Simple strategies

Many children continue to live and work on the streets.

Estimates, several years ago, were that more or less 250 000 children lived on the streets in South Africa.

Homeless children need to be protected as a priority in every nation.

Homeless children need to be supported from a systemic point of view.

How to eradicate poverty? How to end homelessness for children?

It is important to understand the ABC’s of outcomes or events or behaviour. What happened before the event or occurrence to predispose or precipitate the event, what happened during the event, who suffered, who gained, details are important, how were systems affected, what maintained the event or occurrence or behaviour, what happened after the event, the consequences, how was the system affected afterwards, who gained.

For example, most individuals understand that if you provide money to individuals or parties in debt, they are often in worse debt within a very short period of time. Systemic thinking, clinical thinking, based on bio-psycho-social risk and protective factors, are required when understanding behaviour, thoughts, emotions or events, and when making decisions.

Simple and systemic solutions are often the most effective.

Homeless children can have different lives if bio-psycho-social systemic thinking is applied, beyond housing or finance, to maintain the positive outcome.

Sustainability should be an important goal.

A safe and stimulating environment is key.

Education is key.

A place to ‘belong’ is key. This can be a team or a place of work, if need be.

Responsible carers are key.

Responsible peers and seniors are key.

Close, healthy, positive relationships with warmth and caring are key. Animals can be sufficient, if no other alternatives are available. Many adults report that their lives changed or were saved due to an animal.

Engagement in regular, positive, normative activities, where a child is interested and enthusiastic, such as playing a sport or musical instrument, is key.

Accessible, user-friendly, effective, evidence-based (good clinical evidence) healthcare services are key.

Simple strategies can precipitate and maintain positive outcomes.

Some organisations estimate 100-150 million homeless children living in the streets around the world with at least 250,000 children dying every week from diseases and malnutrition.

Please see UN comments relating to homeless children on relevant web pages.

We have joined a Hot Cross Bun Run this year, for Easter – drop a few sealed hot cross buns off with someone in need. Join us.

#belong #enthusiastic #simplesolutions #education #fun #enjoyment #UN #poverty #homeless #children #animals #change #sustainable #debt #developing #hotcrossbun

Priorities for Children and Families

One of the largest informal settlements in the country with approximately 40 000 children under the age of five.

We asked children what their greatest wish was today, and they said “to go to the #beach , but without the masks”.

Children are children in every corner of the world.

We asked 17 year olds what their greatest wish was, they reported “to have our soccer field back, they are taking it away, and it keeps us on the straight and narrow, we have a team we belong to, it is home, it is nice, it is good”.

Simple strategies change children’s lives.

Most children and families, in various countries including the UK, countries in Europe, India, Sri Lanka, Thailand, Cambodia, Malaysia, Vietnam, New Zealand, South Africa and countries in Europe report that the most important items for their family are:

1. physical safety

2. freedom (many explain that this means “education for children”), then

3. health

4. mental health

5. peace

6. joy, then

7. victory with goals (such as “learning to swim”)

Many include beauty, animals, loved ones and friends.

We have been asked to provide a text, book, manual or summary of principles to precipitate and maintain these items for children and for adults, based on our clinical training and experience assisting children and families, from all walks of life, with these goals for the last 20 plus years.

Simple items are often the most effective.

Please email us at if you would like a copy. This is likely to take us a while though, but if there is a sufficient need, we will oblige.

#joy #peace #safety #health #mentalhealth #victory #success #simple #soccer #book #principles #maintain

Relax – enjoy – experience normalcy – learn

Children and families report that they need ideas of places, or a place, to safely relax – enjoy – experience normalcy – learn – evidence-based protective factors to improve health and mental health for themselves and their children.

They want places where evidence-based (good clinical evidence) strategies are followed such as

– alcohol gel, along with wash rooms with soap and water available

– social distancing facilitated and maintained on for example safari or a game drive with animals

– food hygiene where food is covered and children are supervised

– practical education is prioritised for example cover your mouth and nose if you cough or sneeze

– staff and customers are calm and positive

We will provide thoughts on local options. We have liaised with travel agencies and organisations offering these services to families and children.

