it was not easy, because he was testing me to the limits. But I was taking my time, taking deep breaths, trying to understand what his needs were, trying to understand my own needs so I could express them in a respectful way. Another member of the family, observing my conversation with my son, but who had been trained in a different way of communicating, reached over at one point and whispered in my ear, ‘If that was my child, he’d be sorry for what he was saying’. I’ve talked to a lot of other parents who have had similar experiences who, when they are trying to relate in more human ways with their own children, instead of getting support, often get criticised. People can often mistake what I’m talking about as permissiveness or not giving children the direction they need, instead of understanding that it’s a different quality of direction. It’s a direction that comes from two parties trusting each other, rather than one party forcing his or her authority on another. One of the most unfortunate results of making our objective to get our children to do what we want, rather than having our objective be for all of us to get what we want, is that eventually our children will be hearing a demand in whatever we are asking. And whenever people hear a demand, it’s hard for them to keep focus on the value of whatever is being requested, because, as I said earlier, it threatens their autonomy, and that’s a strong need that all people have. They want to be able to do something when they choose to do it, and not because they are forced to do it. As soon as a person hears a demand, it’s going to make any resolution that will get everybody’s needs met much harder to come by. © Marshall Rosenberg Excerpted from Raising Children Compassionately

PARENTING NOW

The internet stole my children Mike Fisher Founder and director, British Association of Anger Management

My background includes training in psycho synthesis, Adlerian counselling and humanistic psychology. I founded the British Association of Anger Management (BAAM) in 1997, co-founded the Centre for Men’s Development in London and have written a couple of books on anger management. I have been working in the field of counselling including anger and stress management for the past 20 years, so when it comes to angry parents and children, I have witnessed a lot over the last 18 years of frontline experience. www.angermanage.co.uk/facilitators

Communications technology is seductive. As a society we are becoming dissociative. Children are more likely to be drawn in and become over-attached to online activities if their parents are themselves distracted and unavailable. Often I have observed a deadlock if parents try to force their children out of the virtual world. To break this vicious circle of withdrawal and anger the solution is for parents to join their children on a journey into emotional intelligence and mutuality; to find one another through sharing the enjoyment of non-virtual activities.

Having had a few months to reflect on writing this article I came to realise that I don’t think the internet stole just my children, but it also stole most of my good friends as well. Then I started to recognise that as I was observing conversations in pubs or over meals dwindle into interrupted episodes of mobile phone checking, I too was colluding with the same need for distraction, dis-engagement; I was even relieved to have it. The internet and the virtual world are reshaping our lives, our communications, our brains. And so we are becoming in many ways more passive and inactive. But if adults show so little self-control around technology, how can we expect children to do any better? And why would they want to listen to us if what we are pushing for is emotional engagement? Or, if the idea of that terrifies you (and them), how about settling for a simple conversation? It seems we live in a world where because we have lost trust in the social space that connects us, just chatting and ‘shooting the breeze’ can no longer be tolerated; as if we are frightened of empty space. I’m an anger management specialist. As a leading expert in the field I am often the first port of call for parents with angry children. Sometimes teachers concerned about a child’s behaviour and growing

hostility towards other kids and teachers contact me. They all want support for a child to be better behaved and more co-operative.

The importance of presence When people first phone me in distress to discuss their concern I ask them two questions. How much time do their kids spend on the internet and gaming daily, and how much quality time do their spend with their child? By quality time I explain I mean time spent fully engaged in activities that interest your children, even if it does not interest you. In an ideal world we would love it if both parties enjoyed it just as much, but in the real world, not every adult can charge across a playground. The point is that most parents know that most children want to feel connected to their parents. The question then is, what’s getting in the way of connecting? Usually the parents I’m dealing with say their child spends four to five hours online or playing computer games every day. And that is just the time they are aware of. Often long after parents have gone to bed the child will still be online, consumed by social media (chatting to friends) or playing games, watching films or listening to music. In my experience

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most of the families I work with don’t tend to spend any quality time with their child and even when they are around them they are not fully present, being in the moment with their child, focusing on what they are saying and doing and not thinking about something else.

to become even more insistent. It’s a catch 22 vicious circle. The challenge for parents who want to break this negative spiral is to find ways to assert their boundaries, encourage co-operation with young people and not manipulate them.

Overloaded parents

The addictive nature of this virtual paradigm

It’s completely understandable that the primary reason why parents don’t feel present with their children is because they spend almost all their time, day and night, working, doing chores and making sure that the family functions smoothly. This is time-consuming and energysapping, so no wonder they complain they often don’t even have time for themselves. Mostly, the only quality time they get to spend with their children, is on holiday; some weekends and school holidays. Life is busy busy busy! Children get angry with parents because they want their parents to be present for them and children yearn for connection and attention. Should this not be available for them, children will simply get hijacked by an exciting virtual paradigm that captures their imagination and equally distracts them from the painful reality that a core emotional need is not being met. The internet offers everyone an opportunity to escape reality; maybe just to switch off, chill out and disconnect from the everyday humdrum of life. Or more darkly, to dissociate from a desolating lack of care, support and the witnessing of another human being that is a basic human need.

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Children get angry with parents because they want their parents to be present for them

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My view is that in such circumstances, human beings do whatever they can to distract themselves from painful feelings. And not just children, but adults and parents as well. Can you imagine how it would be if we shifted attention away from technology and used it instead for conversation, sharing school work, helping with household chores, meditating or being still, reading, or doing yoga, sport or exercise? I can hear almost every parent scoffing at the very idea of trying to get young teenagers to engage in such things. But how utterly lifechanging it would be; how much healthier we would be psychically, emotionally and academically. The virtual world offers an escape route; a way of avoiding things we don’t want to engage with. Adults can choose this option but young people are not so free, because their boring, demanding and controlling parents expect them to relate. Yet the more controlling and demanding parents become, the more the young person yearns to escape their demands. And the more distant and out of reach a child becomes, the more it triggers parents

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Online activities and gaming can seriously damage your health, largely because of their addictive nature. It is not easy once drawn into the compelling virtual worlds they create, to stop being attracted back there, and eventually to be manipulated, dominated and controlled by them. A rather more radical view of addiction comes from Dr Gabore Meta who in Realm of the Hungry Ghosts – Close Encounters with Addiction, presents his view that addiction has its roots in high levels of stress, anxiety and shame. The typical symptoms of internet addiction are very similar to those you would expect in of other sorts of addiction. Do you recognise any of them in yourself or your child?

Emotional symptoms of online addiction Feelings of guilt; anxiety; depression; dishonesty; denial; euphoric feelings when in front of the computer; unable to keep schedules; no sense of time; signs of stress; isolation; defensiveness; argumentative and aggressive; hostile; impatient and irritability towards themselves and others; apathetic when it comes to doing certain things not involved in being online; avoiding doing work; avoidance of all kinds; agitation and irritability; lack of accountability.

Short-term and long-term effects of an online addiction Online addiction has short-term effects that include unfinished tasks and forgotten responsibilities. Long-term effects are seen more in the physical symptoms such as weight gain, backache, neck pain, carpal tunnel syndrome, and vision problems from staring at the screen. It can also lead to bankruptcy, if the time spent online is focused on shopping, gambling and gaming. Technostress is a term being used to designate stress or psychosomatic illness caused by working with computer technology on a daily basis. ‘The modern family is isolated, with each person wrapped in his or her own ‘techno-cocoon’. Just take a look at what the typical family looks like at the end of the day ... Mom preparing dinner while checking the answer machine, head glued to the portable phone while she returns calls. One child is playing games on the computer in

PARENTING NOW The internet stole my children

his bedroom, another is talking on her own phone, and the youngest is playing Nintendo. Dad comes home later from work and goes immediately to the computer……In many homes we are seeing a loss of communication and a major shift in the power balance in the family.’ Weil and Rosen (2004)

Sleep and blue screens The blue light emitted by smartphones and tablets is thought to interfere with sleep, possibly because it reduces natural production of melatonin. Add to this the lack of bedtime routines in busy working homes, and the impact of late nights and high sugar drinks with or without caffeine. All will tend to make sleep problems worse.

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30% of children will suffer with sleep problems during their childhood, costing millions of pounds

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According to the Daily Telegraph (Walter, 2017) more than 8,000 children under 14 were admitted into hospital in 2016 with a primary diagnosis of sleep disorder, up from less than 3,000 in 2006. This has increased year-onyear for nearly 20 years. According to Children’s Sleep Charity, some 30% of children will suffer with sleep problems during their childhood, costing millions of pounds in doctors’ appointments and presumably, because good sleep is now recognised as so important for long-term health, storing up future problems for the NHS.

Self-assessment: is your child an internet addict? Answering positively to five out of the eight questions may be indicative of an online addiction. • Are they preoccupied with using the internet? • Do they think about their previous or future online activity? • Do they have the need to be online longer to be satisfied? • Have they made repeated but unsuccessful attempts to cut back, stop or control their internet use? • Do they become moody, restless, irritable or depressed when they stop or decrease their internet use? • Is their time spent online longer than what they originally planned? • Does their online use negatively affect a significant relationship, education, career or job?

• Do they conceal the extent of their internet usage from family or others? • Does the internet serve as an escape from problems or relief from a bad mood?

Some solutions Here are a few strategies that you can consider with caution: • Share your concerns about how you experience your child as being absent, but don’t shame or blame them (which is what parents tend to do). Talk about how you feel, and how you are affected by this disconnection. Tell them you recognise that you can also sometimes not be present with them. Give yourself permission to be transparent and vulnerable. That’s often the healthiest place to start. For example: ‘I feel sad that there is so much distance between us now and I am aware that I have not been very present and available to you as and when you need me. I feel guilty about how little time I have given you and there is no excuse for it. I love you and miss you and I am hoping that together we can find a way for you to not spend so much time gaming and online. Let’s explore some things that we can do together. Here is my list. Would you try and think about a list too? I hope that between us we can create time and make dates to do these things together. How does that sound to you?’ • Start to become more aware of what your children are consuming. Consider the effect this content is having on their health and wellbeing. Once you have some sense of the effect it’s having on them you can start to negotiate how to reduce their time on the activities affecting them. • You also have to decide, based on their age, whether what they are doing is okay. Here you need to do your research with other parents because most children are exploring and watching what their peers are doing or watching. Then negotiate what is healthy for them and what’s not healthy for them, based on your own research and facts. Once again if they are addicted to something specific you need to negotiate how they wean themselves off. Most young people do not actually know what’s healthy for them or not until of course it’s too late. Do your research and observe their behaviour and how it’s also impacting their health and wellbeing. • You will then have to contract how much time they can spend online. As with any addiction there can be no going cold turkey. One of the things you are both going to have to agree on is how much time your child can spend online. It is about finding a strategy to wean them off and it needs to be replaced with other healthy activities, which you can both agree to do together. It’s vital that whatever you agree gets signed and sealed and delivered on. No mixed messages

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PARENTING NOW The internet stole my children

because that’s what they are expecting you to give them and they have heard many promises and commitments before. • Explore a range of activities you can do with your child and create space to discuss that with them and include them in the decision-making process. Make it as much fun as possible. The whole family will be nourished by doing new things. Get creative and engage them with coming up with solutions too. This is empowering for everyone. • Set and agree times when they can go online. Please, once you have made an agreement, do not let them manipulate you into changing your mind.

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Our job as parents is to mentor and guide our young people through life’s adversity

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Even at its best, being a parent allows you only to witness and steer another being’s ship for a very short period of time. The parent’s task as steersman is neither to over-pressurise nor to fall into a pit of shame when something goes wrong. Life is full of upsetting and

distressing things. Our job as parents is to mentor and guide our young people through life’s adversity. To do so we must learn to be aware of our own feelings and fully embrace them. If we can communicate with kindness and honesty it helps our children learn to articulate and navigate their own emotional life. By reducing our need to hide and hide from distressing feelings, we lessen the need for distraction. This journey requires us to develop an internal narrative of our own, and to have coping strategies and creative outlets. In this way we can start to be more open with our young person and so explore their emotional terrain together. When it works we get to share the high moments and to hang in there with the harder ones. What you will be building is a mutual emotional intelligence; something of great value which they will refer back to for the rest of their lives. I guarantee you it will beat any computer game. Maté G (2013) In the realm of hungry ghosts. Toronto: Vintage Canada. Walter S (2017) Surge in children being admitted to hospital for sleeping disorders with many kept awake by technology. The Telegraph. Available at: www.telegraph.co.uk/news/2017/03/04/surgechildren-admitted-hospital-sleeping-disorders-many-kept (accessed 27 February 2017) Weil M, Rosen L (2004) Available at: www.technostress.com/ tsconversation.htm (accessed 27 February 2017)

Transformative innovations for health: a gathering of change-makers A one day joint working conference organised by Westminster Centre for Resilience, the Scientific and Medical Network and the BHMA The neatness of medical science is unravelling. 20th century medicine focused on smaller and smaller parts with astonishing success: triumphant in infections, deficiency diseases, with surgical excisions and transplants, intensive care and anaesthetics. But 21st century medicine is confronting whole person (indeed whole society) problems: chronic degenerative and inflammatory diseases, stress-, environment- and lifestylemediated diseases, addictions and psychological disorders. Bio-technical single-solution approaches won’t cure them. If, as has been said, the future is already with us but unevenly distributed, where might we find seeds of the new paradigm? This working conference, jointly hosted by Westminster Centre for Resilience, the Scientific and Medical Network and the BHMA, will bring change-makers together to celebrate the future. Speakers and workshops to be announced soon so keep an eye on: www.centreforresilience.co.uk https://explore.scimednet.org https://bhma.org

Saturday 18 November 2017, University of Westminster, London

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EARLY YEARS

Whatever happened to Sure Start? Donna Gaywood Children Centre teacher, Bright Start and First Steps Children Centres

Heidi Limbert Children Centre Service manager, Bright Start Children Centres

I graduated as a registered general nurse (RGN) in 1993 and went on to become a specialist community and public health nurse, and then a health visitor in 2001. In 2008 I completed my National Professional Qualification for Integrated Centre Leadership (NPQICL). I am passionate about addressing social disadvantage and actively seek to promote positive parent–child relationships in order to support both adult and child mental health as ways to break intergenerational cycles of poverty, deprivation and poor outcomes. Heidi Limbert I qualified as a teacher in 1990, gained my NPQICL in 2014 and graduated from Birmingham City University with an MA in Early Education in 2015. I have worked with children of all ages from 0 to18, and adults in a variety of situations. I specialise in supporting the learning of children who find themselves facing significant challenge. Education is far more than the formalised teaching and learning found in the British school system, and I work hard to ensure that all children have access to rich learning opportunities at Bright Start and First Steps Children Centres. Donna Gaywood

This article outlines the development of the Sure Start Local Programme within Bath and North East Somerset. The authors demonstrate how this service has developed since it’s conception and also describe the type of services which are currently on offer for very young children and their families. They also consider the positive impact of Children Centre services for individuals, their families, the local community and more widely for the ongoing health of society.

‘The moral test of a government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick and the needy. Hurbert H Humphrey, 38th Vice President of the United States (1965–1969)

In 1990 the United Nations Convention on the Rights of the Child (www.unicef.org.uk/what-we-do/ un-convention-child-rights) charged governments with the responsibility to support parents and carers by providing ‘institutions, facilities and services for the care of children’ (Article 18). The Convention also recognised the right of each child to ‘engage in play and recreational activities appropriate to the age of the child’ (Article 31). In response to this, Tony Blair’s New Labour government introduced the Sure Start Local Programmes in 1998, with the aim of providing local access for young children to health services, early education and family

support. Initially, central government funding established 250 such programmes in the most deprived areas across England and Wales. With the intention of creating a Sure Start Children’s Centre in every community, this was increased to 3,500 by 2010. 2003 saw the publication of the Laming report following the death of Victoria Climbie which concluded that professionals needed to work more closely to prevent other deaths. Common outcomes for children were developed and the Every Child Matters Outcomes provided the cornerstone for the Sure Start programmes. It was also from 2003 that the Sure Start Children’s Centres began to emerge in Bath and north east Somerset, where we now work. By 2012, the core purposes of Children’s Centres was to: • improve the education outcomes for young children and their families (especially the most disadvantaged) • to reduce inequalities

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• provide high quality universal services to all families within the local area • offer information and advice to support parents to make informed choices • act as a hub for the local community, building social capital and cohesion • provide integrated health and family support services to optimise life chances • share expertise with other early years settings to improve quality and share with specialist services where there are more complex needs. In 2014 the Office for Standards in Education (Ofsted) provided a framework for Sure Start Children’s Centre inspection which identified the children and families that were considered most vulnerable and at risk of failing to meet their Every Child Matters Outcomes*. As a result, Children’s Centre services have been asked to adopt a more ‘targeted’ approach, offering support primarily to those identified young children and families. This, of course, coincided with the government’s austerity measures resulting in significant reductions in local authority funding. By late 2015 there was widespread concern about loss of children’s services (Torjesen, 2016; Toynbee, 2016) In spite of this change of focus, Children’s Centres have continued to deliver health and early education opportunities along with support services for families with children 0 to 5 years, although Children’s Centres within Bath and north east Somerset developed an after-school provision for children with social, emotional and behavioural needs, so were working with children 0 to 11 until recently. This is through a multi-agency team with professionals from a variety of backgrounds working together to improve the outcomes for these children

Working with others The need to develop a cross-sector approach for children under five has been a long established and accepted norm (Laming, 2003) and continues to be so (HM Government, 2015). This remains a core purpose for Children’s Centres ensuring effective local partnerships, particularly between social workers, health visitors, early years educators and children’s centre outreach workers, so that vulnerable families are supported to access appropriate and evidence based services that best meet their needs. With a view to reducing inequalities, child poverty and increasing social mobility, staff currently work with a range of other partners to help them deliver this core purpose, for example: other early (pre-school) education settings, employment support agencies, GP consortia, information and advice organisations, schools and voluntary and community sector organisations. Bright Start Children’s Centres (the name for the Children’s Centres operating within Bath East, Keynsham and Chew Valley and the Somer Valley areas) have recently

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begun working jointly with the local drugs and alcohol service – whereby parents gain their adult-focused support for an hour-and-a-half and then join their children for a further half-hour for targeted ‘Sunshine Circles’ built on the principles of Theraplay (see below). It could be argued that young people and adults turn to over-use of alcohol and drugs to escape and find love and contentment or address a self-loathing. We hope to be able to play our part in reaching the parent and child and breaking the inter-generational cycle in which these public health issues often exist. At the time of going to print, we heard that Theraplay has recently been accepted by the US Substance Abuse and Mental Health Services Administration for inclusion on the National Registry for Evidence-based Programs and Practices. We are keen to contribute to this evidence base as well as the UK’s Early Intervention Foundation (www.eif.org.uk/about-us). Due to the nature of Children’s Centres and their broad inter-disciplinary approach, over the course of 11 years staff have become highly skilled in providing much needed early help services. Staff are adept at promoting voluntary engagement with families who are facing extreme challenges, for example children and families living with domestic abuse, managing the effects of poverty and/or physical ill health or disabilities, mental ill-health and those who abuse substances (alcohol or drugs). In addition, staff understand the effect of early childhood trauma on a young child’s developing brain and are able to provide a positive learning environment both physically and emotionally, alongside cognitive enhancing activities which mitigate the effects of their environment.

