The Community Relations Model (CoRe): An Integrated Systems Response to Early Mental Health Support for Children and Families in Communities

Abstract

Mental health has traditionally followed a medical illness or deficit model, where distress is individualized and treatment is subsequently aimed at individual children and families. Studies of the incidence of child mental health problems across Europe, United States and the United Kingdom (UK) all identified a significant upward trend in prevalence over the last decade. In the UK, resources have been allocated to the development of child mental health services. One priority area has been the development of preventative mental health services within schools. This chapter argues that a rethink is required in order to respond effectively to the significant increase in mental health need and that the current model does not provide an adequate response. This chapter proposes a relational model, one that works systemically with partners and communities, as opposed to a singular expansion in the provision of individualized treatment. It reimages the construct of mental health using a broad evidence base and then develops service provision from this foundation. This creates a wider community resource base to address mental distress in our society and enables mental health practitioners and organizations to have a wider systemic impact on children, young people and families.

Mental health is contextual—both intimate and distal. Our realities are entangled with those of others, and so is our well-being—personal, emotional and social. Mental health is a political and societal issue that needs to be addressed by governments and society at all levels. The pandemic and social movements such as the Me Too and Black Lives Matter are ample evidence of the impact of isolation, discrimination and inequality on vast sections of society and their well-being. Mental health services, while still offering specialist therapeutic support for young people and families who struggle the most, need to be embedded within a broader systemic or ecologic service model addressing the broader causes of mental health problems. Studies of the incidence of child mental health problems across Europe, United States and the UK all identified a significant upward trend in prevalence over the last decade. In the UK, a review noted a rise in child mental health disorders from 1 in 9 in 2017 to 1 in 6 for 6–16-year-olds in 2020 (Children’s Commissioner, 2021; House of Commons Health & Social Care Committee, 2021).

The Community Relations Model (CoRe) provides a new horizon for child mental health care—a framework for a relational and community model of mental health service for children and families (first published as a Systems Relations Model but since broadened to become an integrated systems model). It explains at what levels interventions need to be planned and delivered, and how. It is an evolving and aspirational model, going through constant iterations and learning cycles, while being open to criticism, as part of larger and more powerful systems and influences (van Roosmalen, 2018; van Roosmalen et al., 2013).

The Community Relations Model reconceptualizes a child mental health service, and how it can be operationalized, shifting from an overwhelmingly deficit or illness model of mental health to a relational, resilience-based and integrated systems model, with a focus on thriving communities and professional systems, rather than individuals. Publicly funded Child and Adolescent Mental Health Services (or, CAMHS) in the UK are structured to offer specialist mental health services to children and families predominantly by specialist therapeutic treatment, from early brief support for children and training for frontline staff such as in schools (through community-based teams where available) to specialist and highly specialist multi-disciplinary team provision and inpatient treatment. It is the common Western contemporary model. The broader causes and maintaining factors of mental health difficulties are considered rather than one that is symptom and thus, effect focused. In order to remedy the contextual causes of mental distress and ill health, a re-imagining of what constitutes mental health conceptually and building a service that starts to address these causes, operationally, is required. The concept of resilience is also re-considered.

The Community Relations (CoRe) Model—An Integrated Systems Response

…….he realizes that the truth is infinitely more complicated, that we are beautiful even as we are all part of the problem, and that to be part of the problem is to be human. (Doerr, 2022, p. 524)

The first step in re-thinking child mental health provision is to acknowledge that how current services are planned and delivered needs to be critically evaluated, particularly in the context of overwhelming demand and the lack of resources to respond adequately. Essentially, mental health services themselves are a crucial part of the change required.

The Community Relations Model is a continuation and broadening of the Systems Relations Model, explained by the author as consisting of a three function service model (van Roosmalen, 2018; van Roosmalen et al., 2013) that emerged from a study conducted with an early intervention schools and early years (0–5 years) CAMH service in the UK:

• Function 1: The offer of early specialist support to targeted children and families where children are struggling with their mental well-being.

