Coherence: understanding and making sense of the Young SMILES intervention

The implementation of new interventions in services relies on those involved in their delivery developing a common understanding about their aims and values. Practitioners working across third-sector and NHS environments were consistent in positioning Young SMILES as a much needed solution to a national service gap, and as a meaningful, localised activity with potential to positively influence participant outcomes:

There are obviously a lot of families where mental health is a significant concern where it impacts on parenting, really, and it therefore impacts on children, so I think we felt it was a very valuable service. I don’t think we felt it wasn’t valuable. I think we felt it was valuable.

R8, Voluntary organisation

The Young SMILES intervention was seen as distinct from other services. Much of its value was attributed to its underlying philosophy advocating child-centred support and increased service accessibility for a broader population. Focus group participants repeatedly acknowledged the ‘hidden’ status of CAPRI and displayed a shared set of values around the moral and social imperative to ensure that support was available for subclinical, as well as clinical, populations:

I used to work in CYPS [children and young people services], child and adolescent mental health, you know, so children that had a reasonably significant mental health difficulty could get referred to a service and get a service, but maybe children that had parental mental health, but maybe were or weren’t being affected by that, there was not necessarily an identified service. So that’s what I mean about being missed.

R5, NHS-Voluntary

Additional coherence was evident in the way that the Young SMILES intervention aligned well with new care pathways that were being envisaged locally and in the way that its timely introduction supported the type of organisational and workforce development necessary for these care pathways to emerge:

Within the trust, there had been some work going on about how we identify young carers and then link young carers up with an appropriate service. But actually, we started to ask questions about, well, what do people need and how effective are the interventions that people experience . . . we heard about Young SMILES and it seemed like such a good opportunity to do something that I think ethically we felt we needed to be thinking about as a family therapy team.

R9, NHS-Voluntary

So that’s what got me excited both about Young SMILES but also the potential for a co-delivered project with Barnardo’s, I think, because Barnardo’s were telling us is that the children want more to do with adult mental health workers and we were saying, well, we want more to do with the children’s workers.

R9, NHS-Voluntary

In aligning with these local aspirations, the Young SMILES intervention navigated a unique path. Simultaneously, the intervention was upheld as something meaningful and distinct from current service provision, yet something that also drew on, and benefited from, existing skills and care philosophies:

I think that’s the kind of work that we try to do in our one-to-one sessions with the children and the parents. And we’ve not done . . . we’ve done sibling groups but it wasn’t just mental health, because we work with physical health and drug and alcohol addiction as well, but only one to one because it’s such a delicate area to go in. And you are there as a support worker, people see you as an authority, so what gives you the right to talk to people about these delicate areas of their life, or even give advice, maybe you have got an opinion but they haven’t asked for your advice. But to do it like in a group setting and peer support, and people learn from each other, it’s a lot more client-friendly, I think.

R6, NHS-Voluntary

I think that’s quite typical, isn’t it, of the way that we work already, because we have run coffee mornings, we have done other groups . . . And we know, we’ve already built up relationships with those parents before inviting them along to things. And then we support them to think about coming and sometimes give them a lift. So that is the way that we would generally work to get familiar with them.

R3, Voluntary organisation

Cognitive participation: work needed for a new community of practice

Successful implementation of any new intervention requires facilitators to foster commitment and buy-in from intervention participants and from their colleagues and peers. NPT asserts that, when a new set of practices is initiated, a core problem is often whether or not key participants are working to drive them forward. Intervention facilitators may ultimately need to organise or reorganise themselves and others to contribute collectively to the work involved in the new practices.

In the context of the Young SMILES feasibility trial, considerable interprofessional work was necessary first to identify suitable families for the intervention and then to guide them successfully through the trial referral processes. A key concern for facilitators was the inherent difficulty of identifying the target population and the potential impact of this on intervention reach. Success was perceived to rely heavily on service context and on the working processes already available (or not) at local sites:

I think that services that have been set up to think of the needs of children, like Barnardo’s, were able to identify the families relatively easily, that’s my impression, you might have something different. But actually, in an adult mental health context, I think a lot of it was about working with potential referrers to say why this is important and that it wasn’t necessarily those families who were notably struggling or where there’s difficult relational issues, that actually . . . well, we know there’s such a big wider population of need, and that unless people are taught to look for it, they don’t necessarily see it.

R9, NHS-Voluntary

One of the things that actually struck me, just the last thing I’ll say is, it was interesting the number of people who we identified on the caseload who were already known to you, which made me think, well, is that something about people are thinking about the kids, so they’re already thinking we’re a bit worried about this, that there needs to be something in place, or have they got families who are actively seeking support and intervention. We did not capture the people who we know aren’t accessing this anyway.

R9, NHS-Voluntary

Recruiting families into the feasibility trial of the Young SMILES intervention was acknowledged to be challenging. Although a key difficulty was the need to identify and reach out to families falling within intervention scope proactively, facilitators also recognised that research trial procedures had negatively affected participant enrolment. The fact that a notable proportion of families would be allocated to TAU and would not have access to the Young SMILES intervention was a study design feature that concerned those tasked with implementing the intervention and was, at times, perceived to affect families negatively:

The worry was how is that going to be displayed in the family home and what’s the outcome for the child of this is going to be? Because . . . I hope this doesn’t sound patronising . . . but there is a huge amount of work to make this family understand that this is a good thing for the child. And that took so much work. And then for that child to be randomised. And all they heard that the good thing is not going to happen for the child. And it does send the parent in a downward spiral . . . they’d be in tears when I’m telling them they’re not going.

R6, NHS-Voluntary

Every appointment I’ve had since then, every time, every time I try and contact them about having appointments, I’ve had the same thing about she hasn’t got anything, you know, why did this have to happen. And I know why, there’s an absolute . . . there’s a reason that we have to do it like that, but it was very difficult. This person was very unwell, or is very unwell.

R7, NHS-Voluntary

Many recognised conflicts between trial procedures and those implemented in their current services, where the immediacy of families’ needs was considered on an individual basis. Furthermore, facilitators reported not being involved in the composition of groups, which made it difficult to resolve anticipated challenges in group dynamics:

It’s the pressures of trying to do it when it’s being evaluated, so you’ve got to run a group now, so instead of being able to pick and choose who you wanted or saying, well, they’ll be best for the next group or they need to wait 6 months before they’re ready to move on, we’ve had to stick them all together because of the pressures of you’ve got to bring in another group now because we’re stopping it, sort of thing, so that hasn’t helped.

R7, Voluntary organisation

Because you’ve got a limited sort of pick of people and families, you’ve got no choice over the group dynamics, so some of this lot you wouldn’t want in a group ever together. It makes it impossible working, and ideally you’d assess that before and think, well, just separate them out and think . . .