The principle of attachment within Children’s Centre services Bright Start Children’s Centre services have been developed through understanding the importance and protective nature of safe, stable, nurturing relationships and environments. ‘Evidence is accumulating that human beings of all ages are happiest and able to deploy their talents to best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties arise.’ (Bowlby, 1979:103)

The principle that ‘parents are their child’s first and most enduring educator’ (DfE, 2014) is well established and the importance of the development of this early relationship, has shaped and underpins the work. Our overarching aim is to support: ‘all children and young people to enjoy childhood and to be well prepared for adult life’.

EARLY YEARS Whatever happened to Sure Start?

Three ways to develop nurturing relationships Parents are supported to develop warm, nurturing relationships with their children through the ‘Bright Beginnings’ baby massage programme. The Sign Rhyme Story Time groups enable parents to develop confidence to sing with their children and share books. Theraplay sessions support parents on a one-to-one basis to improve their attachment to their children. For children and families to learn in a wider social environment, there are play and explore groups.

Bright Beginnings This was developed out of two independent models – baby massage and Peers Early Education Partnership (PEEP). Baby massage is a longstanding parenting tradition in many cultures. It was introduced into western cultures in the last 30 years and has been gaining popularity since the late 1990s. It involves the parent or carer giving soothing holds and strokes on different parts of a baby’s body following a sequence which has been developed over many years. Infant massage provides a wonderful experience and a special time to communicate both verbally and non-verbally with babies, so that they feel loved, valued and respected. The International Association of Infant Massage (IAIM) nurturing touch programme (www.iaim.org.uk/about-baby-massage.htm) draws from both the Indian and Swedish massage traditions as well as incorporating principles from yoga and reflexology. PEEP (Peers Early Education Partnership) was set up in 1995. It is an early learning intervention which aims to contribute towards improving the life chances of children, particularly in disadvantaged areas. Its purpose is to raise educational attainment, especially in literacy. The PEEP programme focuses on how to make the most of the learning opportunities in everyday life at home – listening, talking, playing, singing and sharing books every day. PEEP values parents/carers knowledge and experience of their children and works with parents as equal partners, offering a non-judgemental approach towards families. The programme, welcomes people from all backgrounds and cultures and creates opportunities for parents to share experiences and ideas in a safe and supportive environment. PEEP recognises that: • parents/carers are a child’s first and most important educators • self-esteem is central for learning • learning works best when the world is understood from the child’s point of view • children learn through play and interaction • singing, stories and books are extremely important in the education of children, • learning begins at birth

• relationships are at the heart of learning and encourages: – parents/carers to learn together with their children – high expectations of what children and adults can achieve together. Through this eclectic Bright Beginnings model, Bright Start Children’s Centres are able to support the early development of relationships within the family and has proven effective particularly in supporting families affected by postnatal depression, or having experienced difficult births or any other circumstance whereby the ‘connection‘ between parent and child needs support to develop. The PEEP principles now extend to all other areas of the service’s work across all the Bright Start Children’s Centres.

Sign Rhyme Story Time The service-developed programme of Sign Rhyme and Story Time was originally marketed as HARRY – Helping Adult’s Read with the Really Young. A senior family support practitioner developed a six-week course which was designed for parents/carers to develop and increase engagement with reading and communicating with their children in order to promote communication and language skills from birth. Adults were supported to feel confident to share stories through books and creative storytelling, to use Makaton signing to help their children make connections, and encourage talk with their child. There was a craft activity which encouraged families to be creative and enhance language, increasing early literacy skills such as mark making. Each family created their own song box to use at home. HARRY was delivered with the support of the under-five children’s librarians who explained the benefits of becoming a member of the library. The parents were invited to enrol their children as well as themselves with the library service.

Theraplay Children’s Centres work with a variety of families. As part of their ‘universal’ offer, health visitors within the team work with all families to enhance their understanding of, and confidence in ‘being’, a parent. Within their universal partnership approach, they also work with parents who may themselves have had their own childhood and/or mental health affected by adverse life experiences (parental separation, concerns related to their own mental health or that of their parents, poverty, substance misuse, fostering or adoption etc). It is at this point that they will refer them to the children’s centre for more targeted support and where Theraplay is of particular benefit – to both parent and child alike. Theraplay is a child and family therapy for building and enhancing attachment, self-esteem, trust in others, and joyful engagement. It is based on the natural patterns of playful, healthy interaction between parent and child and is personal, physical, and fun. Theraplay interactions focus on four essential qualities found in parent-child

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EARLY YEARS Whatever happened to Sure Start?

relationships: structure, engagement, nurture, and challenge. Theraplay sessions create an active, emotional connection between the child and parent or caregiver, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding. In treatment, the Theraplay therapist guides the parent and child through playful, fun games, developmentally challenging activities, and tender, nurturing activities. The very act of engaging each other in this way helps the parent regulate the child’s behaviour and communicate love, joy, and safety to the child. It helps the child feel secure, cared for, connected and worthy. While it is offered in its ‘pure’ form to address the identified needs of the child and their relationship with their prime carer (ie, where child has been fostered or adopted), it is also beginning to be offered in our collaborative work with adult-focused services. This includes services focused on meeting the needs of the parent victim of domestic abuse and the family affected by parental substance misuse. The aim is to offer time and space to assertively place the child at the centre of the relationship, protect and enhance it, enhance the personal skills of both parties and the skills and confidence in parenting generally

The impact of Bright Start Children’s Centre services The work of Bright Start Children’s Centres is vital for positive community development and ensuring our wider society is a more equitable and transformative for all children. Internally, we are able to provide evidence for the positive impact of Children’s Centre services and how children and families lives can be changed as a result. The Children’s Centre team is committed to a strong participatory ethos which enables parents and the children to reflect on their own learning and consider what gains have been made. The Family Outcome Star (www.crec.uk/ace.pdf) and the Accounting Early for Lifelong Learning Programme (Bertram et al, 2008) are used with parents to demonstrate improved outcomes. The ‘child’s voice’ (Clark and Moss, 2011) is honoured and all children (from birth onwards) are considered as active participants in their own learning. For the wider community we understand that safe, stable, nurturing relationships and environments are essential to preventing child maltreatment and to assuring that all children can reach their full potential. We know that healthy relationships between parents and their children are important, but a recent special issue in the Journal of Adolescent Health has shed light on the importance of safe, stable, nurturing relationships between parents and other adults in preventing child maltreatment. The role of safe, stable, nurturing relationships between adults might be especially beneficial for parents who experienced abuse during their own childhood years. Adverse childhood experiences (ACEs) or maltreatment in one generation is associated with adverse childhood

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experience or maltreatment in the next. However, the cycle can be interrupted. It is important to know that past exposure to ACEs does not define a person. Services such as those offered within Children’s Centres can help to break the cycle. Nurturing relationships can protect against factors that might increase the risk for perpetuating abuse (eg, stress) and they provide models for positive interactions and social support. If you would like to know more about the services on offer or would like to refer a child and their family to Children Centre services, please follow the link on B&NES website www.bathnes.gov.uk/services/childrenyoung-people-and-families/childrens-centres Bertram T, Pascal C, Saunders M (2008) Accounting early for lifelong learning. Birmingham. Amber Publications. Bowlby J (1979) The making and breaking of affectional bonds. Hove: Brunner-Routledge. Clark A, Moss P (2011) Listening to young children: the mosaic approach (2nd ed). London: NCB. DfE (2014) Early Years Foundation Stage 2007, 2014. Available at: www.gov.uk/government/uploads/system/uploads/attachment_ data/file/335504/EYFS_framework_from_1_September_2014__with_ clarification_note.pdf (accessed 4 March 2016). HM Government (2015) Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. London. HMSO. Laming H (2003) The Victoria Climbie Inquiry. Norwich: The Stationery Office. Office for Standards in Education (2014) The framework for Sure Start Children’s Centre inspection. Manchester: Crown publishing. Torjesen I (2016) Austerity cuts are eroding benefits of Sure Start children’s centres BMJ 352:i335. Toynbee P (2016) How does cutting support for families help the poor? The Guardian, 12 January. Available at: www.theguardian.com/ commentisfree/2016/jan/12/david-cameron-parenting-classeschildrens-centres-cuts (accessed 4 March 2016).

* Ofsted vulnerable categories • • • • • • • • • • • •

Lone parents, teenage mothers and pregnant teenagers. Children from low income backgrounds. Children living with domestic abuse, adult mental health issues and substance abuse. Children ‘in need’ or with a child protection plan. Children of offenders and/ or those in custody. Fathers, particularly those with any other identified need, for example, teenage fathers and those in custody. Those with protected characteristics as defined by the equality act 2010**. Adopted children and adopter families. Children who are in the care of the local authority (looked after children). Children who are being cared for by members of their extended family such as a grandparent, aunt or older sibling. Families identified by the local authority as ‘troubled families’ who have children under five. Families who move into and out of the area relatively quickly (transient families), such as asylum seekers, armed forces personnel and those who move into the area seeking employment or taking up seasonal work.

** Children and families with protected characteristics may include: those for whom English is an additional language; those from minority ethnic groups; those from Gypsy, Roma and Traveller families; those from lesbian, gay and transgender families.

RITES OF PASSAGE

Crossing the threshold Gabby Hollis Managing director of Tides Rites of Passage (for teenage girls), Golden Bay, New Zealand

Young people today face one of the most exciting and challenging times of their life – building an independent identity, while moving into the wider world of possible risk and danger. Their physical and mental health depends on the availability of a community that is willing to help navigate the inner and outer changes of the adolescent terrain. Rites of passage can help young people build the confidence they need to make positive life choices. They can also contribute to adolescents finding a sense of belonging, forming strong bonds with multiple generations along the way.

I have been involved with Tides since 2005. I work with up to 27 new teenage girls and their families every year. I also work with the same number of returning young women, some of which have grown through the programme, and their teens, becoming strong adult facilitators themselves. It is a privilege to see young people open their eyes to their own longing and watch whole families embrace each other within the honesty of their own imperfections. It’s from this place that I see empowered young women, healthy families and supportive communities emerge.

Tides has been running since 2004 and is a ‘sister’ programme to Tracks (Rites of Passage for teenage boys). The early programmes evolved out of men’s and women’s gatherings that had been happening regularly at Tui Community (an intentional residential community at Golden Bay, South Island) for 18 years. Those gatherings had provided a forum for men and women to share stories about their lives and address issues that had been holding them back, from making positive life choices, as adults. It came to the attention of Jim Horton (a longstanding Tui resident), that if young people had access to a similar forum then perhaps the path to adulthood would be happier, healthier and more clearly marked. From those beginnings the Rites of Passage Foundation emerged – a charitable trust, based in Golden Bay, New Zealand. The trust now supports and governs the running for six rites for teens and their families, and four trainings for men and women, yearly. I became involved in 2005 and soon recognised the influence that a rite of passage can have towards the overall health and wellbeing of young people. From ancient times and to this day, young people (12 to 24 years) or adolescents have been and still are, biologically driven towards metamorphosis. Aside from the zero to three years, there is no other time in

the life of the human body and brain where transformation occurs to the degree that teenagers experience. For millennia, cultures have given priority to acknowledging and celebrating this important transition by means of a rite of passage. In doing so they supported their young people to be strong, confident and mindful members of society. The future depended on it. For the young person of today, a different level of courage and strength is required to former times. The same drive, hunger and sometimes desperation to evolve is there, but so is the near constant presence of the media and social networks suggesting how to think, act and even feel. The instinct of the young is to seek wildness, be bold, explore and access the longing that sits in the furthest reaches of their being. This is met with a culture that is mostly void of spirituality or generally too busy to notice. It’s a culture that is more comfortable and familiar with ‘an initiation into the addictions of consumerism’ than the teachings of elders, high priests and wise women. In his book Nature and the Human Soul, Bill Plotkin states that: ‘The main task of an adolescent is to create an identity that is both authentic and accepted by their community’. In a world that is full of superheroes, fast food, porn, pop

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stars, drugs and video games, identity formation becomes an elusive undertaking. The concept of community is also far less tangible, and difficult to access, in a world that is rapidly expanding. The need for a young person to feel like a valued member of society is paramount. If achieved they are much less likely to suffer from a wide range of mental health issues that affect 10% of youth. Anxiety, depression, phobias, eating disorders and panic attacks are among the most common, and can seriously affect how a young person thinks, acts, feels and handles life, on a day-to-day basis. Current studies into the youth suicide rates of developed nations show an alarming increase in the last 50 years. Looking at cultural trends, researchers suggest that this rise reflects the loss, in western societies, of appropriate sources of connection and social identity. Those trends also show an increase in the promotion of inappropriate expectations of autonomy.

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Young people need inner tools and resources to develop a strong sense of self and certainty

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In this age of information, it’s hard for young people to make meaningful choices. If you have the means, you can buy pretty much any lifestyle or commodity you want. Whether or not it brings you alive and feeds your spirit is another question. In the absence of a community that can notice and encourage the contributions of their young people, the path to adulthood becomes a long, drawn out and sometimes dangerous trail. Suicide is an obvious extreme but there is a wide range of concerns that go under the radar before that. Loneliness, alienation and addiction to name a few. So how do we initiate our young, when the adults around us have no idea what that looks like or are still trying to figure out what it means to be an adult themselves? In most cases we don’t have the luxury of a clearly defined path to adulthood and if we do it often fails to satiate the hunger of the adolescent psyche. Young people need inner tools and resources to develop a strong sense of self and certainty. They need to recognise what their positive contributions to the world are. They need to feel worthy, beyond the ideals of being special, exceptional or having the ability to surpass others. They need to discover a sense of pride in who they are and in their own identity. They also need to know when they are expected to behave like an adult. Traditionally a rite involves ceremonies, rituals and activities designed to prepare individuals for a new role in society. The focus of the rite is on the successful transition of the young people but it calls forth whole tribes, villages and communities. As a young person moves towards adulthood, all members of their community step toward their next phase of life. In doing

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so, whole societies recognise and understand what their role and importance in the world is, in relation to their life phase. They also recognise the value of contributing to the lives of others in a positive way. A rite itself usually involves three main phases: 1 Separation The aim here is to help the young person leave behind patterns, attachments and ideas that were part of their childhood. On some level most adolescents don’t want to leave the safety of their childhood despite the craving for freedom. For the adolescent to move forward the ‘child self ’ must in some ways die. This phase of a rite helps adolescents move through resistance and connect with the yearning within. 2 Transition or initiation The aim here is about transformation. The initiate is seen as ‘standing between worlds’ as they struggle to break free from what was and become what will be. It includes carefully designed hazards that invite the initiates to engage with an element of risk and challenge. In that, they became conscious of their own mortality and the crucial shift from being protected to self-managing occurs. It is not traditionally designed as a transition of ease or beauty. The young people are required to stretch their capacity and find the deep recesses of their strength. This assists in their understanding of how to meet the trials of life without shutting down. Some of the challenges also allow a young person to reach non-ordinary states of consciousness. From there, new perspectives and understandings emerge. 3 Return or re-integration At this point the young person-becoming-adult has gained entrance into the next phase of their life. They carry new freedoms and responsibilities and are treated differently by the members of their tribe. They also have new insights they can gift back to their community. And so the young person feels worthy, valued and knows what is expected of them. What worked 1,000 or even 100 years ago is unlikely to fit the bill or have relevance for a teenager today. Culture has and needs to evolve to support the wellbeing of young people now and in the future. The details shaping a rite of passage vary, depending on the peoples performing them and the land from which they originate. Despite that, there are some essential threads that run through them all; a tangible relationship with the intangible; a recognition of what is sacred; a knowing that in order to achieve initiation, a degree of selfsacrifice is required, as is an openness to learning. Initiations that are pursued without such fibre only serve as entertainment and can contribute to the equally crushing idealism or disillusionment that young people experience. Whole families are under the pressures of modern society. The ‘child genius’ is separated out and the

