NEST framework: full report

Childhood is the time for children to be in school and at play, to grow strong and confident with the love and encouragement of their family and an extended community of caring adults’. It is a precious time in which children should live free from fear, safe from violence and protected from abuse and exploitation. 

As such, childhood means much more than just the space between birth and the attainment of adulthood. It refers to the state and condition of a child’s life, to the quality of those years.

This United Nations International Children’s Emergency Fund’s (UNICEF) definition of childhood is our aspiration for every child in Wales. These experiences are not only optimal, but essential to childhood development and an individual’s potential to flourish, impacting on both mental and physical health into adulthood.

Despite this, the mental health and wellbeing of our nation’s children continues to be a growing cause for concern.

Mental health issues are amongst the most frequently raised concerns with the Children’s Commissioner for Wales. They are one of three priority ares for the Welsh Youth Parliament, as outlined in their Let’s Talk About Mental Health report (2020). Demand on specialist services continues to grow, out stripping resources despite enhanced provision in recent years.

The Mind Over Matter report (2018) highlighted this concern and called for Welsh Government to make the mental health and wellbeing of our children a national priority. Published by Senedd Cymru’s Children,Young People and Education Committee, it recognised the improvements brought about in specialist services through the first phase of the Together for Children and Young People (T4CYP) Programme, supported by investment from Welsh Government. 

However, subsequent reviews of the Mind Over Matter report (2020) and reviews of progress, stress that there is still much to do, calling for a ‘step-change’ in children’s  mental health and wellbeing services to address this need, which describes it as ‘the missing middle’. This refers to the gaps in services that babies, children and young people can fall through, alongside the need for more child and family centred practice across multi agency provision.

It is easier to build strong children than to repair broken men.

(Frederick Douglass 1818 – 1895)

The language may be dated but the wisdom in this quote has stood the test of time. Even so, the dominant service models in children’s mental health continue to be organised  around deficit and disorder, and of problems needing to reach an increasingly high and specific threshold before meeting the criteria for intervention.

Consequently, specialist services can be seen as remote with access determined via a narrow definition of what it means to have mental health needs (for example, moderate to severe mental disorder or mental illness). This is sometimes referred to as a ‘medical’ or ‘within child’ model of mental health.

Such a narrow definition has the potential to be problematic for several reasons:

• It risks a disempowering message at a societal level - that expertise in mental health resides only in the domain of specialist services, which can be difficult to access.
• It implies a linear journey in developing difficulties when often trajectories are more complex.
• It risks problems that could otherwise have been ameliorated becoming established and even entrenched before they reach the criteria for advice, help and intervention.
• It detracts from the reality that there are often a whole range of contributing factors at a family, school and community level.
• It limits consideration of the potentially rich resources for intervention at a family, school and community level.
• It de-emphasises the significant contribution of wider contextual factors such as poverty, social injustice, inequality and discrimination.

Indeed, there are potential opportunities for prevention and intervention at all these levels, but they can get overshadowed or underutilised in a system that privileges a focus on the individual child and ‘referral on’ to specialist services. Furthermore, when referral criteria are defined by diagnosable mental disorder, it risks either stigmatising or precluding children and young people with mental health difficulties that are both severe and enduring when the root cause is relational and contextual.

These issues often present behaviourally, and in the absence of a diagnosable mental disorder, and can be equally if not more harmful in respect of impact on functioning and healthy development. Often children who present in this way are less able to access clinic-based interventions that require a level of engagement and commitment that can be hard to achieve in the context of historic and ongoing adversity and instability.

The intention of the framework is to move away from organisational and service led design to a needs led approach. What are this child or young person’s and family’s difficulties? What do they need right now?

In response to the evidence it collated, the Mind Over Matter Report calls for a whole system approach and within that, a whole school approach to how we respond to children’s mental health and wellbeing. This means a mental health system that takes the widest possible lens in how it understands and addresses the mental health and wellbeing of children, young people, parents and carers and wider families. The intention is to address ‘the missing middle’ by both promoting the core elements that help all babies, children, young people and families to flourish; alongside developing a range of needs led population based and targeted strategies and services to ensure no one falls through the gaps.

The Together for Children and Young People (2) (T4CYP (2)) Early Help and Enhanced Support Workstream, aims to support a whole system approach by refocusing on multi-agency partnerships and a broader, shared understanding of mental health and wellbeing, alongside a shared responsibility for addressing it.

The ‘step change’ that the EHES Workstream sets out to achieve, is to flip the dominant narrative that mental health is something that resides within a child or young person, and therefore, needs to be ‘treated’ or ‘fixed’ by an ‘expert’, which is often perceived to be the exclusive domain of specialist mental health services.

It recognises the important role specialist services have in supporting this ‘step change’ alongside the provision of specialist interventions when this is indicated.

Through an extended and continuous process of co-production, the workstream has developed a framework that will focus on the core elements, experiences and knowledge base that parents and carers, wider families, schools, communities and indeed, all frontline professionals, need for children and young people to be able to flourish from a mental health and wellbeing perspective.

The role of specialist services will be to re-balance emphasis and align more proactively to support these core elements (and the individuals providing them) with their expertise; determined by the unique circumstances of individual babies, children, young people, parents and carers and wider families in local communities, alongside supporting the settings that require enhanced support at any given point in time.

The framework will provide a map for Regional Partnership Boards, statutory and third sector services to achieve this, co-produced with the communities they serve. The starting point and the route followed will be determined by local terrain.

What is working well? Where are the gaps? And how will we know we are on the right road?

Co-production, accountability and feedback loops are essential to tracking progress.

The framework is inclusive of all babies, children and young people. This is alongside a recognition that there are circumstances and characteristics that can place some at greater risk of developing mental health difficulties. There is also a substantial evidence base targeted at particular issues and populations.

Early Help and Enhanced Support (EHES) is one of three workstreams within phase two of the Together for Children and Young People Programme (T4CYP 2). It works alongside the Partnership Workstream and the Neurodiversity Workstream; and there is considerable over lap and inter-dependency across all three.

T4CYP (2) builds on a robust legacy from the initial lifespan of the T4CYP Programme (2015 – 2019). Key landmarks that informed the trajectory towards identifying the need for the early help and enhanced support workstream include:

• The Hafal Making Sense4 report (2016) that asked children and young people what they wanted from mental health services. The key messages included ‘don’t medicalise growing up’ and ‘help those who are closest to us, like our teachers, to know how to support our mental health.’
• The Mind Over Matter report (2018), that called for a ‘step change’ or ‘culture shift’ in how we understand and support children’s mental health.
• A T4CYP (1) stakeholder event in 2019 that focused on the ‘missing middle’ and identified the core values that should run through all children’s services if this ‘culture shift’ is to be achieved.
• All T4CYP (2) activity between 2020 and 2022, including the development of the framework, is determined using the five ‘pillars’ co-produced at the 2019 event:

COVID-19 has required co-production of the framework to happen primarily on virtual platforms. This has combined a range of formats including formal presentations at established meetings, film and video logs, multiple drop in discussion forums across and between agencies, professions and organisations, and invitations to comment on draft iterations by email.

The National Youth Stakeholder Group (Children in Wales) and Parents and Carers Network (Parent Voices in Wales) have been pivotal in ensuring that the framework has the voice of babies, children, young people, parents and carers front and centre.

A range of stakeholders across all sectors have participated in this process, including Public Health, Primary Care, Specialist Child and Adolescence Mental Health Services (CAMHS), Paediatrics, Social Care, Education, Youth Justice, Youth Work, Advocacy Services, Police, Housing, the Ambulance Service and a broad representation of Third Sector organisations.

Special care has been given to ensure a diverse perspective and a Wales-wide reach. Indeed, the virtual nature of this process has perhaps facilitated a broader range of views as it was easier for interested participants to ‘drop in’ not limited by time or travel constraints.

The intention is for the framework to be a dynamic model that can be developed and adapted based on feedback and advances in evidence and policy, ensuring that the process of co-production is continuous.

A strengths-based approach that focuses on what we know helps children, young people, parents and carers and wider families to flourish.

The World Health Organisation’s positive construct of health is aligned with the proactive promotion of positive experiences in childhood because they are optimal to childhood development and adult flourishing:

Supportive parenting, a secure home life and a positive learning environment in school are the key factors in building and protecting mental wellbeing, or mental capital, in childhood and adolescence (World Health Organisation 2018).

It is essential that society continues to address remediable causes of childhood adversity.

However, equal attention should also be given to the creation of these positive experiences that both reflect and generate resilience in babies, children, young people, parents and carers and wider families and communities.

There is considerable focus on the need for children to become more ‘resilient’ and it is a much studied and widely debated concept.

Masten (2015) states that it is not the preserve of ‘extraordinary people’ with ‘extraordinary internal resources’ but rather is built on more ordinary things. In her book ‘Ordinary Magic’ she describes, how in addition to the significance of physical health and brain function, resilience is defined as ‘…a close relationship with competent caring adults; committed families; effective schools and communities; opportunities to succeed; and beliefs in the self, nurtured by positive interactions with the world.’

