‘She was taking three hours in the shower, not sleeping properly’

Liam and Christina Cashell could see the youngest of their two daughters was suffering terribly from anxiety but they had no idea what was wrong.

The whole household was “walking on eggshells” around her. “We always knew there was something there from an early age. She had these little traits,” says Liam.

But the girl’s insistence on following her own routines and having everything done on her terms provoked frequent rows.

“She controlled everything, we couldn’t even plan a day out,” says Christina.

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Those outside the family had their own opinions: “It’s bad behaviour”, “she’s acting up”, “she’s a drama queen”.

Things came to a head when their then eight-year-old daughter started threatening to self-harm. A child psychiatrist advised them to take her straight to Temple Street hospital in Dublin, where they got a referral to the Child and Adolescent Mental Health Services (CAMHS). The hospital’s social services staff also asked the couple if they would be interested in doing a parenting programme with the children’s charity Barnardos.

“We were open to anything, we were that low down,” says Christina. “I was really at rock bottom with depression with the whole thing. I couldn’t handle it any more. She was taking three hours in the shower; washing her hands constantly in freezing cold water for hours. She wasn’t sleeping properly.”

There was huge pressure on Liam, who is the family’s breadwinner as a taxi driver and to whom Christina was looking for emotional support in the turmoil. “I couldn’t go to work days and then I would get stressed out because the money’s not coming in and there’s bills to be paid, the mortgage,” he recalls.

Their youngest daughter is, explains Christina, highly intelligent, top of the class and very vocal about explaining her feelings. “She says she can’t talk to us because we don’t understand what she’s going through; that it’s not our problem, it is her who has to go through these things. We were literally all at a screaming match.”

From the day in March 2017 that Beverley McMackin, a then project worker with Barnardos Finglas Family Support Service, walked into their home, life took a turn for the better. She was there to lead them through Partnership with Parents (PwP), a one-on-one programme that Barnardos in Ireland has devised for parents of children aged three to 18.

‘A happier child’

At the outset, parents are always asked what they want to get out of it. What did the Cashells say?

“A happier child,” replies Liam immediately.

“A happier environment,” adds Christina, as the couple repeatedly and smoothly exchange the baton of story-telling while they recount the impact of the programme on a family such as theirs in challenging circumstances. The couple reckoned if they could make their younger daughter happier, life would be better for everybody in the house.

“Beverley was there for us, to try and help us reflect on the situation,” says Christina. They looked at how to predict their daughter’s trigger points – and also their own.

For Liam, things would tend to build up in his mind during the night and the moment his feet hit the floor in the bedroom the next morning he would want “to vent”. Christina would encourage him to get up and go out the door without saying a word. The couple laughingly disclose how she uses the code “shark music” (think menacing Jaws theme) if sensing Liam is about to lose it.

McMackin, who is now project co-ordinator at the Finglas West Family Resource Centre, says the couple wanted to know where were they going wrong as parents.  But it was not a question of that, she says, rather a matter of doing things differently.

Diagnosis

During her time working with the family, the younger daughter got a diagnosis of obsessive compulsive disorder through CAMHS.

“She has got additional needs, so it’s about how to support her and manage it,” says McMackin. Yet she also encouraged the couple to put the diagnosis to the side and to distinguish between behaviours that were part of the disorder and then what is okay and not okay in normal child behaviour.

“Whether a child has a diagnosis or not, the child-parent relationship is key,” says McMackin. She helped the couple see how changes in communication style would ripple down into improving the parent-child relationship and calm things down.

“We couldn’t even have a decent conversation because it was all tension and argument about this happening and that happening,” admits Christina. “We had lost complete contact as parents, as people in a relationship.”

On McMackin’s advice, the couple instituted a “date night” on a Wednesday, which they keep up to this day – a walk and maybe a drink. “It’s ‘us time’, to have a talk without the kids hearing us,” says Christina, who suffered from post-natal depression on her first child but didn’t realise until she had it again after the second.

“We had gone through years of IVF and it had all failed and then I fell pregnant naturally. I was even shocked the second time around.”

Before doing the PwP programme, with their lives revolving around their daughters, “we were probably mollycoddling them too much – giving them too much,” remarks Liam.

Christina had tried group parenting programmes but, although they helped a bit, “you get caught up with everybody else”, she says. “You’re coming away with the other person’s issues on your shoulder. It was so different with Beverley coming into the house – it meant we had something tailored to us, to listen to us.”

Barnardos

Parents going to Barnardos for parenting support, most commonly through Tusla and social work or self-referral, generally have higher levels of need than those expected to attend a group-based course. It’s why the organisation has designed, developed and trialled PwP over the past 10 years, which staff have gone into more than 2,200 homes to deliver to date. Its focus is on recognising the importance of “relational issues”.

The results of the first evaluation of its effectiveness were released at a recent conference in Dublin. As Siobhan Greene, Barnardos director of children's services outlined, child behaviour was top of the list of significant improvements reported by participants. This was followed by routines and parent-child relationship. Education and physical development were also areas where smaller improvements were noted.

Parents said the better relationship with their children enabled them to spend more quality time taking part in fun activities. This had a knock-on effect of parents feeling more empowered, more confident and less anxious.

Older children reported more interaction between family members, thanks to the programme, which led to improved relationships and fewer arguments.