RITES OF PASSAGE Crossing the threshold

teenager faces the pressure to be perfect. As adults we are expected to be able to do it all, and flawlessly, only to find that as elders we are expected to be quiet and not take up younger people’s time. This all amounts to whole generations of people becoming more and more separate from each other. Being nature-based, Tracks’ and Tides’ rites bring together communities of up to 40 people, over 7 days. We create a high adult-to-young-person ratio with adults ranging in age from 18 to 65+. They bring a wide range of skills and life experience. From that, the teens bear witness to the huge diversity of what it means to be a man or woman. The rites also call in ‘young leaders’, teens who have been through their rite of passage and return in service to the new people coming through. Being closest in age and experience to the initiates, the young leaders offer a unique and essential role of support. They also have the opportunity to delve deeper into their own exploration of self-discovery. The rite itself is open to 13 to 16-year-olds and their mothers, fathers or caregivers. The importance of the latter being present is that even though the rite is primarily about the young person, everyone around them is affected. The shift that is taking place for a teen has direct and indirect influences on the people they are closest to. A young person might want to make changes in their life but if no one is there to see, hear, understand or support that, they have a much harder task ahead. The way we parent our children needs to grow and change as they do. Mothers and fathers at Tides and Tracks have the opportunity to reflect on their life as a parent or guardian and to see their young people as they stand today. They meet other parents who have the same concerns and challenges and are able to share and hear, real life stories. For a mother at Tides, one of the hardest things can be coming to terms with the fact that she needs to give her daughter more space and allow the relationship to shift somewhat, from mothering to mentoring. It’s a natural instinct to protect our children from the potential dangers, challenges and heartbreak they might encounter in the world, but there comes a time that in continuing to do so, young people become frustrated and start to rebel. It’s not that they are trying to push their parents away, they are trying to push themselves away. Those parents that can stand strong, while understanding their child’s needs, give a young person something firm from which to launch off. Providing opportunities that allow young people to go their edge and take risks in a safe, supported way encourages self-discovery. It also helps them find confidence to overcome the day-to-day challenges of life. An old African proverb states: ‘If we don’t initiate our young, they will burn down the village to feel the heat’. In a phase of life that often presents itself as a series of extremes, young people can appear warrior-like in the

face of the things they care about. They have the power to fall deeply in love, to fight for the worthiest cause or surrender to the deepest of sleeps. They see and feel the need to make positive change in the world and are faced with the various cycles of destruction performed by the ‘adults’ who have gone before. It’s a powerful and vital energy and it has an important role to play in society. It needs recognition. It also needs guidance. Without the former, it becomes suppression. Without the latter the village is burning. The transforming adolescent self aches to be tested, challenged and expressed. To shed the old and travel beyond what is known. When not guided by elders and mentors to channel this energy, adolescents are exposed inadvertently to risk. They need deep soul recognition by peers and mentors and a vision of a future filled with inspiration and purpose. They need good men and women around them, who are prepared to share the deepest truth about their lives. Without that they run the risk of building an identity based on guess work from peers, borrowed images, fantastical heroes and the collective stereotypes of popular culture. Now more than ever, they need real men and women present in their lives. A conscious rite of passage can help a young person grow true to themselves, move beyond childhood, build self-confidence and discover their potential. It can encourage them to recognise and trust their intuition, find their own voice and make healthy choices. From there, they can stand on their own two feet with a sense of belonging and confidence. Not only that, but they are more likely to enjoy life along the way! This being human is a guest-house Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all! Even if they’re a crowd of sorrows, who violently sweep your house empty of its furniture, still, treat every guest honourably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, meet them at the door laughing, and invite them in. Be grateful for whoever comes, because each has been sent as a guide from beyond. Jelalludin Rumi, The Guest House Plotkin B (2008) Nature and the human soul. Novato, CA: New World Library

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RESILIENCE

Nurturing childhood resilience Luke Harrison Nature Nurture group leader

Terri Harrison Co-founder, Nature Nurture Project

I joined the project full time in 2015. I run the 8–11s programme in Camphill School Aberdeen and work as a team member in the under 5s and 5–8s programmes. I am also responsible for the project’s photography and filming, and for maintaining Nature Nurture’s social media presence. I have more than nine years’ experience working with children and young adults with additional support needs. Luke Harrison I was instrumental in the creation and establishment of the Nature Nurture approach, currently acting as a project co-ordinator and group leader. I am also responsible for delivering regular training and CPD sessions for Nature Nurture staff. Before beginning Nature Nurture, I was a teacher and ran residential units in Camphill School Aberdeen. I run training in outdoor learning and play throughout the UK and have been a tutor on a Forest School training course for the past three years. Terri Harrison

Nature has intrinsic restorative qualities. In this project, characterised by holistic therapeutic intervention, these qualities are used to nurture children’s resilience. Over their weekly visits, children, often traumatised or anxious, play in the natural world and experience natural spaces that are challenging but safe.

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The Nature Nurture Project The Nature Nurture Project emerged at a time when understandings of the intrinsic health benefits of nature and outdoor education were still coming to the fore. As a result, the project was one of the first outdoor early intervention schemes for children in the United Kingdom. Established in 2009 by a group of passionate childcare professionals, The Nature Nurture project began running initial pilot sessions in collaboration with Camphill School Aberdeen and Aberdeen City Council. The project aimed to work with Aberdeen’s most vulnerable children and offer them a natural environment within which to promote and nurture the growth of resilience. After receiving substantial funding from the Scottish Government through the Go Play Project, the project’s co-ordinators, Terri and Daniel Harrison, have expanded and developed Nature Nurture’s care provision, offering programmes for primary-aged children. The Nature Nurture approach can be described as a holistic therapeutic

intervention which uses the restorative effects of natural outdoor environments, nurturing relationships and child-led play. In the seven years since the project began, we have facilitated the growth of resilience and wellbeing in hundreds of young children in Aberdeen.

Our understanding of the child The Nature Nurture project was founded on a clear set of understandings of the individual. They can be described as assumptions of being; particular ways of viewing each of the children we work with. These understandings have come to inform the Nature Nurture approach and the early intervention care we provide. The Nature Nurture approach recognises the child as a whole being. That is to say, we are holistic in our approach to understanding and caring for children and their particular needs. We recognise the importance of considering all aspects of the child’s existence and how these are necessarily inculcated in forming the human being that stands before us at

RESILIENCE Nurturing childhood resilience

any given time or place. Our model of resilience reflects this holistic vision, integrating the cognitive, emotional, physiological, social and creative aspects of the child’s life. The Nature Nurture approach recognises the child as a unique being. In this way, children are seen to be unique experiential learners, actively involved in constructing meaning from their experiences of the world. From this process of meaning making arises unique frames of reference which guide the child’s understanding and way of being at any given time. In order to provide effective and meaningful care it is deemed essential to become attuned to each child and their unique ways of sensing, perceiving and learning. The Nature Nurture approach recognises the child as a capable being. By this we mean that children have the ability to become conscious of themselves, affect meaningful choice and actively shape the direction of their own lives. We hold that within every child resides the innate propensity and resources for self-directed growth and development. The child’s recognition of these intrinsic self-qualities is made possible by a particular therapeutic climate of facilitation.

Nature, nurture, play = resilience With these core assumptions of being at the heart of the Nature Nurture approach, our aim is to nurture the resilient being and seek to place the child at the forefront of this endeavour. The resilient child is recognised as being self-aware and in equilibrium, confident in their feelings and resultant actions, empathic and sensitive in their interpersonal communications and connections with the world and creative and open in their thinking. Resilience is defined ultimately as ‘the mental, emotional and physical fortitude to recover from adversity and realise potential’.

Over the seven years that Nature Nurture has been running we have developed an understanding of the environmental conditions which promote wellbeing and resilience. Through close and concise observation of children and the continuous evaluation of the care outcomes associated with their time at Nature Nurture, we have put forward a model for an effective therapeutic climate.

We argue that if children have access to natural environments, nurturing relationships and the freedom of child-led play, they tend to show marked self-directed development in their resilience. This is known as the NNP=R formula. So how can the elements of nature, nurture and play contribute to the promotion of wellbeing and resilience? Nature has intrinsic restorative qualities which hold unique value for each individual. Being outside and active is integral to the work of facilitating wellbeing in children. Anxiety and stress are some of the most common states we witness in the children we receive. They come to us functioning to survive, driven by fight, flight or freeze responses to the world around them. In these hyper or hypo aroused states of stress, many of them have forgotten or are unable to recognise the sensation of being in a balanced or calm-alert state. After a short time spent in our outdoor spaces, however, children come to embody the restorative effects of nature. We have observed that simply being immersed in the grand systematic rhythms and flows of the natural world has a regulatory and calming quality. This paces the children and allows them the time to process and become conscious of themselves and others around them. In this self-affirming calm-alert state they are able to function with purpose and meaning. Nurturing relationships are held to be the foundation upon which the child achieves resilience. The Nature Nurture approach is child-centred and nurturing refers to the facilitation of every child’s growthpotential through fostering a growing self-awareness and recognition of unique value. This begins with the establishment of empathic and authentic relationships between child and adult which are based on respect and reciprocity. We have observed that even the most traumatised children have a purposeful directionality and when they can feel secure, respected and valued in their relationships they will grow and flourish, becoming aware of their strengths and vulnerabilities and actively seeking to learn through their experience. Play is fun. It is this intrinsic value that we cherish most of all at Nature Nurture. Through the freedom of play, so many of our children are able to be themselves and experience enjoyment once more. But play has a plethora of health and wellbeing benefits and is a vehicle for physiological development, social competencies, selfdiscovery and creative expression. Play provides children with a self-constructed stage upon which to test out identities, ways of being and formulate meaning from real-world experience. The vast resources that nature provides along with close and attuned nurturing relationships mean that play meets the specific needs of each individual child. The natural spaces in which we play at Nature Nurture are challenging yet safe, stimulating yet relaxing, peaceful yet exciting. We actively encourage children to evaluate and risk assess their play environments. This is both to encourage awareness and respect for the natural world but also to give children an experience of

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self-worth and allow them to recognise their capability to manage risk in their own lives.

The seven building blocks of resilience The Nature Nurture team needed concise methods for observing and evaluating the development of resilience promoted by the establishment of this therapeutic climate of facilitation. We set out to develop our own holistic model of resilience which could be used in several stages of developmental evaluation. The model divides resilience into seven clearly defined and yet interconnected domains.

long, with children attending half-day sessions once a week. They are collected from home or school in our minibus. Children often stay with us for several programmes until they feel more resilient and the professionals in their lives can see significant improvement in their ability to cope with challenge and adversity. Nature Nurture runs in the grounds of an independent school on the outskirts of Aberdeen. We have access to three woodlands, streams, a care farm, playgrounds and large grassy areas. At present the project is running three programmes: children under five, five to eight and eight to eleven. Each of our groups has their own unique site which suits the children’s developmental needs.

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Nature has intrinsic restorative qualities which hold unique value for each individual

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The seven domains and their respective set of indicators inform all evaluative tools we use in measuring resilience. Our evaluative process of the child comprises an initial base-line assessment, a continuous observational assessment, a mid-way evaluation, a final end of programme report. This process provides our staff and other professionals with a comparative overview of each child’s development throughout the course of their time at Nature Nurture.

The structure and running of the project The children are referred to Nature Nurture by education, health or social work professionals. These children are often traumatised or suffer significant stress or anxiety. Many come from families affected by substance misuse, alcohol abuse or domestic violence and have experienced a degree of neglect. Each programme is 10 to 15 weeks

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Our youngest group has a small woodland which includes a sensory trail. The walk to and from the woodland stays the same each session and incorporates physical challenges such as climbing a steep hill, practising road crossing skills on the quiet driveway, and balancing on stepping stones and logs. The children also like to stop and visit the sheep. Music and songs mark each transition throughout our journey. In the woods we explore and investigate, create sounds with musical instruments and engage in water play. There is a covered snack area in the woods where the children can sit together in a circle and share a snack of fresh fruit, delicious fruit bread made by a local baker, and either hot chocolate or juice. The theme of journeying is continued in the 5 to 8year-old group. The journey to the woodland site is longer and more challenging, but with lots of places to stop and play along the way. Our route includes a playground, a gentle slope for rolling down, a giant leaf pile, a yard with pigs, a barn with cows and a wild wood for collecting sticks. Our main site is beside a stream which the children love to play in. The children gather around a campfire area and discuss the ways in which we can keep ourselves safe

RESILIENCE Nurturing childhood resilience

around fire and throughout the site. We offer children the chance to help light the fire, create objects from natural materials using tools such as knives and saws, and learn how to tie knots and use rope. The children in the 8 to 11-year-old group have a circular route around another campus. This route is more challenging and adventurous. It incorporates several locations such as a steep grassy slope with a rope swing, a vegetable and fruit garden, apple orchard, donkey paddock and coniferous and deciduous woodland. Our campsite is nestled in these woodlands. Our group gathers together around the fireplace and we go through the fire rules and assign tasks such as lighting the fire, collecting wood and helping to prepare snacks. Then the children move off to play on the muddy slopes and in permanent den constructions dotted around the forest. This is where the serious fun begins with adventurous and physically challenging games throughout the wood with the safe haven of the campfire to return to when children need a break or to catch their breath. We are there to teach the children bushcraft skills, identification of wildlife and crafts. The desire to learn these skills can arise from their game or a new interest developed through their natural curiosity about the environment they play in. We don’t have a set agenda or plan to teach, but are always ready and alert to new or emerging talents and interests.

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We don’t have a set agenda or plan but are always alert to new or emerging talents and interests

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The team at Nature Nurture has both full-time and voluntary staff. Our project co-ordinators and programme leaders are all forest school trained, with years of xperience working with children and young adults in various capacities. Our voluntary staff come to us from health, education and social work sectors. We strive to offer a one-to-two ratio for the children and ensure that new staff are supported in providing the specific care required. We also offer courses to other practitioners all over the UK to help them develop projects similar to Nature Nurture.

Practical outcomes – children’s journeys We have been fortunate to help support over 300 children and their families at Nature Nurture since the project began in 2009. We would like to share with you the unique journeys of three children we have worked with and observed in this time. It is hoped that these case studies will offer a clear indication of the self-directed development of resilience which the elements of nature, nurture and play make possible. We have chosen to focus on three

areas of developing resilience which we feel have been most pronounced in each child’s journey.

Brendon’s journey Sometimes we have the opportunity to accompany a child through an ever-evolving landscape of challenge and good fortune. Brendon is one such child who first came to us when he was just three years old. His mother had struggled with post-natal depression and was a victim of domestic abuse. As a result, he was taken out of his mother’s care. Brendon stayed with us for one programme of Nature Nurture, after which we did not see him for several years. Thankfully he was re-referred to us when he began school at the age of five. By this time, he had returned home to live with his mother and her new partner and family life appeared to be more settled. His mother still struggled with some of the behaviour that Brendon displayed at home and in school and was carrying guilt for her absence in the early years of his life. When Brendon returned to Nature Nurture, it was clear that he was a very anxious child who had little trust in the relationships he formed and lack of faith in his own abilities. Physically we could see that he was malnourished and lacked the stamina expected of a boy his age. Within the first few weeks with us, however, we could see how much he enjoyed the possibility of playing outdoors and carried a tentative enthusiasm for learning and developing his skills. Brendon has now been with us for four-and-ahalf years and we have seen some incredible development in all seven domains of resilience in that time. We have chosen to focus on Brendon’s development in the three domains of mental and emotional wellbeing, physical health and wellbeing and social competencies. Brendon’s anxiety was apparent in his flight or fight responses whenever he felt challenged. He balked at new situations and talked incessantly when he felt nervous. Nature Nurture helped him to feel safe by providing routines that were consistent yet flexible and responsive. Effecting clear boundaries has been important in developing a sense of safety. We have worked with Brendon to establish clear physical boundaries such as areas where he can play and also behavioural boundaries which impart particular expectations within the sessions. Being outside in nature helped Brendon to feel well and

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Jennifer’s journey Jennifer has attended Nature Nurture for just six months, but has already made big steps towards becoming a resilient little girl. She has had a traumatic life, witnessing the physical and emotional abuse of her mother by various partners. These experiences have had a substantial impact on the health and wellbeing of both Jennifer and her mother, resulting in a strain on their attachment. Jennifer’s exposure to an environment that was filled with fear, anxiety and aggression has made it very difficult for her to develop an appropriate degree of self-regulation. She was referred to Nature Nurture by her head teacher because of behaviours in school. There was a serious concern about abilities to manage socially and emotionally in group settings. Jennifer can be physically aggressive towards other children and staff. She needs to feel she has control of people and situations and her resulting behaviours are having a significant impact on her ability to access education.

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In the time we have been supporting Jennifer, she has shown greatest development in mental and emotional wellbeing, physical health and wellbeing, and in her social competencies. Jennifer has shown marked change in her reactions and responses to the challenges of social interaction. In general, she shows a greater ability to think about her responses instead of falling into a survival mode of fight. Jennifer now has moments where she can achieve a calm, alert state, even in her play with others. Overall her levels of anxiety have decreased. Nurturing and attuned relationships have been the biggest factor in this development. Our first aim with Jennifer was to establish a trusting, empathic relationship that has clear boundaries and expectations, provided by the consistency, rhythm and routine of sessions. This has helped her to develop a sense of security, familiarity and belonging. The natural environment has allowed Jennifer to explore and learn, develop and grow. It has offered her a space in which she can breathe, relax and put aside some of the anxieties that she lives with on a day to day basis.

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Nurturing and attuned relationships have been the biggest factor in this development

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relaxed. Within each of the sites at Nature Nurture he has come to developed favourite places in which he feels particularly well or secure. Brendon’s physical frailty and lack of stamina has also improved over his time with us. Nature Nurture has contributed to this through providing plenty of opportunity for physical play and challenge. He loves to climb trees, run and roll down hills. As he gains stamina and overcomes his fear of new challenge, he becomes more daring and adventurous, whilst learning to risk assess situations for himself. It has taken Brendon a long time to allow himself to trust relationships. He spent many sessions testing the adult who accompanies him to find out if he/she really cared or could forgive him when he was challenging. Through showing Brendon that he is valued unconditionally, this has gradually decreased and we have been able to talk to him about the way he feels and responds to those who are close to him. He has developed enough trust to be able to talk about his fears and worries and is clearly comfortable in the companionship of all the staff he knows well at Nature Nurture. He has also started to develop meaningful relationships with his peer group.