• Function 2: A systemic function within the case work, where the CAMHS practitioner works with the systems interacting with the targeted children and families. This enables a collective and contextual understanding and formulation to be agreed around the problems experienced by the child, with a collective plan of support. The second function works across a four-phase case pathway. This function emerged from local research (van Roosmalen et al., 2013). This function has a particular focus on the first two phases of the case pathway, called the ‘collaborative problem formulation’ phases, where the network that interacts with the child in their everyday life collaborate on a plan of support with each other. The function is, however, applied across the phases of the pathway.

• Function 3: A universal intervention function. This contains whole school approaches, where the wider understanding of mental health is shared with schools, communities and other relevant stakeholders. It includes developing co-productive strategies and approaches to improve the well-being not only of individual children, but also the resilience and well-being of communities and agencies where children live and go to school and from whom they receive support. Examples are psycho-education strategies, and workshops for school staff to help them work with children with mental health vulnerabilities in order to keep them included in their education.

The first two functions are implemented by Child and Adolescent Mental Health Service practitioners within their early specialist casework with children and families, the school and other agency practitioners. They are not mutually exclusive functions, with the expertise of the CAMHS practitioner widening in their conceptualization of the interactional nature of mental health and distress. In this way, the child’s mental health becomes ‘everyone’s business’ (a term coined in the United Kingdom to try to engage all agencies in taking responsibility for children’s mental health).

The principle across all three functional levels of practice is a relational approach to working with children and their families and the multiple interacting systems they live within. For example, training for schools on mental health is not only symptom focused but explains how mental health difficulties arise from the living context and experiences of children, including within their schools.

The Community Relations Model, illustrated in Fig. 10.1, has evolved into a three-dimensional approach that explains:

Fig. 10.1

The Community Relations Model (CoRe): developing resilient communities and professional networked systems working together

• 1. Dimension 1: How resilient children and families develop in communities, and factors that affect well-being.

• 2. Dimension 2: How frontline practitioners such as school staff can be resilient and support vulnerable children and families.

• 3. Dimension 3: How interconnected networks can work together—family, community and professional/agencies—to be resilient, reflective and where active learning and co-production of services is possible.

The model is a result of continuing cycles of service evaluation and research into the most effective and impactful ways of working with schools, early years’ settings, Early Help social care services and communities.

CoRe Dimension 1: Resilient Children and Families Living in Communities

Children’s development occurs within a context of proximal and distal factors impacting on them, through their parents and wider families, communities and broader groupings such as their ethnicity, and the social capital they and their families hold within these contexts. Children’s attachment to their parents, especially their primary caregiver, and the quality of care are essential elements of their healthy development, physically, emotionally, socially and neuro-developmentally. There is growing evidence how the quality of caregiving can even impact down to the genetic level inter-generationally. Rutter (2012) acknowledged the broad consensus that environmental processes impact down to genetic level (as explained by the study of epigenetics)—genes are switched on and off as a result of environmental interactions.

Broadening the mental health construct needs to include the following elements, some of which are already permeating Western countries’ policy guidance documents and mental health practice:

• an inter-generational and trauma-informed perspective of how mental well-being develops—that all strategies by parents, carers, children (and all stakeholders interacting with them, including practitioners) are adaptive strategies to survive and have their needs met as best they can. The growing discipline of epigenetics is discovering that the childhood experiences of parents can be transmitted to their children and then their grandchildren in a perpetuating cycle.

• Children and their families hold their unique inter-generational stories, and that requires CAMHS practitioners to contextually and systemically formulate in order to understand and work with the family.

• Adverse childhood experiences shape the way children and young people relate to others in their lives, and that these relationships are replicated within schools and interactions with other agencies.

• Resilience and mindfulness are inter-relational and dynamic concepts and cannot just be ‘taught’ to children didactically. Mindful and resilient communities will engender resilient children, not the reverse.