1. Houtbay has a bird park, a small zoo, where children walk amongst monkeys, which most families enjoy. This is an excellent environment to teach children about animals and social behaviour. All safety regulations are followed, from reports and firsthand experience during our brief visit.

2. Sailing in the Waterfront on the Victoria is advised. This is an excellent environment to teach children about the sea, seals and dolphins. All safety regulations are followed, from reports and firsthand experience during our brief visit.

3. Imhoff farm offers lessons on horse riding (very limited instructions for beginners, please ask for more information if you need to – a slow walk through vineyards, valleys and on the beach is available, this remains a high risk sport), 4×4 skills and preparing for challenging terrain and breakdowns, animal farms for children, goats, fish markets and restaurants. Wonderful opportunities for families to relax together and for children to learn about animals. All safety regulations are followed, from reports and firsthand experience during our brief visit.

4. De Meye – a wine farm close to Stellenbosch – offers a wonderful meal next to vines under trees with dogs at your feet. We can absolutely recommend their food and the environment for safe relaxation and enjoyment. Very informal. Lovely people. All safety regulations are followed, from reports and firsthand experience during our visit.

5. Klein Joostenberg – a wine farm close to Stellenbosch – offers a beautiful meal within a ‘kraal’, outside, on the grass or a ‘stoep’ or porch, with dogs at your feet. Lovely staff and friendly people. Very informal. All safety regulations are followed, from reports and firsthand experience during our visit.

We have been asked about ideas or a place that offers safe, normative activities for children and families, to relax, enjoy and learn together, to recover, restore health or mental health and to maintain or promote health or mental health, for several months.

Many want to “blow off steam”, “fill my tank”, “get my bounce back”, “feel like a person again, “get some perspective”, “tick some bucket list boxes”, “make up for lost time” or “enjoy life again”.

We are now working on developing a service in Europe for children and families to recover – relax – laugh – learn (practical skills like survival in the woods or fishing or swimming or snorkelling or boating or cooking food outdoors or working with animals) – we plan for at least half of the service to be pro bono services.

This service will aim to meet the needs of very fortunate children, every day children and also children who have experienced serious trauma.

#safari #game #animals #SouthAfrica #Africa #learn #relax #enjoy #families #children #normalcy #calm #positive #developing #services #Europe #recover #laugh #fishing #snorkelling #boating #cooking #Houtbay #birdpark #zoo #waterfront #sailboat #Imhoff #horseriding #beach #winefarm #vineyard #vines #DeMeye #KleinJoostenberg #Stellenbosch

Normalcy and Good Clinical Evidence in Cape Town, South Africa

A small team arrived in #CapeTown #SouthAfrica.

We have been asked to provide information on #experiences of #normalcy and the following of #goodevidence.

Normalcy is an evidence-based protective factor for children and adults. Protective factors reduce morbidity and mortality from a general health, mental health and social risk point of view. These factors are important in healthy child development (language, cognitive, physical, social and emotional development), children’s well-being, children’s general safety, mental health and general health.

Activities on offer in Cape Town, South Africa, offering normalcy in the context of the pandemic, that do not increase risk, if engaged in safely, with evidence-based risk reducing initiatives.


1. Sailing – there are whales, dolphins, seals and penguins in the bays

2. Horse riding – in vineyards, valleys, mountains or on the beach

3. Hiking

4. Exploring mountains by 4×4 or mountain biking

5. Volunteering with animals or visiting animal parks – many safari experiences in the area now offer private drives to facilitate social distancing.

6. Surfing or kite surfing

7. Tours in vineyards – private tours to facilitate social distancing

8. Live music performances outdoors (or art performances)

9. Restaurants, cafes, pubs, shops – most facilitating social distancing and ventilation

10. Swimming or snorkelling

Cape Town offers lessons on developing or increasing skills in all activities above in safe ways that do not increase risk.