When we first met Jennifer, she displayed poor gross motor control and co-ordination. Throughout her time at Nature Nurture, she has shown significant improvements in her confidence. She clearly feels more secure in her own body and Jennifer now actively seeks out activities which challenge her physically. She has found water play to be particularly calming and fulfilling. Her growing confidence in movement is also mirrored in her general health and wellbeing. She seems happier and her levels of physical tension have reduced. There has been a significant change in Jennifer’s ability to co-operate and collaborate. She has made a real effort to understand the intricacies of social interaction and now feels an important part of the group. As Jennifer has come to experience being valued, she has had the courage to trust herself in decision-making and building friendships. Within clear expectations and boundaries, she has the opportunity to take control and make her mark in a positive and productive way that is recognised and acknowledged by others. What has taken place so far is a foundation on which we can help her build the next key areas of resilience. We aim to support her understanding and empathy of other people and her environment and to value her unique talents and contributions. We also want to promote her creativity and imagination, particularly her problem-solving skills. The development in these areas will support her social interactions and her sense of self-agency.

RESILIENCE Nurturing childhood resilience

Nature Nurture receives many children who are diagnosed with attention deficit hyperactivity disorder (ADHD). Logan’s story is important because it demonstrates how quick and effective the Nature Nurture approach has been in facilitating the needs of children with ADHD. They come to value the energy and enthusiasm they have for life by being afforded the possibility of channelling it towards creative and positive outcomes. Logan is one of our most recent referrals, joining the 8 to 11s programme in autumn 2016. He was referred to us after concerns that his behaviour in school and at home were becoming too challenging. Family relations were beginning to deteriorate as Logan became ever more violent and aggressive in his interactions with his mother. This aggressive behaviour was also becoming prominent at school, where Logan’s teachers described him as being angry, argumentative and controlling. The school struggled to find activities for Logan, although they noted that he could be incredibly creative and loved music therapy. It was hoped that Nature Nurture could meet his needs. When we met Logan, we could see that he was hyper-sensitive. He was in a constant state of anxiety and uncertainty and he often anticipated the worst outcomes in all situations. In this state, the unknown was a threat and triggered fight responses. Despite this, it was clear that he was desperate to understand his world and held an incredible sense of creativity and imagination. In the short time Logan has been with us, we have seen substantial development in his mental and emotional wellbeing, physical health and wellbeing and creativity and imagination. It was clear that we needed to support Logan in his abilities to self-regulate. By the end of our first session with him, we could see the freedom of the outdoors helped him to feel calm and in control. Over a few weeks, the development of a predictable routine and familiarity with the group began to ease his anxieties and self-doubts. The close relationships that he has come to form with the adults in our team has been fundamental in Logan feeling valued and respected. He has cherished the one-to-one interaction and play with his keyworker and is quickly feeling secure enough to explore and identify his emotional states. As his calm-alert state persists within sessions, he is able to interact with others more effectively, seeking to understand behaviour. In a short time, we have seen a significant reduction in violent and angry outbursts as Logan has come to develop his own self-regulatory strategies. It was clear from the beginning that Logan needed the space to be active and play. Logan has finally been able to expel his pent up energy by having fun. The natural spaces provide him with the possibility of improving his fine and gross motor skills, discover the limits of his body and begin to risk assess his environment, which has been incredibly rewarding. He has now begun to help others manage risk in their play. Rough and tumble play has been

integral in this process and in developing his self-regulation. For example, in stick sword fighting with other children, he has become conscious of his strength and the need to be careful and considerate of others. As this self-regulation has improved, Logan has begun to explore his creativity. While he still suffers from low selfesteem, he seeks to try new experiences. In a calm-alert state, Logan is able to express his creativity and learn very quickly. He has gone on to learn how to use different tools such as fire steels, knives, saws, rope and loppers. These tools have helped him bring ideas to fruition, for example building a swing, and allowed more elaborative play, creating a bow and arrow from scratch. In just one programme, Logan has become more selfaware, engaging in positive and meaningful interaction and using his energy in fulfilling ways. Reports from school show a marked reduction in aggression and a greater involvement in curricular activities.

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The promotion of resilience begins with the way each individual is perceived

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Logan’s journey

The future Nature Nurture continues to provide unique journeys of self-discovery and mastery for each of these children. The promotion of resilience begins with the way each individual is perceived, as a whole being, a unique being and a capable being. While every child we meet is on a different path and moving at their own pace, they all have the resources to reach their potential, to guide themselves with intention and purpose. These self-directed journeys are made possible by the effective climate of facilitation that the elements of nature, nurture and play bring about. We know it works because we observe it in every child and in each Nature Nurture session they attend. Moving into our eighth year, The Nature Nurture project continues to grow and expand. Over the course of 2017 we will be developing and running additional programmes, including a new under-5s group and an 11–14s group. We will be delivering a variety of talks and training courses up and down the country, seeking to network and extend our reach to other cities in the UK and across the world. The social, economic and environmental benefits of an outdoor early intervention scheme like Nature Nurture are clear and increasingly relevant. We are continuing to see a growing awareness throughout the UK of the restorative and therapeutic effects which outdoor experiences can hold. It is our hope that this awareness will continue to bring about new progressive childcare and education initiatives and policies which afford children increased access to nurturing play experiences in nature

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FO R EST SCHO OLS

Transformative learning in nature An educational pilot programme at Hazel Hill Wood Louisa Clark Independent arts and nature education practitioner

Daniel Körner Independent project facilitator and lecturer; Development manager, Hazel Hill Wood

The following article addresses the more and more recognised positive impacts of outdoor and nature education activities for children and youth. As an example of such educational work, the Transformative learning in nature pilot programme at Hazel Hill Wood in Wiltshire and three visits of local groups at the wood are presented. A closer look is taken at the specific activities with the children in and with the wood, and learnings, outcomes and feedbacks from both the children as well as the respective carers is discussed.

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I am an arts and nature education practitioner, working with children and adults to promote connection, health and wellbeing. Working in an education outreach role for Hazel Hill Conservation Woodland near Salisbury, I co-ordinated the Transformative learning in nature programme for local groups in 2015/16, which aimed to build resilience and wellbeing through dedicated time in nature. www.louisaclarkartsed.co.uk. Louisa Clark Through my work as a collaborative project facilitator I try to invigorate and accompany individuals and groups to grow into their full potential. I took over the co-ordination of the Transformative learning in nature programme from Louisa Clark early this year. Daniel Körner

Introduction The positive benefits of time in nature, especially for children, has been widely researched in the last two decades and more and more actions are taken to accommodate these findings. We find activities of naturalising outdoor learning environments and an increased inclusion of outdoor activities into curricula across the country (eg Nicol et al, 2007). Spending time in nature has been proven to have a wide range of health benefits both for people with specific conditions like ADHD (see Taylor et al, 2001) as well as generally for every human being, young and old (see www.childrenandnature.org/ research-library for a collection of research articles on this theme). Some of the biggest and best researched benefits of connecting children and youth with nature are: • positive stimulation of social interaction between children (Moore, 1986, Bixler et al, 2002) • higher scores on tests of concentration and self-discipline. (Wells, 2000, Taylor et al, 2002)

• children who play regularly in natural environments show more advanced motor fitness, including co-ordination, balance and agility, and they are sick less often (Grahn et al, 1997, Fjortoft and Sageie, 2000) • buffering the impact of life’s stresses and helps them deal with adversity (Wells and Evans, 2003) • positive impact on cognitive development by improving children’s awareness, reasoning and observational skills (Pyle, 2002). In this article we want to introduce the work with young people that has been done over the last two years at Hazel Hill Wood, a conservation woodland retreat centre in Wiltshire. The outdoors at Hazel Hill Wood provide a wide array of opportunities to create transformative learning experiences and bring some of the above benefits into the children’s lives. Some require careful design and facilitation, whereas others simply arise from being outdoors.

FOREST SCHOOLS Transformative learning in nature

The visits varied in duration, from a half day to an overnight, and were led by members of the Hazel Hill education team and education freelancers, bringing a wide range of skills and activities including conservation, bushcraft, wellbeing, mindfulness and creativity. To measure impact, and help shape future programmes, each visit was evaluated, with the methods tailored for each group.

Group outcome

The Transformative Learning in Nature pilot Hazel Hill Trust is a registered charity which took over the ownership and operation of Hazel Hill Wood in July 2015. The overall aim and vision of the Trust is to promote wellbeing, resilience and sustainability: for individuals, society and the natural world. Enabling people to engage more deeply with nature, especially woodlands, is a major means of fulfilling this aim. A key focus is to extend the benefits of the wood to different groups, particularly local ones, and to this aim the Transformative Learning in Nature (TLiN) education pilot was launched. The TLiN pilot ran from October 2015 to May 2016. Its main objectives were to engage local groups with the wood and cause positive impact through conservation and wellbeing activities, and to evaluate this work to develop a case for future sustainable funding for projects and programmes that aligned with local priorities, groups and organisations. Key outcomes for the programme were that participants would: • become more confident spending time outdoors in nature • start to spend more time outdoors, using time in nature in a positive way to help cope with stress • find better ways to cope with challenging situations in their lives.

As the groups taking part in the pilot mainly involved young people, we have been able to see the impact of the time spent in nature. Details of each group follows, looking at their preconceptions, experience on the day, and where available the impact. This work is ongoing and benefits may take time to be seen. However, we are sure that this work of connecting young people to nature, will have positive outcomes to their wellbeing. The groups covered here are: Young Carers – Youth Action Wiltshire, Winterslow C of E Primary School, and Pitton and Farley Guides and Brownies.

Young Carers – Youth Action Wiltshire The Wiltshire Young Carers Service sits within Youth Action Wiltshire, and has been running since 1999 with over 500 young carers across the county. The small Salisbury based group was approached about TLiN and was very keen to make a connection. Fifteen young people came, ranging from five to eight years old. The perspectives from the youngest age to the eldest were quite different, however staff fed back that all were looking forward to the visit, with many enjoying being in nature but not getting much time to spend outdoors due to their caring commitments. They were excited to try something new and go on an overnight visit as a group; some of them had never been away from home before. The group wanted an overnight stay as this would really give the children some space from their caring responsibilities, and a chance to immerse themselves into the natural environment.

It also sought to teach participants new conservation and creative skills and knowledge, and connect with local groups for future visits. There was not originally a focus on age range or background for the local groups approached, however participants were mostly young people, ranging from 5 to 14 years old (the only exception was a group of older men from the Alzheimer’s Society who visited for conservation work and social cohesion time). The rest of the visiting groups included two primary schools, a young carers group, and the local guides and brownies group. All the groups fed back that the experience had been a positive one, with at least three very keen to continue a relationship with the wood.

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Activities On the day, after an introduction, lunch, and a game, the first activity was a conservation one; to plant several holly bushes, and during this to learn how woodlands work. Then, after a break, the group went on a mini beast hunt, made insect houses and looked for footprints in the wood. After this the children worked on evaluation, drew pictures and played indoors while the staff prepared food. After supper, the group went out to the roundhouse with torches, and a fire was lit. Stories were told in the circle, with each child making up a bit of the story. The following day the group took part in a natural art activity by foraging in the wood and making mobiles and stick people from what they found. The final session was about resilience tools and using nature to become calm, followed by a short relaxation/mindfulness activity.

What was most successful? The children were very excited to be at the wood and wanted to play and explore, but also really enjoyed the activities that were offered to them. Some of the most successful were the active ones, such as the mini beast hunt and looking for footprints in the wood, as they got to release a little energy and be outdoors. The storytelling game in the evening was also a huge success, with their creative ideas coming to the forefront. Making the mobiles and stick people was a favourite activity too, and gave the group some quieter time for relaxation.

What could be improved? With such a span of ages, excitement and behavioural needs in the group, some of the more focused and indoor activities were quite challenging to deliver. More time outside for free play and exploration would be great, balanced with staff responsibilities for safety and care.

Outcomes ‘The best thing was for them to have the chance to be young people with nature. Thank you for a brilliant residential, they all had a wonderful time.’ Alan Burke, group co-leader

Many of the children said they most enjoyed the bug hunt and making insect homes, planting the holly, playing games in the woods and the storytelling. The majority said they wouldn’t change anything, and that they’d like to do more of the same, plus to climb trees! They loved the sleepover, although a few missed home, which wasn’t expected, but they were quite young and for some it was a first trip away.

were immediately interested. The school was scheduled for the first to visit in the TLiN programme, choosing to bring one class of children aged 7/8, for two half days. None of the children had visited Hazel Hill before and, along with the teachers, were excited to get out of the classroom and into the woods for the morning. The majority said they already enjoyed spending time outside in nature, although a couple said they felt a bit scared of woods and forests generally because they were dark, and ‘scary things’ may be in there. When asked what they were looking forward to and what they thought they’d see or do at Hazel Hill a lot said they wanted to build dens, see animals, particularly owls and foxes, make a campfire, climb trees, learn about surviving in the wild, and for one, find a fairy village! The teachers mentioned that they hoped the visit would inspire the children’s imaginations and story-writing skills. They also wanted the children to spend some quiet, reflective time in nature, supporting their ability to cope with stress and increase wellbeing.

Activities In the conservation activities, they practised how to safely make fires in the roundhouse, went on an animal hunt, and found out about sustainable living. They also learnt the names of the trees around them and discovered how the forest and nature is interconnected. The wellbeing/creativity activities brought them into a circle where they introduced themselves and became their favourite animal. They then took part in a sensory walk into the woods, and learnt about being quiet for relaxation, and to have more of a chance to see wildlife. After this they created mini forest dens for little animals or fairies.

Winterslow C of E Primary School Winterslow is a small school close to the wood. We contacted the head teacher about taking part in the pilot and although they hadn’t visited the wood before, they

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What was most successful?

Activities

The children seemed to really respond to Hazel Hill staff and enjoyed meeting new people. They were very keen to get involved in the walks, fire lighting, and den building, and playing a ‘build a tree’ game at the end of the session. Working with two smaller groups worked well, keeping the energy focused. Also, the timings of the sessions worked well.

The guides started with animal tracking and time in the woods, learning about the animals, insects, birds, trees and plants that survive there. They also learnt about conservation and sustainable living, including off-grid practices like the compost toilets. In the afternoon they built shelters in the woods, and then made outdoor collages with natural materials found on the ground. They finished with an outdoor game. For the challenge badge, a small group of the guides took part in extra conservation activities and learnt about the maintenance of the woodland. The brownies started their day by learning about compost toilets and off-grid living. They then made fires using knives to scrape birch bark as a natural firelighter. These resulted in building quite big fires, which was exciting for the girls and a new experience. They then went on an animal hunt, and learnt which animals live in the woods by being led to find their droppings. Following this the group made bug homes and outdoor collages. To end the day, they also played games in the wood.

What could be improved? It would have been good to have more time for the children to explore further in the woods. They only ventured into the Heartwood for the mini den building and from comments made at the time would have benefited from a longer walk and adventure into the ‘wild’.

Outcomes ‘It has been magical watching the children being free, exploring and imaginative.’ Lynn Fortis, Year 3 teacher

After the visit, the children wrote stories called The Night the Woods Came Alive, inspired by the animal/fairy dens they had made. Developing imaginative writing was a direct educational outcome for the school, and they were all really pleased that this had been achieved. They also created ‘how to behave and respect the woods’ posters. The teachers felt the children had benefited from time to be still and use all the senses to experience the natural environment around them. Using natural materials to be creative and working collaboratively with others were also key outcomes.

Pitton and Farley guides and brownies This local guides and brownies group is well-established and attended by local girls aged 7 to 14. The group hadn’t visited the wood before, but responded to the opportunity with enthusiasm. Due to the size of the whole group, it was agreed that the 16 guides would come one day, and the 18 brownies another. Although they didn’t really know what to expect, both groups were very excited about coming to Hazel Hill. Most of the girls already spent quite a bit of time out in nature. Many said that they had dogs which they walked in woods, and some had ridden horses or bikes in woods. Most also lived in villages so were out in nature regularly, and a couple said that they enjoyed spending time ‘out in the wild’. When asked what it was they thought/felt about woodlands and forests, the girl responded, ‘We love them and think they are important for nature’. Nicki, the group leader, was keen for the girls to learn more about conservation and biodiversity in the wood, along with sustainability, as these were areas that they hadn’t experienced previously. Nicki also asked that a small group of the older guides took part in an extra activity to gain their challenge badge.

What was most successful? The guides said they most enjoyed their shelter-building, and the brownies loved making the bug homes and their animal hunt. All the girls fed back that they really enjoyed being outside for the day in a quiet environment and finding out about the animals and bugs that lived in the wood through the trails and tracking. Both groups also enjoyed the games and natural picture-making.

What could be improved? The main feedback was that more time would have been good for exploring further in the woods and more activities, games and free outdoor time.

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Outcomes ‘The girls all really enjoyed the freedom of wandering around the woods without being overly restricted to paths.’ Nicki McCarney, group leader

Many of the girls said that they wouldn’t change anything about their visit, other than having longer, with some adding they would have liked an overnight stay, marshmallows around the fire, and to see more animals. The guides also said they were interested in a ‘survivalthemed’ day in the wood, and the brownies would love to do some pond-dipping and shelter building.

Conferences to look out for Plant medicine: does nature have more tools for modern health needs? Thursday 8 June 2017, London

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Conclusion Working with these three groups of on the Transformative Learning in Nature pilot has given some great insight and tangible outcomes of the benefit of time in nature for young people. Taking learning, exploration, creativity and wellbeing outdoors, seems to only enhance its impact, and offer much more to the development of the whole person and the group. We will are staying in touch with these groups to monitor the impact, and look forward to welcoming them, and others, back to the wood to build on this work.