• Influences on mental health such as discrimination, poverty and lack of social capital need to be explicitly acknowledged. These experiences often occur across multiple generations as seen, for example, in the Black Lives Matter movement.

All of the above elements need to become part of the normal discourse about mental health, and a core part of training in mental health for all of those working in universal children’s services, from schools, children’s centres, child health, social care and other children-focused agencies. This will aid the emergence of sub-ordinate community narratives that have not been acknowledged, from narratives of failure (and blame) to an appreciation of the challenges that communities and families can face, as a first step to addressing the causes. In the author’s experience, this leads to an enlivened dialogue about mental health and takes a significant step to demystifying, destigmatizing and normalizing mental health concerns.

Resilience and Inequality

In terms of re-evaluating the concept of resilience, longitudinal studies have shown that resilience is a dynamic process between the individual and their environment, both proximal and distal. It is a fluid interaction between the two over time (Rutter, 2012). Resilience is thus less an individual trait and more of a quality of the child’s social and physical ecology (Ungar, 2011).

Faulconbridge et al. (2019) surmised from the research on the relational nature of resilience, that:

…..if we take this wider evidence informed view that resilience is a dynamic interaction between the individual and their ecology, over time, it opens up exciting, and perhaps more helpful concepts of what a mental health intervention is and how we conceptualise mental health services. (p. 49)

The training needs to acknowledge the (distal) societal causal factors of mental health, as evidenced by extensive reviews conducted by Wilkinson and Pickett (2009, 2018). Through studying the social, health and mental health outcomes data of the wealthiest twenty nations in the world, a direct causal relationship was found to exist between social inequality and mental health:

Inequality affects the vast majority of the population, not only the poor minority…..larger income differences across a society immerse everyone more deeply in issues of status competition and insecurity. (Wilkinson & Pickett, 2018, p. 21)

These findings are essential in helping all stakeholders to understand and acknowledge the wide range of factors impacting on children’s mental health, and that it is not a sign of their individual failure, or of their family, but that they are impacted by other wider influences. This would make it easier for communities and families to engage in dialogues about their children’s, and their own, mental well-being.

Wilkinson and Pickett’s findings are consistent across social, health and mental health outcomes:

It is because inequality affects most people that the differences in rates of health and social problems between more and less equal societies are often very large indeed. We found that mental illness and infant mortality rates were two to three times as high in more unequal countries. (Wilkinson & Pickett, 2018, p. 21)

CoRe 2: Resilient Frontline Practitioners Working with Children and Families

The second dimension addresses how frontline practitioners can develop and maintain their resilience and well-being while educating and supporting children and their families. Schools and other frontline agencies, such as children’s centres, are increasingly seen as central points of contact for children and families and more emphasis is placed on schools to provide more holistic services rather than only education. School staff are increasingly faced with vulnerable children and families in their daily work, and there is broad acknowledgement that they require support and training in how to respond to this growing need.

Emotional Awareness and Responsive Practice

In order to develop their resilience, frontline practitioners would benefit from becoming more aware of their feelings and how to manage these in their relationships with others, particularly in an environment such as a school. This will enable them to be more mindful and compassionate towards themselves and others and to appreciate that all feelings and reactions are understandable (see Fig. 10.2), both theirs and those of the children. By accepting these feelings and understanding them (and crucially, having opportunities to do so) can lead to greater insight into both their own and the child and family’s emotional worlds (see further Figs. 10.3 and 10.4) and thus supporting them at a universal level.

Fig. 10.2

The reflective practitioner: responsive and mindful practice

An example of an exercise with frontline practitioners is:

Can you think about a situation you have been in with a child:

• How did the child make you feel?

• Accept this feeling, what is its meaning for you?

• What might be replicated – for the child?

• What the meaning of the behaviour might be?

• How can you respond to the behaviour AND accept and validate the underlying meaning/need?

