Findings of children's views of mental health services
Thirty-nine studies were identified, of which 14 met inclusion criteria (Table 1). This represented the views of over 200 children. Despite the range of ages, gender, presenting difficulties and orientation of services, analysis identified eight common themes.
1. Perceptions, evaluations and recollections of interventions (studies 1–13). Children were able to provide valuable information about the services they received, which were balanced (including positive and negative comments). Their perceptions also altered in ways consistent with the therapeutic process. Taken together with research demonstrating vulnerable children (including looked-after children) were able to meaningfully comment on important aspects of their lives, there is consistent support for guidelines recommending consulting with looked-after children at all levels: in their individual treatment and service provision discussions.
2. Personal qualities, skills, and attitudes of staff (1, 2, 3, 5, 6, 7, 8, 11, 12, 14). The primary importance of individual contacts was a recurring theme in the studies including personal attributes (e.g. kind, approachable), the sense of something being done, and respect for confidentiality. Taken together these data suggested that participant's experience of being heard and understood could be the foundation for a good match between child's need for action and therapeutic responsiveness. This implies that, despite NICE guidelines focusing on intervention type, other aspects of staff interactions may be more important to children. These aspects may cut across therapeutic orientation and may be important for staff training. This is consistent with literature suggesting therapeutic orientation might be secondary to other factors in distinguishing effective therapies (Stiles, Shapiro & Elliot, 1986). The importance of attending to the way that staff relate to children is likely to be particularly significant for looked-after children, given that children's responses to staff may well be influenced by previous damaging interactions with adults (Golding et al., 2006, Hughes, 2004)
3. Therapy process (3, 5, 6, 7, 8, 11, 12, 14). Children could meaningfully comment on the therapeutic process, identifying aspects that they felt were helpful and unhelpful, including particular techniques - analogous to adult clinical populations (Llewelyn et al., 1988). For many children talking was a source of challenge and discomfort as well as being helpful and valuable. Consistently across modalities and age groups, the value of non-verbal interactions (e.g. drawing, and playing) in enabling children to be engaged in therapy was acknowledged. This included the adoption of a variety of strategies to manage difficult situations. Excepting play therapy, play and other non-verbal communications were frequently regarded as relegated activities rather than central and rarely mentioned in guidelines for good practice. This theme suggests a more central importance, reflected in the training of mental health professionals. The use of dolls in paediatric services to explain procedures is an example of good practice that could be built on. Considering looked-after children, representing attachment relations is important - key to which is the use of guided and non-verbal techniques such as drawing and story-stem methodologies (Binney & Wright, 1997; Goldwyn et al., 2000). Implications for working therapeutically with foster families includes; alerting clinicians to find ways of enabling foster-family members to think about their use of different communication modalities. An example of good practice from CBT/systemic orientation is given by Hobday, Kirby and Ollier (2002), suggesting exercises incorporating non-verbal elements to undertake with foster and adoptive families.
4. Practical arrangements and physical surroundings (2, 3, 5, 11). Both physical surroundings and practical arrangements, including quality of play materials, cleanliness of environment, and general management of sessions, are an important therapeutic feature. These factors were given more significance by children than is often reflected by services despite many identified as key NHS targets. For looked-after children services paying attention to high quality physical surroundings and the importance of practical arrangements may be especially pertinent, echoing Bruno Bettleheim (1950).
5. Desire for inclusion (7, 8, 11, 13, 14). Children value meaningful involvement in their therapy, and in decisions about their treatment. Some participants offered helpful and constructive suggestions as to how their participation and inclusion could be facilitated. Clearly inclusion of children in decision making is complex and needs to balance children's rights and adults responsibilities as discussed above. However, in principle children's inclusion should be actively pursued at all levels.
6. Outcome of intervention (3, 4, 5, 6, 9, 11, 14). Children in the studies consistently reported overall therapy outcomes positively. Therapy during childhood was frequently appraised as having helped, both at the time and at least in one study retrospectively in adulthood. However, as in general mental health work, more objective assessments suggest the ratio of helpful to unhelpful outcomes is more mixed. The most straightforward interpretation of these data is that it represents a bias in sampling, which suggests that adopting purposeful sampling of a group of children who experience a poor outcome or a longitudinal cohort sample would be fruitful avenues for future research.
7. Suggestions and improvements (2, 4, 8, 13). Young people proposed improvements in service delivery including better access to therapies, more information and that their suggestions are received with due respect and consideration. These proposals mirror government guidelines. The implications are particularly important for looked-after children where past experiences with adults may have been a source of denigration or abandonment (Hughes, 2004). A useful general principle might be that suggestions are valued but undertaken such that decision-making responsibilities reflect the child's best interests (Golding et al., 2006).
8. Social context (4, 7, 9). Across a number of studies children acknowledged the relevance of social context and awareness of pertinent social processes inherent in homogenous groups: both the advantageous (such as support from those sharing similar experiences) and disadvantageous (social stigma). This raises the issues of public awareness and media representations of mental distress in children in society. Increasing awareness of mental health problems in schools, analogous to anti-bullying projects, may offer a solution. Looked-after children with mental health difficulties face the double stigma of being a ‘child in care’ and having a ‘mental illness’. Research into the impact of positive media representations, such as in the children's TV programme/novel ‘Tracey Beaker’ (Wilson, 1991) may offer important insights for raising public awareness.