Social prescribing: from rhetoric to reality Monday 8 May 2017, London

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Bixler R, Floyd M, Hammitt W (2002) Environmental Socialization: Quantitative Tests of the Childhood Play Hypothesis. Environment and Behavior 34(6) pp 795–818. Christie B, Beames S, Higgins Peter, Nicol R, Ross H (2014) Outdoor learning provision in Scottish Schools. Scottish Educational Review 46 (1) pp 48–64. Fjortoft I, Sageie J (2000) The natural environment as a playground for children: landscape description and analysis of a natural landscape. Landscape and Urban Planning 48(1/2) pp 83–97 Grahn P, Martensson F, Llindblad B, Nilsson P, Ekman A (1997) UTE pa DAGIS. Stad & Land 93/1991. Alnarp: Swedish University of Agricultural Science. Moore R (1986) The power of nature orientations of girls and boys toward biotic and abiotic play settings on a reconstructed schoolyard. Children’s Environments Quarterly 3(3). Nicol R, Higgins P, Ross H, Mannion G (2007) Outdoor education in Scotland: a summary of recent research. Perth: SNH. Pyle R (2002) Eden in a vacant lot: special places, species and kids in community of life. In: Kahn PH and Kellert SR (eds) Children and nature: psychological, sociocultural and evolutionary investigations. Cambridge, MA: MIT Press. Taylor AF, Kuo FE, Sullivan WC (2001) Coping with ADD: the surprising connection to green play settings. Environment and Behavior 33(1) pp 54–77. Taylor AF, Kuo FE, Sullivan WC (2002). Views of nature and self-discipline: evidence from inner city children. Journal of Environmental Psychology 22, pp 49–63. Wells N (2000).At home with nature, effects of ‘greenness’ on children’s cognitive functioning. Environment and Behavior, 32(6) pp775–795. Wells N, Evans G (2003). Nearby nature: a buffer of life stress among rural children. Environment and Behavior 35(3)pp 311–330.

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An opportunity to join an international line up of physicians, researchers, clinicians, and pharmacists, to introduce a new evidence base for potential health service benefits of herbal medicines, culinary spices and plant food ingredients. The day will focus on practical, safe and effective self-care prospects. www.collegeofmedicine.org.uk/events/#!event/2017/ 6/8/plant-medicine-conferencedoes-nature-havemore-tools-for-modern-health-needs

Social prescribing, sometimes described as community referral, allows primary care professionals to refer people to a range of local, non-clinical services. But does it work? And how does it fit in with wider health and care policy? This one-day event, run in partnership between The King’s Fund, the Social Prescribing Network and the College of Medicine, seeks to answer these questions. The Secretary of State for Health, Jeremy Hunt MP, will give you his views on social prescribing and how he plans to support it. www.kingsfund.org.uk/events/social-prescribing

Transformative innovations in health: a gathering of changemakers Saturday 18 November 2017, London

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The neatness of medical science is unravelling. 20th century medicine focused on smaller and smaller parts with astonishing success: triumphant in infections, deficiency diseases, with surgical excisions and transplants, intensive care and anaesthetics. But 21st century medicine is confronting whole person (indeed whole society) problems: chronic degenerative and inflammatory diseases, stress-, environment- and lifestyle-mediated diseases, addictions and psychological disorders. Bio-technical single-solution approaches won’t cure them. If, as has been said, the future is already with us but unevenly distributed, where might we find seeds of the new paradigm? This working conference, jointly hosted by Westminster Centre for Resilience, the Scientific and Medical Network and the BHMA, will bring change-makers together to celebrate the future. Speakers and workshops to be announced soon so keep an eye on: www.centreforresilience.co.uk https://explore.scimednet.org https://bhma.org

HEALTH EDUC ATION

Educating children for health Hugh van’t Hoff Founder and director, Facts4Life; GP, Stonehouse, Gloucestershire

Medicine is in crisis. It faces two major challenges, financial and existential. Facts4Life seeks to address both these issues by helping children and adults take meaningful responsibility for their health by opening up a dialogue about illness, giving permission for people to own their health and by fostering a more collaborative approach to shared decision-making ‘at source’.

I qualified in London in the 80s. My medical outlook was profoundly altered by doing the diploma in tropical medicine and hygiene in Liverpool in 1990 where I learned that my outlook was narrow, (over) developed and western. Also that, broadly speaking, wealth is health and that if you want to change the health of a population you need to concentrate on educating that population about their health. To then work in GP in a deprived area of Bristol made me realise we could and should be doing these things here and now in the UK. Putting these ideas into practice has been my work since then. Facts4Life is the result. www.facts4life.org

Facts4Life grew out of my training in both tropical medicine and general practice. Doing the diploma in tropical medicine and hygiene changed my outlook on medicine. It showed me that the medicine we learn in the west is narrow in focus, world health is a political issue, good health is largely a result of higher wealth, improving health can be addressed by increasing the sharing of wealth (narrowing the divide between richest and poorest) and that the education of women and children is a key milestone/aim (these latter ideas are generally called ‘the lessons of Alma-Ata’, the Millennium Development Goals (MDG) and more recently the sustainable development goals – since we failed to meet the MDGs). Instead of going abroad, I found myself working in a deprived part of inner city Bristol. I realised that the lessons I had learnt in tropical medicine did, after all, have relevance to my GP community. In every nation the burden of ill-health is borne by the poorest. Many of my patients were ill but also poorly educated about health and illness. I also realised that we all hypothesise about why we are ill, who is responsible and what might make us better. Discussions around our differing ideas form the basis of most contacts with general practitioners. On the other hand, I feel we doctors have not done enough to challenge the prevailing ideas we have as a society

about health. We are too quick to accept our role as the keepers of special knowledge when in fact much of it could be shared. This and the need to ‘process’ patients has driven the reliance on medication and has fostered an understanding that whatever is wrong with us we probably need a pill or an operation. Politicians have commoditised health too, promoting the idea that any ill could and should have a cure. This and new media have probably promoted the general feeling that we can achieve perfection in mental and physical health. This ‘perfection agenda’ is, I believe, driving the current health crisis. Perfection is the new normal and anything other than perfection is illness. All illness can and should be cured immediately. We forget that most of the time we get better from most problems – both mental and physical – on our own (the ‘most’ idea). We have failed to get across the key ideas that we heal and that this takes time and needs fostering. These are the fundamental guidelines we use as GPs yet they are so much a part of our ‘medical DNA’ we are unaware of them. We need to share these ideas and more. Facts4Life is an innovative health resilience programme which is trying to get these ideas across. It is designed for primary age children. It helps young people take ownership of their health by exploring illness and

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growing perception of the threat of illness. This I call the wellness or perfection agenda. It is the idea, promoted by advertising and a lot of traditional and new media, that we should have a perfect body and/or perfect health. It is also the consumerist idea that if we don’t have these things then we should be able to do something about it. If we don’t have a perfectly functioning body, we are likely to feel this constitutes an illness and that health professionals should make us better, often immediately. The medical profession has unwittingly connived with this demand or certainly failed to challenge this perception.

The under use of lifestyle interventions and the need for instant solutions increasing motivation to develop strategies for wellbeing. The programme is about to be extended to secondary schools in the county. We have developed a training programme for teachers, introducing them to our ideas and resources which embed matters of health within the curriculum. Funding has been provided by Gloucestershire Clinical Commissioning Group.

The context Facts4Life has been developed against a background of growing crisis within the medical world. Political and social pressures have created a context in which there are everincreasing expectations made on practitioners. In so many cases, the burden of responsibility now weighs upon those in primary and secondary care to ‘fix’ patients, to make good the shortfall in the individual’s perception of how they should be feeling, often through medical or surgical intervention. We aim to challenge this context in three significant areas.

The drivers that promote the use of drugs or surgery as an intervention, when lifestyle changes would be more effective, are many and various. They are justified at times intellectually and financially, supported on grounds of greater professional efficiency and reinforced in training. However, in the 30 years I have been practicing medicine I have seen a wholesale change in the attitude towards health and lifestyle. For example, people with osteoarthritis used to be told to rest as much as possible and now are encouraged to lose weight and exercise. There are virtually no conditions where exercise is now thought to be harmful. Despite this change in attitude, the pressures on time, both within the consultation and more widely within our culture, mean that drugs or surgery are the preferred solution to the problem on both sides. In this context it is often extremely difficult to hand back the responsibility to

Responsibility and shared decision-making It is no surprise that patient expectations increase in the light of improved recovery rates from serious illness, the ability to function well despite chronic disease and the greater accessibility of information through the use of Google doctor and other online oracles. The question is: How do we best give people the ability to make sensible decisions about their health? At the moment, this tends to be addressed downstream by complicated ways of shared decision-making (SDM). SDM between patients and health professionals in primary care or secondary care settings is supposed to ensure that the patient is in the correct mental space to make a decision. The effect can sometimes be to bamboozle the patient with information. It jars with some patients who have come specifically to see their doctor for guidance. The idea of meaningful SDM seems ridiculous, if patients have no insight into the way doctors think.

The perfection agenda It is a paradox that in spite of the evidence that we are becoming healthier by most measures, there remains a

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HEALTH EDUCATION Educating children for health

the patient and encourage lifestyle change. This is clearly a very complex issue. But it is also clear that the NHS as an organisation has made an implicit contract with the population to take responsibility for the problem and provide the instant cure, even if this is not in the patient’s long-term interest.

The Facts4Life response We begin by responding to the interest of young people in their own bodies, their health and their experience of illness, through the use of educational materials in the classroom. We are also extending this dialogue to the families and wider community, including medical practitioners in primary care. Our three key messages are: • Riding the ups and downs – life is a series of ups and downs. As a society we have to accept this and help our children understand it too. This is a message about the journey we take in a state of flux between health and ill-health. • Keeping in balance – our bodies naturally keep themselves in balance both physiologically and in terms of our mental health. This is the key medical fact we’re trying to get across – most of the time we are in balance and most of the time we get better on our own. Exploring illness helps us understand these forces in action. • Smoothing the path – with the previous two messages in mind, it follows we can reduce the ups and downs by paying attention to the factors which keep us in balance. We seek to influence the perceptions that children have about illness from an early age. We also need to give them opportunity at an appropriate level to learn about some of the important facts and approaches that are addressed at medical school so that they can understand the way that we health professionals think about illness, attitudes to

risk and the determinants of health. Many quite complex subjects can be explained with the help of analogies or metaphors – I’m sure many of you practise this. We can reassure children that illness is, by and large, another challenge that they can meet in the same way that they meet educational challenges that are presented to them. We are building partnerships with GPs and sharing our approach and the language of our materials with practices that are working within the communities of Facts4Life schools. One of the central aims of Facts4Life is to improve the dialogue between health professionals and patients so that people feel they have better ownership of their own health. Ultimately, we see Facts4Life as altering the nature of this dialogue so that in time patients will feel that they have a collaborative, rather than hierarchical, relationship with the healthcare professional. By providing opportunities in the classroom for young people to explore the wide range of normality in their health experience and in the experience of others, we can begin to address the ‘perfection agenda’ and the unattainable expectations it brings. The central idea within the resources of ‘riding the ups and downs’ brings a dose of realism to the notion that wellness is a constant that can be provided by others. Through the development of a sense of meaningful responsibility for health, lifestyle interventions become an accepted part of the dialogue between patient and GP. The nature of the interaction moves from prescription to one in which there is a more open exchange of information. When I heard Hugh van’t Hoff ’s presentation about the initial evaluation of the programme and the outcomes, I was completely blown away. The only positive, constructive idea on solving the NHS’s problems in a positive and preventative way that I have heard in my entire 40-year career in medicine. Stroud GP

I think the most interesting part for me was when we learnt how to fight some of the diseases and the common cold and a lot of those things because it could help me in the rest of my life so I don’t get the worst part of it. KS2 (8 to 11-year-olds) student

I feel having Facts4Life’s comprehensive health education programme is such an important part of the curriculum… to help prevent illness and promote healthy living. Parent

The delivery of the training was really slick and focused. I was fascinated by the ‘sciencey’ bit at the start of the presentation as it put the Facts4Life work in context. The presence of a GP and paediatrician gave the programme credibility. It was a great starting point for us to re-think our PSHCE programme with current up-to-date thinking and issues that relate to the children of today. Cheltenham Headteacher

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CHILDREN AND COMMU NITY HEALT H

Partnership for change in Newcastle David Stobbs Health improvement practitioner, Public Health, Newcastle City Council

In 2013 Newcastle Wellbeing for Life Board set out ‘Our Wellbeing for Life Strategy’ with the overarching ambition for people who live, work or learn in Newcastle to equally enjoy positive wellbeing and good health. West Newcastle is an area with some of the highest health and social inequalities nationally and high rates of overweight and obesity in children. Focusing on children and young people, the

In the 20 years I have been working in health improvement we have always recognised that the best way to help people make behaviour changes we believe would improve their health is through working with those community organisations and individuals who know them best. In Newcastle upon Tyne we have a strong commitment to working with and commissioning the community and voluntary sector to work with people ‘from where they are at’. That’s why any credit for the success of the partnership goes to Kath English, the Change4Life West Newcastle co-ordinator based with HealthWorks Newcastle.

Change4Life is a partnership of providers linking up services and projects in the inner-West of Newcastle upon Tyne to encourage families to follow the national campaign’s messages of ‘eat well, move more and live longer’. The wards of Elswick, Benwell & Scotswood and Wingrove have some of the highest health and social inequalities in the city and nationally. The National Child Measurement Programme (NCMP) which measures all pupils in reception and year 6 across England found high rates of overweight and obesity in children in these areas. Now in its sixth year the partnership, working in the areas around the area’s schools as well as in children’s centres and community settings in the inner west end, has developed a vibrant partnership with joint working taking place on a regular basis. Public Health in Newcastle City Council has confirmed funding until the end of March 2018.

Change4Life Partnership aims to improve the nutrition of families through healthy eating initiatives and increased participation in physical activity.

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Healthy Lives, Healthy People: A call to action on obesity in England (DofH, 2011) calls for: A sustained downward trend in the level of excess weight in children by 2020 A downward trend in the level of excess weight averaged across all adults by 2020

The objectives of the Change4Life West Newcastle Partnership are to: • increase physical activity, specifically in inactive groups • improve nutritional and/or cooking skills of families and specific children’s groups • help participants set realistic goals to achieve behaviour change • encourage children, young people and parents to develop skills to help others (eg peer support/young sport leaders/young cooks/health champions) • build capacity of frontline staff to deliver key consistent messages through the partnership • focus on improving the health of children 0 to 11 (early and primary years) to ensure early intervention and prevention • provide a family focus.

The partnership’s specifically funded programmes are: • Newcastle United Foundation’s Match Fit provides nutritional information and some fun physical activity for children and young people • Newcastle Nutrition’s specialist dietetic service for early years provides help, support and advice to families with a child under five who is very overweight

CHILDREN AND COMMUNITY HEALTH Partnership for change in Newcastle

• West End Women and Girls are funded separately to deliver the Seeds4Life project which provides food growing and cooking opportunities to children from local schools and early year’s settings • Newcastle Action for Parents and Toddlers Initiative (NAPI) are funded separately to provide support and resources to parent and toddler groups in the area. • HealthWorks Newcastle is funded to host the Change4Life West Newcastle co-ordinator who brings together the wider partnership, which successfully links in all organisations and projects in the area working around healthy eating and physical activity into the programme. HealthWorks also host the Change4Life champions support worker. The Change4Life Partnership has 99 organisations signed up and through them has links to all the people they work with as well as their own staff. This communication system, which includes three partnership events a year, provides information to organisations about the evidencebased Change4Life messages. It also receives feedback on what works in promoting these messages and what the partners have been doing. By sharing information through networking the partners can plan work together to ensure effective and ‘fair’ provision of services in the area.

Our Wellbeing for Life strategy The Newcastle Wellbeing for Life Board’s ‘Our Wellbeing for Life Strategy’ (www.wellbeingforlife.org.uk/our-strategy) is committed to tackling inequalities by improving the conditions in which people are born, grow up, live their lives and grow old. The Change4Life Partnership supports the strategy’s focus on keeping children healthy so they may achieve and learn at school and succeed in their working lives.

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Inequalities in access to money, power and resources … damage wellbeing and health

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• Newcastle Nutrition’s training programme is offered free of charge to organisations and individuals working in the area around nutrition and healthy eating

The partnership creates volunteering opportunities and training for children and adults, and contributes to the target for ‘decent neighbourhoods’, providing as it does many opportunities for communities to come together to look at lifestyle choices. By linking into other programmes such as Cycling in the City it helps provide activities for children and families to be more physically active and better informed about their food choices and to celebrate the diversity of the cultures the food comes from.

Diversity equality and fairness There is emphasis in the Strategy for Newcastle to be a place of fairness. Yet inequalities in access to money, power and resources exist in the city and these inequalities damage wellbeing and health. The concept of ‘progressive universalism’ refers to taking actions in ways that can benefit all social groups. Children and families in West Newcastle with the greatest need for support are identified by schools or community organisations in the partnership, through the NCMP or On the Go, who carry out height and weight measures in primary schools. By working not just with children, but with all family members including grandparents and siblings, the various organisations in the wider partnership works across the ‘life course’. This approach aims to tackle inequalities by providing

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CHILDREN AND COMMUNITY HEALTH Partnership for change in Newcastle

Outcomes The Change4Life West Newcastle partnership has certain service outcomes for which it is solely responsible. It also contributes to important population outcomes.