Actively supporting the increased emotional and relational awareness and resilience of frontline practitioners helps them to deal with the everyday stress they face in the current climate of the increasing amount and complexity of mental health, social and health needs of the communities they serve. It can also help prevent the cumulative emotional impact of these daily interactions on their mental well-being. Schools’ staff are often the primary source of support that young people and their parents turn to when experiencing emotional distress. They need continuing support in how to manage it.

Interacting Stories of Practitioners with Children and Their Families

Practitioners can practise to become reflective about the stories and histories that children carry as well as how their own stories and histories inform their interactions with the children they work with. This will support a realization of how their own reality is interpreted through the lens of their own experiences and that this is also the case for others. They learn generally that this is what gets played out in relationships between people. Practitioners can benefit from using a reflective relational framework which can help them understand both the interactions between them and the families they support, and the emotional impact it can have on them as a result. As stated by Axberg and Petitt in their chapter in this volume, a child’s behaviour can only be understood by within the network of interactions and relationships that exists between them and others in a specific context.

This framework was used by the author in a training workshop and continued reflective learning sets with Early Help social care children’s service practitioners. These practitioners provide intensive early support to families who are struggling in caring for their children. The CoRe Model and reflective framework helped the practitioners to form strong collaborative relationships with the families and reduce their own stress in having to be the agent to solve the family’s problems (van Roosmalen & Parrish, paper in preparation for submission). When reflecting on children’s behaviour, practitioners can consider what emotions are being communicated, and what the underlying meaning of their emotions are. Behaviours are seen as compromised needs, and the challenge is, and was to understand the stories that are told through these. When faced with a vulnerable child’s needs, the challenge would be how to connect with, not control, the child, which is often an issue school staff are faced with. Schools are environments where there are strict codes of behaviour, and where control is a big concern.

Figure 10.3 illustrates an interaction that regularly occurs between Early Help (Social Care Children’s Services) staff and families, or teaching or other frontline staff, with a parent or child. In order for the practitioner to come to an understanding of the interaction, an exercise like the following can be used:

Think of a situation that has taken place with a student that has aroused a strong reaction in you. Think about your reaction, emotional and physical, and what it could say about:

• You – your story and experiences

• The parent + child – his/her stories and experiences

• Something that is happening in the interaction between you

Fig. 10.3

The practitioner, the child and the family—interacting stories

Children and young people enter the school environment with established patterns of relating, and adaptive strategies from their families and communities that they replicate with school and other agency staff. Frontline practitioners often get drawn into these replicating patterns of relating, which can become toxic and a ‘battle for control’ can ensue, which can spiral out of control and lead to school exclusions and disengagement with education. With many children, minor school adjustments are possible, but many will not be able to make more significant adjustments, which can lead to frustrations on the part of the school and often, a resultant gradual polarization of positions taken by the child (and at times, the family) and school, leading to conflict and at times, a stalemate and exclusion.

The Reflective Relational Framework

The reflective relational framework (Fig. 10.4), in its simplest form of interacting stories (Fig. 10.3), illustrates how frontline practitioners who work with families, join the systems they are trying to support and become part of the interactional cycle with them. This is commonly described as the problem-determined system. This is an important shift from a linear pattern of thinking and practice, such as an objective outsider trying to effect change in the ‘other’ (child and/or family). Insight as to how this interaction occurs is necessary for frontline practitioners to understand how and why they get drawn into patterns of reactions and interaction. They can often go home after a day at school, for instance, with very powerful feelings of, anger, rejection, abandonment, sadness, or often, helplessness. Being a mindful adult for a young person or child can have a powerful impact, for both the child and practitioner. For this, developing a reflexivity of self within the interconnecting systems of the school and family can ensure the resilience of the practitioner and benefit the child and family.