This concept of resilience building being about the everyday interactions across a range of relationships and settings is at the heart of the framework and a whole system approach to mental health and wellbeing. It recognises the power of these interactions to protect and buffer against the impact of adversity, and the value they have in both the prevention of and intervention with mental health difficulties.

Elevating the value and power of ‘everyday magic’, and supporting frontline professionals most proximal to babies, children, young people and families, to have the confidence, competence, support, supervision, time and flexibility to deliver this, is a key focus of the framework. The emphasis is on recognising the importance of the relationships close to (and preferably chosen by) the child, young person, and their family. It is the quality of these relationships that makes the biggest difference, and asking 'who is most important to you?' is a crucial question on the journey towards maximising this potential.

The Youth Engagement and Progression Framework highlights the importance of this, making reference to the ‘lead worker’ being determined by whoever has the most influential role in a child or young person’s life at a given point, recognising that this can change over time.

The more healthy relationships a child has, the more likely they will be to recover from trauma and thrive. Relationships are the agents of change and the most powerful therapy is human love, (Perry, B. and Szalavitz, M. 2017).

There is a growing evidence base, underpinned by the fields of neuroscience, attachment theory, developmental psychology and systemic practice regarding the vital importance of human relationships for mental health and wellbeing of babies, children and young people. More significantly, the recognition of the therapeutic value of these trusting relationships, is essential if we are to elevate them to the status they deserve.

This is particularly important for those babies, children and young people who, for whatever reason, have gaps in their relationships with trusted adults (children who struggle to make and maintain friendships, for example, or who are in care or on the edge of care, are particularly at risk).

All too often, frontline practitioners underestimate or dismiss their skills, believing therapeutic intervention to be the preserve of ‘therapists’. The structures that support specialist services have inadvertently reinforced this as a result of their perceived inaccessibility due to limited resources and increasing demand.

That is not to devalue the role of specialists and of specialist therapy of course, and it can be extremely beneficial, life changing and even life saving for the babies, children and young people who are able to benefit from it. However, everyday interactions with trusted adults have the potential to be very powerful and impactful, particularly for babies, children and young people who are our greatest concern; and especially for those who are unable to access more formal therapy for practical and/or psychological reasons or wider systemic issues (eg. poverty, cultural barriers).

Treisman (2021), a renowned expert on relational approaches, writes extensively about this and has coined the phrase “every interaction is an intervention”. This highlights the importance of trusting relationships not only for the prevention of mental health difficulties, but also as a powerful therapeutic tool for our most traumatised babies, children and young people as well. They have a key role in helping babies, children and young people, and also parents and carers, to regulate their emotions. The concept of a containing adult in supporting emotionally dysregulated children and young people is central to many therapeutic interventions. In order for the grown-ups closest to children to provide this containment, then they will need to feel contained and regulated themselves. The framework goes a step further, recognising the importance of emotional regulation for front line staff and, indeed, the professional and organisational systems that support babies, children, young people and families.

This is one reason why the framework moves away from a tiered and linear ‘refer on’ model of service provision; recognising instead the importance of a ‘needs led’ approach, that can flex up and flex down according to the wide range of factors that determine how, when and why support is required at a particular point in time, and how that can change over time.

Building in the necessary time, flexibility, training, structures, specialist supervision and accessible advice and support for frontline professionals is a crucial aspect of the framework. This is in recognition of the transformational role, and ‘everyday magic’, they have the potential to provide and are able to grow in other key adults too.

There is supporting evidence that the combination of positive childhood experiences, delivered through safe and trusted adult relationships, can have lifelong consequences for mental and relational health despite co- occurring adversities. It is crucial, therefore, that we address this from all angles and avenues available if we are to achieve the ‘step change’ required.

The call for a whole system approach for children’s mental health and wellbeing sits comfortably within a broader strategic context in Wales. Key drivers include:

Prosperity for All8 - the Welsh Government’s national strategy that sets out priority areas with the greatest potential contribution to long term prosperity and wellbeing, including mental health.

Wellbeing of Future Generations Act  (2015) - based on the principles of wellbeing and placing people at the centre of decision making about their lives, and on prevention and early intervention.

ACE Aware Wales - making Wales a leader in tackling adverse childhood experiences.

A Healthier Wales: Our plan for Health  and Social Care - calling for bold new models of seamless health and social care at local and regional levels.

A Whole School Approach Framework – is about supporting good emotional and mental well-being by making relationships stronger children, young adults, parents and carers and wider families, teachers and any professionals working with the school.

In addition to making intuitive sense, there is compelling theoretical support for the need to combine our efforts across all public and third sector organisations, and work together at a local, regional and national level to achieve the best outcomes for babies, children, young people and their families.

As far back as 1979, Bronfenbrenner’s ‘Ecological Model of Child Development’, highlighted the complex interaction between a range of factors, all of which combine to impact on a child’s mental health and wellbeing, and development more generally.

Indeed, as one young person pointed out in one of the T4CYP (2) co-production sessions, Maslow’s Hierarchy of Needs, dating back to 1943, is relevant in that it recognises that if basic needs are not met then we all struggle to engage proactively with higher order aspirations. Kim Golding (2015) has enhanced this for thinking about how to support children who have experienced trauma with her 'pyramid of needs':

This sets out very clearly the importance of addressing basic safety and security in relationships first and foremost, before advancing to more individualised and traditionally clinic based interventions for babies, children and young people who have been impacted by trauma. It is imperative, therefore, that there is a shift in focus towards this broader, system wide, ‘trauma informed’ model of intervention if we are to address this impact. Old narratives that rely on therapy to create stability, and conversely that babies, children and young people need stability to access mental health services, are unhelpful as they fail to recognise how inextricably linked these factors are.

It is a complex field to formally evaluate. However, the early intervention foundation  undertook a review of the evidence base in respect of adverse childhood experiences in 2020. While this report acknowledges the limitations of both the scope and application of this field, and in particular the risks associated with screening for and counting adverse childhood experiences, it recognises a clear need for a system-wide focus on the negative impact of childhood adversity. The report highlights evidence to support a whole system approach, with workforce practice, services, commissioning and leadership, all aligned in a commitment to identifying and meeting the needs of the most impacted families. To achieve this, they identify the following requirements:

• Effective leadership - which ensures that services are well configured and connected to meet the needs of the local population.
• Strong professional workforces - who are equipped to meet the needs of babies, children and families struggling with adversity. This support should include training and supervision, as well as the time necessary to establish positive relationships with families.
• Robust and stable services - which include the use of interventions informed by the best available evidence of improving outcomes for babies, children and young adults.

This is a new and emerging evidence base in a complex area of service delivery impacted by societal and political determinants that are constantly changing. COVID-19 has certainly brought this into sharp relief. However, the early intervention foundation identified common features of interventions that should inform service delivery models. Most significantly, trust between practitioners and families was a core component of all evidence based interventions that they identified. This is because trust is essential for intervention, to ensure participants feel safe and supported to share their experiences and work through the difficult emotions associated with trauma and adversity.

It is important to recognise that establishing trust can be particularly challenging when individuals have learned to mistrust others through their experiences of trauma and adversity, which can include service and organisational experiences that are re- traumatising in and of themselves. As a result, high levels of practitioner skill, time and support are required to ensure this trust is established or re-established and maintained over time.

Organisational factors also determine the time and privilege afforded to practitioners to work in this way, such as:

• ensuring they are well supported to meet the needs of families and well connected through effective leadership
• positive interagency working  
• robust pathways to support
• ensuring services are reaching the families who most need them

A whole system approach, therefore, requires trust at all levels – from multi-agency strategic and commissioning forums, through to the day-to-day practice of and between front line practitioners. Relationships are, of course, central to developing the level of trust this requires.

Relationships matter: the currency for systemic change is trust, and trust comes through forming healthy working relationships (Perry, B. and Szalavitz, M. 2017).

The need to establish ongoing research and evaluation in this field is essential. In a recent Anna Freud seminar, as part of their Transformation Series, Professor Eamon McCory summarises the evidence about how we understand and address childhood trauma from both a prevention and intervention perspective. He concludes by calling for more research and for disciplines and theoretical approaches to work together to achieve this. However, in the meantime there is a need to ensure that responses of adults, priorities of services and the working of systems are focused on the child cultivating and maintaining trusting relationships and reducing stress generation.

The Framework sets out to create the conditions to achieve this, developing as and when more evidence emerges to support specific interventions within this. We know enough to start to act now, listening and learning from babies, children, young people, parents and carers and wider families, about what matters most and what makes the biggest difference to them. In the words of Voltaire:

Don’t let perfect be the enemy of good

The framework reflects a process of extended co-production across a broad range of stakeholder groups and has undergone a number of adaptations to get to this point, including the decision to call it NEST. 

