IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

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THE PRACTICE OF CHILD MENTALHEALTH NURSES
Kathleen R Delaney, Janice L. Cooper & Sylvia Nshemerewire

Kathleen R Delaney PhD,PMHNP, FAAN

Professor, Rush College ofNursing, 600 S Paulina Street,
Chicago, Illinois 60210, USA
Conflict of interest: none
declared

Janice L Cooper PhD, MPA
The Carter Center and Emory
University School of Public
Health, Atlanta, GA 30322,
USA
Conflict of interest: none
declared

Sylvia Nshemerewire

MBChB, MMEd Psychiatry

Butabika Hospital, Kampala,
UgandaConflict of interest: none
declaredThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2018. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Delaney KR, Cooper JL, Nshemerewire S. The practice of child mental health nurses. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2018.

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IACAPAP Textbook of Child and Adolescent Mental HealthChild and adolescent mental health nurses (CAMHNs) are registerednurses who focus their work in supporting the optimal development ofyouth as well as the coordination and delivery of mental health care tochildren and their families. As one of the largest group of health care providers whocome into contact with children and adolescents, nurses are vital to child mental
health promotion and early intervention (RCN, 2016). Child mental healthnurses bring a particular orientation to their work, the value of the relationship, a
health focus, and a view of the child in relation to social systems such as school andcommunity (American Nurses Association, 1985). They practice wherever healthcare is delivered, in hospitals, community health centers as well as schools andoutreach agencies. Worldwide, psychiatric nurses are a major provider of services,
particularly in low-income countries; the last available data indicate their numbers
increased by 37% since 2011 (mean rate per 100,000 population) (World HealthOrganization, 2015). Recently there have been initiatives globally to train more
psychiatric nurses, including CAMHNs, and thus increase access to child mental
health services (Zegura et al, 2015).
In this chapter, the traditional role of CAMHNs in inpatient treatment
settings will be discussed; highlighting how CAMHNs assume responsibility for thetherapeutic milieu, its safety, structure and supportive functions. Also highlighted
will be the role of CAMHNs in child mental health promotion, early identificationand community-based care. Initiatives around workforce development in selectcountries will be presented as well as region-specific collaborations that support
psychiatric nursing. The expanding role of CAMHNs will be explored particularlyaround the growth of pediatric primary care. To begin, the history of child mental
health nursing in the United States (US) is outlined to exemplify the nursing
perspective on child mental health and how the specialty developed. Unlessspecified otherwise, the word “child” refers to both children and adolescents.

HISTORY
In the US, child mental health nursing evolved alongside the formationof treatment structures such as the child guidance centers and, in the 1930s, theopening of specialized inpatient centers for children. In these hospital units, nurses
cared for the children’s physical needs, monitored medications but also used thetime to build a relationship with the child (West & Evans, 1992). The specialty
of CAMHN gained momentum in the 1950’s through the 1970’s when federal
initiatives supported the training of 20,000 psychiatric mental health advanced
practice nurses (APNs) which spurned the development of the psychiatric mental
health graduate program in child psychiatric nursing. During this time, masters’degree programs in child psychiatric nursing graduated approximate 1,000 APNs.
In 1985 the American Nurses Association published a scope of practice specificto child mental health nurses detailing their role in the treatment of child mental
health disorders and highlighting their work with families and children, particularly
within schools and communities. In these documents the CAMHNs’ perspective
on care evolved into one marked by collaboration with families, a developmental
focus, holism, health promotion, and intervening via the relationship (West &Evans, 1985). The CAMHNs role in mental health continues to evolve with the
movement toward community-based care and integrated pediatric primary care(Martin et al, 2014).

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IACAPAP Textbook of Child and Adolescent Mental Health