R1, Voluntary organisation

Lack of individual control over intervention set-up and implementation was a key theme for facilitators and highlighted how critical it was to build communal engagement in Young SMILES, so that the process and outcomes of this new practice could be optimised and sustained. Incorporating additional procedures to ensure family engagement and understanding, with particular emphasis on parents, was strongly advocated:

. . . it’s probably something that you consider for the manual I think about engagement and the first stage of the manual, you know. So if we were running a group together, you know, would we go out and meet every family beforehand and individually, and talk about what the group was about and help prepare people to attend.

R1, NHS-Voluntary

One variable that facilitators debated at length was parental readiness for change. Although children engaged well with the Young SMILES intervention, parental engagement varied. Facilitators’ perceptions of parent readiness to change contrasted across the two sites, with those working at the health and social care interface more likely to comment on engagement challenges. Whether the difference observed between the sites was solely a reflection of true differences in group membership or was, in fact, partially influenced by professional experience, role and expectation remained unclear. What was evident was that a combination of cognitive and relational work was required with parents at intervention initiation and that this work was perceived to be the joint responsibility of intervention facilitators and intervention participants:

These parents have really severe mental health issues, most of them that are coming to them, and some of them don’t even go out, they don’t even open their door to people, so it’s been very difficult just to get in to start with some families.

R3, Voluntary organisation

They’re still not ready for group work, some are just not ready, and they’re not ready to deal with and cope with and listen to and discuss the impact on their child, because they’ve got so many issues of their own that’s blocking them from coping with their children’s feelings and emotions and so on . . .

R4, Voluntary organisation

Running a parent group with participants who were not ready to identify and explore their children’s experiences (as opposed to their own) caused some facilitators to question the ethics of this aspect of the intervention design and had a negative influence on their motivation and commitment to this role:

The children all love coming and have been very positive, but of course the parents haven’t been, and we feel like we’ll get to them and they’ll be hearing about the same rubbish, nothing will change for them in their lives, but we’ve shown them that it could be different but it’s not going to be.

R2, Voluntary organisation

Those sessions were near impossible . . . they’re very stuck, you’re constantly bringing them back and they’re just not getting it.

R2, Voluntary organisation

Despite these sentiments, the conceptual and theoretical arguments for including parents in a child-centred intervention were well understood. Clear tensions were evident between the magnitude of work that was required to engage and sustain parental input, and the perceived consequence that this would have for children if it could not be achieved. Parent engagement was considered vital not only to assist with their own understanding of their children’s experiences, but also to ensure that their children felt included in the intervention and experienced maximum socioemotional benefit:

Unless you can change the parent, and it isn’t the child in this, it is the parent. The parent has to own some responsibility, yes, the mental health is there, no denying that, we understand the mental health, but they’ve got to have the capacity to change, if that change doesn’t happen, you’re setting children up to fail.

R8, Voluntary organisation

Just observing from the children’s group, is that a child was on his own, his parents didn’t come with him to the session, and so when all the parents come in to pick them up, this child hadn’t got anyone to pick him up . . . there are things like that, and it’s that feeling of being separate, with this young child that their mum wouldn’t come to the group.

R6, Voluntary organisation

Facilitators in one site suggested that parental engagement with the Young SMILES intervention was naturally enhanced by some of the parents meeting informally before the parent sessions commenced. It was thought that meeting spontaneously while waiting to collect their children from their first sessions allowed parents to build relationships before meeting in the more formal sessions. Parents who had not had this opportunity, or who struggled to relate to their peers, were disadvantaged socially and struggled to integrate into the group. In this sense, relational work instigated by and sustained by the parent participants was upheld as an important ingredient for intervention success:

By the time [we] started the first group and we had a group contract, people knew each other already, they exchanged telephone numbers already. In a way, they did quite a bit of the work that was meant to be done in the first session, they gelled.

R6, NHS-Voluntary

And some parents seemed to get lost through the process once they’d started informally because, you know, it was an unfacilitated process that was happening, or some joined later and then relationships had formed between certain members of the group, so what it would be like to try and join the group that was already formed at that point.

R9, NHS-Voluntary

For others, more explicit solutions were necessary. This included allocating more time to precipitate parent change within the intervention and providing more dedicated opportunities for families to work through their experiences as a unit:

We talked around as well linking in some work and more sessions around changing the women’s beliefs as well, you know, how we would work with them to change their beliefs, the beliefs like I can’t cope, or my life’s over, actually changing those beliefs and getting them to change those beliefs and look at how they need to behave differently and how they need then to give those beliefs to their children, and how they’re going to do that . . . to give the best possible service, I suppose.

R3, Voluntary organisation

I think there must be more active joint activities, like you only have an hour together rather than them going there and the kids down here, I think they need to do things together so that we can see what’s going on in the kids’ heads if they do those activities together . . .

R7, Voluntary organisation

Collective action: delivering the intervention in practice

A central tenet of NPT is that any novel or modified intervention must display interactional workability in order to be taken up and integrated into routine practice. Although facilitators across both sites reported that CYP were engaged with the Young SMILES intervention, there was some recognition that CYP commitment varied depending on the approaches taken. This observation was applicable to both age groups, with facilitators consistently acknowledging that opportunities to engage the group in dynamic activities were more likely to be well received and more likely to engage participants than direct group discussion:

They weren’t verbal about not wanting to talk [laugh] but they just didn’t say anything. So we had silence. So we knew they didn’t want to do the discussion-based things because it was just really awkward and they didn’t . . . they just weren’t willing to share in front of everybody.

R3, NHS-Voluntary

They were a bit like, oh, not this again . . . I think with the little ones, it felt like we really had to keep the serious bits to a minimum, because they just got bored actually, we just lost them. So we were almost bribing them with, we’ll do this bit and then we’ll do something fun. So I think as well, to make it any kind of a worthwhile activity for them, just keep it really short.

R8, Voluntary organisation

It became apparent that, for some CYP, a major barrier to talking was the expectation that their thoughts and feelings would be shared with their parents. Fear of disclosure was closely linked to a reluctance to prioritise their own needs and a reluctance to tell their parents what they had been experiencing as a result of their parent’s mental illness:

There was a feeling of what, you know, their parent might think, put two and two together and knew that it was them that had said that. I think that’s quite a big thing for a little one to carry, isn’t it, and worry about. So, we kept things quite general at times, didn’t we, and really respected what the little ones had said.