The NEST analogy was chosen because it captures key qualities, values and aims that the framework sets out to achieve:

• The importance of a safe and nurturing base for all babies, children and young people.
• The aspiration for all babies, children and young people to be enabled to ‘fly the NEST’ and ‘aim high’.
• The possibility for all babies, children and young people to ‘return to the NEST’ if they need to.
• That each NEST is unique to the individual, created by the relationships, experiences and communities that surround them.
• That a child or young person’s NEST is built on natural resources that enhance their existing relationships and contexts.
• That each baby, child or young person’s NEST is multi-layered reflecting the complexity of their individual circumstances, and the potential for support across all aspects of their lives.
• That every baby, child and young person has the same basic need – but some require additional layers of support at different points in their lives, and across different levels. Our babies, children and young people of greatest concern are likely to need an enhanced NEST over a prolonged period of time.
• That every interaction from every person in a baby, child or young person’s NEST has the potential to support their mental health and wellbeing, and as such is an ‘intervention’.
• That it is these small interactions that provide ‘every day magic’ building to make a difference to babies, children, young people and their families and helping to layer the NEST.
• That this framework facilitates a shift away from asking ‘what is wrong’ with a child towards asking ‘what is their NEST like?’And ‘how can this NEST’ be enhanced?

We consulted with a range of people who speak Welsh as their first language regarding the acronym. Rather than a direct translation of NEST, their preference was to develop an acronym for NYTH.

The acronym Nurturing, Empowering, Safe and Trusted were the preferred core qualities chosen by stakeholders during co-production sessions.

Nurturing - (Taken care of and cherished)

Empowering - (Feeling strong and listened to)

Safe - (Protected and able to be yourself)

Trusted - (Reliable and there for you)

Nurturing

Dictionary definitions of nurture include the care and attention given to someone that is ‘growing’ and ‘developing’; ‘protection’ and ‘cherish’. These are all qualities that are aspired to within the framework, and fit with the concept of a nurturing NEST or safe base.

Within Education settings, six principles of nurture have been identified and applied both to classroom and whole school approaches (Lucas, 2019):

1. Children’s learning is understood developmentally.
2. The environment offers a safe base.
3. The importance of nurture for the development of wellbeing.
4. Language is a vital means of communication.
5. All behaviour is communication.
6. The importance of transition in children and young people’s lives.

These principles are applicable across a wide range of settings and are relevant at both the universal and targeted level, promoting inclusive, respectful relationships between babies, children, young people, parents and carers and professional and voluntary networks.

The Welsh acronym word chosen to capture the essence of Nurture, is Hybu which means encourage. The dictionary definition of Encourage is to make (someone) more determined, hopeful, or confident.

Empowering

According to the dictionary definition, something that is empowering ‘makes you more confident and helps you feel that you are in control of your life’. This absolutely captures the essence of the framework and the essential role of agency and efficacy in supporting mental health and wellbeing. It also fits with the aspiration of the framework to be as relevant for parents and carers, front line professionals and strategic partners as it is for babies, children and young people. The aim is for everyone to feel empowered to achieve the best outcomes within their respective roles. It aligns with the co-production pillar, sharing the balance of power to ensure the voices of babies, children, young people, parents and carers are central in service development and design. This is outlined in self determination theory which highlights the importance of a sense of agency (Deci, E L and Ryan, R M 2012).

The framework acknowledges that within the trauma informed movement, there are  perspectives that question empowerment as a helpful concept. It can imply there will always be those with more and those with less power. Given that the framework is broader than trauma informed practice, and has a focus on babies, children and young people who inevitably will have limits on their power, it is the co-produced choice of word for now, but as with all of the core elements, it is open to be reviewed and developed.

Safe

It is, of course, critical that we work together to ensure babies, children, young people and their families are, and feel safe and protected from harm. This is often prioritised in respect of physical safety, but the NEST framework extends this to both ‘relational safety’ and ‘emotional safety’. Relational safety refers to the sense of felt safety babies, children and young people have in their relationships with others – whether that is within their families, with adults in the wider community or with their peers. Emotional safety refers to a sense of felt safety to be to able express emotions, as wide ranging and extreme as they may be. Acceptance, validation and naming of emotions, are key components of many therapeutic interventions. The framework aims to broaden the value of these principles into wider and more accessible opportunities for babies, children and young people, parents and carers and their wider families.

A sense of felt safety can be achieved through a broad range of initiatives including the physical environment, regular routines and clear boundaries, creating a sense of belonging, feeling valued, included and ‘seen’, having visible representation and role models, and having your voice heard, acknowledged and acted on.

The Welsh acronym word chosen to capture the essence of Empowering is rhoi Nerth which means to give strength / empower.

Trusted

According to the dictionary definitions, trust is ‘the firm belief in the reliability, truth or ability of someone or something’. It was frequently referred to as being the most important factor in our co-production sessions, and is critical for babies, children, young people and families who have experienced considerable uncertainty in their lives. It is perhaps one of the reasons why the pandemic has been so unsettling because things we could once have been certain of – like schools being open and end of year exams, have suddenly been thrown into question.

Trust builds slowly through repeated reliable experiences, and it is why basics like keeping appointment times, returning phone calls as agreed, and being honest about what is possible, are key components of practice that need to be prioritised and recognised as such. As mentioned previously, trust is one component of a range of evidence based interventions focused on supporting babies, children and families who have experienced trauma and adversity. It is very individualised, takes time and effort and organisational support to achieve, but its impact can be transformational.

Trust overlaps with safety, providing the building blocks for therapeutic change to take place.

The NEST qualities help to facilitate the cultural shift that 'Mind Over Matter' aims to achieve; moving away from a primarily ‘within child’ model of mental health towards curiosity regarding a baby, child, young person, parent and carers and wider family’s experiences of feeling nurtured, empowered, safe and trusted. This is further facilitated by the following questions:

• ‘What was a child’s NEST like at key developmental stages?’
• ‘What is their NEST like now?’
• ‘What can be done to ensure that their NEST becomes more Nurturing, more Empowering, feels Safe and is Trusted by the baby, child or young person and their parents, carers and wider family moving forward?’

It highlights that a baby, child or young person’s NEST is often the most powerful agent for change. It prompts important questions about the system around the baby, child, including family, school, wider community and the organisational culture of supporting systems. It brings to the foreground the need to invest in supportive NESTs for babies, children and young people, if we are to promote their mental health and wellbeing (eg. frontline professionals who can build flexible and supportive relationships and positive opportunities that support a child or young person’s, and carers and their family’s strengths).

The NEST image at the centre of the framework was co-produced and aims to capture the significance of the layers of support we all need to reach our potential from a mental health and wellbeing perspective. This is just as important for parents, carers and professionals as it is for babies, children and young people, hence the neutrality of the representation.

This understanding in itself marks a significant shift from the dominant culture in mental health services, which can reinforce a focus on the individual. This is often entrenched in many aspects of the system – from clinical records that require a ‘referred child’, to contacts only ‘counting’ if the child or young person is present.

If we are to shift the culture towards a broader understanding of what contributes to, perpetuates and also often helps to address mental health difficulties, then we need to notice and address the built in biases and expectations these organisational systems potentially set up. Invariably services do endeavour to include the wider family and network in their work but this could be facilitated more easily, and indeed promoted, by simple shifts in language and service design and a broadening of wider questions and curiosity at the outset.

A rights based approach

A rights based approach underpins every aspect of the framework; and is at the heart of promoting the conditions for babies, children and young people to support their mental health and wellbeing.

The Right Way Framework developed by the Children’s Commissioner for Wales, can be used to facilitate the embedding of a rights- based approach organisationally.

The key principles are summarised below:

• Organisations will prioritise embedding children’s rights in their work with children and families to improve children’s lives.
• All children are given the opportunities to make the most of their talents and potential.
• All children are given access to information and resources to enable them to take full advantage of their rights.
• Authorities and individuals are accountable to children for decisions, and for outcomes that affect children’s lives.

The Children and Young People’s National  Participation Standards support the delivery of the UNCRC principles at a more individual level, by identifying the seven participation standards that all workers should be aware of when working directly with children and young people in Wales. These participation standards are as follows:

1. Information – will they provide information in a clear and accessible way that thinks about the audience of children as a whole but also different ages and abilities?
2. It’s your choice – will young people get a choice about being involved, and get all the information they need to make that decision?
3. Non-discrimination – how will the organisation ensure non-discrimination during all the participation processes? What opportunities can you provide to meet the needs of all children?
4. Respect – will young people’s opinions be respected and taken seriously?
5. You get something out of it – what will young people get out of it? How will their participation be made safe and enjoyable, and – where appropriate – can you show your appreciation with a free lunch or certificate? Find out if these offers would be something the young people would like.
6. Feedback – when and what feedback will be given? How have their ideas been used and why; and what happens next with the views they have shared?
7. Improving how we work – how will the organisation use this process to ensure they evaluate it and continue to improve how they work with children and young people?