INPATIENT TREATMENT ROLE
Inpatient treatment of children and adolescents, while rare in low-income
countries, is part of the care continuum utilized when youth are considereddangerous to self or others or in need of intensive services (Torio et al, 2015).
During short-term child inpatient treatment, the multidisciplinary team prescribes
regimes to help children regain a sense of control in their lives as well as alignservices so that children return to their communities and to optimal functioning.
In brief treatment, the focus is stabilization of the behaviors and addressing thecrisis that precipitated hospitalization, which often involves a thorough assessment
and possibly change in medication (Gathright et al, 2015). This chapter focuses on
short-term hospitalization of children. The principles are applicable to residential
treatment but the issues and treatment in residential care settings may differ,particularly approaches to children with complex problems and trauma histories(Hodgdon et al, 2013; Zelechoski, 2013).
Child mental health nurses and mental health clinicians play a critical rolein achieving the goals of hospitalization. Their 24-hour exposure to the childprovides data useful for diagnosis. Observing how the child responds to milieu
situations, copes, regulates, problem solves and relates to peers and adults informs
the amount of structure and support the child will need to function at the optimallevel (Delaney, 2006a). Since children and adolescents in acute distress need anenvironment that assures both safety and healing, staff has a split focus: attending
to the individual child as well at the overall environment of care.
To build and maintain a therapeutic environment staff members must
understand how program structure and staff presence blends to maintain themilieu. One way to think about this work is to organize interventions into four
categories, safety, structure, support and self-management (Four S model) (Delaney
et al, 2000). The idea of grouping therapeutic aspects of the environment into
categories was first suggested by Gunderson (1978). In this nursing adaptation, thecategories were updated and redefined to delineate how they are operationalized
during short-term inpatient treatment (Delaney et al, 2008). Fundamentally, staff
develops and maintains these milieu qualities by the way they attend to the physicalenvironment, organize the program, develop relationships with the children, andpartner with the child to improve self-regulation and self-management of behaviors.
Explained below is how staff creates these elements of the Four S milieu model in
their everyday use of space, group programming, and interactions with patients.

SafetyTreatment environments must be psychologically and physically safe forhospitalized children. At the most basic level safety is maintained by creating aphysical environment that is “aseptic” – free of any objects that could be used for
self-harm or to easily harm others. Inpatient psychiatric units also have systems
to monitor aggression or suicide risk that set out the frequency of monitoring
commensurate with estimated risk. Safety also requires a system for unit safety
checks, policies about visitors and contraband, and a system for tracking andmonitoring risks, incidents, and safety breaches. The recent inpatient mental
health standards published by the Ontario Cooperative provide an excellent listingof safety considerations and related standards of care (click on the side figure toChild mental health nursing

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IACAPAP Textbook of Child and Adolescent Mental Healthaccess). Staff also keeps units safe by the way they position themselves in the unit
such that common spaces are within view, which allows them to stay aware of
the tone and pace of the milieu as well as changes in a particular child’s behavior.
Anticipation is a key element of milieu safety since it facilitates early intervention
and provides an opportunity to calmly interrupt a behavior that appears to be
escalating (Delaney & Johnson, 2006).
But keeping a safe atmosphere in a unit requires much more. Safety demands
staff engagement: deliberate, meaningful interactions aimed at developing atrusting relationship with the patient (Polacek et al, 2015). An interaction aimed
at engagement is more than just talking. Rather, it is communication that operates
at the interpersonal level; a genuine response that involves empathy, conveys
caring, aims to grasp the child’s experience, and responds in such a way that thechild feels understood (Salamone‐Violi et al, 2015). A researcher in the United
Kingdom, Len Bowers, has studied safety for many years and recently developed
Safewards (Bowers, 2014a). This model has many aspects, all aimed at reducing
conflict and coercive measures. Staff engagement is one component. According to
the Safewards model, the consistent engagement of staff members is critical, seen
as dependent on interpersonal skills (such as empathy and respect) as well as staff
members’ emotional regulation and technical mastery. Thus, an escalating situation
demands a staff member who remains calm and focused, has some relationshipleverage with the patient, and good de-escalation skills (Bowers, 2014b). Readersinterested in the Safewards model can access in the side column videos that explain
its elements in detail. (Links to right).

Click on the image above tohear Len Bowers talks about
the quality of the evidence
for Safewards (11:03). Clickon the image below for a
detailed description of themodel (59:07)