R4, NHS-Voluntary

One important discussion point for the Young SMILES facilitators was the recommendation in the intervention manual that groups create an ‘imaginary family’. Although this tool was viewed as a useful mechanism for older children to share experiences in a non-threatening way, facilitators reported that, among younger children, the concept was not always fully understood. Younger children were typically perceived as less ‘self-conscious’ and ‘happy to talk’ directly about their own family; therefore, facilitators were forced to adopt a more flexible and adaptive approach, gauging the value of some intervention tools and exercises depending on how the group attendees responded to their introduction and use:

They used it [the imaginary family] when there was something particularly difficult, like when we were talking about what they would want to say to their parent, they found it a lot easier to think what the imaginary child would want to say, because that just gave them that chance to remove it from themselves. So it was definitely useful in some cases, but other times it did just get ignored and it felt . . . they knew why we were bringing it out, they knew it was to give them that opportunity to not talk about themselves. So I think it felt a bit false maybe.

R3, NHS-Voluntary

It’s just a reflection just because [we] did the younger children. A lot of hard work, trying to get it right. We actually didn’t use the . . . the made-up family just didn’t work with the little ones, they just didn’t get the concept . . . they were just talking about their own families, which I felt was more . . . went more successfully. So there was a lot of adapting.

R8, NHS-Voluntary

Having responsive facilitators with the necessary knowledge and expertise to facilitate child-centred groups was regarded as a vital element of the successful delivery of Young SMILES. Although it was acknowledged that intervention training, in part, fulfilled this objective, facilitators recognised the ‘hard work’ that was subsequently required to deliver the Young SMILES intervention.

For those working in the co-organisation delivery site, working alongside individuals from a different field allowed them to draw upon their differing strengths to fill in gaps in their current knowledge and experience. For NHS facilitators, this involved developing their skills and understanding of how to work with groups of children, whereas for those working in the third-sector organisation the chance to work with someone who was skilled in supporting adults with mental health problems was key. Working within a collaborative model was thought to provide an efficient solution to individual skill gaps and positively added to their ability to fulfil the needs of families attending the Young SMILES sessions:

Certainly, I mean, I couldn’t have done it without [third-sector facilitator], because it’s that expertise and knowing what’s going to work with kids and pitching things. And I really just followed your [their] with that and been able to sort of draw on lots of experience of working with people and knowing what might work, what mightn’t work, you know, that kind of thing. And just having ideas as well, creative ideas, that was great, yeah.

R1, NHS-Voluntary

I felt very reassured co-facilitating with [NHS facilitator] because I knew we had some quite unwell parents in our group, and just knowing that that’s what you do, you know, was very reassuring, yeah.

R2, NHS-Voluntary

Sharing responsibility between facilitators with complementary skill sets built accountability and maintained confidence in Young SMILES, an intervention that by design was relatively structured and manualised. Facilitators recognised the usefulness of the Young SMILES manualised approach in providing structure and coherence within and between sessions, simultaneously acknowledging that such an approach could be challenging when faced with dynamic family circumstances and differing participant needs:

It’s an age-old tension, isn’t it, you know, between how do you have a manual that allows you to do things in a relatively informed way that hopefully is linked to what proves to be helpful and effective, but also has enough room to wriggle. You know, that’s a tension with any manualised approach, isn’t it . . .

R9, NHS-Voluntary

It would be difficult but I can also see the benefit of that [open intervention], you know, I don’t know if it would allow you more flexibility for people to come and go . . . if you did have that flexibility for just people to come in and out when they were feeling well or whatever was doable for them, does that make that more accessible, rather than being very constrained, right, we have to get this done in 6 weeks and just plough through the manual, which I think maybe it felt like that at times. I think time was tight.

R4, NHS-Voluntary

Navigating the different needs and preferences of the group while maintaining intervention fidelity was an ongoing challenge in intervention delivery and required considerable sensitivity and creativity on the part of the facilitators. One facilitator recognised the ‘chaos’ that many children are experiencing in their lives and the importance of allowing time for both children and parents to work through those stressors before re-enforcing the aims of the session:

I think it was . . . chaotic. So they came in with that, you know, on the ceiling and then it was that job of bringing them back down and refocusing it again . . . it’s helpful for the child that they’re sorting that kind of thing out . . . we need to just let them voice that but then bring them back to, you know, [to] what the aim of the session was about. I think that works really well. And they heard it, didn’t they?

R4, NHS-Voluntary

. . . everyone would stick with the theme of the session but we might have to divert a little bit so that session might be, like, OK, what we need to do is go in, yes, look at them, how it felt for them when that happened, then get them to link it to their children, because, you know, obviously if they can’t, if they’re stuck and they can’t make the link, you’re going to have to go back to their stuff, get them to look at how it felt and do an exercise around that and then get them to link it, you know, and stuff like that, and you know, we’ve had to do things like that sometimes to try and shift people on a bit and stuff, so they can benefit from the programme.

R3, Voluntary organisation

Facilitators were clear that the division of labour underpinning the sessions should be weighted towards the group leader, with the onus on them to optimise intervention delivery and effect change. Homework completed by participants between sessions was piloted but was not considered viable. A key barrier was the need for CYP to have access to the necessary resources to complete the homework but, even after this was identified and resources were provided, facilitators felt that, for many children, homework was unfeasible:

They still struggled to bring it [homework] in and a lot of the same, they’ve got enough to do with the homework from school without doing this.

R6, Voluntary organisation

. . . you’ve got to take it into account, haven’t you, I mean, I’m not being funny, these are the sorts of families that won’t be doing the homework at home . . . Because the parents won’t be motivated to sort of sit and support the children with their homework, you know, and again, like I said, that comes down to some of the issues with the parents, doesn’t it, you know, so getting them to do homework for us is pointless, really.

R8, Voluntary organisation

For the parent group, homework was generally considered to be more feasible:

. . . you can sometimes in the adults group give little bits of practical homework . . . we want you to do an activity with your child and then report back to us what you did and how that went, you know, things like that are quite useful in the adult group, but for the kids, I think, you know, we need to knock that one on the head.

R8, Voluntary organisation

Reflexive monitoring: appraising and redefining the intended intervention

Reflecting on the process and outcomes of the Young SMILES intervention, most facilitators commented on the benefits it had for CYP, parents and collective family units. Third-sector representatives who retained close links with their intervention referrers provided feedback that went beyond their own observations. Reported benefits to CYP included increased confidence, concentration and self-esteem:

Some of those children were very good, weren’t they? I always remember we got some very positive feedback about how they’d seen the children’s self-esteem grow and their confidence grow, the children were able to express themselves better and the schools saw some very positive changes in the children, you know?