One teenager felt they were better equipped to express their feelings because their parents were showing a new ability to respond in a more predictable manner. Other children said a more stable home environment meant they could engage better at school.

The evaluation also identified some challenges around the use of the PwP, stressing that it “will not work for all parents at all times”. External factors can also threaten the gains made.

Family routines

One participant facing homelessness was concerned about how they could keep up the family routines that were working for them: “I am worried everything will just fall apart and I will fall apart with it.”

There is no shortage of international evidence that parenting programmes are an effective intervention but it's not just a case of plucking one off the shelf, the head of a UK Centre for Parent and Child support, Dr Crispin Day, told the conference. It's not going to work if it's not the sort of help the parents need or want; if it isn't offered early enough and if it's difficult for families already operating in straitened circumstances to access.

He said he found it “troubling and baffling” that one in 10 children in “big economies” across the world now suffers from a significant mental health problem. That’s, on average, three children sitting in every classroom of 30.

It’s “a disgraceful state of affairs”, he said, that we “create and enable” the conditions in which children suffer these sorts of difficulties.

Children with early behavioural difficulties are estimated to cost a country's exchequer up to 10 times more than a typical child

In areas of socio-economic disadvantage, the problems are compounded and you can expect up to nine children in every classroom of 30 to have significant behavioural and/or emotional issues. A recent report from the Royal College of Physicians in Ireland found that among our most vulnerable families – the homeless – almost 40 per cent of children are experiencing "clinically significant" mental health and behavioural difficulties.

"Life happens" to all of us.  But "life happens" much more frequently to vulnerable families than to wealthier people, said Day, a psychologist who works with the NHS in south London and Maudsley.

Buffers

The more privileged among us may underestimate just how important good education, financial means and emotional stability are as buffers against adverse events.

In communities of generational poverty, there can be “long-standing, inter-related circles of ‘this is how life is for us’,” he explained. Professionals need to appreciate that the “scope for change is limited”, then “work out how to be ambitious and realistic about what is possible”.

Early intervention is what has been shown to work in stopping young children with behavioural difficulties “stepping on to an escalator” to teenage and adult years characterised by the same problems.

Children with early behavioural difficulties are estimated to cost a country’s exchequer up to 10 times more than a typical child, due to their own needs and their impact on society. Entrenched problems can range from ill-health and unemployment to addiction, crime and inability to make and sustain relationships. It makes economic, never mind moral, sense to try to break the cycle.

The desired outcomes of early interventions are not just about change in a child’s behavioural issues but “relate to the ecology of the family”, said Day. This requires a personalised approach, as exemplified by PwP and he commended Barnardos here in Ireland for the way it was already changing the lives of children and families.

The development of a national model of parenting services is a priority of the parenting support policy set up at the beginning of this year within the Department of Children and Youth Affairs, Ciara Pidgeon, head of the unit, told the conference.

“First 5”, a cross-departmental 10-year strategy to support babies, young children and their families that was launched at the end of 2018, acknowledges the importance of parents, she pointed out.

Challenge

The challenge for the Department of Children and Youth Affairs is to provide a better link between policy and the people it is designed to support, said Pidgeon. The focus must be on “what works for parents in real-life situations and not what works in ideal conditions”.

The Cashells have no doubt that PwP worked for them, not as a magic wand but rather in strengthening their abilities to cope.

“We still have issues and problems that we have to deal with – it’s life,” says Christina. But when something does go wrong, they have learnt to reflect calmly on why and what they could have done to avert or defuse the situation.

The programme was very helpful too for their older daughter, now aged 13, who had her own anxiety problems in the past. “She is thriving in secondary school – doing everything a teenager should do,” says Liam.

What their project worker describes as “fantastic” was the way the couple, empowered by the programme, started to advocate for their younger daughter at school, where she had been getting detention at lunchtime for coming in late.

Every room in the house has a ritual for her and she didn't want to be in the house anymore

“After 10 weeks, Liam went over to the school, explained how his daughter is, what his daughter needs and he said ‘we don’t want punishments, we don’t want lines, what she needs is support’. It was very powerful,” says McMackin.

Liam says his daughter had been “holding it in at school, so the school didn’t see the tendencies and when she got home, we got the full lash of it”.  They had no idea that this pupil was turning up 10 or 15 minutes late because she had so many routines to go through in the morning, putting on and taking off clothes repeatedly. The school is very understanding and supportive now.

Relax

Having come on “in leaps and bounds”, the Cashells were able to enjoy their first family holiday in three years in Spain last summer. The younger daughter was able to relax more in new surroundings, which had no previous associations with moods or actions.

But the return home was tough. “Every room in the house has a ritual for her and she didn’t want to be in the house anymore.” She has to do things and think things before she can move from one room to another.

“It’s so hard for her, going through this at 11 years of age,” says Christina who, on the advice of CAMHS, is her enabler while staff try to teach her daughter coping mechanisms. “She has me doing the rituals for her, to try and ease the anxiety.”

Families in Ireland in numbers
1,218,370 families*
218,817 families headed by single parent*
6.7% of population in consistent poverty**
20.7% consistent poverty rate among households of one adult and one or more children under 18**
31.3 average age of first-time mothers***
77.7% babies born to Irish mothers***
22.3% babies born to mothers of other nationalities***
62% babies born within marriage***
Sources: *Central Statistics Office 2016; **CSO 2017; ***CSO 2019