Engagement is particularly important in child inpatient units, especiallyin tense situations. Hospitalized children and adolescents may lack self-regulation
skills, the ability to modulate strong feelings and emotional states (Eisenberg et al,2014). Frustration can quickly move into anger and anger into rage. Regulation ofemotional states requires control over attention, arousal, appraisal, and inhibition(Izard et al, 2002). Children use these skills to recognize the emotion they areexperiencing, read the cues of the situation generating the emotion, and tolerate
the negative emotion long enough to process what is occurring and what would
be their next best step. When these controls are lacking, children and adolescentsneed adults who engage and read the situation, step in, and help them dampen
down the emotion. This proactive engagement reduces reactive aggression (anger
that erupts in response to a situation) and thus keeps the child, staff, and other
patients safe (Delaney, 2009).
Early intervention into an escalating situation is also critical to reduce
the use of physical restraints — any device, material or equipment attached toa person’s body, which cannot be controlled by the person and is deliberately
intended to prevent a person’s free body movements to a position of choice. In
the last twenty years, efforts to reduce, if not eliminate, the use of restraints has
led to strategies including adopting a restraint-free unit philosophy, staff training
in non-coercive interventions, assessing the patient and intervening early with lessrestrictive measures, and promoting a culture of negotiation and collaboration
rather than coercion (American Psychiatric Nurses Association, 2014). In the US
and elsewhere an effective approach for restraint reduction is outlined in the “SixCore Principles”, developed for adults but also applicable to children (Azeem etal, 2011). The principles include how the unit’s culture is developed, staff training

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Physical Restraint
Any device, material or
equipment attached toa person’s body, whichcannot be controlled by the
person, and is deliberately
intended to preventa person’s free body
movements to a position of
choice.

4

IACAPAP Textbook of Child and Adolescent Mental Healthon de-escalation, the role of leadership, use of data to inform restraint-reduction
efforts, and instituting debriefing. The video clips linked at the right discuss
restraint reduction with children, use of the six core principles, and the responsesof staff to restraint reduction efforts. They demonstrate that change is possible andpositive for both staff and patients.

Trauma-Informed Care
Threaded throughout this chapter is the concept of trauma-informed careand the role of trauma in emotional distress. Children with a history of trauma are
a substantial portion of the inpatient populations and often present with complex
behavioral pictures (Keeshin et al, 2014). Trauma-informed care emphasizes anunderstanding of behavior in light of trauma history and encourages approaches toavoid replicating traumatic experiences and building a sense of safety in interactions.
In inpatient units, enacting trauma-informed care is not just instituting discreteinterventions but demands embedding a broad understanding of the traumaticstress response and building a culture of non-violence, learning and collaboration(Bryson et al, 2017).

Click on the image above
to access a PowerPoint
presentation about the useof restraints and seclusion
in a pediatric population (byKimberly Allan).

This is particularly important with children who have a history of trauma,
who may react to perceived confrontation with reactive aggression. With all
children, but particularly with traumatized youth, nurses strive to maintain apositive tone in their interactions, which not only dampens the child’s negative
affect but helps boost how children take in the situation at hand (cognitive
information processing) (Delaney, 2009). A recent review of the literature about
instituting trauma-informed care also highlights the steps a unit can take tointroduce changes through leadership vision and by building staff competencies,
particularly to reduce the use of restraint (Bryson et al, 2017).
Summarizing the strategies, the authors combine the six core strategies
discussed above and the National Implementation Research Strategy. Unit
leadership might use these strategies for trauma-informed care as a roadmap to
reduce restraint. Keeping children safe and eliminating coercive measures should
also be viewed as a moral imperative considering nurses’ responsibility to safeguard
the rights of children. An in-depth discussion about trauma-informed care isavailable via the videos in the right column.

Structure
Structure is a straightforward element of the therapeutic milieu. At themost basic level, it involves maintaining a schedule that organizes the child’s day.
Indeed, the unit’s daily schedule is at the heart of the structure since it provides
a sense of order and introduces predictability, which is particularly important for
disorganized children or those who have difficultly responding to unexpectedchange (Kim et al, 2012). Staff must be alert to such issues particularly duringtransition times, which can be difficult for children who lack response flexibility.
These children may also lack flexibility in their coping mechanisms and do notswitch coping styles to match the demands of a situation. For instance, a child
may respond to all frustrations, be they school difficulties or peer altercations, withconfrontation rather than a problem-solving approach.

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Click on the image above toaccess a detailed descriptionof the six core strategies asadapted in New Zealand.
Click on the image below tolearn about the reactions ofstaff.