Many refer to the CCHH rules of evidence-based risk reducing initiatives (good clinical evidence):

1. Close – keep a safe distance at restaurants, cafes, pubs or during sport or exercise.

2. Cover – cover your mouth when cough or sneeze – avoid those who don’t, and cover food.

3. Hands – keep hands clean before touching food or face.

4. Home – stay home if you have symptoms or are sick or have been in recent confirmed contact with a positive case.

Good Clinical Evidence:

1. Temperature and symptom screens are available at nearly every shop, restaurant, cafe or pub. Screens were offered at airports and hotels.

2. Alcohol gel is available on nearly every restaurant table.

3. Many restaurants eg #Wimpy have facilitated screens to ensure social distancing.

4. Outdoor events such as music shows are on offer to facilitate social distancing.

5. People engage in protective and normative initiatives and activities – eg many children and adults are spending time with loved ones in nature – in safe ways – ensuring their hands are clean before eating and keeping a safe distance. Most individuals appear very calm and positive – “we do the basics, we look after ourselves, do what relaxes us and makes us happy, and we believe we will be fine, then we are fine”, as reported by a father of five children.

Unfortunately masks are mandatory for every individual in every context. Except for this item, South Africa is following good clinical evidence.

“At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” World Health Organisation, Dec 2020.  More details available at  

“There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control

We will provide more details in the next days or weeks.

#safari #4×4 #mountainbiking #hiking #horseriding #surfing #kitesurfing #sailing #mountains #livemusic #artperformances #whales #dolphins #seals #penguins

Evidence-based risk reducing initiatives for children in schools

Evidence-based risk reducing initiatives for children in schools:

Schools and education play an important protective role for all children, including the most vulnerable, in terms of cognitive, language, social, emotional and physical development, mental health, physical health, social risk and well-being.  Please see statements relating to evidence-based protective factors and normative activities.

Systemic risk and protective factors in the context of #covid19 must however be assessed, identified, considered, weighed and managed by professionals with experience in this context (experience in respiratory infections, children’s health, children’s social, emotional, language, cognitive and physical development, including children’s neurodevelopment, children’s mental health and social risk).

Doctors with training and experience in neurodevelopment, especially in the context of respiratory infections, will likely have concerns regarding schools opening without additional and effective (based ONLY on GOOD clinical evidence) risk reducing initiatives, that do not increase risk for children in other ways.  

Most adults who work with children present with frequently increased incidence of upper respiratory infections (colds or flu).  Children also visit grandparents and elderly relatives, and engage within the general community unsupervised or supervised.  This impacts on risk for communities.  

Normal neurodevelopmental stages of children indicate that children (without learning, neurodevelopmental and mental health problems) are often significantly more physically playful, fidgety, impulsive, inattentive and forgetful than adults.  Consider research where authority figures inform children that they cannot touch an object; that it would very likely result in imminent death.  Children proceed to touching and playing with the object within minutes.  This is normal behaviour for most children without mental health, neurodevelopmental or learning problems.  Research indicates that adults (mostly with fully developed frontal lobes and neurological systems) touch their faces more or less 16-23 times per hour, often without registering this behaviour.  In Europe and the UK, we observe most adults #touching their #faces underneath their #masks with #unwashed #hands on a daily basis, masks hanging on #ears or #chins, or adults dropping masks on wet floors and wearing it again – this increases risk and harm relating to general health significantly.  We can provide many photographs from many countries. Children’s behaviour in this context will likely not be safer or more #responsible, the contrary will be likely. 

Mental health problems, learning problems or neurodevelopmental disorders such as #ASD or #ADHD, often increase these features, relating to physical playfulness, fidgeting, impulsivity, inattentiveness and forgetfulness, markedly for children or adults.  

In the UK more or less 2.5% of children present with #learning disabilities, as reported by MENCAP.  Learning problems are more prevalent, 14.9% of school aged children have special educational needs, as reported by GOV. UK.  Many children with learning problems have not been identified.  More or less 30% of children with developmental delay, present with associated mental health problems or concerns. 