Equity, diversity and inclusion

Fundamental to a human rights approach, is an understanding of the complex and important relationship that equity, diversity and inclusion can have across mental health and wellbeing. Babies, children, young people and their parents and carers, are at greater risk of developing mental health difficulties as a result of a range of protected and marginalised characteristics they may have and life experiences including, for example, race, ethnicity, culture, religion, gender identity, sexual orientation, physical health and disability, neurodiversity, additional learning needs, adversity and poverty. This can happen overtly as a result of racism or bullying, for example, or through systemic and structural barriers and blind spots at an organisational and service delivery level.

Intersectionality as highlighted by Crenshaw (1989), describes how discrimination and oppression along interconnecting axes can interweave, combining and exacerbating the impacts of two or more areas. This is about understanding the way in which the above characteristics can interact and produce unique and often multiple experiences of discrimination and disadvantage in specific situations. One form of discrimination cannot and should not, be understood in isolation from another. For example, a black, lesbian mother might face homophobia, racism and misogyny.

Equally, defining a person’s needs according to these risk factors and making assumptions about their experiences and hopes can be prejudicial in itself. It can result in babies, children, young people, parents and carers and their wider families, and indeed professionals, not feeling understood in a holistic way that takes account of all aspects of their identity, and the priorities that are important to them. Indeed, it is important to acknowledge that a protected or marginalised characteristic may have little or no impact on a person’s reasons for accessing service.

In her latest book, Treisman (2021) proposes that, given this complexity, it is perhaps more appropriate to focus on cultural humility in recognition of the importance of an awareness and sensitivity that holds the individual’s experiences and wishes at the centre of interactions. This approach also highlights the evolutionary nature of our understanding of the impact of these issues, and society’s ability to respond and adapt accordingly. 

We are at different stages in the journey with respect to racism and sexual orientation for example, than we are with respect to neurodiversity. Even so, cultural and societal influences impact significantly on that journey and how it is experienced by individuals at any given point in time. Taking ‘Black Lives Matter’ as an example, this has both moved society’s understanding forward at the same time as exposing fault lines that will have been experienced in traumatising ways by many.

Indeed, there are both direct and indirect impacts of prejudice based discrimination on mental health and wellbeing. For instance, babies, children and young people may be bullied directly, but can also continue to be affected by hearing negative stories in the media. The framework aims to take this complexity into account, ensuring a continuous and reflective lens on these issues and their impact on the mental health and wellbeing of babies, children, young people, parents and carers and their wider families.

From a rights based and strengths based perspective, it is crucial that all babies, children and young people are helped to feel that they belong, are important, have a voice and can expect to have the same opportunities and experiences as their peers regardless of their individual characteristics and life circumstances. It is also crucial that they feel safe to express their whole self, and are enabled to celebrate their unique identity. To do this they need to feel seen, represented, accepted and have access to visible role models who they can see themselves in and aspire to.

Values led

Children and young people’s services are a busy and complex landscape with a range of competing priorities across agencies, organisations, services, and professions.

Focusing on common core values can help everyone to understand what behaviours are regarded as most worthwhile and important to promote, pursue, monitor and measure.

Furthermore, people generally feel more satisfied working in contexts where their personal values align with the values of those around them; and where these are enacted at all levels of an organisation. This is sometimes referred to as ‘modelling the model’, and this congruence is vital in achieving the cultural shift towards more relational, person centred practice the framework aims to achieve. It is hard to empower a child to trust that their feelings are valid if your own feelings are dismissed or diminished within your own context.

The NEST framework is a multi-agency endeavour that has co-production with children, young people, parents, and carers and professionals woven throughout. The graphic below highlights the most important values shared by delegates who attended a T4CYP Early Help and Enhanced Support stakeholder event held in 2019 that focused on the Missing Middle. 

Indeed, the process of achieving this consensus at the event was as important as the end product as it enabled a space to listen and learn from each other. It is anticipated that the implementation of the framework will require opportunities to think and plan together across Partnership Boards regarding the values that are prioritised across a region, its respective localities, communities and needs led services. Most significantly, how will the impact of these values be evidenced and experienced by babies, children, young people, parents and carers and their wider families, as well as by the service providers and strategic partners charged with their implementation.

Child development

Child development refers to the sequence of physical, sensory, language, cognitive, emotional and behavioural changes that occur in a child from conception to the beginning  of adulthood. During this process a child progresses from dependency to increasing independence, and this journey is facilitated by a complex interaction between individual differences, relationships and environmental factors. A sophisticated understanding of this complexity is important, particularly as each domain of development is not always linear, and can be significantly enhanced, halted or regressed by a range of relational and environmental experiences.

Services tend to be organised around children’s ages. This can place an unrealistic expectation that children at the same age are at the same stage of development. A flexible approach, recognising that babies, children and young people reach milestones and achieve developmental tasks according to multiple internal and external factors, is important if we are to remove this additional burden of pressure from children and their families, and indeed professionals charged with evenly progressing their trajectory. 

The new and emerging evidence based around brain development in adolescence is particularly pertinent here (Arain et al 2013). Indeed it is posing questions about organisational structures, service delivery models and interventions for this age group that are important to keep under review in light of this growing body of knowledge (Yeager, Dahl and Dweck, 2017).

This is highly relevant around transitions between services and recognised stress points in the system, for example the move from primary to secondary education. Babies, children and young people who are sensitive to changes in routines, and for those impacted by developmental trauma, may need particular attention as the profile variables can be more extreme. For example, a child who is very settled in primary school precisely because it is a familiar and safe environment may struggle in ways that aren’t anticipated when there is a change in all aspects of the school day. A young person who has been in a caring role from a young age may appear very independent and self-reliant, but may struggle significantly both emotionally and cognitively, especially at times of change.

Falconbridge et al (2019), have edited a practical book summarising the evidence for developing services aimed at improving the psychological wellbeing of babies, children and young people across health, education and social care. In it they helpfully reference the concept of ‘developmental cascades’ used by Marsten and Ciccheti (2010), to describe the way problems can interact and escalate in a child’s life as they develop, and why it is important to intervene early in order to avoid this escalation. In his Anna Freud Transformation Seminar (2021), Professor Eamon McCory makes reference to ‘social thinning’. This refers to how buffering experiences that protects babies, children and young people become less and less available to the children who are often most at risk. These are the babies, children and young people who are most in need of precisely these experiences.

Psychologically informed

Central to the NEST framework, is a determination to ensure all babies, children, young people, parent and carers and their wider families, benefit from the core experiences they all need to flourish. This is both in order to prevent difficulties in the future, and also to protect and remediate from exposure to harms that have not been able to be avoided.

The evidence base for ways in which our psychological wellbeing can be protected and enhanced is beyond the scope of this document. However, key to the Framework is an emphasis on drawing on the most recent developments in this field and ensuring services incorporate them into their evolving practice. This will inevitably vary according to the specific tasks they are there to address, and the populations they serve. However, it is important that there is a general awareness of what is available and how it can be applied.

Approaches like ‘trauma informed’ and ‘psychologically informed environments’ are becoming more mainstream having developed in response to significant needs in acute adult settings, for example forensic and in patient mental health units and homeless services. This is in recognition that our most traumatised populations have often experienced a severe paucity in safe, warm, responsive relationships growing up and throughout their lives, and benefit hugely from environments that provide this for them as adults. They also acknowledge that in order to achieve this in challenging contexts, the professionals involved need supportive and containing relationships also.

The basic premises underlying these approaches are often founded in child development, models of social learning, self-determination theory, attachment theory, psychotherapeutic approaches (eg. Psychodynamic, Cognitive Behavioural, Dyadic Developmental Psychotherapy Systematic Psychotherapy and Narrative approaches) and systems theory. Ironically, this influence is not always present in our childcare environments and institutions, where it has the greatest potential to make a difference. It is, however, growing in momentum thanks to population based approaches such as the Adverse Childhood Experiences (ACE) movement and trauma informed approaches across education.

The Welsh Government Whole School Approach Framework also recognises the broader influence of psychologically informed approaches highlighting as it does the importance of creating a sense of belonging, agency and efficacy not only for babies, children and young people, but for teachers and support staff, parents and carers as well. This represents a cultural shift in the shared understanding that we all have mental health that needs to be attended to proactively if we are to achieve our optimum level of functioning as human beings, particularly those charged with the task of maximising this potential in others.

It is acknowledged that these are evolving areas of discovery, and the application of theory and practitioner experience into evidence informed and evidence based intervention is a complex journey fraught with conjecture. The ACE movement is a classic example of a potential force for good (who could argue that adverse childhood experiences are undesirable and can take their toll across the lifespan?) that has been variably adopted and critiqued. It has at its core, the very best of intentions and is achieving a significant positive impact, but also risks misinterpretation, over simplification and poor and even damaging application. As is often the case with ‘movements’, ‘models’ and ‘approaches’, there is a risk of it either being seen as the ‘silver bullet’ by some, or rejected in totality by others as a result of its inevitable gaps and flaws.