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IACAPAP Textbook of Child and Adolescent Mental Health

The daily schedule is usually a mix of activities: therapy groups, occupational
therapy, school, and expressive therapies such as art or music. It should
include pleasurable and demanding activities that are motivating and engaging.
Ascertaining a child’s response to a group and to particular task demands can be
useful for assessment and to determine the amount of structure and stimulationa child needs to remain organized and in control (Delaney, 2006a). For instance,
staff may note that a particular child becomes irritable or disruptive in a loudrecreational group and may need the presence of additional staff (a staff member
sitting nearby) to remain focused. A child may do well in occupational therapy
but becomes avoidant and sullen in the classroom. This child may need extra help
to decipher and structure work around the educational task at hand.
The overall aim in a children’s unit is for youth to succeed and experiencea sense of competency. That means, groups must have a sufficient number of staff
such that the appropriate tone and activity level are maintained. In a poorly staffed
unit, groups consistently become disorganized and too loud or, at the opposite
end, become repetitive and boring. When this occurs, children may re-live theirdisorganization and their inability to focus.

Table J.11.1 Crossmatch of National Implementation Research Network (NIRN) implementation
drivers with six core strategies (reproduced from Bryson S et al (2017).

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IACAPAP Textbook of Child and Adolescent Mental Health

One difficult aspect is how to set expectations and implement rules.
Providing structure demands that nursing staff reach a balance between maintaining
order in the unit while not infringing on the youth’s autonomy or sense of personal
control (Voogt et al, 2014). Staff may have the mistaken notion that imposing
stringent expectations will help control behavior and “shape up” the child. Quite
the opposite is true. To nourish a child’s coping abilities, staff should support
autonomy and provide a rationale for rules and expectations (Skinner & Wellborn,1994). Moreover, to reduce stress, staff should aim to elicit the child’s cooperationand set coping demands that are within the child’s reach (Delaney, 2009). For
example, how long a child remains in a group should depend on staff’s assessmentof the child’s current capacity to stay organized and focused on a task. If a childunravels at the end of a group, it is then planned that the child leaves the group 10
minutes prior to the end. As a general rule, unit expectations should be revised toensure that they serve the needs of the child (Bowers, 2014a).
Finally, the way staff approaches decisions around children’s participationand expectations sets the unit culture — the norms of the unit become commonly
held assumptions about how the children there should be treated. The culture ofa unit is evident in the moment- to-moment decisions and responses to children’s
behaviors. A culture can be rule-driven and dominated by efforts to enforce rules
or it can be marked by a flexible interpretation of what is needed to maintain anorderly milieu, but one responsive to a child’s needs. The later approach helps
children develop coping skills and begin to see adults as helpful in their efforts toremain organized and in control. Using techniques such as collaborative problemsolving are helpful to explore the cognitive skills a child needs to navigate difficult
situations and work with them to reach solutions (Ercole-Fricke et al, 2016). It
is useful for staff to be aware of their own beliefs around how children in the unit
should be treated and, given the unit’s approach, how they will improve and grow.
Example of Unit Philosophy•

All behavior has meaning. To therapeutically intervene with a child, staff must firstunderstand the meaning of a particular behavior.

•

Families are a critical partner in the treatment.

•Children ask only for as much as they need. Staff works with the child to achieve an
understanding of any limitations of what the adult world can provide.

•

Relationships matter. Learning and growth occur in the context of a relationship.

•

Rules and norms need to be flexible enough to service the needs of the child.

•Children should experience joy in their lives. The environment is structured to enhance
the child’s experience of joy and pleasure with themselves, peers and adults.

•

Children vary in their ability to process information, sort stimuli, and manage theiremotions. By experiencing the child’s ability to meet milieu expectations staff determine
the amount of structure and clarity the child needs to function.

•

Competence matters. Staff structure educational and social experiences so the childexperiences a sense of competence•

The goal of all interventions is to help the child achieve self-regulation.

•

Empathic resonance with a child enables staff to intervene and bolster the child’s
faltering functions (the ability to deal with demands, frustrations and powerful affects).
Through this repeated, reliable and consistent attuning, the child gradually takes on
staff’s organizing, affirming and soothing functions.

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IACAPAP Textbook of Child and Adolescent Mental Health

Guiding principles of a child/adolescent unit in the US, a list drawn up by staff
and seen as a grounding philosophy for their work with children, can be seen in
the box in page 7.