Fig. 10.4

The reflective relational framework

Frontline practitioners should be supported to learn how children’s mental health problems develop (Dimension 1), and how they as practitioners can respond in a compassionate, mindful and reflexive way, as part of the system. They can learn how they are also part of multiple systems that interact in particular ways (part of an organizational culture), cognizant of taking explicit positions of power (‘there is something wrong with you and you need to change to fit in, otherwise you will become a failure’). This will develop their capacity to promote a relationship of more distributed power with families (“how can we work together to support your child who seems to be struggling”, “we are struggling too with him/her”, “we are at a loss and want to help”), validating the child’s position (as an adaptive strategy) and that of the family (more of this in the third dimension).

CoRe 3: Resilient Interconnected Professional, Family and Community Systems

The third dimension describes how interconnected networks of practitioners, agencies, families and communities communicate and work together to meet the needs of vulnerable children and young people. A research study by the author and colleagues analysed how such interconnected systems can work. It identified the factors that improved the chances of constructive networking and led to positive outcomes for children in their mental health, educational inclusion, and improved the relationships between families and schools (van Roosmalen et al., 2013).

Partnership work between the local CAMH Service and school partners identified two distinct ways interconnected systems can function (illustrated by Fig. 10.5) (van Roosmalen, 2018). In the first model, coined the Individual Model, the following concept of well-being is applied:

Fig. 10.5

Two models of interconnected systems working

• That mental health problems and well-being develop and are located in individuals.

• Children will often feel responsible for their predicament, as it is described as their ‘problem’, which can understandably lead to a defensive reaction.

• It is often the case in discourses of blame, that the most vulnerable in the system who has the least power, carries the most responsibility. This can be replicated in it also being a parent in social care discourses of responsibility (“they are a poor mother and failing”).

• The system is helpless as the child or parent (or another) is the one who needs to change, and the system is trying to help them to change. This can disable a system, causing ‘stuck systems’ as they have failed to convince the family (of the need) to change.

• Responsibility, or its negative counterpart, blame, can be mirrored throughout the multi-agency system—such as the school seen to be failing the child pastorally, CAMHS not offering the therapy that is required for the child, all of which is contradictory to collaborative working.

• Different perspectives are often a source of conflict, with some views being valued over others, while others might be silenced in order to resolve the conflict in the system.

• The sum of the multi-agency network is less than its parts—which can lead to a ‘stuck’ and a demotivated system.

In the second model, originally named a Systems Relations Model (since updated to the Community Relations Model), the approach taken to mental health and well-being is:

• Mental health well-being and problems develop in relationships.

• No-one has sole responsibility and thus no one is blamed for the “problem” or to change—this leads to a lack of defensiveness, and where collaboration and dialogue are possible between stakeholders. It is acknowledged that everyone is part of the problem-determined system.

• Everyone involved in the child’s life carries some responsibility, as all are relating with the child and all are part of a potentially resilient interconnected system.

• People in the system are empowered to change and support, which can be “enabling”, as power and the capacity to change is distributed through the network.

• This encourages a culture of working together and collective responsibility.

• Differences between stakeholders, and multiple perspectives, are regarded as sources of richness and all views are valid and valued, increasing social capital.

• The sum of stakeholders becomes more than its separate parts, as it allows a greater pool of thinking and solutions and a motivated and energised professional and family network.

Schools form a key part of frontline systems providing universal and targeted support to children and young people. In terms of the context within which schools function, they evolve or adapt in connection with their neighbouring and community systems, and may show unpredictable patterns of cause and effect. Without a clear and strong self-organizing principle (and one that is reflective and thoughtful) schools can act and organize in similar ways as the communities they serve. Menzies Lyth (1960) described how organizations develop customs or patterns (which she described as defences) that have the effect of reducing anxiety, doubt or distress for staff. Child mental health service staff can act and react in similar ways, and also need to put themselves under the spotlight as part of the system that needs to look at its own culture and the defences it might have developed that might inhibit change.