R8, Voluntary organisation

The schools were saying that the children were concentrating a lot better . . . I think the other thing, I think the schools were saying they were concentrating more, their self-esteem grew and I’m sure they said they felt they’d got a sense that the children were less dissociated . . . obviously we couldn’t measure that . . . remembering it back now as well about parents and schools also saying things like the children were talking more about their feelings, so that had been positive, so the children were actually saying about how they were feeling so that was then having a positive impact on their behaviours, because they were talking more about how they were feeling.

R3, Voluntary organisation

Most benefits appeared to emanate directly from children’s engagement in the group intervention. The effect of parental engagement on CYP appeared more variable. For parents, facilitators felt that the manualised activities were successful, enabling some parents to improve their understanding and insight into their child’s experiences to a ‘significant and remarkable’ extent. For others, the benefits were not so apparent and not as long-lived:

It’s very powerful [sharing information from CYP], and the timing of it is key . . . you knew instantly those that had connected because they went quiet, their body language told you and some of them became a bit tearful . . . I remember one of the parents said I’m parenting how my mum parented me’, and I thought, oh my god, and that was like a light bulb, that’s when we knew she had it, because she actually thought she wasn’t her mum and when she looked and she was able to do the flip, she just was very . . . you could see it in her face . . . And that was kind of . . . and you could tell that when we went to see her at home, it was very different, there was a shift, an evident shift . . .

R4, Voluntary organisation

All the children wrote down the impact on them so their parents would hear from them, and then we got the adults to look at it, and they said it was really hard-hitting. It did stop them in their tracks for about 2 seconds, you know? And then they started making excuses and banging on again, but I do think it is potentially quite powerful, that. They do go, oh, they’re sad, look at that, someone’s sad, whose child is sad? It just dropped, like a realisation, but then there was the cover-up of the feelings and then it’s their fault, they should know what my feelings are like, they should look after me. If that had been a bit longer, then we could have explored that with them, but there’s just not the time.

R4, Voluntary organisation

Time constraints on the Young SMILES intervention were frequently discussed. Reflecting on the time available, facilitators focused on three core aspects of the intervention: (1) time allocated to conduct initial assessments, (2) time dedicated to the intervention itself and (3) time available to optimise communication between the CYP and parent sessions.

Voluntary organisation staff were clear in emphasising the importance of the initial family assessment and in highlighting that the time dedicated to this assessment was less than that available for the assessments that they routinely conducted for other comparable interventions delivered by their organisation. Lack of time in the assessment period was perceived to limit the depth of information that could be shared and to affect relationship quality at a critical time for participant engagement. Much of the practitioners’ concern about assessment of the family appeared to link to parent-focused approaches with which they may have been more familiar:

We would say there needs to be a longer assessment period, so there needs to be a longer assessment period and more opportunity to do a more thorough assessment at the beginning, really, because I think we felt we were having to rush to do those assessments, and that’s not ideal, really, you know? So I think we would feel that that would need looking at, really.

R8, Voluntary organisation

You can’t go in, can you, and say tell us about your childhood experiences, well, that’s fine, move onto the next thing now. Obviously you’ve got to deal with that in a sensitive, responsive way . . . those sorts of issues aren’t quick issues that you can turn around within 1 week, you know? So I think it’s more that, even what we were saying, you know, for us to do a proper job and for us to sort of do this well, we would have appreciated a bit more time, really.

R8, Voluntary organisation

The desire to have more time allocated to assessment indicated a broader preference for a time-rich intervention. A time-limited intervention lasting only 8 weeks was generally viewed as too short, with one facilitator emphasising the potential negative effects that such a short length of time may have on CYP and on the coherence of the intervention for other members of the family:

Yes, and we know especially for the children it goes really quick and then we’re just leaving them, that’s what it feels like, we’re just dropping them and it doesn’t seem fair on them.

R5, Voluntary organisation

And I found that that bit was really rushed, it was all jammed together; and then the end was also rushed. Because we prepared and we told parents, this is a celebration event, but they had to do a really hard piece of work, which is goal-setting. And if it had been me doing that, I would have been sweating, it would not have been a celebration for me to set goals. And it really showed what people thought about this, because they all left, they all left the paperwork with us, they left it behind. And I think that was a clear sign that either we didn’t give enough time or it was too hard a task when they were expecting a celebration of eating and drinking, to think about what do I need to change and how am I going to do that?

R6, NHS-Voluntary

Across both sites, facilitators explicitly focused on the time allocated to the parent sessions, noting that parents started their sessions 3 weeks after their children and that this felt counterintuitive to intervention success:

You see, to me, systemically I think about context, you know, when we work with families rather than an individual, because the system changes and the context of somebody’s life changes over the time . . . So, if you think about a child, you know, if you think about you’re working with the parents, then the context is that they will become more aware of the child’s needs and maybe respond in different ways. That kind of makes me think it might be more important to have the parents group start at the beginning, so that there is more time and opportunity for that to develop, you know.

R5, NHS-Voluntary

Consensus among the facilitators was that additional work with the parents at the outset may have helped to enhance the outcomes of the intervention for children. Ensuring that sufficient time was available to communicate discussions from CYP to parent groups was considered a vital component of a high-quality service and something that had not been fully addressed in the Young SMILES manual or training information:

I think ideally, you know, lots of the families that we have could deal with a programme on their own first, you know, so if they had a parents programme with 8 or 10 weeks first and then we did work with them and their children, we have a children’s group and maybe some joint sessions with the parents and children together as part of the children’s programme, you know, then that will probably be a better service overall, you know . . .

R3, Voluntary organisation

Before every session, we had to spend time knowing where the children’s team is, because the adult group work relies on what is happening . . . and the information we received from the facilitators was absolutely invaluable. Without that I think it would have been really difficult.

R6, NHS-Voluntary

Support to deliver the intervention was at times perceived to be compromised by a failure to validate the resource that was required at a team and an organisational level. Concepts of resource encompassed access to the practical tools necessary to conduct activities, such as art materials, but also extended to staff. Facilitators were mindful that, at times, CYP or parents may need to be individually supported, which represented an additional burden on local systems. Having the capacity to augment or extend the intervention was recognised as fundamental to enhancing service provision, but was acknowledged to be difficult in the context of contemporary health services:

I think if it’s agreed that it’s built into somebody’s sort of job plan, you know, that that’s part of their role for however long that is, yes, otherwise things get squeezed or put to the side.

R5, NHS-Voluntary

Families also need to be supported to access the intervention; without this, many would not have engaged. However, arranging transport was a burden for facilitators across both sites and affected their ability to run the groups effectively:

The first group we kind of went with the taxis. I think I did the first when I look back, you know I would meet at a school, get in a taxi but that kind of worked, and those that lived local were fine. So that wasn’t too bad, believe it or not, and again it was time to free up . . . This one has been a logistic nightmare, but again I also think would they have come if a taxi arrived, probably some of them not. So there’s swings and roundabouts with both, and it has been hard, and kind of had to think about this because we’ve had to cancel some groups because clearly there were not enough that was coming, and all of that, and also we’ve run over the holidays. That in itself, and then the other part about that is we’ve had some of the primary children go to high school.