There are, of course, always lessons to learn as our understanding of what it is to be human evolves and the aim of the NEST framework is to focus on the consistent core elements of what we know is likely to help, at the same time drawing on and contributing to an ever growing practice and evidence base. The climate of Nurturing, Empowering, Safe and Trusted it aims to promote applies as much to the professional and academic arena, and creating an atmosphere of supportive curiosity, reflection, and collaboration towards advancement.

Most importantly, we know enough to use the knowledge to develop services, determining their impact by listening closely to the voices of babies, children, young people and their families, and focusing on the outcomes we know are important to promote.

It does, however, feel appropriate to say something more specific about the application of attachment theory, as this is perhaps the most influential component of the framework that is least well understood outside of therapeutic practice.

Attachment theory

Attachment theory and the growing body of evidence from neuroscience to support it, is an important concept across the framework. In brief, the key message is that humans are born helpless and are primed to attach to an adult who will help them survive. Through this attachment relationship, a baby will learn hour by hour the answers to some crucial questions which will keep them safe:

• Who am I?
• What can I expect from others?
• What can I expect from the world?

These are questions that can only be resolved by paying attention to their caregiver’s facial expressions, tone of voice, and responses.

These interactions are how a baby makes sense of themselves and their environment. In a ‘good enough’ attachment relationship, a child will build a sense of themselves as ‘ok’, ‘of interest’, ‘loveable’, and’ ‘worthwhile’.

They might build a sense of others as ‘trustworthy’ or ‘reliable’ and hopefully ‘kind’. Ideally, they will experience the world as ‘safe’ and ‘predictable’.

At birth and through infancy and childhood, our emotions can be experienced as confusing, overwhelming and even dangerous. It is through a ‘good enough’ attachment relationship that we experience a trusted caregiver supporting us through the highs and lows of our emotional range. We learn through this process that we are not alone in our emotions. We learn emotions can be understood and made sense of with others, emotions come and go, and that others can help us regulate our emotions and soothe our upset. Over time we learn to manage or self- regulate our strong emotions for ourselves, but only through first having many experiences with someone doing this alongside us (co-regulation).

If a child does not have a ‘good enough’ attachment relationship - perhaps through adverse circumstances putting too much strain on a caregiver or environment - a child’s experiences might lead them to make sense of themselves as ‘unlovable’ or ‘worthless’. They might experience others as ‘untrustworthy’ or ‘threatening’ and the world as ‘unpredictable’. This hugely undermines a child’s ability to feel emotionally safe. Without safety, our brains can prioritise little else and so global development across all domains (physical, sensory, language, cognitive, emotional, and behavioural) can be compromised.

‘Developmental trauma’ occurs when a child’s circumstances repeatedly undermine safety - either emotionally or physically. This can also occur in the context of a ‘good enough’ attachment relationship – perhaps through significant disruptions in accommodation, unavoidable changes of caregiver, repeated losses or bereavements, domestic violence, or repeated hardships that cause upset and distress in the family.

Neuroscience tells us that our brains respond to a lack of safety by triggering the fight/ flight/freeze response – essentially getting our bodies and brains ready to act to defend and protect from threat. This is not a comfortable state to be in, but it does keep us safe.

Babies, children and young people who have experienced developmental trauma tend to have well developed neuronal pathways prioritising the identification of threat. In other words, ‘survival’ means they are primed to see the world in this way and can interpret even benign interactions through this lens.

Unfortunately, and because survival is our primary basic instinct, this will likely be at the expense of brain pathways associated with all other areas of development.

A child who may not have experienced developmental trauma but has not had the benefit of a secure attachment relationship, will also have some of the increased fight/flight/freeze response because without someone to keep us safe and guide us through our emotions, it is difficult to build a fundamental experience of emotional safety.

Babies and children who have experienced difficult attachment relationships, tend to have a negative sense of self, others and the world. Every interaction is then seen through this lens. Even consequences given with compassionate and well-reasoned explanations can be experienced as further evidence that: ‘I am worthless and unlikeable, you are unfair and unreliable, and the world is unpredictable’.

This might mean that it can be difficult for a child to make sense of consequences and to trust that a professional (and their carers and peers) has positive intentions. They may struggle with the academic and behavioural demands of school, further intensifying their feelings of isolation and fear. The tried and tested approaches within the childcare and education systems (eg. social learning theory, rewards and consequences) can be less effective with children who are prioritising safety and survival in their interactions, and who have limited prior experiences of personal success and feeling valued. This can result in huge frustration and a sense of failure for both children and professionals alike. The need for the child to fit the system rather than the system adapting to fit the child is a difficult dynamic that can ensue, exacerbating the situation.

Making organisations attachment and trauma informed means making sure that the environments, processes and procedures, are geared towards promoting emotional, relational and physical safety. It means privileging trust, transparency, fairness, equality, kindness, belonging, safety, security, curiosity and reflection across all levels of the organisational structure. All staff need to be included in that, from those in more strategic to those in behind-the-scenes roles. The importance of the school secretary, the crossing patrol person or the lunchtime supervisor for children in their day to day lives highlights this, and why everyone benefits from these insights.

It might seem that attachment and trauma informed approaches are for the benefit of just a select few in our society. The ACEs research in Wales tells us that the experiences that undermine a sense of safety in childhood are not uncommon, and in large organisations this includes a high percentage of the workforce. Indeed, many of us are drawn to social, care and institutional environments precisely because of our own experiences of trauma and adversity.

Fundamentally, these approaches benefit everyone in an organisation, and indeed across society as they are based on the basic psychological needs that help all humans to flourish. However, and most importantly in respect of a framework that has been developed to address mental health and wellbeing, they benefit those at risk of psychological distress even more.

Furthermore, with our basic needs for safety and security attended to, we are all better able to learn, develop and become our best possible selves.

Recent events with COVID-19 and lockdown have brought into the foreground how trauma, adversity, and lack of safety are unfortunately experiences that can impact upon any of us at any time. Indeed, Treisman (2021) helpfully highlights the various forms ‘trauma’ can take, underlining the importance of these concepts for all our lives. These include, for example, single events, abuse and maltreatment, cultural and racial trauma, intergenerational and historical trauma, war, refugee and political trauma, traumatic grief, medical and birth trauma, organisational and institutional trauma, and secondary and vicarious trauma as a result of bearing witness.

Offering an approach that anticipates the human need for environments and relationships that promote safety and security puts us in a good position to respond to all manner of difficult experiences that may impact individuals, families, or whole communities as they arise. Indeed, Treisman refers to the multiple types of trauma and the multiple layers in which they can interact with relational and contextual factors.

This complexity can feel overwhelming. However, it is also mitigated by the simplicity of making no assumptions and instead remaining curious and empathic in our interactions with everyone. This is the difference that a Nurturing, Empowering, Safe and Trusted NEST can make.

The section on psychologically informed practice leads neatly onto the first and, arguably, most important of six core elements of a whole system approach - the crucial need for all children to feel supported by trusted adults who are themselves well supported and have flexibility and time in their roles to be attuned and responsive to their needs. Linked to this is the importance of these adults to be able to co-regulate emotions, particularly for our most distressed children and young people.

These relationships are, of course, often found in abundance within the context of children’s own families and extended communities.

However, for a variety of reasons, this is not always possible and our most at risk babies, children and young people, or indeed all children and young people at vulnerable times in their life, depend on a professional and voluntary network to enhance this for them. The significance of this cannot be overstated as these relationships have the power to both prevent, protect, and heal babies, children and young people who are experiencing significant psychological distress, trauma, and adversity.

Indeed, this can be ‘the thing’ that makes the biggest difference for any child, young person or indeed parent or carer at a point or points of crisis.

The therapeutic and transformational potential of these relationships is important both in helping babies, children and young people to have their feelings and physical sensations named, validated, acknowledged, and explained; and in helping them to learn to regulate strong emotions. For the child or young person to have an adult who can support them to recognise these feelings and who is able to join in teaching them to respond, cope with and manage these feelings can be a very powerful factor in promoting mental health and wellbeing. This supports babies, children and young people to start to learn, experience and internalise coping strategies and resources.

Indeed, co-regulation (this process when done within the context of a safe relationship) is an essential precursor to being able to self- regulate. Self-regulation – being able to understand and manage strong emotions and impulses and bodily states - is central to mental health and wellbeing across the lifespan.

Furthermore, these supportive relationships are equally crucial for parents and carers who are experiencing stress or psychological distress, especially those who have experienced trauma and adversity in childhood themselves and who may be struggling to be available to their own children as a result.