Population outcomes • The children of Newcastle are of a healthy weight (linked to the national indicator to halt the year-onyear rise in obesity in the under 11s). • The children of the west of Newcastle are a healthy weight. • Health inequalities are reduced, particularly child obesity and teenage pregnancy. • Children and young people enjoy their lives and have access to opportunities, culture and activities. The key outcome of the Change4Life Partnership is to reduce obesity and overweight children under 11 years old in West Newcastle. The 2014/2015 NCMP data tells us that in reception class: • 10.1% of pupils are obese, compared with the England average of 9.1% • 12.6% of pupils are overweight compared with England average of 12.8%

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And in year 6: • 24% of pupils are obese, compared with the England average of 19.1% • 13.6% of pupils are overweight compared with the England average of 14.2% The NCMP data for Change4Life West Newcastle shows that the trend for obesity in reception is down while the

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The Change4Life champions programme supports local volunteers

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activities and programmes for all ages. There is a commitment to assetbased practice which recognises and builds on people’s skills, strengths, aspirations and networks, and enables them to be active in improving their own and others’ wellbeing and health. The partnership’s Change4Life champions programme supports local volunteers to promote messages in their own settings and communities. Many champions, whether based with partners or in schools, work face-to-face with children and families and feed back to the partnership their views and needs. Newcastle Nutrition’s wider training programmes link healthy eating, physical activity, obesity and food growing, all of which support the development and use of capacity within the city.

trend in year 6 is up. In reception 14% of boys and 11.4% of girls are obese: so male and female obesity has decreased, and the overall trend is down. In year 6 however, 37.4% of males and 23.9% of females are obese: so male obesity has increased and the overall trend is up, while female obesity has increased though the overall trend is down. This clearly suggests that we need to focus more work on boys in primary school settings. The data around ethnicity highlights that in reception BME pupils have a lower rate of obesity than non BME, both girls and boys. However, in year 6 both BME boys and girls have a higher rate of obesity than non BME pupils. Therefore more work with BME communities during primary school years appears to be needed. Looking at Newcastle overall the most recent data suggests a small improvement in the prevalence of overweight and obesity. However, the fact that children in

CHILDREN AND COMMUNITY HEALTH Partnership for change in Newcastle

the Change4Life schools continue to have higher levels of obesity than children in the non Change4Life schools suggest that deprivation continues to be a factor in overweight and obesity. This further supports the need for work in areas of higher social deprivation.

Service outcomes A range of service outcomes have been discussed and agreed and each partner has identified outcomes for their projects for which they are responsible and can measure and report on. The main strength of the programme is that the partnership links funded programmes with the wider community and schools. There has been an increase of membership during

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Engaging families to join our programmes continues to be a challenge

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2015/16, from 97 to 99: a small increase but understandable given that relevant organisations are already signed up as partners. The success of the programme shows in their having remained engaged, and that since the beginning of the programme the partnership has increased from 32 to 99 organisations. 72% of organisations who attended a wider partnership event completed a link-up sheet 66% of organisations who attended requested follow-up information from the speakers 61% of organisations who attended made contact with speakers on the day 90% of organisations say they benefit from attending the partnership events. Objectives and activities within programmes continue to change in the light of experience and learning gained. Engaging families to join our programmes continues to be a challenge: we have found that people fail to recognise when they or their children are overweight, or they do not consider addressing the issue to be a priority.

Recommendations • Tie in with the Obesity Delivery Group’s review of commissioned services to develop a whole systems approach to obesity. • Continue to fund programmes to target areas with high rates of overweight and obesity which are linked to high rates of social deprivation. • Consider longer-term contracts or commissioning so that organisations can work on and show success with longer-term outcomes linked into other strategies and NICE guidance. • Target more programmes at BME boys and girls in primary schools whose levels of obesity are increasing at a higher rate than non-BME pupils. • Target more work on boys in primary schools whose levels of obesity are increasing at a higher rate than girls. • Celebrate the success of the wider partnership and continue to promote networking which results in joined up working and greater knowledge of services and activities available in the area. • Develop a more targeted programme or campaign to raise awareness of how to recognise overweight and obesity and raise it as an issue. Department of Health (2011) Healthy lives, healthy people: A call to action on obesity in England. London: DoH. Available at: www.gov.uk/government/publications/healthy-lives-healthy-people-acall-to-action-on-obesity-in-england (accessed 25 February 2017).

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CHILD ANALYSIS

Children and psychosomatic disorders: perspective from a child psychotherapist Angele Wallis Child and adolescent psychotherapist

Child analysis in the NHS helped a teenage girl’s

My approach as a child psychotherapist is based on examining, within the supportive therapeutic relationship, the child or young person’s internal conflicts and anxiety conveyed through their play, body and behaviour in order to understand their emotional suffering and to name their feelings. At the core of my practice is a profound interest in supporting the child or young person to develop a better understanding of their difficulties, and learn a healthier and authentic way to relate to themselves and others.

disabling chronic mouth ulcers and migraines. In

Introduction

Jungian psychology

Humans have a tendency to experience body and mind as separate, despite compelling evidence to suggest that body and mind are one. Perplexing in their nature, psychosomatic disorders present a particular kind of conundrum for medics and psychotherapists (Kradin, 2011). It is not surprising that theoretical and therapeutic aspects of psychosomatic disorders remain challenging. As a child and adolescent psychotherapist in child and adolescent mental health services (CAMHS) working with children and young people with a range of emotional and behavioural difficulties, I have encountered the challenges of psychosomatic disorders, understood here as persistent physical symptoms affecting the child’s daily functioning, causing significant suffering but unexplained by medical testing. In this paper I hold the view that complexities in the early caregiver– child interactions during infancy shape body and mind relationship in the child and throughout the lifespan. Through the case of Tia I hope to illustrate the usefulness of a multidisciplinary holistic approach in treating psychosomatic disorders in children, combining medication when appropriate with a talking cure,

individuation names the process through which the individual self develops out of an undifferentiated unconscious, so that the experiences of a person’s life become integrated over time into a well-functioning whole. In this case study the containment of a slowly growing two-year-long therapeutic relationship allowed Tia to trust another and herself enough to be able to think about her body and the contents of her mind, recall forgotten trauma, and make contact with split off emotions.

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mirroring on some level the integrity of feelings and thoughts/body and mind. I hope to highlight the importance of empathy, the relevance of taking into account current stressors and allowing for the detailed reconstruction of early attachment patterns to unfold within the containment of a therapeutic relationship with the child.

The case of Tia Initial assessment Tia was 14 years old when she was referred to CAMHS by the general hospital. She suffered from debilitating mouth ulcers which began appearing when she was a toddler. From the onset of puberty, she developed migraine headaches accompanied by vomiting and abdominal pain. Her referral highlighted that her father was an alcoholic and was on bail pending a court hearing for sexual assault. Her mother suffered from a chronic illness affecting her immune system with poor prognosis. I first met Tia and her mother with my psychiatrist colleague for an initial assessment. I then met with Tia alone over a three-week period for specialist assessment for psychotherapy.

CHILD ANALYSIS Children and psychosomatic disorders: perspective from a child psychotherapist

Clinical presentation Tia came to the clinic by herself. She presented as a pleasant but confused teenage girl. She spent much of her sessions describing her suffering from debilitating migraines and her painful mouth ulcers, explaining that despite several biopsies over the years her mouth ulcers remained undiagnosed. When her mouth ulcers flared up, the lining of her mouth was sore but not painful, she could not eat and required her food to be bland and liquidised, like a baby. When she did not have a flare-up of her mouth ulcers, Tia suffered from migraine headaches, preventing her from opening her eyes for at least a week. She was treated with various medications but these provided only temporary relief. Her view was that doctors were useless because they had not found anything wrong with her and she did not need psychotherapy.

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In Tia’s eyes people were useless, unreliable and untrustworthy

At home and school, Tia’s relationships were impaired, largely devoid of intimacy and characterised by unsustained connections. On the rare occasions she spoke about aspects of her home life, she recounted with little affect memories from childhood and recent experience of domestic violence, abandonment by her abusive and alcoholic father’s unexplained absences and by her mother’s rejection. At school Tia’s attendance was poor partly due to her recurring flare up of mouth ulcers and migraine headaches. When she was able to attend, she had repeated outbursts of rage, although she could never recall having them. She was constantly falling out with peers, on several occasions punched someone in the face, causing a nosebleed and leading to her temporary exclusion from school. She appeared genuinely unable to recall any of these incidents, and in the same way had great deal of difficulty describing her internal sensations and feelings. I attributed this to a high level of dissociation and alexithymia – difficulty in experiencing, expressing, and describing emotional responses – which is a common feature in psychosomatic disorders. In Tia’s eyes people were useless, unreliable and untrustworthy, a view which I thought gave her a false sense of autonomy and power. Yet Tia also seemed crippled by her profound passivity and infantile need for attention and care, which her body was expressing through somatic symptoms.

Theoretical assumptions I made the following considerations after assessing her for psychotherapy. Tia’s relationship with her caregivers severely frustrated her innate and fundamental needs for attachment. Her mother was emotionally distant and unexpressive and, I would think, upset and preoccupied with her own trauma and predicaments. Tia’s father was

an extremely violent man unable to contain his own aggression and frustrations. This emotional climate and lack of containment lead to parts of Tia’s self becoming being split off and dissociated. Her inability to express her own archetypal primitive aggression created an internal pressure she was unable to manage. Tia adopted a number of sophisticated defenses as ways of protecting herself from this internal pressure and from her external reality. However, at another level these defences significantly hindered her development, and thus compromised her individuation process. Tia’s migraines appeared to prevent her from thinking about her unbearable experiences. They forced her to shut down and not take anything in. In addition, her migraines and mouth ulcers made it hard for her to take in nourishment, physical and psychological, and prevented her from verbally expressing her distress and fury about her reality.

Evolution of therapy Tia used her therapy to convey her dissociated feelings through behaviour in which she reversed the role of adult and child. She treated me like a child by painfully rejecting and abandoning me, making me feel like a neglected and isolated child, whose mother had no time for her at all. Her rejection and abandonment of me was expressed through her inconsistent and unpredictable attendance for therapy or by rejecting any reflection I made. At the very beginning of therapy she told me that she did not like to think about her feelings preferring, she said, to ‘sweep them aside’, which I thought reflected the depth of her psychosomatic splitting. About three months into therapy, Tia’s difficulty in maintaining connection and the problem of regulating her closeness and distance with me rapidly surfaced. Tia’s modes of relating to me illustrated multiple confusions over her relationships with adults, and in parallel with this, confusion about her own body. It seemed that part of herself sometimes needed to be cared for, yet at the same time rejected the care she seemed to be longing for. Tia actively demonstrated to me how disconnected and out of touch she was with her feelings and acted out in therapy with me a fragmented and deprived caregiver–infant relationship. She could only regulate intimacy through physical means rather than psychological. It seemed that in infancy Tia felt cared for only in terms of surface attentions to her physical requirements and never experienced any psychological and intuitive sense of being held in her caregiver’s thoughts. In this context, Tia’s somatic symptoms prompted contacts with doctors which in turn provided her with something of the experience of adults caring and attending to her physical needs. This way she would passively and helplessly lie on a doctor’s couch while a biopsy would be taken from her mouth, perhaps a symbolic representation of her inability to use words to articulate the helplessness and emotional neglect she was experiencing with her caregivers. When doctors did not find anything wrong she would criticise them, seeing them as useless.

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CHILD ANALYSIS Children and psychosomatic disorders: perspective from a child psychotherapist

Tia’s inability to recall her outbursts of rage highlighted her tendency to dissociate when she encountered psychic distress. Most significantly any stressful situation she encountered was followed by debilitating migraines and painful mouth ulcers which prevented her from speaking or eating. This was also reflected in the pattern that, following a productive or creative therapy session, Tia would often miss the following session, as if to erase any understanding that had emerged and the possibility of further insight. Her unspoken frustration and repressed anger were feelings I picked up in our sessions (my ‘counter-transference’). In navigating through my responses to the rejecting and abandoning way she treated me, I gained an understanding of the part of Tia who felt deeply angry, let down and humiliated over her longing for a secure attachment. This split off or dissociated part of her desperately needed to be given expression but Tia could not allow herself to do this. This seemed to link with her feelings of shame that if she felt or expressed any aggression she would be rejected and punished, a very significant issue for Tia. As a way to manage her anxiety, she developed a paranoid resistance to getting close to me, as if I was her abusive father or her hostile and distant mother. This new understanding enabled me to endure the difficulties and to continue thinking about her, and to keep noticing and containing the rage and the despair that Tia brought to her sessions but which she was unable to process. I felt that it was important not to lose sight of Tia, largely because I feared that if I did she would not find the part of herself which strived for expression and needed to be integrated.

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I gained an understanding of the part of Tia who felt deeply angry, let down and humiliated

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As her therapy sessions became important to her, Tia became less rejecting of me. Her attendance improved and she was more receptive to my reflections, an indication that she appreciated the consistency of my presence. In this second phase of her therapy I began to understand that while Tia possibly longed for empathy and attunement with me, her suspicions and fears derived from her traumatic past experience of abandonment and emotional deprivation with her caregivers. This made it considerably difficult for her to engage deeply and fully utilise our therapeutic relationship. Although Tia seemed to want to form trusting relationships, it was apparent that for her, psychological contact itself was the fear element, perhaps because it brought a promise of love, safety and comfort that could not ultimately be fulfilled and this reminded her of the abrupt breaches of infancy she had experienced with her caregivers (Hedges, 1997). With this challenge in mind I saw my task with Tia as being to increase her

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ability to engage with me, first by respecting her need for limited emotional proximity and subsequently by paying careful attention to her levels of tolerance, which she communicated bodily and non-verbally, for example by sitting rigidly on the edge of her seat, or taking to bed with her migraine headaches, or through her mouth ulcers flaring up – an indication of psychic distress. Approximately two years into twice-weekly therapy, memories of sexual abuse by her father began to surface. Tia recollected that when she was a young child her mother went to work leaving her at home in the care of her father. She remembered her father ‘always looking sleepy’ and recalled that he fondled her and obliged her to fondle him. Initially she thought the situation pleasurable but as time passed her father became more abusive. Afraid of what he might do to her and her mother (a result of living with domestic violence) Tia kept her mouth shut and did not tell her mother. When she did manage a disclosure to her mother, she was dismissed and not taken seriously. In recalling the sexual abuse by her father and her mother’s rejections and abandonment, Tia’s migraines returned. Her eyes closed, she described red lights around her and perceived volcanos and flowing lava flooding her. In the sessions which followed she began for the first time to get in touch with what she felt and confessed guilt, shame and angry feelings. Tia’s somatic symptoms gradually faded and by the end of her therapy, although her mouth ulcers still flared up, these episodes were few and far between. Her migraines had completely disappeared and her school attendance increased. With her emotional repertoire growing, Tia no longer had outbursts of rage at school as she could now put into words her feelings which meant that she could be understood by others. It seemed she no longer heavily relied on her body to speak out about her discomfort and distress.

Conclusion Tia’s body and mind relationship had become fragmented as a result of her caregiver–infant experience. In the absence of an emotionally available adult’s mind to provide her with a ‘thinking skin’, Tia’s bodily sensations had failed to become thinkable emotions. As a result of this failure, her mind failed to develop a capacity to transform unprocessed psychic events into symbolic thoughts: to make sense of herself, in other words. Twice-weekly psychotherapy over two years allowed for the reconstruction of early attachment patterns to unfold within the containment of a therapeutic relationship, giving Tia the opportunity, with the help of her therapist, to think about her body and the contents of her mind in order to facilitate her re-integrating that which had become split off. Hedges L (1997). Surviving the transference psychosis. In L Hedges, R Hilton, V Hilton, OJ Caudill (eds) The therapists at risk: perils of the intimacy of the therapeutic relationship. Northvale NJ: Jason Aronson. Kradin R (2011) Psychosomatic disorders: the canalization of mind into matter. Journal of Analytical Psychology 56 (1) pp 1–155.

HERB AL FIRST AID

Herbal medicine in paediatric practice Dedj Leibbrandt Medical herbalist/acupuncturist

While many herbal medicines are not suitable for use with children, as herbalists we do have at our disposal some simple, safe and effective medicines for use in childhood illnesses. Based on many years of practising herbal

After school I trained as a nurse and then studied western herbal medicine for four years, qualifying in 1992. While running my family-oriented practice, I studied Chinese herbal medicine and acupuncture. I regularly see 20+ patients a week at my practice in Chandlers Ford in Hampshire. I have a longstanding interest in first aid and lead a herbal medicine first aid and acute clinic at several child-friendly events – a great place for paediatric clinical experience.

Introduction

German chamomile

Children respond well to herbs. They don’t have to be strong herbs, nor do you need large amount of them. The herbs described here are all easily accessible, easily applied and with high child compliance. They are ubiquitous and simple but for more complex situations professional help should be sought. Qualified herbalists have a great deal to offer with a greater range of herbs and the ability to prescribe individualised preparations. This article is based on my own personal clinical experiences of treating children.

The spelling of the common name is interchangeable, both with an ‘h’ and without. The spelling depends on the origin of the word that you choose to use. Chamomile grows throughout Europe. In the wild it can often be mistaken for scentless mayweed by the untrained eye. They look quite similar but scentless mayweed has no scent. Crush the flower head to be sure – chamomile has a very distinct smell. Harvest the flower heads on a warm sunny day from June to August.

medicine, my favourite five herbs for children are discussed in the context of paediatric practice. These preparations are easy to make and administer: they also have the benefit of good compliance.

Chamomile

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HERBAL FIRST AID Herbal medicine in paediatric practice

German chamomile (Matricaria recutita also known as Matricaria chamomilla) Constituents: 0.24–1.9% volatile oil with the pharmoacopoeial standard of not less than 4mg/kg blue oil. The main volatile oil is bisabolol – up to 50%, and chamazulene 1–15%. Other constituents include amino acids, anthemic acid, choline polysaccharides, tannins, plant and fatty acids and triperpene hydrocarbons. Good quality essential oil is expensive and should be blue in colour. The colour is formed during distillation when the chamazulene is formed from matricin. Actions: anti-inflammatory, spasmolytic, vulnerary (wound-healing), antimicrobial, mild sedative, carminative (anti-flatulent), antiseptic, anticatarrhal.

