As an extension of the SchoolKit Clinic model, some families with complex psychosocial needs can benefit from the input of a child and adolescent psychiatrist taking a ‘whole of family’ approach.
To this end a Whole of Family Needs Assessment (WFNA) Clinic model has also been developed. This can be successfully held at schools concurrently with other clinics to help families at difficult times.
Having a child with a disability, compounded by a mental health issue, has a very significant impact on all family members. In addition to these problems in the child, other members of the child’s family may also be struggling with very complex personal issues. These may include sensitivities in family relationships, or individual difficulties. All of these factors may be impacting on the functioning of the family, including having an impact on the emotional and physical wellbeing of the child themselves.
Getting the Full Picture
Gaining an understanding of the interplay of these complex psychosocial and family relationship issues is essential in getting to the full picture of a child’s behavioural and emotional difficulties. Such an assessment forms the basis for developing a comprehensive whole of family support plan involving multiple support and treatment options.
This ‘multi-modal’ approach optimises outcomes for the child and family alike. A child, adolescent and family psychiatrist has specialist skills in conducting a whole of family assessment and can play a pivotal role – in partnership with the family and all other professionals involved – in developing holistic ‘whole of family’ support and management plans.
Running this specialist and comprehensive type of SchoolKit Clinic takes extra time, has a different format and requires additional planning to be successful. Challenges that must be addressed include:
- Establishing and maintaining the trust of each family member.
- Balancing the open communication and collaborative processes (which underpin SchoolKit Clinics) while respecting confidentiality and privacy related to sensitive matters.
Referrals to a WFNA Clinic may take two forms:
- A school clinic uncovers new issues previously not known about which are most suitably addressed in a WFNA Clinic. The family is then invited to attend a Whole of Family Needs Assessment Clinic.
- Direct Referral to a WFNA Clinic (where family issues were previously known to the school).
What factors might suggest a WFNA Clinic may be helpful?
- Significant individual issues for the parent(s) or carer(s) or other family members (for example, severe distress, mental or physical illness, substance use, forensic history, past trauma or abuse in the parent’s childhood).
- Significant family relationship issues (including parental conflict; parenting after separation or divorce).
- History of family trauma including family violence or any form of child abuse (neglect, physical, emotional or sexual abuse) in the child or a sibling.
Family and carer attendance at a WFNA Clinic
It is essential both parents or carers are invited and encouraged to attend. This invitation is based on the philosophy that the child’s parents are nature’s greatest resource to their child and their involvement and support will be at the core of any successful treatment plan.
Other family members with a significant support role or living in the family home (for example, siblings or grandparents) are also invited where appropriate and available.
Even if the parents are separated or divorced it is important to invite both parents unless there are significant reasons not to (for example, an Apprehended Violence Order (AVO) forbidding contact). This promotes all adults ‘getting on the same page’ about the issue and management plans. This is the key to successful outcomes and especially important if a child’s care is shared between two households.
Asking to see legal orders (for example, from the Family Law Court) can provide a helpful guide if there are high levels of acrimony, allegations and confusion.
For cases of high levels of conflict, special arrangements can be made to alter the structure of the WFNA Clinic to so that each parent can be seen separately, to promote partnership but minimise distress and conflict.
Professional attendance at a WFNA Clinic
Consideration is given to which specialists and professionals need to be present to optimise the outcomes and offer support.
The family’s consent is sought regarding the professionals attending and a rationale for their involvement is discussed. The school counsellor may be the most appropriate school representative, however the involvement of other staff may also be relevant. It may also be appropriate for professionals from other agencies (for example, family support services and child protection agencies) to attend.
The clinic may be staged to have different professionals present during different segments.
How long does a WFNA Clinic take?
This specialist SchoolKit Clinic is likely to take two to three hours.
The clinic can be staged so that different professionals are present for key parts only (for example, the introduction or feedback phase), thus limiting the time required of each professional.