R2, Voluntary organisation

Facilitators recognised that, despite receiving training and being able to draw on previous experiences and skills, implementation of the Young SMILES intervention faced inherent challenges. Being involved in the development of the intervention in the earlier stage of the feasibility study was viewed as beneficial, but several uncertainties about how it would work in practice remained. Some practitioners reflected that, with hindsight, they were ‘not clear’ about what they were doing and resolving this uncertainty regularly demanded extra preparation time ahead of intervention delivery:

I think the one thing we did realise is you need a lot more time to prepare. We spent . . . we met a good couple of times, took a good couple of hours out I think to look at the manual. And then there was kind of before the group came, we had conversations. And even on the night, we were just sort of talking, actually is this working, maybe we should try something else. So there was quite a lot of that going on.

R1, NHS-Voluntary

I think sometimes it felt like we were just talking a lot rather than doing, so we had tweaked it a little bit, it’s better now than what it was originally, we kept to the model but just changed the activity to make it a little bit more engaging . . . we’ve used some activities that we’ve used before in groups with children which worked really well, but obviously with mental health . . . more arts and crafts.

R4, Voluntary organisation

All facilitators recognised potential adaptations that could be made to the Young SMILES manual and facilitator training programme to ensure success and sustainability. Some felt that the manual was not developed fully, was repetitive at times and did not provide enough information or guidance to be able to deliver the Young SMILES intervention without additional work:

I guess a manual that was more formed from the start, you know, it would have helped me. And it wasn’t really. Maybe that’s part of kind of a pilot study. And I guess connected to that, there was repetition in the manual, so there was maybe . . . yeah, a more finished product. You could have like an appendix after each session or at the end, you know, optional additional exercises for different age groups, something like that . . . pages people could refer to for seeds of ideas.

R5, NHS-Voluntary

When we first talked about this as a manualised model, I was influenced by other manualised training that I’ve had, which has been very much this is what you do within the manual. And for some of the exercises, it was difficult to know exactly what they were and we actually locally ended up arranging . . . we had four extra training, half-day training days where we went through the manual step by step and we experimented, we role-played what we might do . . .

R9, NHS-Voluntary

For those with experience of similar models, explicit permission to introduce new activities or modify activities in situ was recommended. Supervision of less experienced facilitators by more experienced personnel was advocated as one way of preserving intervention fidelity and quality, but this was not operationalised in practice:

I wonder whether reassurance as well, if there’s an activity you know of that fulfils the same purpose but you think you’re more familiar with, you can do it. Because I think I was asked a couple of times, ‘well, I’ve done this activity in this way, can I do it?’. Not that I’m the oracle on things, but I think just having that reassurance for somebody, if you were to pick up and think, have I got to follow it exactly because I don’t know. I mean, as an example, the example of volcano, don’t know how to make a volcano. But if I know how to do this and it does the same purpose, I mean something from . . . I think it would reassure people.

R7, NHS-Voluntary

Because I know there was that all that business about, wasn’t there, at one point, because when it all first started off, all that business about we were meant to be offering some supervision, and then that never happened, I don’t know what happened with it.

R8, Voluntary organisation

Further discussions about delivery in relation to future developments of the intervention focused around whether or not a co-delivered model between the NHS and the third sector would be offered. The value of this approach was, again, emphasised but concerns about governance surrounding such an approach were identified:

It’s one of the complexities of the joint model, you know. If you had a commission to do the whole of the same area as we had [in the trial], I’m guessing we would have moved groups around the areas. Because ultimately, it was staff at the end of the night who were putting potentially unaccompanied minors in taxis, and different organisations have different ideas about the expectations of that. I think there’d have to be quite clear service level agreements in place around that. There is an issue about how you influence commissioners . . . So there’s a lot of work would have to take place’.

R9, NHS-Voluntary

Coherence

Referrers recognised the value of the Young SMILES intervention, reporting that it aligned with the objectives of their organisations. Of particular relevance for referrers was the acknowledgement that there was a lack of services at a local and national level that take into account the impact of parental mental health on CYP. Although there was recognition of parental support and separate support for children experiencing difficulties, Young SMILES was regarded as a novel ‘whole family approach’ with the potential to fill this identified gap in services:

I think most of our families that are in similar schools to us, in similar areas to us, will all say that mental health is one of our big hot spots, so trying to be able to address family support. And you unpick a child’s, you unpick a behaviour of a child, there’s always some sort of mental health problem with a family member that we’re trying to unpick as well . . . if a family are saying that they’re struggling I think it’s and they’ve got mental health or the child has got mental health I think it’s a brilliant scheme to be able to get families in.

R3, Referrer

I can’t believe that you’ve not been inundated . . . it’s what we’ve been looking for, something to support our children who are dealing with highs and lows of parents. It’s what we’ve been looking for. There’s nothing out there.

R1, Referrer

In attending, referrers were hopeful that Young SMILES would positively contribute to children attaining insight into their parents’ experiences and, consequently, have a direct impact on aspects of their QoL:

Yeah, I suppose it would be things like regular school attendance, improved sort of . . . maybe more parents’ motivation, understanding, you know, when medication stopped, things like that, that it does impact on the children.

R2, Referrer

Yeah, I mean I’d hoped that it would achieve sort of changes really and sort of I suppose a bit of a better understanding because I suppose when parents are locked in all their own needs and sort of, you know, some quite serious mental health conditions sometimes the child’s needs can be overlooked in a way, and I suppose it’s hopefully giving them a better appreciation of that. That’s perhaps the hope maybe, and that would have then an impact on things like attendance, getting them ready for school, homework, hopefully, in some way, give them a . . . yeah.

R2, Referrer

Referrers spoke positively about the information packs that had been produced for families. They felt that the information was accessible and conveyed all aspects of the intervention and feasibility trial effectively. However, many referrers recognised that they lacked awareness of some of the research processes that may have influenced how the trial was explained to families, highlighting a tension between the research design and the referral pathway. Some mistook the mechanism by which families were included and randomised, highlighting the fact that some families would not be offered anything:

Really clear [information pack] and I just want to say that it was that clear that the meetings that I had I took the pack into the meeting and some of our parents can’t access long words, lengthy documents, all that kind of thing but it was easy accessible for the parents that struggle with reading, things like that. So I would share it in a meeting with them and they’d be like, oh, yes, yes, this is something I want to do . . . The only thing, I was a bit like, so who’s going to be delivering it? Why are we sending it to Manchester? I was a bit like . . . I don’t get that side of it but do you know what, I’m going to send the referral in anyway . . . Maybe again on my behalf, I didn’t fully understand that so I didn’t get them ready for . . . I thought once the referral had gone in, if you’d got past that stage you were in.