De-polarizing the views between different stakeholders, such as school and the family, and the building of a collective understanding and formulation with the child, family and the school can lead to commonly agreed resolutions (Campbell & Groenbaeck, 2006). This exemplifies the second function of the model. Parents and school can often fall into positions of mutual blame, which can inhibit collaborative working and put more pressure on the child, a pattern also identified by Axberg and Pettit in their chapter in this volume. Using this function more broadly in relationships with other practitioners and agencies, and not only with specific children and families can lead to a culture of collaborative practice across stakeholders and more distributed power (van Roosmalen, 2018).

An Integrated Schools, Family and CAMHS Case Pathway

Figure 10.6 illustrates how both the first and second functions can work within a case pathway of a child. The pathway usually starts when the school discusses a child with a CAMHS practitioner due to their concerns for their mental health. All involved with the child at school form part of this consultation. The CAMHS practitioner then invites all professional and familial stakeholders to contribute to a dialogue about the difficulties the child is experiencing and their views, moving towards a systems-agreed collaborative formulation, using the principles of the CoRe Model described above. Collaboratively agreed support interventions are agreed to resolve the challenges being faced by all stakeholders. There is a focus on developing a collaborative formulation of the difficulties in the first two phases with the school, the family and any significant others involved, to process what can initially be divergent views. This requires attention and active facilitation, described by Axberg and Petitt in their chapter in this volume as establishing epistemic trust when variant and even conflicting narratives are held. The establishment of trust is required before a coherent plan of intervention can be agreed, laying the basis for collaborative and coordinated interventions. Phases 3 and 4 describe, respectively, the intervention and review phases, after which further intervention or closure is agreed. A more detailed explanation of the case pathway and the functional model is offered in van Roosmalen (2018). In a small-scale outcome study of school and parental views of this approach, family and school relationships were found to have improved (van Roosmalen & Gardner, 2007).

Fig. 10.6

A case pathway illustrating Function 1 and 2 of the CoRe Model

Wider Systems and Community-Based Resilience

In order to create systems and community-wide resilience and not only for individual targeted children and their systems, Faulconbridge et al. (2019) adapted Friedl and Carlin’s (2009) recommendations (which were substantiated by longitudinal studies):

• Strengthen social relationships and community connections for children, young people and families.

• Enable and build social capital, social networks and social support within and between communities.

• Strengthen and repair relationships between communities and health and social care agencies, for example, enhancing community control by co-production.

• Improve the quality of the social relationships of care between children, young people and families, and professionals.

The above can potentially form part of universal school and community approaches in addition to being a crucial element of casework pathways when supporting targeted children and their families.

For example, local Early Help Children’s Service practitioners (Social Care) were provided an introductory training to the Community Relations Model, which was followed by six months of group-based reflective learning sets. At these sets, they discussed current casework, integrated learning into practice, and were able to learn more widely in applying a wide range of systemic, resilience (and trauma-informed) techniques and practices into their daily practice. As a key aim of children’s social care practice is to support more constructive parenting, this can easily be perceived by parents as blaming of them, for being a poor or failing parent. Early Help practitioners found that in order to break this interactional pattern they introduced the co-production of a three-generation genogram with the parents (and at times also with the children), a key technique learnt in the training. They discovered that it opened up a discussion about the parents’ experiences of being parented themselves, which developed curiosity about their intentions as parents themselves, trans-generationally. The practitioners both led and enabled a conversation of appreciation of the difficult lives and circumstances of the families, resulting in a less defensive initial assessment phase with the families (van Roosmalen & Parrish, paper in preparation for submission). Linked to this was a key question they asked of their families, “What happened to you?” rather than a question such as “what is going wrong”, the latter of which targeted deficits with the family, parent or child. This approach improved the relationships between their service staff and families.

Health Inequalities and Co-producing Services with Communities

One of the newly established local schools-based teams, who are part of a broader community-based early intervention mental health services for children and families (in the south of the UK of which the author is the lead), is working with 14 schools within an ethnically diverse and socially disadvantaged community to improve health equalities. They have embarked on a programme of engagement, planning and service delivery with all community stakeholders, including citizen stakeholders, community leaders, schools, local agencies and charities. The intention is to co-produce a needs-based integrated services response to mental health inequalities in the locality. A structured quality improvement methodology is being applied to encapsulate a broad response from all stakeholders that addresses contextual factors that have been identified as impacting on the mental health of the community. A broad theory of change and action plan is being co-produced with the wide range of stakeholders to produce an integrated multi-systems response to the community’s needs.