Historically, services have recognised this to some extent with ‘named professionals’ built into support services, for example ‘key worker’, ‘care co-ordinator’ or ‘wellbeing lead’. While these roles serve important functions, they may not be the person chosen by the child or young person themselves, and their impact may be less powerful as a result. Indeed asking a child or young person directly who is most important to them, and wrapping support around these individuals, represents a significant shift in the emphasis the framework seeks to bring.

Furthermore, the organisational systems and processes can mean that assigned relationships finish abruptly. This can be due to ‘episodes of care’, rationed and time limited interventions, changes of team allocation, and the inevitable interruptions of working life (for example, sickness, change of role or job). It is perhaps unrealistic to suggest that services can operate without some of these constraints. However, it does feel important to recognise the impact they can have on babies, children and young people through an attachment lens, and ensure we do everything within our power to mitigate against this where possible; and particularly for the babies, children and young people, parents and carers and wider families who rely on these relationships the most.

One very achievable goal would be for every professional to prioritise their relationships with babies, children and young people, as an important, if not the most important aspect of their role. Organisations can look at their practices with this in mind, valuing behaviours that support this and questioning the priorities that work against it. There is inevitably a balance to be achieved but unhelpful justifications like ‘not wanting to create dependency’ can be challenged through an attachment lens. Equally, when there are struggles to form a relationship with a child, young person or family, reflective analysis as to ‘why’ are important to have. ‘Failure to engage’ and other short cut justifications that locate the blame within the individual without considering the potential failings and lack of flexibility or goodness of fit in the system are also important to reflect upon.

This is relevant for all children and families, but it is crucial and potentially life changing for those of greatest concern, as this often reflects a lack of trust in services, or a belief that they are underserving of support. It may take numerous attempts on behalf of a worker before trust is established. Youth Work is very familiar with these strategies, and the document Time to Act highlights the importance of this approach. The five pillars of youth work, Educative, Expressive, Participative, Inclusive and Empowering as outlined in the National Youth Work Strategy (2014-2018) clearly map well onto the NEST Framework, highlighting the vital contribution of this profession to supporting mental health and wellbeing.

For those children and young people who struggle to identify their ‘safe and trusted adults’, or where professionals question whether those they do identify are indeed ‘safe and trusted’, enhanced and flexible role boundaries are essential. It is not necessarily a hugely time-consuming shift, but rather a change of focus to ensure that usual priorities do not eclipse the development and maintenance of Nurturing, Empowering, Safe and Trusted relationships.

Basic practices like not changing appointment times at short notice, returning calls as agreed, and undertaking follow-up tasks as promised, make a huge difference in creating and maintaining these all-important trusted relationship. They may seem like simple things but often they do not happen in practice. If you have other adults in your life you can rely on, then that may be experienced as frustrating and disappointing; for those children who do not it can be devastating, reinforcing their view that relationships cannot be trusted; the world is unreliable, and their needs are not worthy of being met.

From early years through to compulsory schooling and on to higher education, there are multiple opportunities provided by our education establishments to support and enhance the mental health and wellbeing of every child and person in Wales. It is an exciting time with several key strategic developments that all come together to support the mental health and wellbeing of babies, children and young people.

These include the new Curriculum for Wales, the Additional Learning Needs (ALN) Bill and the Whole School Approach Framework.

Estyn have also placed a greater focus on this area, publishing a number of documents supporting a more holistic and inclusive approach to how we support babies, children and young people in their educational settings, including their Healthy and Happy report. Particularly refreshing is how this is understood in the context of partnership working and within a whole system approach. This recognises the crucial role our education establishments have in supporting the mental health and wellbeing of babies, children and young people from early years, throughout their schooling and on to college, but that they cannot and should not be expected to undertake this on their own. It takes a village to raise a child and our schools are at the heart of that village.

The Whole School Approach Framework focuses on the culture of our schools – that all important feeling when you walk through the door. It draws out key components as central to achieving this including a sense of belonging, a sense for efficacy and a sense of agency (having your voice heard). It recognises that these components are as important for school staff and parents as they are for babies, children and young people. Indeed, this recognition that focusing in on children without taking care of the grown-ups, represents a significant shift towards the cultural change the framework is seeking to achieve.

In addition to the role that senior leadership teams, teaching, and support staff play across education that supports a culture of positive mental health and wellbeing, there are also a range of specialist support services and roles that have this as their specific focus.

For example, Educational Psychology Services, School Counselling Services, Wellbeing Leads, Youth Worker Services and School Health Nurses are already well-placed to co- ordinate and deliver a range of both universal and targeted interventions within schools, alternative provisions and home schooling and informal settings.

The framework aims to facilitate the co- ordination of these services and interventions within a multi-agency context, ensuring that staff have access to specialist support as required and that babies, children, young people, parents and carers and wider families are clear about respective roles and responsibilities. The Schools In-Reach pilot is one example of this working in practice, as are a whole range of other partnership initiatives that happen in collaboration with education. NHS Scotland have developed a helpful tool to guide early years settings about the most appropriate interventions to meet their needs given a range of relevant factors from evidence of effectiveness, to cost, to population need. This is something that has the potential to be developed both nationally and regionally, and across age groups.

Most importantly, the NEST framework aims to give a clear message that whilst early years settings, schools and colleges play a crucial role in supporting the mental health and wellbeing of babies, children and young people, they cannot be expected to do this alone. Teachers and support staff are often the safe and trusted adult for our babies, children and young people of greatest concern. They need to have the competencies, the confidence and flexibility in their role to be able to respond in the moment, but also
to feel that they have access to timely advice and support. Strengthening relationships with local service provision across all agencies is key to achieving this, which in turn creates a safe and containing experience for babies, children, young people, parents and carers and their wider families, as well as the staff supporting them.

Co-production is an essential vehicle in the promotion and development of transformational change in the mental health system.The phrase 'nothing about me without me' is a powerful reminder of the priority this needs to be afforded if we are to create services that are relevant and effective for the people they serve. 

The NEST Framework aims to ensure that co-production is a routine and meaningful aspect of how our organisations and services operate, and it is important to safeguard against it becoming a tokenistic, tick box activity. 

When it works well it is a dynamic, relational way of enhancing the quality of services and our lives, not an ‘extra’ to be ‘added on’ to existing provision. 

Co-production is one of the five pillars of the T4CYP (2) Programme and has contributed  significantly to the development of the NEST framework. Special thanks needs to be  given to the two reference groups - Parents and Carers Network and the National Youth  Stakeholder Group. They provide a diverse perspective from parents, carers, children,  and young people feeding into discussions and decision making at every point in the process. 

Developing an ongoing relationship and communicating the impact of the contribution helps to shift the balance of power, with growing confidence from members of such groups ensuring they feel enabled to bring scrutiny and challenge. Linked to this is the growing area of peer support and the powerful role this can play in promoting mental health and wellbeing. The benefits of peer support are wide ranging for those on the receiving end, and for the peer support workers themselves. One of the key benefits is the greater perceived empathy and respect from people who have gone through similar experiences to one another. It can also benefit the peer support workers themselves with increased confidence and the positive feelings that come from giving back and doing  something to help others.

The framework aims to highlight the potential of this approach in service development plans - both within existing provision and for newly commissioned services.

Digital innovation is another of the five pillars of the programme, and COVID-19 has accelerated the relevance of this significantly. The use of virtual platforms, online resources, apps, and film and video logs has changed the way we are able to work, learn and offer support. The development of this framework is, again, an example of this with meetings, co-production sessions and focus groups all taking place virtually. This afforded a broader geographical reach and attendance at events than might otherwise have been  achieved. This rapid adjustment has been driven by necessity, but it will leave a positive  legacy about the art of the possible; and the involvement of children and young people will drive this innovation moving forward.

This is perhaps the most important section in achieving the ambitious step change away from ‘referring on’ towards supporting front line professionals to have the confidence,  competence, and support to feel better able to ‘hold on’ when a child or young person is experiencing distress, particularly where there is risk of harm to self or others. 

Specialist services are often criticised for being remote and inaccessible with 
increasingly high thresholds for accepting referrals. In return, specialist services often  criticise referrers for ‘passing responsibility’, referring inappropriately and having  unrealistic expectations regarding what can be achieved in their settings. The framework  aims to address this unhelpful dichotomy by calling on multiagency partnerships to come  together to bridge this gap with the aim of achieving two key shifts:

1. Make specialist mental health services and expertise more available with easy access to advice, consultation, joint working, and intervention where there are concerns.
2. Prioritise the crucial role all frontline practitioners have in supporting the mental health and wellbeing of babies, children and young people, regardless of the severity of the difficulties and providing ‘therapeutic’ interactions (everyday magic) with babies, children, young people, parents and carers and their wider families.

In other words, the NEST framework aims to move away from a separating out of responsibilities for aspects of a child or young person’s life, recognising that we all have a  collective role. Indeed, the time, effort and cost of trying to work out whose job it is to do  what could be better spent – one person on the co-production journey referred to it as a bit like putting energy into unscrambling eggs. Most importantly, the greatest therapeutic  potential is held in the day-to-day relationships with the adults that babies, children, and young people are closest to, but these frontline practitioners need to feel supported and clear about what to do if this is to be maximised. 