Indications This herb has to be included in an article about herbs for children, because it has a vast range of uses. It is the matriarch of all children’s herbs as is indicated in its name (matricaria). Chamomile is specifically indicated for children with nervous irritability and gastro-intestinal disturbance. The antispasmodic properties of the volatile oil component of the plant are well documented and responsible for this action. I use it for colic, flatulence, anxiety and mild insomnia. The bitterness in the plant will gently stimulate appetite and digestive activity. Topically this is a very useful herb. Chamazulene and bisabolol directly reduce inflammation in tissues they come into contact with, stimulate the formation of granulation tissue, and have an antibacterial action. I have used it to treat leg ulcers in the elderly, and on eczema and inflamed irritated skin in children. It is ideal for babies with nappy rash and teething, both of which can happen concurrently. I recommend making an infusion of the dried herb (two or three teabags per teapot), leaving for half an hour then straining and adding this tea to the baby’s bath. Repeat for several days. It not only heals the inflamed skin, but eases the irritability associated with teething as well. It is worth mentioning that there have been reported incidences of side effects of chamomile. These include anaphylaxis in people with pre-existing hypersensitivity to ragwort (Asteracea and Compostiae family) and allergic skin reactions when used topically. It is important to note that these are rare. I am sorry to say that Peter was not very well during the evening. His mother put him to bed, and made some camomile tea; and she gave a dose of it to Peter! ‘One teaspoonful to be taken at bed-time.’ Beatrix Potter, The Tale of Peter Rabbit

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Elderflower and elderberries Elderflower and elderberry cordial is now available from most large supermarkets and can easily be made at home. The flowers can be gathered in spring and early summer; and the berries are collected in August and September.

Elderflower/berries (Sambucus nigra) Constituents: Flowers: Flavonoids: up to 3% (including quercitrine and kaempherol), quercetin glycosides (including hyperoside, isoquercitrin and rutin). Triterpenes – oleanolic and ursolic acids. Volatile oils (mostly linoleic, linolenic and palmitic), and alkanes. There are also many other constituents including ethers, aldehydes, alcohols and ketones. Berries: Invert sugar, fruit acids, pectin, tannin, vitamin C, anthrocyanic pigments, traces of essential oil. Actions: Flowers: diaphoretic (promotes perspiration), anti-catarrhal, expectorant, circulatory stimulant, diuretic, topically anti-inflammatory. It is used for the treatment of influenza, chronic nasal catarrh with deafness, sinusitis and is specifically indicated in the common cold. Berries: diaphoretic, diuretic, laxative.

Sambucus nigra

Indications I often use elderflower cordial as a diaphoretic in the management of childhood fevers. The flowers are mildly relaxing and they ease agitation and restlessness. Since there is often a catarrhal element for many childhood fevers, this herb is especially indicated for use due to its anti-catarrhal astringent properties. At a time when you are trying to ensure that enough fluids are taken, elderflower cordial cannot be beaten – children love it and will drink it freely. Elderflower cordial can be given prophylactically before the pollen count rises to strengthen the upper respiratory tract and ease hay fever symptoms. It is also useful in the treatment of allergic rhinitis. The fresh tea is anti-inflammatory and can be used topically to soothe inflamed eyes. Simply infuse in boiling water, let it cool and use as a compress. It is also recommended as a gargle for mouth ulcers and tonsillitis.

HERBAL FIRST AID Herbal medicine in paediatric practice

Catarrh is common in children. In conjunction with elderflower, I recommend the removal of dairy products, sugary and junk foods and also fridge-cold foods for the duration of the catarrh. The diet should contain plenty of fruit and vegetables, chicken and fish, and a calciumcontaining milk alternative (not soya). I use the berries, which are rich in Vitamin C, as a cordial. This is also very palatable for children and can be given as a prophylactic in the winter against colds. The berries, when combined with expectorant thyme tea, are also useful in the treatment of coughs. As with most fruits, the berries have a gentle laxative effect in quantity and can be used for mild constipation in children.

Garlic In my mind, there can be no other more powerful antimicrobial herb for children. If a child is too young or unwilling to eat garlic, then it can be rubbed onto the soles of their feet and within an hour you will smell the volatile oil that we are all familiar with on their breath. This makes it an excellent remedy for respiratory tract infections.

Indications There is traditional use for the treatment of chronic bronchitis, respiratory catarrh, recurrent colds, bronchitic asthma, influenza, and whooping cough. More modern research is focused on its use in atherosclerosis and hypertension with fibrinolytic and lipid lowering effects. Also its anticarcinogenic and immunomodulatory activities. The uses of garlic are vast and we could all benefit from its huge array of good actions. Garlic can be added to soups or in many other foods and the caregiver of the sick child should use their knowledge of the child and their culinary skills to find ways of administering this useful herb. Useful tips: cut open a garlic capsule and add the contents to a teaspoon of honey. In the treatment of threadworms a small clove of garlic can be inserted in the child’s anus overnight – prick the garlic with a pin a few times and leave the papery layer on. Do this for two nights in a row and then repeat on day 14 and 15 days to kill the recently hatched eggs.

Garlic (Allium sativum) Constituents: volatile oil 0.1-0.36% (including sulphurcontaining alliin and allicin), enzymes including allinase, peroxidase, myrosinase and others, proteins, amino acids, Vitamins, minerals, trace elements, lipids and prostaglandins. (Barnes, J, Anderson L, Phillipson D, 2002) Actions: antimicrobial, antiviral, promotes leucocytosis, hypotensive, lowers blood viscosity, lowers blood cholesterol and triglycerides, prevents atheroma when used long term, and anthelmintic. Actions: In vitro studies have shown significant antimicrobial activity of garlic to include a wide range of species from staphylococcus aureus and faecalis, escherichia coli, proteus mirabilis, salmonella typhi, providencia, citrobacter, klebsiella pneumoniae, hafnia, aeromanas, vibrio, bacillus gener, candida spp, aspergillus spp, mycobaterium tuberculosis, helicobacter pylori, giardia intestinalis, parainfluenza type 3, herpes simplex type 1 and influenza B.

Thymus vulgaris

Thyme Thyme tea is an extremely useful antimicrobial herb with far reaching affects. The best time to collect thyme leaves is on a hot day between June and August when the plant is in flower and the essential oils are at their peak.

Thyme (Thymus vulgaris) Constituents: 0.8–2.6% volatile oil with the pharmaceutical standard of no less than 1.2%. Phenols are the major component (20–80%) primarily thymol and carvacrol. Other constituents include flavonoids, caffeic and rosmarinic acid, reins, saponins and tannins. Allium sativum

Actions: Carminative, digestive tonic, spasmolytic, antimicrobial, antiseptic, relaxing expectorant, astringent, anthelmintic, antitussive, secretomotor effect.

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HERBAL FIRST AID Herbal medicine in paediatric practice

Indications Dyspepsia, chronic gastritis, bronchitis, pertussis, asthma, diarrhoea in children, enuresis in children; as a gargle for laryngitis and tonsillitis. Specifically indicated in pertussis and bronchitis. The use of this herb for pertussis is well documented and according to Weiss (1991), the tea on its own will, in most cases be sufficient. There is a traditional combination used by medical herbalists of thyme and wild cherry bark (Prunus serotina) which, when used together, is invaluable in treating an irritable tickly cough in all ages. Sore throats and tonsillitis/ laryngitis can be soothed with sage or thyme tea. Thyme tea is delicious and lends itself to the addition of honey and lemon especially where children are concerned. It is a useful carminative with antimicrobial with high tannin properties so it not only treats the cause of infective diarrhoea, but also stops it and eases spasmodic visceral pains.

Oats I have included this useful plant due to its accessibility in the shops. Perhaps it is not widely known that this is also a fantastic medicinal plant that has been used for centuries.

Oats (Avena sativa) Constituents: Saponins (including avenacosides A and B), alkaloids (including indole alkaloid, gramine, trigonelline, avenine), sterol (avenasterol), flavonoids, silica (particularly in the straw), starch (50% in the seeds), protein (including gluten), minerals (calcium, iron, phosphorus, copper, magnesium, zinc), vitamins B1, B2, D and E, carotene, fat, fixed oil. Actions: antidepressive, thymoleptic, cardiac tonic, nervous system restorative, nutritive, demulcent, vulnerary

Conversely, oats can be taken at bedtime due to their mild sedative and hypnotic properties, which are due to the indole alkaloid gramine. Somehow our bodies know how to use the chemical constituents to our best advantage. Oats are easy to administer to children in porridge or oat bran, which provides nourishment and nervous support especially during the winter months. The nourishment aspect is also useful after a bout of illness as oats contain a high percentage of protein and are easy to digest. Porridge provides good recuperative properties and stamina, addresses fatigue and lifts the spirits. Oat bran contains silica, which has local healing effects, which can help heal skin problems when applied locally. It can be applied as a poultice for wounds, burns and neuralgia. I use this herb in the form of an oat milk bath in atopic eczema presenting with dry and itchy skin. This is easy to make by placing two large handfuls of oats inside a pop-sock or old pair of tights, tying to the hot water tap and allowing the bath water to run through it. This will turn the bath a milky white colour. The oats in the sock can be used as a sponge directly onto the skin instead of soap. Oats have fairly recently been put back into the British National Formulary in the preparation Aveeno cream which contains colloidal oatmeal in an emollient base and is recommended for dry and itchy skin. Caution: Gluten may be a problem in sensitive individuals (eg those with coeliac disease). Bibliography British Herbal Medicine Association (1983) British herbal pharmacopoeia. Bournemouth: BHMA. British National Formulary 64, December 2012. London: BMJ Group and Pharmaceutical Press. Grieve M (1931) A modern herbal, (ed CF Leyel 1985).London: Jonathan Cape. Hoffmann D (1990) The new holistic herbal, second edition. Shaftesbury: Element.

Indications

Mabey R (ed) 1991 The complete new herbal. London: Penguin.

Depression, melancholia, menopausal neurasthenia, general debility, childhood eczema. It is not uncommon for plants to have seemingly opposite effects and oats is a prime example of this. Oats can give us energy in the morning for breakfast due to the alkaloid avenine, which stimulates the central nervous system. It is the component that causes horses fed on large quantities of oats to become highly excitable.

Mills SY (1993) The essential book of herbal medicine. London: Penguin.

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Weiss RF (1991) Herbal medicine. Beaconsfield: Beaconsfield Arcanum. Wren RC (1988) Potterâ&#x20AC;&#x2122;s new cyclopaedia of botanical drugs and preparations. Saffron Walden: C W Daniel.

A childhood at the edge William House Retired GP; Chair of the BHMA

Life is what happens to you while you are busy making other plans. John Lennon Reading and reviewing Alison Gopnik’s thought-provoking book on parenting (see review page 47) gave me pause to test her ideas and stories against my own childhood. So here goes! When my parents married my father was running the family packing business in a ramshackle haulage yard at the side of his family home in Islington, central London. Both parents were from large local families. My father’s was a tough masculine world of the boxing club and hardy outdoor swimming, softened by a family talent in fine art. They had both left school aged 14. My big sister was born eight years before me in 1939, becoming the apple of my father’s eye. But her childhood was disrupted not only by the war, but also by our mother’s post-natal depression. After the war, the family business was thriving, prompting my parents to move out of Islington to the northern edge of London where I was born. The father I knew aspired to posher things in the new suburbia. He joined a Masonic Lodge and took my mother to Masonic Ladies Nights at the Grosvenor Hotel in Mayfair and to The Royal Opera House in Covent Garden. My mother was warm, kind, very clever and anxious. She sang operatic arias when she wasn’t cooking, cleaning or crying. My father had bigoted views and fell out of friendships. My first memories were of a 1930s house much loved by my mother, with a playmate living opposite. My increasingly self-possessed sister taught me to read, but would beat me up if I tried to join her and her friends. Sadly, for my father this house was much too near other people and when I was five he sold the house (without consulting my mother) and we moved to a small cottage two miles down a country lane. In the midst of the move they forgot to register me for school. So with the nearest other child living a mile away I was left to play alone. I grew to love this solitary childhood. I explored at every level. My toys were taken to pieces and put back together. I was obsessed with how things worked and as I grew older I moved through electric train sets and onto dismantling and rebuilding pre-war Austin 7 cars to drive around the field below the cottage. When I wasn’t driving or riding my bike (with no brakes), I climbed ‘like a monkey’ up the mighty lime tree towering over the

The House family about 1951

cottage. My feet and hands knew every branch to the very top, where I sat like a bird looking down on its little world. I finally started school, like Christopher Robin, when I was six. I enjoyed the lessons and made friends. My mother took me and collected me and all was well. But this would not last. The family business began to fail and when my mother became company secretary I had to take the bus home from school. Alone at home my solitary explorations continued. After a few years the business ceased trading. Through her intelligence and social skills my mother quickly found secure, well paid work, while my father had a series of poorly paid unreliable jobs. She was the breadwinner and housekeeper and child carer. I watched her struggle, smoking and drinking gin. I hid her cigarettes but she found them again. My sister lost interest in school and was pursued by foolish boys, one day falling pregnant on the hearth rug. From my tree I watched the perverse pageantry of human folly. I managed to scrape through the 11+ exam a year early so was back with my own age group. I chose the grammar school three bus rides away. Though bright I was put in the bottom stream. My classmates struggled and I helped them. I had friends, but was never part of the crowd. I watched from the edge of school life and did what I wanted to do, including at age 13 deciding on medicine. I caught the three buses until I was 17 when I drove my Austin 7. It was in that year that my mother died of cancer and I met this tragedy with the emotional detachment I had, unknowingly, spent my life cultivating. My father sold up and moved to France, still trying to get away. Years later, and two weeks before her own death, my sister said sorry for her treatment of me. I can see many elements of Gopnik’s book in this story: the importance of love from my mother, having fun and playing (albeit often alone), a messy childhood. I have ended up being very good at ideas and imagination, curiosity, perseverance, self-reliance, resilience and helping people who struggle. This is nearly all accidental. The price I have paid is having a poor paternal role model, clumsy social skills and being too much inside my own head. If nothing else, it makes a nonsense of attempting to design a child.

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Research summaries Recent child and adolescent research Dangers of teenage cannabis This study, which recruited 1,009 boys from 1st and 7th grades, suggests that adolescents who smoke marijuana regularly significantly increase their risk of experiencing persistent subclinical psychotic symptoms. For each year these adolescent boys engaged in regular marijuana use, their expected level of subsequent sub-clinical psychotic symptoms rose by 21% and their expected odds of experiencing subsequent subclinical paranoia or hallucinations rose by 133% and 92%, respectively. No evidence was found for these boys being unusually prone in other ways to mental illness or that such factors made them more likely to smoke marijuana. Bechtold J, Hipwell A et al (2016) Concurrent and sustained cumulative effects of adolescent marijuana use on subclinical psychotic symptoms. American Journal of Psychiatry 173(8): 781–789. http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2016.15070878

Child abuse and depression Childhood maltreatment (CM) has been shown to be related to the severity and/or chronicity of major depressive disorder. This study, which used an online survey sample of 340 acute or recovered depressed individuals, investigated how this relationship can be explained. It found that CM was related to difficulties in emotion regulation, relationships and thinking style, and symptoms of post-traumatic stress disorder. Statistical analyses showed that these four variables (partly) explained how CM is related to more severe depression. Treatment for depression in individuals who have experienced CM may need to directly target these variables. Schierholz A, Krüger A, Barenbrügge J, Ehring. T (2016) What mediates the link between childhood maltreatment and depression? The role of emotion dysregulation, attachment, and attributional style. European Journal of Psychotraumatology 7: 32652. http://dx.doi.org/10.3402/ejpt.v7.32652

Introduce new foods in the first year of life? The timing of introduction of potentially allergenic foods to the infant diet may influence the risk of allergic or auto-immune disease. This systematic review pooled the relevant evidence from 60 years of trials and observational studies evaluating the timing of allergenic food introduction during the first year of life and which included reports of allergic or auto-immune disease or allergic sensitisation. 16,289 original titles were screened, but there were only 146 high-quality studies. In this systematic review, early egg or peanut introduction to the infant diet was associated with lower risk of developing egg or peanut allergy. However, these findings must be considered in the context of limitations in the primary studies. Ierodiakonou D, Garcia-Larsen V et al (2016) Timing of allergenic food introduction to the infant diet and risk of allergic or autoimmune disease: A systematic review and meta-analysis. JAMA 316(11): 1181–1192. http://dx.doi.org/10.1001/jama.2016.12623

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Parenting skills help children deal with eczema Childhood chronic health conditions have considerable impact on children. The researchers worked with 107 parents of 2- to 10-year-old children with asthma and/or eczema, to test the efficacy of a brief, group-based parenting intervention for improving illness-related child behaviour problems, parents’ selfefficacy, quality of life, parents’ competence with treatment, and symptom severity. Parents in the intervention group reported fewer eczema-related, but not asthma-related, child behaviour problems. Self-efficacy for managing eczema improved, but not asthma. Parents and family reported better quality of life, but the affected children did not. There was no change in parental treatment competence, but there was reduced symptom severity, particularly for children prescribed corticosteroid-based treatments. These outcomes suggest that brief parenting interventions can improve childhood chronic illness management, child health outcomes, and family wellbeing. The effects were stronger for eczema compared to asthma. Morawska A, Mitchell AE et al (2016) Effects of triple parenting intervention on child health outcomes for childhood asthma and eczema: Randomised controlled trial. Behaviour Research and Therapy 83: 35–44. http://www.sciencedirect.com/science/article/pii/S0005796716300961

Lack of sleep may impair children’s brain development According to international guidelines children aged 6 to 13 need 9 to 11 hours sleep a night. New brain scan studies show sleep deprivation affects children’s brains more than was previously realised. Researchers measured the brain activity of 13 children aged between 5 and 12, comparing the impact of a normal night’s sleep (bedtime 9pm) with a limited night’s sleep (bedtime 2am) but the same wake-up time for both groups. Previous studies in adults show that sleep restriction increases deep sleep waves – patterns of brain activity associated with the deepest sleep – in the frontal region of the brain. The researchers found similar effects in children, but this time at the back and side regions of the brain involved in planned movements, spatial reasoning, and attention. Adequate good quality sleep may influence how neuronal connections develop during childhood and adolescence. Scientists are speculating that chronic insufficient sleep in this sensitive period may alter lifelong the brain structure required for deep sleep slow-waves. Kurth S, Dean DC et al (2016) Increased sleep depth in developing neural networks: new insights from sleep restriction in children. Frontiers in Human Neuroscience. Online September 21.doi:10.3389/fnhum.2016.00456

Thanks to James Hawkins http://goodmedicine.org.uk/goodknowledge

Reviews Last child in the woods Richard Louv Atlantic Books, 2009 (UK edition) ISBN: 978 1 84887 083 3 This book is a cogent, well-researched explanation of the many ways that kids benefit from contact with nature, the problems if they don’t, and ways to tackle the problem. Louv coined the term nature deficit disorder (NDD): this is a persuasive and upsetting account of a widespread problem. He cites numerous studies, from the US and Europe: for example, the percentage of children regularly playing outdoors has dropped dramatically. For example, a US study showed that 70% of today’s mothers recall playing outdoors every day as children, but only 26% said their own kids play outdoors daily. Also the area of outdoors where children play has been hugely constricted: instead of the great outdoors, many kids are only playing in their small backyard or school playgrounds. Why is this happening? He observes that many parents convey fear messages about nature, for example ‘stranger danger’. Many ‘play’ activities of 40 years ago – climbing trees, lighting bonfires, building tree houses, may now be seen as dangerous, damaging, even illegal: his third chapter is called The Criminalisation of Natural Play. And even nature education may be a problem. David Sobel, one of the US experts in this field, says: ‘If we fill our classrooms with examples of environmental abuse, we may be engendering… dissociation. In our zest for making them aware of and responsible for the world’s problems, we cut our children off from their roots.’ Louv also quotes a chilling comment by leading environmentalist Theodore Roszack: ‘Environmentalists, by and large, are very deeply invested in tactics that have worked to their satisfaction over the last 30 years, mainly scaring and shaming people…’. Put another way, it’s easy for environmentalists to see children as part of the threat to nature, not as the potential future guardians of it. The damaging effects of nature deficit disorder can be deduced from numerous studies showing the benefits of contact with nature. So read on! Louv offers numerous solid examples of this. A 10-year study in 160 US schools showed that environment-based education had substantial benefits on academic learning and such wider skills as critical thinking, problem-solving and decision-making, social skills, and also reduced disciplinary issues. Both children and adults gain a greater sense of wellbeing from time in nature – and even from views of it. The Finnish school system puts high emphasis on play and outdoor learning, and doesn’t start formal education until age 7.