R1, Referrer

We had others that were interested but I think there was some complications with some people getting in and some people not receiving anything . . . It was something to do with being research, wasn’t it? That some families get the service and some don’t to see if works or not.

R5, Non-referrer

Cognitive participation

Referrers demonstrated their commitment to ensuring that family access to the Young SMILES intervention was a smooth time-efficient process. They regarded themselves as responsible for ensuring the successful engagement of families with this process, with some assuming accountability for the resultant outcome(s):

Once a parent has said they’ll do it, I like to try and get it in straight away because then it’s done and dusted really. And it’s not hanging round like, saying, well come in next week and we’ll fill the form in. It’s like it’s getting them here again.

R3, Referrer

Referrers recognised that families generally want support and that Young SMILES could serve as an alternative support mechanism. For some, persuading families to participate in the trial was straightforward. However, it was acknowledged that, in spite of their own commitment, they would have to invest time and effort to ensure the commitment of many of the families they encountered. Overcoming parental barriers to engaging with mental health services led to low expectations of getting families to engage:

It’s not going to be an easy sell ever I think because it’s quite a commitment isn’t it for that family to take on. I think it’s much needed but I think it was one that was, once you sort of got over being able to talk about it, because some parents just want to deal with it in isolation and not bring the children into it because they, they, my children doesn’t know about my mental health.

R3, Referrer

Further difficulties were anticipated when trying to engage families where the parent is not committed to invest in their own recovery. Poor parental engagement was regarded as a generalised problem, but not one that was necessarily restricted to mental health research or interventions:

I just feel like some of the parents who we have contact with, we struggle getting them to attend . . . to take their children to their own health appointments and to even access health appointments for themselves, without them committing to do something that’s a course, just statistically, we tend to have quite poor engagement with parents. They’ll contact . . . we’ll have a good one-to-one and we can have that contact but for them to actually attend things, it’s really hard.

R4, Non-referrer

Referrers acknowledged that non-engagement did not reflect the parent’s lack of interest in supporting their children’s needs; parents had a genuine interest in trying to improve the lives of their children, but were often hampered by the mental health difficulties they were experiencing. It was clear that parent engagement was difficult across numerous services, not just those with a specific family focus. It was thought that parents may have been more persuaded by the value of the Young SMILES intervention if their participation was not required:

I think most parents genuinely want the best for their children and they want the children’s needs met and their emotional needs met. So I think most parents wouldn’t have an issue with the children or young people being referred but the actual commitment of them to have to attend something, I don’t think a lot of them have that ability, due to their poor mental health, if that makes sense? . . . I’d say I tried on three or four occasions about support for the child or young person and the parent seemed keen initially and then as soon as you suggest that it’s something that they might have to attend, they weren’t interested.

R4, Non-referrer

Parents’ apprehension about their problems becoming known to social services conflicted with their desire to participate:

I suppose for . . . the concern is that the parents, because of sometimes lack of engagement and the way that, you know, mental health can be where you can sort of bury your head a bit really, if you like, stop taking your medication, not engage with people in the outside world, and things, that that would . . . could have an impact where they think, well I don’t want to . . . I can see the benefits but I’m not going to do that, you know? . . . they’re the ones that . . . they’re the ones you want to help because they’re the ones whose children aren’t coming in and aren’t doing their homework, and all the things that the impact . . . don’t engage in, other things with school, and, you know? . . . But obviously they’re scared, saying, oh, my children are going to be taken off me, I don’t want that . . . because people don’t quite know how . . . what the response will be to them or them disclosing something about their . . . particular things around self-harm and children being . . . you know, all that kind of stuff is, yeah.

R2, Referrer

Despite their enthusiasm for the Young SMILES intervention and their identification of the gap in current services that the intervention has the potential to fill, at times referrers were apprehensive about promoting involvement in the trial as they were unable to sell the benefits of the intervention in the face of this being an early-phase trial and, therefore, coming before a supportive evidence base. Initial caution about the Young SMILES intervention was apparent. The gap in current knowledge about the Young SMILES intervention had a direct effect on the attitudes of referrers and their anticipated belief that the parents they approached would be happy to participate. Gathering knowledge about the outcomes and experience of families who have been involved in the Young SMILES intervention increased referrers’ optimism about the anticipated engagement of families. Having the opportunity to communicate directly with other families who had participated was regarded as a potentially effective mechanism to legitimise the intervention and ensure commitment from future families:

If I refer young people onto things, I normally have evidence of, it might be something that you don’t engage in, it might be something that you don’t feel of benefit to, but I’ve usually got evidence, or I’ve got some proof that this has worked before and once something is up and running, I am confident, as a practitioner, to recommend and refer that person onto the service.

R4, Non-referrer

Once we’ve got this family through I think it will definitely have a snowball effect and we’ll be able to get through families, more families through. Even more me, you know what I mean as, because I’d have more of a sort of, know what it’s about . . . it’s having knowledge of, you’ve had a family that’s gone through it and then you can sort of really say how the impact of that on that family. It’s good to have one to say, I know a family that have done this project, they’ve got this, this and this out of it and I think it would be a really good one for you. I think that’s a good sell.

R3, Referrer

I think, you know, parents saying to other parents who, because best will in the world those parents will talk to parents with similar needs and they will sort of say, well, we’ve done this project. It was brilliant. We really got this, this and this out of it. Go and have a chat with [member of staff]. That’s how I find a lot of my things come. I get more from parents selling it to other parents than me trying to sell it to other parents.

R3, Referrer

Collective action

Having conceived the Young SMILES intervention as a beneficial addition to the services that already existed, referrers reported the ease of endorsing it in practice for the identification of families to participate. Many reported that their day-to-day roles facilitated the process of engaging with CYP or families whom the trial may benefit. Existing systems to flag concerns about children were easily utilised to refer to the Young SMILES intervention and the identification of suitable families was also enhanced where there was an existing awareness of parental mental illness influencing family life:

We can refer clients quite quickly after they have first engaged with our service . . . they’re normally really happy to let you get on with your job like that. If they come to you asking for help it makes your job of supporting them so much easier.