Prevalence of neurodevelopmental disorders, such as ADHD, in children is more or less 3-4% in England and Wales.  It must be noted that children in this category are often most vulnerable for co-morbid mental health morbidity, often presenting with more than one co-morbid mental health diagnosis or concern, which are not always easy to identify; this is one of the reasons we recommend that children are assessed, diagnosed and treated or managed by Child Psychiatrists with training, CCTs, in Child Psychiatry, and that children with #ADHD or #ASD remain within generic #CAMHS teams, rather than be referred to separate neurodevelopmental, ADHD or ASD teams.  Children also often wait months or years on ADHD waiting lists, whilst presenting with serious co-morbid concerns such as #depression and #suicidal ideation, which lead to markedly increased risk.  Co-morbidities of ADHD include depression (15%), anxiety disorders (25%), learning disabilities (15-40%), language impairment (15-75%), Oppositional Defiant Disorder (35-50%) and Conduct Disorder (25%).  More than 50% of children with ADHD meet criteria for 2 co-morbid conditions.  

The WHO reports that more or less 20% of adolescents may experience a mental health problem in any given year.  GOV.UK reports that more or less 12.5% of 5-19 year olds had at least one mental health disorder and that more or less 5% met criteria for 2 or more mental health disorders (survey 2017, published 2019).  The Children’s Society reports that more or less 10% of children and young people aged 5-16 years have a clinically diagnosable mental health problem, yet 70% of children and adolescents with mental health problems have not had appropriate interventions at a sufficiently early age. This is one of the reasons we recommend that children referred to CAHMS are seen by a medical doctor / Child Psychiatrists within 2 weeks of referral.

It might be relevant to add in this context, considering recent research published by the Lancet, that longstanding research indicates that all or most physical health problems or disorders can increase mental health morbidity by up to 50%, neurological injury can increase prevalence by up to 500%, and neurological injury associated with epilepsy can increase prevalence by up to 1000%.

Biological risks in schools will affect risk in communities.  Risk reducing initiatives, based ONLY on GOOD clinical evidence, have been employed to reduce risk and harm from a bio-psycho-social point of view for children attending schools in many nations – we will provide examples.  

Evidence-based risk reducing initiatives for children in schools:

1. Children now rotate through schools in some countries to keep the numbers down per classroom (if a large number of children in a small classroom) and at the school in general, for instance in corridors, to facilitate social distancing and reduce risk.  

2. We have observed that social distancing is possible in almost all contexts in the public.

3. Good ventilation is facilitated, even if it has to be through open windows and doors.

4. Some classes are taught in gym class or outside if weather permits.

5. Clear instructions are given to staff and pupils to remain at home if a raised temperature, symptoms or recent confirmed contact (some include a recent traveller at their homes).

6. Temperature screens and symptom or health questionnaires are in place for every student, staff member and teacher to complete every morning at home before attending schools on interactive apps or on paper format. Many countries still identify individuals with symptoms by paper questionnaires and old fashioned temperature screens, this is equally effective.

7. It is our clinical opinion as Consultant Child Psychiatrists with more or less 15 years training and more than 20 years clinical experience that indiscriminate mandatory mask wearing will likely increase risk markedly from a general health, mental health, child development and social risk point of view for children (and adults).

There is no good clinical evidence that supports the wearing of face masks in the community for healthy individuals, there is however significant evidence indicating increased risk.

The WHO and ECDC agree that there is no good clinical evidence to support face masks for healthy individuals in the community:

“At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2”  World Health Organisation

“There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control

In our opinion it is not clinically indicated and it is not based on good clinical evidence to ask all children to wear face masks in schools.

Children at high risk for severe COVID-19 and children who have symptoms need to follow different protocols.

8. It is our clinical opinion that face masks should never be ‘normalised’ for children or adults, considering the lack of good clinical evidence to support face masks in the community for healthy individuals, and the evidence that risk is increased for many. We have written extensively on this topic, normalcy (and evidence-based protective factors), liaising with appropriate parties.

9. It is our clinical opinion that absolutely no #clinical #tests (side-room or special #investigations) should be completed on children unless there are clinical #indications based on good clinical #research.