SupportSupport is another deceptively simple element of the milieu. Novice membersof staff may see it as providing encouragement or being empathetic with the child’s
emotions. While empathy is one element, providing support demands that staff
forge a deeper level of engagement, one that affords the patient the experience ofbeing recognized, responded to, and understood (Carlsson et al, 2006). The ideaof support has been framed in psychiatry in line with professionals’ response tocrises, as a moderating effect of social support or, in the treatment literature, asa specific type of therapy (supportive). Psychiatric nurses view support in termsof the interpersonal aspects of care and within the context of the nurse-patient
relationship. For nurses, it is within this relationship that individuals address
anxieties and move towards greater health and wellbeing (D’Antonio et al, 2014).
As with adults, relationship-building with children in inpatient units does
not necessarily involve a verbal “working through” of longstanding problems.
Rather, supportive engagement involves interactions that help children deal withthe more immediate issues of unit life, their current anxieties, and how they will
integrate back into their life at home and at school. The child may not articulatethese issues; thus, it is important to carefully observe milieu behavior, patterns ofresponding to unit expectations, and deciphering what is triggering the child’s
distress. Even with this understanding in hand, a child may not readily respond toadult overtures. Over time, children may have learned that adults are not useful tothem in moments of distress or in helping them manage their emotions. If this is
the case, initial overtures may be met with disdain; developing a relationship will
require a consistent, empathetic response to the child’s affect and to the underlying
message of their behavior (Proffer, 1966).
How does one create a bridge of understanding with a child? There has beena good deal of research on engagement with adults hospitalized in inpatient units(McAndrew et al, 2014). That research tells us that engagment is facilitated whennurses are committed to making a connection with the patient, listening, and using
a partnership model characterised by problem-solving and shared decision making(Gunasekara et al, 2013). To bring that connection to the interpersonal level(so that the patient experiences a connection), requires being present, empathy,
self-awareness of one’s responses to what is occurring in the interaction, andtailoring responses on the bases of the patient’s experience and the meaning of the
behavior (Delaney et al, 2017). The video link to the right is not about nursing,but about emotion, empathy, and connecting to experience. It reminds us of theneed to connect via a shared emotion and the gains realized throgh interpersonalconnections.

Click on the image to view.

Unfortunately, there are elements of inpatient treatment that hinder
the development of empathy, engagement, and relationships. Being attuned tothe child’s experience takes energy, as does being emotionally available. It takes
commitment to notice patterns of how children respond and to convey a true
interest in their experience of the world. It requires staff to be generous with theirtime, which all too often is taken up with administrative demands, admissions,Child mental health nursing

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IACAPAP Textbook of Child and Adolescent Mental Healthmedications, and paperwork (Seed et al, 2010). For staff to maintain engagement,
the leadership of the unit must be supportive and take a genuine interest in theconcerns of the staff. Thus, support must operate at multiple levels: staff support
to the children and management support to the staff.
A final concern is how nursing staff balance this supportive stance with
their aspiration of maintaining structure and safety in the unit. The staff member
who is seeking to form a relationship with the child based on caring concern, mayalso be the person who sets limits in an escalating situation. These times can strain
child-staff relationships. To deal with this conflict, staff must redouble their efforts
to respect the child’s need for autonomy, to adopt a non-authoritarian attitude, todeal with the situation in an authentic manner, and give the child room to save face
(Carlsson et al, 2006; Delaney, 2009).

Self- Management
Self-management can be defined as the way one adapts day-to-day activities
to maintain health or manage the symptoms associated with an illness. For instance,
for individuals dealing with depression, self-management strategies may include
efforts to control automatic negative thoughts (Hoffman, 2012). Children andadolescents in an inpatient unit have a wide variety of serious emotional disordersthat may have specific self-management regimes (Torio et al, 2015) but there are
general principles nurses can follow.
What might self-management mean for the child? Often children in inpatient
units struggle with maintaining control of their emotions or behaviors. This may
involve dampening down strong affects such as sadness or frustration. Children
learn to decrease negative feelings and self-soothe during their early years whencaregivers, sensing that their child was overwhelmed with emotion, responded with
comfort and helped the child regulate affects such as anger, frustration, or sadness(Socarides & Stolorow, 1984). Children in an inpatient unit may lack these selfsoothing skills. Moreover, they may lack the ability to detect an emotion, connect
it to an event, and articulate the feeling to adults. In this instance they may express
their distress in actions, not words. When staff observe loud, negative behavior
what they might actually be seeing is a child who cannot handle frustration. A
sulking child may be a lonely or an irritable one, or a youngster experiencing
depressive feelings (Stringaris et al, 2013). The staff’s role is to learn the pattern ina child’s responses and the accompanying affective presentation, step in and bolster
faltering regulation (McCluskey et al, 1999). Once the child is experiencing lessdistress, staff may attempt to teach the first steps in affect regulation, in identifying
feelings and learning how they arise in particular situations (Delaney, 2006b).
For the adolescent, self-management efforts might focus on teaching specifictechniques to reduce stress or to deal with depression and suicidal thoughts.
Adolescent units may decide to adopt a specific form of group treatment suchas Acceptance and Commitment Therapy (ACT). Here, using evidence-based
techniques, the adolescent is taught a new set of coping skills to deal with distressand to accept their experiences. Using the ACT approach, staff encourages youth
to move towards creating the kind of life they most want to live. Interventions aredesigned to help adolescents increase their awareness of environmental demands,
their personal values, and to be able to live with challenging thoughts and feelings
while taking steps to achieve necessary and desired life goals (Twohig et al, 2013).

