General practitioner and senior research fellow.Section of general practice and primary care, University of Glasgow, 1 Horselethill Rd, Glasgow, G12 9LX. email: Abstract:Aim This paper is a report of a study to describe the workload of health visitors and school nurses in relation to children and young people with psychological, emotional or behavioural problems, and to identify perceived challenges, obstacles and sources of satisfaction associated with this aspect of their work. Background There is little published information on the work done by non-specialist community nurses with children and young people who have psychological, emotional and behavioural problems. Method We analysed data from a survey of 1049 Scottish professionals working with children and young people. Data included quantitative responses and free text describing the cases seen by respondents. Responses from a sub-sample of 71 health visitors and 100 school nurses were analysed using a combination of descriptive statistics and analysis of themes emerging from the text. Findings Although community-based nurses saw a relatively small number of children with psychological, emotional or behavioural problems each week, dealing with these problems took up a disproportionate amount of time. The commonest types of problem were self-harm, externalising behaviours and family difficulties. Few respondents had received specific training in child and adolescent mental health but most expressed a wish to receive such training. ConclusionThe work of health visitors and school nurses in caring for children with mental health problems is substantial and important. Development of their public health role should not be at the expense of this important contribution. There is a need for rigorous evaluation of nursing mental health interventions among children and young people. KEYWORDSHealth visitors, school nurses, questionnaire, empirical research report, children, psychological problems, behavioural problems SUMMARY STATEMENT What is already known on this topic• There is some evidence that input by community-based nurses can have a major impact on the mental well-being of children and young people• Policy documents acknowledge the important role of both school nurses and health visitors, who are responsible for providing professional support for children and young people with psychological and behavioural problems.• Detailed information on the precise nature of school nurses' and health visitors' involvement -workload, demands, and satisfaction -is not available. 'What this study adds'• Health visitors and school nurses have substantial, but different, mental health caseloads • Nurses reported that a lack of training and support limited their ability to provide good quality care to children and young people• Self-harm, externalising behaviours and family difficulties were the commonest problems described.

The Scottish Needs Assessment Programme (SNAP) was established in 2000 to advise the Scottish government on the emotional health of the country's children and young people. The second phase, conducted in 2002-03, involved surveying professionals who provide specialist mental health services to children and young people, and also those who work with children and young people in a variety of settings but whose training is not in mental health. Based on the survey, this paper outlines the emotional difficulties faced by children and young people in educational settings, and describes how teachers in particular are responding to these difficulties.It also discusses teachers' experiences of working with other professionals and agencies, in particular the frustrations they feel in their efforts to make suitable arrangements on behalf of young people.

Policy and practice in relation to the education of looked-after children in Scotland have been significantly influenced as a result of two landmark reports, Learning with Care (2001), and Looked After Children: We Can and Must do Better (2007). This paper provides an account of the main policy developments which are set within the distinctive Scottish legal and educational context. The second report, in particular, has been followed by a more strategic approach to implementing change. There is evidence of considerable infrastructural development, both in the looked-after children sector and more widely in education services. There is also evidence of improvement in outcomes, notably in school attendance and the attainment of children in out of home care. While outcomes generally still lag behind those of children who are not looked after, those of children who are looked after while remaining in the family home remain relatively resistant to improvement. This aspect has been neglected in research so far. It is also not well understood how the policy changes have impacted on organisational change and developments in practice.

Residential child care is an inherently distressing and multi-layered endeavour undertaken by staff who are often poorly trained and supported. In addition, the children, and the adults who care for them, can provide a convenient receptacle for the split off negative feelings of professionals, politicians and the public. The complexity and difficulty of this work is often unrecognised and a simplistic response based on a programmatic, behavioural framework, reinforced by performance-based management and an audit culture, is common. This paper argues for the usefulness of a different approach, drawing on psychoanalytic and open systems thinking, to provide a more nuanced understanding of what is happening in these volatile settings that can guide interventions which match the complexity of the work. Alongside advocating the use of key psychoanalytic and systems concepts to improve understanding, it argues for the importance of providing a containing and reflective environment for staff.