Yet in a 2003 OECD review, Finland scored first out of 32 countries for literacy, and in the top five for maths and science. Louv also highlights the particular benefits of nature contact for children with behavioural problems, learning difficulties, and physical disability. There is also good research in the US showing the benefits of nature contact on attention deficit hyperactivity disorder (ADHD) which is now a major issue for many children. Louv points out that the major growth in problems of nature deficit disorder and obesity among US children have coincided with major growth in the number of kids participating in organised outdoor sports, so one of his key points is that the need is for unstructured experiences, and exposure to wild nature where possible. He quotes the ‘loose-parts’ theory of play, invented by UK architect Simon Nicholson: ‘In any environment, both the degree of inventiveness and creativity, and the possibility of discovery, are directly proportional to the number and kind of variables in it’. Natural settings can potentially be the ultimate loose-parts toy, but this clearly needs children to be free to interact, eg making shelters, digging and planting, playing with mud and water etc. Possible examples include: • more stimulating open spaces in urban contexts, including school playgrounds and parks • longer wilderness experiences providing a ‘restorative environment’: US research has identified a widespread problem of ‘directed-attention fatigue’. longer periods of simply being quiet in wild nature can offset this and improve wellbeing and thinking skills • enjoying ‘back yard nature’, and getting to know one space really well • using gardening to connect kids with nature, including the ‘sunflower house’ idea: growing sunflowers in a square so they create a semi-enclosed space • more nature contact in teaching: both in the indoor classroom, and outdoors • wildcrafting: ‘the hunting and gathering of plants in their wild state, of food, herbal medicines or crafts’ • observation of birds, plants etc: Louv emphasises the value of encouraging children to record their own observations and keep a journal, instead of swamping them with external information. In general, parents/adults should find ways to offer ‘controlled risk’ experiences for children: ‘modern life narrows our senses until our focus is mostly visual…By contrast, nature accentuates all the senses’. The skills children develop in assessing and handling natural risks, eg scrambling down slopes, crossing streams, walking on ice, are applicable very widely. Linked to this is the need for children to have interactive sensory experiences, not the passive visual experiences which are now so common. The book has a whole chapter on the relevance of green urbanism. Many of the best examples are from the Netherlands, drawn from the book Green Urbanism: Learning from European

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REVIEWS

Cities by Timothy Beatley, who comments that kids in such cities feel much freer and safer than kids in US cities. Louv points out that ‘most urban theory ignores non-human species, and that there is great potential to encourage wildlife and increase nature contact through good urban design’: he comments that ‘landscape urbanism is one conceptual framework’. Louv highlights the benefits of city trail networks, as in Portland, Oregon, which not only increase contact with nature, but can prevent green pockets from being built on by joining them up in a functional network.He shares the view of other experts that there is good potential for new, nature-linked, sustainable rural settlements to be created. The spiritual necessity of nature for the young is one of Louv’s chapter headings. He quotes the research of Edward Hoffmann, an American psychologist, demonstrating that many children have spiritual experiences, and that ‘most transcendent childhood experiences happen in nature’. Louv mentions a number of American religious groups, Christian and other, who promote good stewardship of nature, and children’s contact with it, however he admits that these tend to be fringe rather than mainstream. Louv hopes that a mainstream movement will emerge and is the chairman and co-founder of the Children and Nature Network (www.childrenandnature.org). He sees the movement to ban smoking in public places as an encouraging precedent: it arose from the combination of authoritative scientific research with grass roots concern among individuals and local communities. The UK edition of Last Child in the Woods ends with a field guide, specially researched for the UK, including relevant books, organisations, and potential action points for parents, schools, business etc. A few of the good ideas in this include: • establish a ‘green hour’ as part of the family routine: 30 or 60 minutes every day where the family spend time outdoors together • numerous ways to enrich wildlife activity in the back garden • websites to find green spaces near you: bbc.co.uk/ breathingplaces; www.green-space.org.uk • encourage older children to volunteer in conservation projects, eg with the National Trust or Wildlife Trust. Alan Heeks, Chairman, Hazel Hill Trust This review first appeared on the Hazel Hill Trust website www.hazelhill.org.uk

The gardener and the carpenter Alison Gopnik Farrar, Straus and Giroux, New York: 2016 ISBN: 978 0 37422 9 702 But the more we intentionally and deliberately cook and eat in order to become healthy, or raise children in order to make them happy and successful adults, the less healthy and happy we and our children seem to become. (p25) I bought Alison Gopnik’s book because I liked her central theme: that ‘caring for children is like tending a garden, and being a parent is like being a gardener’. This sort of garden focuses on

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creating a protected and nurturing space in which plants can grow and thrive and become whatever they are destined to become. The carpenter, on the other hand, shapes her materials into a final product designed in advance according to her own preferences and the demands of the market. The Americans call this ‘carpenter way’ parenting. The designed child trend is also here in the UK. Gopnik argues vigorously against this and in favour of the parent as gardener. It has happened, she says, because of smaller and more dispersed families – the practical wisdom of grandparents and aunts and uncles is not on the doorstep as they once were. The experience in the extended family is being replaced by supposed expertise from various professionals and writers of the thousands of parenting manuals. She calls instead for giving children more freedom to do their own thing. This is messier, but has deep and far-reaching benefits. The positive value of diversity and emergence is nature’s way. The central scientific idea of this book is that the answer lies in disorder. (p26) In Chapter 2 she marshalls impressive arguments from the study of the evolution of the human child: that the evolutionary focus of our species is in adapting to the very fact of change itself. She finishes her arguments with this summary statement: ‘Shaping [children] in our own image, or in the image of our current ideals, might actually keep them from adapting to changes in the future.’ Chapter 3 starts with an intriguing discussion of pair-bonding and co-operative breeding in humans and a few other species. The human and the gibbon are the only apes to pair-bond – that is, they share their lives, conceive and care for offspring together, though neither achieve total monogamy! Beyond this pairing is the importance of grandmothers. Gopnik is obviously strongly influenced by her own active role as the grandmother to her son’s two children, Augie and Georgie. Caring for children by individuals other than the mother is called ‘alloparenting’, again setting humans apart from most mammals, though not elephants – they do it like us. It certainly seems that with humans ‘we don’t care for children because we love them, we love them because we care for them’. Parents and other caregivers don’t have to teach young children so much as they have to let them learn… The gardener’s picture, that being a parent is fundamentally a relationship, a form of love, gives you a different take on how children learn from adults. And it actually fits better with the research. (p145-6) Chapters 4 and 5 are about how children learn and its relevance to care-giving and education. She insists that even very young children combine information they receive with their own observations and experiences, building this into a synthesis of their own ‘in sophisticated ways’. The central paradox of learning is the tension between old knowledge (that’s ours) and new knowledge (theirs). Children create their own futures by building on the present, not copying it. She supports this with a mass of scientific data, mostly derived from reductionist experimental methods. Alongside these are stories from her own family life, and her philosophical and evolutionary knowledge. When these disparate sources gel they are compelling but they sometimes sit uncomfortably together and she clearly likes writing about her grandchildren! Chapter 6 is about the importance of play particularly when ‘spontaneous, random and by themselves’.

REVIEWS

More on this below. A standardised test score is the apotheosis of the goaldirected, child-shaping, carpentry picture of schooling. The last three chapters (7–9) are packed with interest and wisdom. Chapter 7 is about the transition from pre-schoolers to school-age children. Of course, this transition at around 6–7 years (when adult teeth arrive) precedes the invention of schools by thousands of years. It has often been marked by rites of passage and the beginning of apprenticeships for mastering the particular skills of the child’s own culture. In contrast to early childhood when the ‘evolutionary task is to explore as many possibilities as widely as possible’ (‘exploration learning’), Gopnik calls this next phase, ‘mastery learning’. This is about exploiting, not exploring. Developing and exploiting natural skills demands application, detailed instruction and relentless practice, failing and trying again. She calls this the ‘apprentice model’. This can work well in stable societies before the modern era, but brings major problems in the fast-changing society of the 21st century. ‘Mastery of scholastic skills such as reading, writing and arithmetic isn’t an end in itself ’, but it provides the tools for discovery later. So many school-aged children neither discover, not achieve mastery of anything approaching a natural human activity, except for some on the sports field or in the music room. The default focus becomes test-taking. Some manage this, many don’t. Even for those who are good at tests, this is not a useful skill for life. ADHD is both biological and social … Instead of drugging children’s brains to get them fit for our schools, we could change our schools to accommodate a wider range of children’s brains. (p196) To Gopnik, the educational system’s obsession with tests and examinations creates all sorts of problems. One of the most obvious is attention deficit hyperactivity disorder (ADHD). For Gopnik, ADHD is a ‘particular point on a continuum of attention style’. We learn there is a spectrum of attention that children can achieve from very wide to very narrow. In early human societies there was room for children at both extremes and anything in between. But test- and examination-focused education leaves no room for those whose ability to focus comes late or not at all. The stimulant drugs used to ‘treat’ ADHD work by narrowing attention. But as Gopnik points out: ‘Narrowing attention may be part of growing up but wide attention is part of being young. It’s not something we need to fix.’ One of the answers, she suggests, is to couple schooling with apprenticeship. On the web, we communicate with the planet, but rely on psychology designed for the village. (p229)

In chapter 8 Gopnik revisits her paradox of tradition and innovation. She uses the challenges of electronic media as her platform. She argues that what the adolescent child needs has not changed – to establish a community of friends from among their peers, to distance themselves from parents, to gossip, experiment, rebel. The parents’ role is to provide a stable base from which children invent themselves and what is becoming their world. In case we are worried about the risks of the internet, she reminds us that Socrates was worried about the damage to memory, conversation and critical thought through the spreading habit of reading and writing! Deciding whether to have children isn’t just a matter of deciding what you want. It means deciding who you are going to be. (p237) The closing chapter is about why we have children and why all of this is so important. She makes a heart-felt plea for childcare to have unconditional high value. She argues from a philosophical standpoint that caring for children is a good in itself, meaning that the goodness has no need to justify itself through its outcomes. It must have high priority. Sadly this is not how things are in much of the developed world: 20% of children in the USA (and 19% in the UK) grow up in poverty. Similar lack of priority applies to other relationships, particularly to older people. Even though relationships to specific people are at the core of our moral and emotional being… because they aren’t work, they are economically and politically invisible. (p247) Finally she returns to play. Like relationships, the deeper benefits come later. Gopnik illustrates the importance of play and fun by referring to a classic silent film, Nanook of the North (www.youtube.com/watch?v=uoUafjAH0cg) made in the 1922 and tracing the life of an Inuit hunter and his family. Theirs was an isolated community in a hostile climate. At one point, Nanook builds a toy sled for his toddler son and uses this to play in the snow. The only immediate payoff is fun, but in the end it was the beginnings of the adult skills the child will need for survival. But their life had changed little for perhaps a thousand years, whereas our fast-moving society transforms every generation. But though we live and express ourselves in changing ways, the fundamental needs of our humanity are the same as Nanook’s. We are one family and the children are all our futures. Our parents give us the past, and we hand on the future to our children. (p254) William House, Chair, BHMA

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Volume 14 Issue 1 Spring 2017

Guidelines for Contributors About the journal The Journal of Holistic Healthcare is a UK-based journal focusing on evidence-based holistic practice and the practical implications of holistic health and social care. Our target audience is everyone concerned with developing integrated, humane healthcare services. Our aim is to be useful to anyone who is interested in creative change in the way we think about health, and the way healthcare is practised and organised. Our basic assumption is that holism can improve healthcare outcomes and will often point to costeffective ways of improving health. Holistic healthcare can be understood as a response to our turbulent times, and medicine’s crisis of vision and values; an evolutionary impulse driving individuals and organisation to innovate. But when complex and creative adaptations do occur, these ideas, experiences and social inventions don’t always take root. Though they might be the butterfly wingbeats that could fan the winds of change, even crucial seeds of change may fail to germinate when isolated, unnoticed and lacking the oxygen of publicity or vital political support. Some of these ideas and social inventions have to be rediscovered or reinvented, and thrive once the culture becomes more receptive – or more desperate for solutions. The JHH sees holism as one such idea, a nest of notions whose time has come. So we want the journal to be a channel for publishing ideas and experiences that don’t fit easily into more conventional mainstream journals, because by making them visible, their energy for change becomes available to the system. The journal’s themes include the theory and practice of mind-body medicine; every aspect of whole person care – but especially examples of it in the NHS; patients’ participation in their own healing; inter-professional care and education; integration of CAM and other promising new approaches into mainstream medicine; health worker wellbeing; creating and sustaining good health – at every level from the genome to the ozone layer; environment health and the health politics of the environment; diversity and creativity in healthcare delivery, as well as holistic development in organisations and their management: a necessarily broad remit!

Writing for the journal We intend the journal to be intensely practical; displaying not only research, but also stories about holism in action. Personal viewpoint and theoretical articles are welcome too, providing they can be illuminated by examples of their application. The Journal of Holistic Healthcare is a vehicle for injecting

inspiration into the system: ideas and research that might enable positive change. We realise that there is nothing as practical as a good theory, and we encourage authors to foreground what they have done and their experiences, as well as what they know. Though we don’t always need or want extensive references, we ask authors to refer to research and writing that supports, debates or contextualises the work they are describing, wherever appropriate. We like further reading and website URLs wherever possible. And we like authors to suggest images, photos, quotes, poems, illustrations or cartoons that enrich what they have written about. Because the JHH aims to include both authors’ ideas and their experience we invite authors to submit case studies and examples of successful holistic practice and services, research findings providing evidence for effective holistic practice, debate about new methodologies and commentaries on holistic policy and service developments. Our aim is to be a source of high-quality information about all aspects of holistic practice for anyone interested in holistic health, including policy-makers, practitioners and ‘the public’. We aim to link theory to practice and to be a forum for sharing experiences and the insights of reflective practice. Articles should be accessible and readable, but also challenging. Key articles will link theory and research to practice and policy development. Contributions from the whole spectrum of healthcare disciplines are welcome. The journal is particularly concerned to highlight ways of embedding holistic thinking and practice into health care structures, including primary care organisations, networks and collaborative initiatives.

Original research JHH is a platform for holistic ideas, authentic experiences, and original research. We estimate our regular (and growing) circulation of 700 copies is read by as many as 2000. And, though we don’t yet attract researchers seeking RAE points, we are free to be a voice for the kind of ideas, reports, experiences and social inventions that wouldn’t fit easily into more conventional mainstream journals: small studies, pilots, local reports, surveys and audits, accounts of action research, narratives, dissertation findings (otherwise hidden in the grey literature), pragmatic and qualitative studies and practice evaluations. By publishing them in the JHH, important seeds for change become available to people who need to grow them on. Another advantage of submitting to JHH is the peer feedback to authors, some of which we may include as commentaries on a published paper.

If you would like to submit an article please contact either editor-in chief David Peters on petersd@westminster.ac.uk or editor Edwina Rowling on edwina.rowling@gmail.com. For our full contributors guidelines see www.bhma.org.

Editorial Board Peter Donebauer Ian Henghes Dr William House (Chair) Professor David Peters Dr Thuli Whitehouse Dr Antonia Wrigley

British Holistic Medical Association West Barn Chewton Keynsham BRISTOL BS31 2SR Email: contactbhma@aol.co.uk www.bhma.org

ISSN 1743-9493 PROMOTING HOLISTIC PRACTICE IN UK HEALTHC ARE

Children's health

Articles inside

Must reads - our book reviews on children's health

A childhood at the edge

Herbal medicine in paediatric practice

Children and psychosomatic disorders: perspective from a child psychotherapist

Children and community health - partnership for change in Newcastle

Educating children for health

Transformative learning in nature - forest schools

Nurturing childhood resilience

Crossing the threshold

Whatever happened to Sure Start?

The internet stole my children

Raising children compassionately