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IACAPAP Textbook of Child and Adolescent Mental Health

The adolescent may be caught in a negative cycle, such as running away
repeatedly or using drugs. During hospitalization, they may focus on the life theywant to have, how they deal with inner turmoil, and how they might exercise
control. As they become aware of internal experiences, they have an opportunity
to consider new alternative behaviors. Understanding emotional regulation deficits
and mapping alternative responses is at the heart of Dialectic Behavior Therapy(DBT), an approach that has been successfully implemented with adolescentsin inpatient units (MacPherson et al, 2013). Through teaching and practicing
techniques such as mindfulness, distress tolerance, and emotional awareness, theadolescent comes to understand the two poles of their experience and how toreconcile these opposing forces. For instance, one set may be the teen’s emotional
vulnerability at one end and self-invalidation at the other (MacPherson et al,2013). With DBT techniques, the teen may come to reconcile emotional intensity
and suffering at one end and dismissal/invalidation at the other (see video link on
the side for a succinct explanation of DBT).

Click on the image to watcha short video clip about DBT(8:01).

Depending on the population treated in the unit, different strategies for selfmanagement may be employed. Given the frequency of adolescents with suicidal
ideation, specific strategies to address these thoughts may need to be implemented(Glenn, Franklin, & Nock, 2014). The critical element is that interventions areevidence-based and fit with the unit program, developmental level of the patientgroup, and overall goals for treatment

THE EXPANDING ROLE OF CHILD MENTALHEALTH NURSES
Early Identification – The Role of Prevention and Mental
Health First Aid
Worldwide, the scope of child mental health continues to grow as does
the urgency for early recognition of emerging issues in a child’s life. Since nurses
are the largest group of professionals who come in contact with children, theirrole in mental health promotion and prevention is critical. As the Royal College
of Nursing (RCN) emphasized, every nurse should consider themselves a childmental health nurse (Royal College of Nursing, 2016). In addition to the mhGAP,
which is discussed elsewhere in this book, additional toolkits exist to help nurses
assess and respond to behaviors that may indicate a child’s emotional distress(Royal College of Nursing, 2014).
Psychiatric nurses are also active in raising individuals’ mental health literacy,
particularly on how a behavior may be indicative of psychological distress. This
educational format is increasingly adapted and delivered in low income countries,
particularly after crises or disasters. Labadee & Bennett point out that reactions
to disaster differ on its nature and scope but also depend on the individual’s age.
They remind us that children may lack the verbal and emotional skills to copewith tremendous upheavals in their lives. In line with WHO
recommendations around psychological first aid for those whohave experienced disaster, it is important to make contact,
listen to concerns, and help the person feel calm.

Click on the image to accessthe publication “Mental
Health in Children and Young
People” by the Royal College
of Nursing.

Click on the image below
to access a blog aboutcommunity health that has
extensive links to WHO
documents dealing withmental health first aid.

For example, early recognition of stress and mental

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IACAPAP Textbook of Child and Adolescent Mental Healthhealth issues is a cornerstone of a project initiated in Malawi under the directionof Jerome Wright, from York University in the UK. This adaptation of a mental
health curriculum was centered in a health model aimed at understanding stressand reaching people in distress, but also acknowledging the health beliefs andpersonal values of the community as well as the cultural context of rural Malawi(Wright & Chiwandira, 2016). After carefully designing a curriculum that met
these goals, Wright and his team trained 430 “health surveillance assistants”. In
reporting on the progress of the initiative, Wright notes that these individuals
were able to identify and intervene with people in distress through more than
850 mental health promotion activities. In the two-year evaluation of the project,
43,049 people attended 850 mental health promotion events. In the course of
training groups to work with the health surveillance assistants, over 200 nurses
were also trained (Personal Communication, J Wright, October 2017). Wright
explains the project in detail in a blog (to access see link at the column on theright).