R5, Non-referrer

We have a system called CPOMS [software application] in school, so it’s a way of writing down. So, all staff have access to that, to write down if the child’s got a concern, if you’re concerned and that gets flagged to myself and the head, who then will look at ways of what we need to do next . . . So, it might be the PANTS programme [NSPCC framework], the programme that we might need to do with the child and the best people to do that was the class teacher, or it might be a referral to CAMHS, and we’re thinking well if we stick a CAMHS referral in we might as well stick a Young SMILES one. You know to me it’s that sort of look at things really.

R2, Referrer

Referrers all identified that success in identifying suitable families and their subsequent engagement with the trial relied on them having established relationships with families, particularly with parents. Such families were open to discussions about their mental health, which removed some of the concerns that some parents had about opening up about difficulties they are experiencing:

Well, because of the relationship I have with the families that go to our school, I mean, the thing is I’m . . . Because of the relationship I have with them I’m outside morning and night. They tell me what they’ve had for breakfast, that relationship is, you know, how many lagers they had last night. Even if they’re going to get in trouble with me they tell me. So by me saying to them, look, there’s this course, it’s about mental health, they wouldn’t think, God, she thinks I’m going crazy. It’s not . . . because I said to you we talk about the mental health every single day so it’s not a swear word. It’s not a, oh my God, they’re going to take my kids off me. We talk about it so they don’t take it as, I’m not doing that because they’re going to take my kids. They think, oh, yes, brilliant that, brilliant.

R1, Referrer

Challenges were faced where potential families were recognised but relationships did not already exist. Referrers acknowledged that they were more likely to prioritise referral of those already familiar to them. Developing a level of trust with families was considered vital prior to suggesting routes to support:

If I went to a family that started at our school last week and said, oh, I’ve got this course about mental health, they’d go, on your bike, because, yes, I haven’t built up that relationship.

R1, Referrer

Following identification, the process of referring families to the trial was reported as being straightforward. It aligned well with existing referral protocols and, at times, was actually a less convoluted process than the demands associated with referring to other services. Referrers spoke about how easy the trial and intervention was to discuss with families. In aiming to convince families to participate they used the study pack and highlighted their methods of giving families time before following up to gauge interest:

I thought it was an easy one. You know, there’s an easy referral form to get in. It was pretty straightforward, it certainly wasn’t like other referrals. It wasn’t that, it wasn’t pages and pages, which always puts people off. Yeah, it was, you know, it was a quick one-sided thing and talking to the family, them agreeing to it and then you sort of made contact with the family. That’s the only thing I thought that may be a sticky wicket with some of our families, because they don’t answer the phone very well.

R3, Referrer

Sometimes when you initially say to parents that, what about a bit of a referral to this? It’s, you sort of do that once and then you walk . . . have a think about. Then you come back to it and you say, what do you think about it? And it’s sort of that drip feed into there and sort of talking about the project.

R2, Referrer

It was just dead easy. That’s why I couldn’t understand you weren’t inundated because it was so easy, so easy and the families thought it was so easy. I was able to give them a leaflet, talk through it in a meeting, take this leaflet home, have a read, come back tomorrow and if you still want it we’ll fill the form in and that’s how quick and easy it was.

R1, Referrer

After being made aware of the Young SMILES intervention, all practitioners reportedly integrated into their daily routines the business of referring families to the research team straight away and without too much difficulty. This was because of how the referral pathway fitted into their existing work without any reported difficulty:

I’m always keen to refer people onto good quality services that I feel that they’re going to benefit from. So I do feel . . . because I have a drop-in service within one of my . . . I’ve got a high school, so my high school, I’m in my high school for 4 to 5 hours a week.

R4, Non-referrer

I do an awful lot of referring into different, to different, to different companies for different things and it’s trying to find one that will help that certain family sort of thing. So I found it was, I’m quite open about talking about mental health . . .

R2, Referrer

Referrers stated that they worked independently to embed the referral pathway into their existing work-based settings, requiring little or no consultation with others to do so. However, there was recognition that a number of key individuals were involved in the process of obtaining support for CYP and that raising and widening the awareness of the existence of new interventions would enhance the decision-making process:

I wouldn’t need much help in referring families as it is an easy thing to do . . . I mean it doesn’t take much time at all. It would be good if the period you could refer families was longer . . . we had other families that could have been referred . . . as you know [laughs].

R5, Non-referrer

Although the referral process was straightforward, adding little or no burden to current procedures, one referrer took responsibility for following up the progress of a family through the recruitment and intervention process. This aligned with their views that once a referral had been made this did not mean that all responsibility for that family had been passed on. They wanted to retain a role in the process, taking time to support ongoing procedures if needed:

To be honest, that’s why I went that extra mile because when I refer a family it’s not like I fill a piece of paper in and then it’s your business. As far as I’m concerned when I’m referring someone I’m buying into that as well. So when you [researcher] rang me back and said, can’t get hold of . . . it’s not, oh, well, I’m sorry you can’t get hold of . . . I think that’s . . . I’m the referrer so I need to make sure that’s happening. That’s why I did the extra bits to make sure that happened . . . if I got a message off the NSPCC saying it’s been postponed or whatever, I would make sure I spoke to those families that morning and if they weren’t on the playground I’d ring them but when you talk about taking up time in my day, I would say that’s part of my job. It’s part of my job to make sure my families know when the course that I’ve referred on is going to start.

R1, Referrer

This approach of chasing up referral progress and re-engaging with parents, however, was a personal choice and not one practised by others and thus it was not considered vital to the implementation of the Young SMILES intervention. For some, because the Young SMILES trial was voluntary, they did not want to seem like they were forcing parents into it:

I’m more, I do, I do the playground every morning so parents will predominantly come and speak to me about their days and it’s just an informal way of me getting on that playground to see parents and see families and see how they tick. And to sort of say, how’s it going? How’s your day? How’s this week been? Do you need anything? Where are you up to? And to sort of say, well don’t forget we’ve had a chat about that. Don’t forget if you want to do it, if you need the paperwork again come and see me. I’ll print it off and we can go through it again.

R3, Referrer

Reflexive monitoring

Referrers were all interested in developing insight into the experiences of the children they referred to the trial. No formalised ways of obtaining that feedback had been implemented, but referrers reporting seeking feedback during any communication opportunities with the children of parents that arose, for example during scheduled or unscheduled telephone calls or meetings. For the majority, reported outcomes were positive. Children were also offered support after attending sessions, but it was never required:

When I have a parent ask to see me at the front that, I mean, she was one of the ones that we had to keep chasing and rearranging and all that, when I have a parent come to me at the front and say, Young SMILES has changed my life, that’s enough for me.