Preparing for a WFNA Clinic
Preparations for a clinic may take considerable time but build the foundation for successful outcomes. In discussing the family challenges, school and health (child psychiatry) staff determine that a WFNA Clinic would be most suitable. Key school and health staff clarify their roles in organising and facilitating the clinic.
An invitation is then extended to the family and the nature of the clinic is explained to them. The aims and process of a WFNA Clinic are outlined in detail (a fact sheet may be provided). In discussion with the family, their key professional advisors are identified and consent is gained for them to attend the session (or part thereof).
Other current and past agencies and service providers involved in assisting the family are also identified and written consent is sought for connecting with these agencies to collate information.
What happens in a WFNA Clinic?
The whole of family needs assessment is a highly systematised assessment process which has a number of key phases and includes full family, marital or parental and individual subsections.
The clinic is lead by a senior child and adolescent psychiatrist, or a similarly trained mental health professional with child psychiatrist supervision. Collaborative process, transparency and respect underpin the assessment. Priority is given to a detailed exploration of complex safety factors (for example, child protection, domestic violence and mental health risk). Specialist child and adolescent mental health skills are required to successfully conduct such a clinic.
Establishing strong partnerships between the family, school, health team and other agencies is a key objective of the clinic. Open communication, in a calm way, about difficult issues may be at the core of achieving safety. Such communication needs to be based on thoughtful consideration about sharing sensitive information, for example, on a ‘need to know’ basis only, so as to achieve key outcomes.
Attention to language is important. Respectful and non-judgmental language (with explanations of jargon) is at the foundation of trust and collaboration.
Included in this clinic process are phases of professional-only discussion, and professional and family discussion.
Professional-only discussions during a WFNA Clinic
Both pre- and middle (inter-) session discussions may take place between professionals in the WFNA Clinic in the absence of the family. This differs from the usual process of professionals and family all speaking together in one place in the usual SchoolKit Clinic format.
Such processes are necessitated by the nature of the safety and sensitive issues that professionals may need to openly address to achieve safety and best outcomes for each and every family member.
The family need to be told in advance that this will happen and fully informed of the rationale for these brief professionals-only discussions (i.e. to bring together the complex perspectives being explored in the clinic). Of course it is essential that they provide their consent for this to happen.
What happens after the WFNA Clinic?
The WFNA Clinic is geared around helping the family move forward and develop systems of safety and support.
The outcomes of the clinic are documented into a comprehensive report, with attention to using language understandable by the family. A whole of family support and intervention plan is described which includes detail of clear roles and responsibilities.
The report, which is copied to the family, is distributed with the family’s consent to all the relevant clinic participants to form the foundation for cohesive partnerships and coordinated care. The report may also be used as a vehicle for advocacy for the activation of other agencies and funding options.
Ongoing multiagency professional meetings following the usual SchoolKit Clinic formats are then planned to review and monitor progress.
What are the advantages of a WFNA Clinic?
The advantages of hosting a WFNA Clinic in a school setting include:
- Enhancing the therapeutic relationship and trust with the family by building upon the trusting relationship the family already have established with the school.
- Practical issues related to not having to transport the child, allowing for professional observation of the child in the school setting.
- Strengthening the partnerships between the child’s natural support system (school and family) and health and other agencies through the collaborative development of an understanding of the complex challenges a family may be facing.
Such a comprehensive assessment may open options for change beyond a child-focused intervention, which will have significant positive impact for all family members, not just on the child and their functioning.
What are the disadvantages of a WFNA Clinic?
When the family do not have a positive or well-established partnership with the school, they may not give consent for holding a clinic at the school and involving school staff. Alternative assessment options may need to be sought.
Additionally, such clinics require a significant time commitment and often scarce and expensive resources (a child psychiatrist’s time, for example). It is essential therefore that careful consideration is given to whether a WFNA Clinic is right for a particular family.
- Bickerton A, Hense T, Benstock A, Ward J, Wallace L. ‘Safety First: A Model of Care for Working Systemically With High Risk Young People and Their Families in an Acute CAMHS Service’. ANZJFT Volume 28 Number 3. September 2007