This is not a passing or shirking of responsibility, but rather a recognition of what the evidence tells us is most effective, particularly where trauma and adversity is the root cause; and an acknowledgement that traditional models of service delivery are clearly not meeting the needs of many.

Accessibility can happen in several ways:

• Information and advice in a variety of formats (leaflets, apps, posters, videos, websites, social media platforms).
• Regular training sessions - general and bespoke.
• Telephone advice and consultation lines (in language of choice).
• Named and consistent link professionals from within specialist services such that trusting cross agency partnerships and relationships develop.
• Regular consultation sessions (bookable in advance and drop in).
• Accessible service/team consultation, reflection, and supervision sessions.
• Facilitated network consultation meetings about babies, children or young people of concern (with appropriate consent and attendance).
• Multi agency/multi disciplinary joint formulation sessions where appropriate.
• Embedded mental health practitioners in teams/services where mental health and trauma is a key component of the work.
• Clinically led multi-agency and community-based teams with a focus on specific areas of need. 

This shift towards shared responsibility is vital if we are to embrace the complexity of  mental health, its numerous root causes and potential solutions. It is also very containing  for babies, children and young people to know that the adults supporting them feel safe and contained themselves. It recognises that for many babies, children and young people, particularly those of greatest concern to all services, there are no straightforward  solutions. It is only by working together that we can create the best possible conditions to nurture and support complex, continuously changing and often unpredictable needs.

It is important to recognise here that there are different models across mental health for  offering advice, consultation, and intervention. A more traditional triage model that assesses  for the presence of a ’mental disorder’ and advises accordingly has an important role and can usefully gate keep access to specialist intervention for specific presentations. However, where trauma and adversity are clearly the underlying cause of distress and ongoing risk, consultation from appropriately trained and supported practitioners is more appropriate, as this has as its focus a detailed psychological  formulation, and a trauma informed response to both risk management and intervention which often requires ongoing support, consultation or supervision as opposed to a ‘one off’ event. A lack of recognition of these important distinctions often lies at the heart of frustrations when the conclusion reached is ‘no mental disorder’ and the specialist involvement is withdrawn; yet the concerns and risks are ongoing (and often including significant self-harm and suicidal behaviour). This is precisely the gap where services need to move closer together and is a critical aspect of the framework in its attempt to address the ‘missing middle’. It is why the framework is not just about early intervention and prevention; and extends to managing complexity and uncertainty for often the babies, children, young people, parents and carers and wider families of greatest concern across all agencies. Led by Professor Miranda Wolpert, The Wellcome Trust’s recent focus on the ‘Active Ingredients’ to support child and adolescent mental health and wellbeing is testament to the broader range of interventions that should be considered, and the tailoring to individual preferences that services across all agencies need to be facilitating, alongside the call for more evidence to support this. (Brookman-Byrne, 2020).

Children grow and develop in the context of relationships. Relationships with their family,  their friends, and their wider community. Many factors will influence and shape their  experiences of growing up, how they develop into adults and how they themselves parent. We therefore need to consider these multiple layers of influence if we are to create contexts that can help them flourish.

Healthy communities have a central role in this and in ensuring that the fundamental  human rights of babies, children and young people are upheld. First and foremost,  children need to feel safe. Safe in their relationships and safe at home. Adequate housing, access to healthy food and safe areas to relax and play, including in nature are all critical to healthy development, mental health and wellbeing. Factors such as employment,  adequate transport, and green space will of course all influence how ‘healthy’ a  community is able to be.

Babies, children and young people, parents and carers and their wider families, also need to feel a sense of belonging and connectedness to a range of communities however these are defined. For example, community as:

• a place where they live
• a school they attend
• their friendship and peer groups
• attendance at afterschool activities, clubs and groups
• being a member of a sports team or a performance or arts based group
• a place of work

These experiences of a shared sense of community and endeavour to provide an important context for the development of resilience. They bring a sense of togetherness, shared purpose, and shared identity. They reduce our sense of isolation and can act as a buffer against life’s struggles. They also play a central role in upholding a child and young person’s right not to be harmed and to be looked after and kept safe, as they create opportunities for our babies, children and young people to be ‘seen’ by others.

Children do not live in isolation and are very dependent upon the adults in their lives to create and maintain the conditions necessary to support their growth and development. Babies and children and young people have less power to know what changes are necessary to support their mental health and wellbeing, let alone being in a position to make the changes themselves. Services that focus only on the individual, risks locating responsibility within that child or young person to create change. We cannot escape the fundamental importance of context in shaping young people’s experience, including their experience of distress. It is to these contexts, and crucially the relationships within these contexts, that we need to turn to if we are to create the conditions needed to nurture mental health and wellbeing. The NEST Framework aims to orientate Partnership Boards to pay attention to this as a collective at a regional level, alongside the provision of more traditional models of service delivery.

No epidemic has ever been resolved by paying attention to the affected individual (Albee, 1983)

Again, COVID shines the light on the importance of this concept as the social 
inequalities the pandemic has brought into the foreground emerge. It is beyond the scope of this document to summarise the links between poverty and mental health and wellbeing, but needless to say, there is a significant body of evidence highlighting this. The framework attempts to address these issues for babies, children, young people, parents and carers and their wider families and no amount of investment in specialist services can compensate for the widening equalities in our society. The Marmont Review (2020) highlights the lack of progress on this agenda since 2010; alongside the impact of COVID exacerbated by these gaps and opportunities it affords to Build Back Fairer.

Just as there is a deepening recognition of the impact of trauma and adversity on the  individual, so there is a growing understanding that trauma impacts at a community level. High rates of deprivation, violence and crime are all contributing and perpetuating  factors. The World Health Organisation’s Social Determinants of Mental Health paper  states that a person’s mental health and many common 'mental disorders' are shaped by various social, economic, and physical environments operating at different stages of life, and risk factors are heavily associated first with social inequalities. For children  disadvantaged by adversity, this is further exacerbated by the fact that they are less likely to be able to access and benefit from traditional clinic-based services because of a poverty of financial, practical, or psychological resources. 

Equally, their day-to-day access to protective factors such as safe places to play, green  space, nutritious food, restful sleep, quiet environments for study, access to  technology,  and opportunities to take part in sports, arts and leisure clubs are also likely to be limited.  Too many areas across Wales are impacted by trauma from experiencing adverse community conditions, including deprivation, lack of employment opportunities, violence, drug use, structural inequalities and high rates of physical and mental ill health and disability – both a consequence of deprivation and an exacerbation of deprivation for families. 

Trauma-informed care is an important development, but it is also critical that attention goes beyond individuals. Addressing community trauma requires intervention at a  population level, and consideration of what can be done to prevent trauma in the first place. A range of community based organisations including statutory, third sector and voluntary services are well placed to strengthen such endeavours. These include GP’s, midwives, health visitors, community nurses, Flying Start, Families First, parenting groups, children’s centres, libraries, community centres, Hubs, natural environments, play areas, sports activities, leisure facilities, music, performance arts, environmental and youth groups. This is by no means a comprehensive list, and local communities will have developed their own networks and resources. The NEST framework aims to strengthen this dependent on the unique needs of the populations served.

Community psychology is one one example of a proactive initiative to further enhance  local provision. It applies psychological theory and practice to harness the strengths of  communities to develop their own solutions to these issues. It takes a proactive, strengths based approach in its design, aiming to address the multiple levels that impact on the mental health of babies, children and young people.

Psychologists work with local communities and structures, particularly excluded and marginalised groups, to define challenges and co-produce solutions. Its focus is empowerment, building alliances and networks, co-producing solutions and impacting the most marginalised. At its simplest, community psychology provides accessible expertise to existing community groups and forums (sports coaches, youth movements, food banks), promoting the invaluable contribution these can make to the mental health and wellbeing of the babies,children and young people, parents and carers and wider families they support. It has the potential, however, to mobilise resources more proactively, drawing on applied psychology to act as a catalyst to empower communities to generate their own solutions to the issues they face.

The Children’s Commissioner for Wales’ No Wrong Door report highlights the common problem of children and young people either waiting too long to receive the support they need, or being bounced around services because there is disagreement about who is best able to support them. The report calls for services to wrap around children and families, rather than them having to navigate their own way through complex systems. This also requires a move towards services responding to need rather than diagnosis or other tightly guarded referral criteria, and a more flexible matching of resources with what will be most helpful at a given point in time.

The report acknowledges that some regions in Wales have taken steps towards this by setting up multi-agency panels where mental health and wellbeing are the focus. In addition to ensuring that babies, children and young people receive the right support at the right time; this approach is much more straight forward for referrers to navigate as their role becomes one of providing comprehensive information about need rather than working out which service to refer to. It has the added benefit of bringing professionals together so that they can learn first-hand about what is available in their locality, as well as building trust and addressing misconceptions that are commonplace across multi-agency relationships.