Training for CAMHS Practitioners and the Dissemination of CoRe

For CAMHS community practitioners to feel competent and skilled to deliver the CoRe Model of practice, a systemic consultation training was designed and delivered following the study of the case pathway and three functional model (van Roosmalen et al., 2013). A qualitative study exploring the impact of the training on CAMHS practitioners’ practice and confidence found the training to have greatly enhanced their skills in working with interconnected systems, fostering dialogue with at times stressed and overwrought schools systems, and improving their effectiveness in producing positive mental health outcomes (van Roosmalen et al., paper in preparation for submission). Gardner-Elahi’s (2011) study of the impact of the style of consultation on school staff and parental consultees found the consultations had an empowering effect on them, and increased their confidence and competence to work together to support the children’s needs.

The current schools teams have grown over the last few years following several years of recession and resultant public sector cuts in the locality of the author. They have an overview of the CoRe Model, but its application is variable and not yet systems wide. Aspects of the model are in the process of being applied to inform broader learning. The wider integrated systems model is now being applied and seen as the new horizon for local CAMH Services particularly in early support and community working. There is a current push for all mental health training to follow the CoRe approach, and to identify school practitioners who work daily with the most vulnerable children, to be trained in Dimension 2, which would follow a similar model of training to the Early Help training described earlier.

Conclusion—Why Is This Response so Urgent Now?

Studies on the incidence of child mental health problems across high-income countries (Barican et al., 2022), the United States (Whitney & Peterson, 2018), Europe (Neufeld, 2022; United Nations Children’s Fund, 2021) and the United Kingdom (Children’s Commissioner, 2021; House of Commons Health & Social Care Committee, 2021; Loades et al., 2020) have all identified a significant upward trend in prevalence in child mental health problems over the last decade. All studies internationally reveal the pandemic’s further negative impact on children’s mental health across all regions. Growing inequalities in countries such as the United Kingdom are only worsening its prevalence.

The social (including social media), environmental and economic factors impacting on children’s mental health is almost universally acknowledged, yet the question remains why services are still only treating the effects being created by these proximal and distal causal factors, rather than starting to remodel and re-imagine child mental health services to start targeting the causes. The local effort, and that of the Community Relations integrated systems approach, is an attempt at targeting the factors impacting on mental health and developing community resilience. These innovations will need to be financially sustained long enough for them to evidence their effectiveness, as emphasized by Hannah (2010) in her paper on a sustainable future of an overstretched UK National Health Service.

We can be reassured by the existence of a wider than traditional evidence base. Quantum theory has grown in prominence as one of the dominant scientific theories explaining the physical world. Rovelli (2020) describes quantum theory as putting aside a reality which is object driven but in essence relational. Objects or things in the physical world exist in a context and not of themselves, with interaction an inextricable part of a phenomenon. This is expressed by the concept of contextuality:

We cannot separate out the properties of the objects from the objects interacting with them in order for these properties to be manifested in the first place. All of the (variable) properties of an object, in the final analysis, are such and exist only with respect to other objects. (Rovelli, 2020, p. 120)

All information we have about the world are of these correlations. The multiplicity of perspectives is, however, made coherent by a consistency where we influence (each other in) the way we ‘see’ the world. Rovelli says it is this consistency, called inter-subjectivity, which is the basis of our communal vision of the world. Public child mental health services need to change their horizon according to the emerging acknowledgement that ‘the world’ is impacting on children’s mental health, and our services need to respond effectively to the causes, not only treat its effects. The latter would merely give responsibility, and its negative counterpart, blame, to children for their mental health problems, and that they need fixing, not the world around them.