Mental Health Integration into Primary Care
As outlined in Chapter J-5 on service delivery, a strategic direction forincreasing mental health services is to integrate mental health into general healthservices (WHO, 2008). Integrated care recognizes the connection of mental andphysical health, and that mental health issues often present as physical complaints.
The WHO report on primary care documents best practice examples from South
Africa and Brazil, where nurses are delivering mental health services or educating
and training primary care workers. The benefits of integrated care are increasingly
recognized in pediatric health services, including access to care, closing thetreatment gap for mental health disorders and cost effectiveness (See Figure J.11.1).
In industrialized countries there is an organized effort to optimize the role ofnurses in integrated care, encouraging use of their education in screening and carecoordination (Smolowitz et al, 2015). The movement of mental health nurses into
primary care will require more than training in additional skills. Building working

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Click on the image to access
Jerome Wright’s blog aboutdeveloping village-based
community mental healthcare in Malawi.

Mental Health First Aid
Mental health first aid is
the help provided to aperson who is developinga mental health problem,
experiencing a worseningof an existing mental healthproblem or in a mental
health crisis. The first aid
is given until appropriate
professional help is received
or the crisis resolves.
Apart from being able
to listen empathically, toprovide mental health firstaid is necessary to have agood understanding of theeffects of mental ill-health onwork and relationships, toknow about the early signs,
what emergency procedures
to follow in a crisis, available
community resources andhow to use them.

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Figure J.11.1 Seven good reasons for integrating mental health into
primary care (World Health Organization, 2008).

relationships between nurse and general practitioner will demand educating theservice on the role of nurses in primary care, their competencies and scope ofpractice (Meehan & Robertson, 2013).

Development of the Child Mental Health Nursing Workforce
A key to increasing access to mental health care is building the strength andsize of the mental health workforce, particularly nurses. Reported below is one
country’s success in educating a cadre of child mental health nurses.

LIBERIA’S POST-BASIC TRAINING PROGRAM IN
CHILD & ADOLESCENT MENTAL HEALTH
There are efforts around the globe to develop the mental health nursing
workforce. Initiatives specific to child nursing include a recent program in
Liberia where children and adolescents make up over half of the population. An
estimated 20% of children and adolescents globally suffer from a debilitatingsocial, emotional, behavioral or mental health disorder (Kieling et al, 2014). No
data exist on prevalence in Liberia. However, data from low- and middle-income

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IACAPAP Textbook of Child and Adolescent Mental Healthcountries suggest that child mental health disorders in sub-Saharan Africa accountfor 14% of individuals with a psychological problem and 9.5% of individuals witha diagnosable psychiatric disorder (Cortina et al, 2012). Compounding this is thelegacy of 14-years of civil conflict, parenting by former child soldiers, poverty, andsexual violence (Johnson et al, 2008; Samuels et al, 2015).
When the Ministry of Health and the Carter Center Mental Healthpartnered to produce a new corps of mental health workers focused on children
and adolescents, we turned to professionals in the global mental health field withexperience from Africa, Europe and America. Through the University of South
Caroline Medical School, we developed a curriculum tailored to the Liberiancontext. We recruited a child psychiatrist and a child psychologist from Uganda
and other experts from the sub-continent with prior experience in Liberia who colead the courses with Liberian professionals.
The intensive six-month post-basic training program for nurses, midwives
and physician assistants comprises of six courses varying in length from three to six
weeks with concurrent clinical practice at both the national mental health referral
hospital, health facilities, and community-based mental health practices, including
school-based clinics and a group home for youth. Core texts include: WHO’s
mhGAP-IG. 2.0, Principles of Psychiatric Nursing, the IACAPAP eTextbook and,
where there were no child psychiatrists, Dulcan’s Textbook of Child & Adolescent
Psychiatry and Family Psycho-Education for Children & Adolescents (The
Carter Center, 2016). Key competencies taught and tested included the use ofvalidated assessment tools to detect biopsychosocial, developmental, psychiatric,
mental health and substance use disorders, relying on the DSM-5 and the British
National Formulary for Children & Adolescents, and setting-specific evidencebased mental health treatments and psychosocial interventions. Core training on
advocacy, human rights, anti-stigma interventions and frameworks, determinants,
and evidence for practice was also delivered. Assessment of knowledge, skills andattitudes included pre-and post-program tests, assessment of therapeutic skills,
and course- and module-specific competency exams. The program is conducted
alternatively in Liberia’s capital, Monrovia, and at the Kakata Rural Training
Institute in Margibi.
To date, the Liberia Board of Nursing & Midwifery has certified 64 child andadolescent mental health clinicians for independent practice through a state board
examination. They practice in all but one of Liberia’s 15 counties. The program
also runs eight inservice courses per year and supports community practices in 45
facilities and six school-based clinics with funding from UBS Optimus and theWorld Bank. Other core components of the course include clinical blogging andcompetency in using computers as learning and investigative tools. All graduates
receive paper and laminated copies of key screening tools, individual copies of core
textbooks, including IACAPAP’s, copies of the pocket DSM-5 for children andadolescents, and a laptop computer and modem to upload and report cases basedon patient encounter forms.
Supporting clinicians in developing the practice of outcomes reporting andmanagement is a core course component. Approximately 40% of graduates haveschool-based or school-linked mental health practices. A recent adaptation of the
WHO EMRO School Health Manual for Liberia is another step toward increasingChild mental health nursing