R1, Referrer

The feedback from the children, the feedback from the parents, after a Thursday was amazing; absolutely amazing. I sent kids on there that had anxiety. I sent children on there that don’t like to be with anybody that they don’t know and they were amazing. They came back, ate their dinner, no worries, no crying, no . . . As a safeguarding manager I left time in my day on a Thursday to give them children support when they came back in case; they didn’t need it.

R1, Referrer

In addition to the feedback received, referrers observed changes in the behaviour of CYP who opened up about talking about mental health after attending the Young SMILES intervention, sharing their learning with other CYP who did not attend:

One of the girls that went on the course, she’s in a group that I do in school as well and she said to me, am I allowed to share things that was on the Young SMILES? I said to her, well, you’re not allowed to share things with names, but you can share . . . if you think that would help our group or it’s a strategy that you could use, and a number of times she shared strategies with a group of children suffering with anxiety.

R1, Referrer

Despite recognising the benefits of the intervention, parents expressed scepticism:

No, I’ve read lots of course details. I’ve read lots of programme details and my families say to me, it’s just the same thing over and over again. They’re just telling us the same things. You just think my parenting’s rubbish. You think this. You think . . . So I thought if I start low, if I get one thing or a parent gets one thing from this course my job has been worth referring.

R3, Referrer

In reflecting on the referral process and how it could be enhanced, the importance of building collaborative supportive relationships between referrers, their organisations and the delivering organisation to involve key individuals at early stages of the process was highlighted. Referrers demonstrated their commitment to making this work and discussed the possibility of developing ‘working parties’ to ensure that barriers or unexpected challenges (particularly those not aligned with their working protocols) are challenged and resolved:

About the taxis, I mean, I think the people who were setting it up, without being horrible to anybody, don’t work in the school so the logistics of a child getting in a taxi is massive. So like the [voluntary organisation] was ringing me and saying, right, yes, OK, we’ll put taxis on. So I said, OK, so what about when that parent goes that child’s in the taxi with them, fine. What about if that parent doesn’t turn up? I can’t send that child with somebody else’s parent because we haven’t had an acceptance with that. Oh, right, well, we’ll have to look into that. So I think the people who designed the programme, fantastic. I think the people of the set-up need to be aware of the policies and procedures in school because I can’t just let somebody go in a taxi with somebody else’s parent.

R1, Referrer

Enhancing engagement with CYP and their parents was something that referrers indicated that they had failed to do to a great extent and something that they felt in the future could enhance engagement and experience:

I think it might be better if there’s a few, a few of us sort of talking it through. And I think it would be better if, to be able to have an open morning, thinking like the, and your, the people are coming here. I’m going to invite a few to come and sort of sell it to them that way. That’s always gone pretty well with getting services in; and I think it’s that knock on effect if others, of other families in the area doing it as well. And then you sort of say, oh well they’re and if they’re not even in primary, some sort of youth service, that type of thing and sort of saying, you know, get those in. Drugs and alcohol maybe that’s the need. So, it’s a bit more of a crossover of people and doing referrals in.

R3, Referrer

In hindsight as a . . . if you were to run it again, that where you put the poster in the thing where all parents can see and . . . things, or maybe on the newsletter. I don’t know. We’ve done that about other things. We didn’t on this occasion. I think it was new. They came in and did it and, yeah, perhaps with more thought if you knew it better you could do that . . . So, it . . . I suppose it’s giving them opportunity to see that this programme’s on offer, and that’s probably where it’s . . . the shortfall’s been maybe, looking at it, but I didn’t even think of it until you come today . . . Early help maybe, yeah, preventative stuff are the ones what we’ve perhaps not targeted, and it’s probably a variety of . . . the time limit you get, someone coming in, oh, we’ve got this project. Great, I’ll refer in. And it’s the ones who immediately come to your head that you refer rather than thinking, right, I’ll think this through and I’ll put the poster up.

R2, Referrer

Referrers acknowledged that incorporating Young SMILES referrals had little effect on their workload but identified that aspects of its implementation could be modified to ensure the well-being of users and enhance experiences including removing the waiting list group, increasing the window of time for receiving referrals and reliable information about waiting times. Despite positive views about outcome, randomisation of some families to usual care was perceived to have detrimental effects and could be challenging for referrers to respond to. Eliminating the option of being referred to nothing was considered an important future approach to overcome such negative effects:

It was hard. It was like [parent] came in and she was like, look, I’m not even good enough for that, because at the time as well she was having job interviews and she’d been knocked back from two of them so she was just like, see, I’m not even good enough. You’re telling me that . . . so it was all that. So I had quite a heated meeting with her and I was like, yes, you are, and had to bring her back down to, look, this is about . . . I did say to her then, this is about a screen with names on, tick numbers, if you’ve got enough ticks you go through. If you’re not right for this scheme you’ll go on the next one maybe. I didn’t know what would happen next and I just needed to come to a plan with her that she didn’t feel low self-esteem and that she’d been let down.

R1, Referrer

Having a longer time period to introduce the value of the Young SMILES intervention to families could improve the referral pathway and have a significant effect on awareness and use of the service:

If it was a longer-term project it is something that could, sort of you can roll out to staff in school. So I could talk, we do safeguarding days. So September we always have a safeguarding day, so we would re-hash all the things that we stand for and we do in our school and we will talk about, I talk about projects like parenting referrals and all those sort of things. So at that point, you know, I would probably stand up and say, we’ve got this new project come in. If any parents, you’re thinking parents will address it or want to talk about it, tell them to come and have a chat with somebody about it. Or they’ll come and bring them down.

R3, Referrer

Reliable information about processes that could be communicated to families was a vital part of sustaining the engagement of families. Referrers reported gaps in their knowledge about some aspects of the process, particularly in relation to waiting times that were of unknown length, which had an impact on the work of the referrer:

Yes, you see my parents do as I say, a little bit. So I say to them, it starts then, and then I go back to them and say, it’s not starting this week so don’t worry, I’ll let you know, so it was all that. So they’re really good but I’ve never come up with a problem that they say, oh, you told me last week, I’m not going on it now. I haven’t come up with that because they do listen and I say, look, it’s been postponed, don’t worry I’ll come back to you. This is when it’s going to start, and they just listen to my word. Again, I think that’s because of the relationship but I could do one next time and if it’s put back put back, put back, they might be, oh, I’m not going on it now.

R1, Referrer

Although acknowledging that referring families to the Young SMILES intervention was not complicated or a burden on referrers’ time, it was suggested that referral rates could be enhanced via adult services where work is focused directly on the parents:

I mean we can sell something to parents and as I say and to families, maybe it’s something that should be sold more with adult services, who the parents are engaging with. Maybe it’s to get adult services, when they have contact with parents to say, this would be really good for your child to attend, I don’t know.

R4, Non-referrer