Children are very sensitive to various mental health problems including different anxiety disorders at different ages, which can cause long term, sometimes life long, debilitating symptoms, distress and impairment. Medical #tests provide a very strong #message to a #child, often of ‘sick’ or ‘patient’, which often causes emotions such as fear, panic, frustration, anger or low mood, and negative beliefs regarding germs, sickness, health, death and safety – this affects behaviours, general health, mental health and social risk.

Most professionals who work with children with mental health problems have seen children referred with little or no #skin on their hands due to excessive, repetitive and longstanding #handwashing eg due to #OCD or #germ #phobias , or children with serious #wounds due to #selfharm (we have often had to refer children to plastic surgery). Children may also present with wounds inside of their mouths due to regular biting, secondary to high levels of anxiety or stress – adults, parents or carers, are sometimes not aware that children engage in these behaviours. These are often complex matters with complex predisposing, precipitating and maintaining factors, and it is essential that clinical experts in this domain be consulted.

It is our clinical opinion that indiscriminate mandatory mask wearing initiatives, along with other initiatives associated with deprivation of liberty, not based on clinical indications and good clinical evidence, such as ongoing and repetitive quarantine, curfews, stay at home and lockdown, will likely markedly affect children’s social, language, cognitive, emotional and physical development, along with mental health, general health and social risk in negative ways.

Children’s development often (not always) experiences ‘catch up’ when they are removed from abusive or neglectful environments, however, we have to ask whether it is ethical to expose children to initiatives associated with risk, when there is no good clinical evidence to support these initiatives. We have to first do no harm, as per the oath most medical doctors took after their initial 6 years of training.

Increased risk in terms of mental health, general health and social concerns, such as violence, however, can be associated with significant long term consequences. It is also important to note that mental health affects general health and social risk; any one of these factors, including child development, affects the other factors. Immediate, short term, long term risk is therefore increased.

Ethical and medico-legal questions have to be asked and answered in these contexts, considering that this is a health (or medical) crisis and medical (or clinical) decisions are (or should be) made based on medical (clinical) evidence and patient specific clinical indications to protect children and adults in the community, preventing increased risk and harm.

10. Education is key – regarding good hand or food #hygiene and #healthy #food and life style – but this has to be executed in a #fun and ‘ #normalising ‘ manner – children should not experience increased anxiety, anger, frustration or sadness by these ‘ #lessons ‘, the opposite should be relevant – children should be #distracted, #relax, #enjoy themselves and feel #empowered by these #narratives and #activities, by #learning new #skills and developing exciting dreams for tomorrow. This is essential.

It is very important to focus on age appropriate topics for children, considering their developmental age, not chronological age – and to execute the lessons or education in an age appropriate manner.

We receive too many statements from children age 3 to 13, that are not appropriate for children relating to the pandemic. Many children do not have the tools, due to their normal developmental age, to manage these concerns. Let children be children and let them deal with children’s issues, until it is their time to gradually start taking different roles, and eventually lead. We often refer to children taking adult roles as ‘young carers’ – this is not in the best interest of a child’s development, mental health and general health.

#Creative evidence-based options to reduce risk are always available in every domain and context, however, it is essential that risk factors and protective factors are assessed, identified, acknowledged, understood and managed appropriately, by professionals with experience in this domain, with regular review.  

The importance of #eduction for the general public is relevant in this and every context.  It is our opinion, based on observation in more or less 20 countries since the pandemic was reported, that this has not been achieve in many nations regarding the basic evidence-based (good clinical evidence) risk reducing and protective factors in the context of respiratory infections.

We have shared observations and concerns with relevant authorities since March 2020. Many authorities, health ministries, public health departments as well as international and national organisations safeguarding children are working together to ensure that good clinical evidence is followed to prevent increased risk and harm for children and adults. We thank everyone for their responses and efforts to work in collaboration to achieve clinical goals.

We offer pro bono training and presentations relating to this topic to staff supporting vulnerable children such as teachers, youth offending teams, Social Care or the Police, twice a year. Please contact us at for details of upcoming training events.