At a system wide level this approach offers an excellent opportunity to provide the necessary meta-perspective on need and the gaps in provision to aid service development moving forward. It also allows for a more careful analysis of referral patterns and trends to target training, resources, and more systemic and community and population based interventions.Indeed, the framework sees this development as the key to a whole system approach. The clear benefits for babies, children, young people and  their families; multiagency working and strategic planning make it a priority in working towards this. The multi-agency nature of these forums highlights the breadth of the mental health and wellbeing landscape, recognising that there are many options available across health, education, social care and the third sector. It challenges the default position that specialist CAMHS hold all the answers, removing pressure from this resource so that they can focus on the babies, children and young people they are most able to help, and freeing them up to become more flexible and forward facing in their offer to the wider system.

Innovative and co-produced developments, for example community hubs and drop in centres, and 24 hour safe havens, would naturally follow on where the focus becomes one of responding to the needs of local populations. There are populations and/or individual experiences and characteristics that benefit from a particular focus, alongside more general access to psychological therapies and interventions based on need. The list below is by no means comprehensive but recognises the range of services either already available in some regions, or where there is a clear rationale for service development. These services are often provided by health as the lead agency but can also be multi-agency or provided within education, social care or the third sector. The aim of the framework is to recognise that collectively there is a need to work towards ensuring these services are available to babies, children, young people and their families across all regions and dependent on need.

• adoption services
• children in institutional care who would be better served in highly intensive community placements and schools 
• children in the ‘looked after’ system
• children on the edge of care 
• chronic and acute physical health services
• disability services
• educational psychology services
• family based intervention services including parenting interventions and formulation informed interventions
• forensic and youth justice services
• learning disability and additional learning needs services
• LGBTQI+ services
• neurodevelopmental services
• parent infant mental health services
• primary care mental health 
• psychological Therapy services
• school based counselling services
• school in Reach services
• specialist CAMHS services
• substance dependency services
• support services
• whole school approach multi agency consultation teams

These services can also be complimented by services that target specific issues, again not exhaustive, but including for example:

• advocacy
• bereavement
• bullying 
• developmental trauma 
• domestic abuse 
• gender identity 
• post abuse 
• refugee and asylum seeker services
• young carers 

The provision of interventions within these services is beyond the scope of this document  but key guidance is included in, for example, documents such as Matrics Plant, and the  draft CAMHS specification which is currently out for consultation. 

These, together with UK wide organisations such as the Early Intervention Foundation and the Anna Freud Centre, will help Regional Partnership Boards ensure that they are drawing on the latest evidence base, alongside appropriately qualified and experienced professionals and clinicians interpreting and applying this according to local need.

The advantage of the ‘No Wrong Door’ or single point of access model means that at an individual level, families and referrers experience a smooth matching of the best service to meet a particular need at a particular point in time (no bounce). 

However, at a whole system level, consistent gaps in service provision and children who repeatedly come through the process, their needs never quite being met, immediately rise to the fore ground. This enables strategic partners to develop services based on unmet need, and facilitates a continuous process of service improvement. 

Indeed, this lies at the heart of the whole system approach that the framework aims to achieve.

Adult mental health services

The whole system approach also aims to recognise that the adults in children’s lives may have their own mental health and wellbeing needs, and often these may be a significant factor in a child or young person’s distress. Children’s Mental Health Services and Adult Mental Health Services need to work together, recognising the significant overlap in achieving integrated models of support.

Transition

Alongside this is the vital attention needed at points of transition between child and adult services, and the consistent pinch point this remains in the system despite numerous reports highlighting the risks associated with it, and policies that attempt to address these risks. 

The connections and relationships with the full range of services for the adult population is essential. This is not an exhaustive list but are likely to include 
the following:

• adult mental health services (community mental health teams and acute settings)
• disability services
• domestic abuse services
• emergency services (police, ambulance and fire services)
• forensic services
• housing
• learning disability services
• national statutory advocacy services
• perinatal services
• primary care mental health services
• substance dependency services

Central to the framework is the concept that all agencies work together to create a unique  NEST to meet the needs of individual babies, children, young people, parents and carers  and their wider families. Furthermore, it aims to place their voices and experiences at the  centre, using the ‘No Wrong Door’ principle to identify and develop needs led services moving forward. This represents a shift away from silos of expertise and delivery models towards a collective responsibility through partnership working to intervene earlier, address the missing middle, and identify the gaps that so many babies, children and young people of concern risk falling through.

We can only achieve this by working in partnership, and across Wales. The Regional Partnership Boards provide the ideal forum to initiate and support this process. The intention of the NEST framework is to provide guidance on the core components and principles; but at the same time allowing space for freedom and creativity that recognises the need to develop services that are bespoke and responsive to the communities they serve. Furthermore, this is a strengths based model for babies, children, young people parents and carers and their wider families, but also for the services currently working hard to meet their needs. Many regions are already on this journey and the framework aims to recognise the distance travelled, alongside highlighting the areas that could be enhanced or strengthened or are yet to be developed.

During the initial implementation phase, pilot regions will be identified and supported by the T4CYP (2) Programme to apply the framework across their locality. This in itself is a partnership, dependent on the development of Nurturing, Empowering, Safe and Trusted relationships. 

Is there an acknowledgement that trusting relationships at a strategic level are as important as at a frontline practice level, and that collaboration occurs best in the context of Nurturing, Empowering, Safe and Trusted relationships?

In order to establish their readiness for implementation, Regional Partnership 
Boards have been asked to consider the following questions:

• Is there an acknowledgement that multi-agency partnership working to support the mental health and wellbeing of babies, children, young people and their families could be improved?
• Are all the partners who need to be around the table represented; alongside a recognition that change involves everyone?
• Is there a recognition that change involves an element of risk and experimentation?
• Is there an acknowledgement that a narrowly defined evidence based approach? 
• Has limitations and there is a need to embrace practice based and values led innovations; alongside a focus on measuring what matters most to babies, children, young people and their families through co-production?
• Is there an awareness of the importance of moving towards all practice in children’s services being informed by child development and psychologically informed practice that promote mental health and wellbeing?
• Is there an acknowledgement that trusting relationships at a strategic level are as important as at a frontline practice level, and that collaboration occurs best in the context of Nurturing, Empowering, Safe and Trusted relationships?

Early adopters will have the benefit of direct support from the T4CYP (2) programme to  walk alongside them in this journey. This does not preclude other regions using the  framework to begin and/or chart their own journey. Also the learning from the early adopters will be fed into the work of the programme and shared widely. This will require a significant process of co-production and so the details are beyond the scope of this  document at this stage.

However, as a helpful starting point, the Spiral of Enquiry provides a useful model for the continuous improvement approach the framework aims to achieve. First developed by Halbert, J and Kaser, L (2013), the purpose of the spiral of inquiry was to support schools  in taking an action-orientated, evidence based approach to learning and teaching. As with all inquiry methods, it is a tool which supports practitioners to evaluate and adapt their practice based on the needs of the people they are working with. It requires  that  practitioners ask questions which may seem simple but can lead to profound changes.

The Spiral of Inquiry has six key stages:

1. Scanning
2. Focusing
3. Developing a hunch
4. New professional learning
5. Taking action 
6. Checking that enough difference has been made. At each stage in the spiral, three questions are asked: 

• What is going on for our community?
• How do we know?
• Why does it matter?

The spiral image captures the nature of inquiry in that it is a continuous process of listening deeply to our communities and reflecting upon our purpose and is not a fixed cycle with an end point.

Evaluation of the NEST framework is complex as its intention is to create, support and  maintain a cultural shift towards more baby, child, young people, parent and carer and  wider family centred practice that cuts across traditional and linear agency and service  boundaries. Its successful implementation will be judged by children, young people, parents and carers and families themselves. Methods of capturing their experiences and outcomes will be a crucial aspect of both its early implementation and ensuring it is achieving its aims on an ongoing basis.

Indeed, the framework is still in its development phase, and comprehensive sections on both the implementation and evaluation phases are beyond the scope of this document, particularly as co-production are central to both. However, basic principles that focus on capturing experiences and outcomes for babies, children, young people, their families and wider professional networks will be crucial to monitor at both a local, regional and national level.

The focus will be on the experiences of babies, children, young people, parents and carers, and we will know we are making progress as we hear direct feedback that their experiences of services have felt Nurturing, Empowering, Safe and Trusted.

This alongside hearing from both families and professionals across all agencies that they know who to turn to for help and advice; and that this is accessed in timely manner, and makes a positive difference to their lives.

The co development of the NEST framework has been co-ordinated and lead by the T4CYP Team. We would like to acknowledge the contributors for bringing the framework together, with special thanks to:

Dr Liz Gregory – Chair of the early help and enhanced support workstream & consultant clinical psychologist 

Deb Austin – T4CYP programme lead 

T4CYP wider team