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IACAPAP Textbook of Child and Adolescent Mental Health

Twenty-one clinicians
specializing in child andadolescent mental healthgraduated in 2017 in Kakata
City, Liberia, from a training
program developed by The
Carter Center in partnershipwith the Liberia Ministry of
Health, Ministry of Education,and the Ministry of Gender,Children, and Social. Click on
the picture to view a report(2:42)

the number of schools with child and adolescent mental health clinicians in fullor part-time roles. In the schools with school-based clinics, parent advisorygroups are being trained to support work with the clinics. Among the challenges
graduates face upon returning to practice include: poor remuneration, medication
stock-outs, and lack of space for practice. The goal is to train 100 child andadolescent mental health clinicians and over 280 teachers who can work to support
the health, socio-emotional development, and mental health needs of children
across the county. The program plans to conduct its first national school-healthconference early in 2018 (access the video link on the right for more information
about the graduates of the program).

SUPPORTING THE WORK OF CHILD MENTALHEALTH NURSES
Around the globe, the role of nursing continues to expand with an emphasison child mental health prevention and promotion. Many international and regional
WHO centers provide both vision and materials that will assist child mental
health nurses in delivering programs, particularly about community outreach andprevention. The Pan American Health Organization(PAHO) has collaborating centers supporting nursing
as well as a wealth of information on mental healthin their region. The PAHO Mental Health Bulletin,
available on the web, lists the training programs
occurring in various regions, of which nurses are an
integral part. An interesting new resource comes from
Canada, a website that educates and informs bothprofessionals and teens about mental health. Here thevision of a healthy culture extends directly to teens,
reducing stigma via education and opportunities todialog about their own mental health

Click on the image toaccess the Pan American
Health Organization’s(PAHO) website that lists
collaborating centers
supporting nursing and lists
training programs taking
place in various regions.

Nurses are delivering basic mental healthinterventions, assuring health literary, andcombating stigma in low income countries (World
Health Organization, 2015). In that regard many

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IACAPAP Textbook of Child and Adolescent Mental Healthof the chapters in this textbook are applicable to the work of child psychiatricnurses who assess, screen, and identify presenting behaviors/symptoms andtheir associated precipitants. Child psychiatric nurses around the globe
also utilize principles of communication to establish family engagement
and understand caretaker priorities for helping the child and adolescent.
They understand how to use available coping resources and coping mechanisms

within the family and within the community

CONCLUSION
Child mental health nurses are vital to improving access to mental healthservices and the well-being of children and their families. In most countries there
are too few mental health nurses to serve the needs of the citizenry (WHO, 2015).
Nurses report practicing in contexts of significant unrest, often in an atmosphereof stigma, with a substantial lack of resources, and in the absence of an organizedsystem to support mental health (Marie, Hannigan, & Jones, 2017). As theroles of child mental health nurses and community workers expand so must the
documentation of their efforts: whom they see, what needs they address, and withwhat outcomes. With increasing ownership of their practice, nurses’ efforts andinnovations can be disseminated and scaled up to provide services to a greaternumber of individuals and improve the mental health of children.

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