For more comments on protecting children, please see comments on:

An Achievable, Sustainable New Normal

Our General Recommendations to Maintain Good Health

Healthy Enjoyable Food Options

Simple Initiatives to Support the Immune System

The Importance of Normalcy for Children and Adults

Simple Initiatives Can Positively Impact on Mental State

#adhd #asd #neurodevelopment #learning #schools #mentalhealth #disabilities #childrensdevelopment #masks #facemasks #playful #fidget #hyperactive #impulsive #forgetful #inattentive #risk #depression #comorbidities #mentalillness #ventilation #safety #health #neurological #socialdistancing #education #teachers #pupils #college


Fear Can Put Us in Chains

Fear can put us in chains:

This photo was taken in Asia in January 2020. #Tourists paying to #touch this #tiger supports this industry that has taken away #rights of #animals including tigers. The tiger’s eyes say quite a lot.

Fear is one of the emotions that can save our lives and keep us safe, it is therefore important to listen to what the emotion is saying, but it can also lead to losing lives and increasing risk and harm.

We need to listen to fear, question it, be curious, look at the evidence, weigh evidence-based risks and benefits, finalise a risk management plan or strategy, and act accordingly to reduce risk and prevent harm. This often means running towards a building on fire or meeting with the child in prison classed as ‘very dangerous’, when a team advised that the child not be seen, to positively affect morbidity or mortality.

Risk assessment and management should be completed by individuals, eg clinicians or doctors or Police Officers or social workers, with extensive training and experience in systemic risk assessment and management.

Assessment and management in Medicine are associated with risk – risk is divided in immediate, short term or longterm, and low, high and very high.

We have worked in high risk fields from a bio-psycho-social point of view for at least 25 years and we know from experience that when one tries to avoid risk, one usually causes more harm and increased risk. This is very relevant in when working with hard to reach children, child protection work or working with personality difficulties.

In most medical or mental health domains it is impossible to avoid risk – but clinicians or doctors with extensive and appropriate training and experience in risk assessment and management (which includes assessment of protective factors) can balance risks and benefits, and provide a systemic risk management plan where risk is reduced effectively from a biological, psychological and social view.

Decisions should never be based in fear, if a good outcome is the goal.

Decisions should be based on information, good clinical, medical or scientific evidence and strategy; systemic risk assessments and a risk management plan.

Decisions should be made with a calm mind. Liaison with colleagues or seniors, collaborative working and good communication are evidence-based strategies of risk assessment and management, leading to good clinical outcomes.


May your choices reflect your hopes, not your fears. Nelson Mandela

I have learned over the years that when one’s mind is made up, this diminishes fear; knowing what must be done does away with fear. #RosaParks

We owe our children, the most vulnerable citizens in any society, a life free from violence and fear. Nelson Mandela

I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear. #NelsonMandela

Courage is not the absence of fear, it’s #inspiring others to move beyond it. Nelson Mandela

We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light. Plato

Fear is mastered through love. Hate is rooted in fear, and the only cure for fear-hate is love. #MartinLutherKingJr

Fear is the path to the dark side. Fear leads to anger, anger leads to hate, hate leads to suffering. Yoda, Star Wars

The enemy is fear. We think it is hate; but, it is fear. #Gandhi

In time we hate that which we often fear. #WilliamShakespeare

Nothing in life is to be feared, it is only to be understood. Now is the time to understand more so that we may fear less. #MarieCurie

Fear defeats more people than any other one thing in the world. #RalphWaldoEmerson

No power so effectually robs the mind of all its powers of acting and reasoning as fear. #EdmundBurke

#Ignorance is the parent of fear. #HermanMelville

A man that flies from his fear may find that he has only taken a short cut to meet it. #JRRTolkien

He who has overcome his fears will truly be free. Aristotle

#fear #chains #safe #prison #child #children #harm #risk #medicine #mentalhealth #training #experience #balance #decisions #calm #mind #communication #yoda #starwars #hope #courage #free #love #quotations