‘I get joy out of confounding people’s expectations’

From the start of her career as a clinical psychologist Dr Miriam Silver was interested in the 'complicated end' of children and families. 'I've always been particularly interested in children who are not living with the parents they were born to – adopted children, foster children, those in residential care, children living with aunties and grandmas and connected people.

I also had an interest in whether it is meaningful to differentiate between children who have experienced abuse, neglect and poor attachment relationships, and therefore have a need for a predictable life and difficulties with interpersonal relationships; and children with neurodevelopmental disorders, who may often have similar needs and difficulties. A lot of my post-qualifying career was doing neurodevelopmental assessments jointly with paediatricians and psychiatrists.'

Silver worked as a Consultant Clinical Psychologist in Northamptonshire in its pioneering adoption and permanence team, and felt she would likely work in the NHS for her whole career. However, across the course of a year, a series of life shocks – her NHS Trust lost its CAMHS contract, including Silver's specialist service, she went through a difficult twin pregnancy and premature birth, her husband was made redundant, her grandfather died – led to difficulties at ¬work. 'I didn't want to feel like I wasn't doing a good job at work, but I felt I was being asked to climb a cliff, which I was up for climbing, but in handcuffs. I started to think there must be another way.'

Common sense and doodles

Silver took redundancy from her NHS job and began to feel excited and energetic about her work again. 'I had rediscovered my own shape as a psychologist, outside of the adverse conditions of my NHS job. I somehow had the time and energy to write a book that came out in early 2013. My aim was to take the growing evidence base around the impact of attachment and trauma on children's mental health and behaviour and make it accessible to adoptive parents, foster carers, residential care staff and professionals.

The publishers told me they hoped it would sell 600-800 copies, but amazingly it has gone on to sell 10,000 copies, so I am about to release a second edition with a slightly improved title, Childhood Attachment and Trauma in Common Sense and Doodles. I've also improved the content around grooming and sexual exploitation, as well as mentioning wider contextual traumas like war, migration, racism and bullying.'

Later, Silver began work as a consultant for a large residential care provider on a contract for children's homes, in which five local authorities had commissioned a set of 'closer-to-home' beds to bring looked-after children closer to their social workers and families. Part of the contract required one day per month of clinical psychology support and Silver was asked to provide this for the project. She had been working on developing a questionnaire to help identify and track the needs of children, which she suggested could be used with the children in the project to see if the closer-to-home beds would make a difference.

'Nationally, the only outcome measure that was being routinely used was the Strengths and Difficulties Questionnaire (SDQ): it's very simplistic and it hits a ceiling effect. The government was saying if you score 17 or above on the SDQ you're entitled to a CAMHS service but two-thirds to three-quarters of all looked-after children score above that threshold of 17.' Silver wanted to develop a questionnaire which better captured the needs of looked-after children – from this work BERRI was born.

Silver had run focus groups with residential care workers and the professional networks around children in residential care, and with foster carers and their networks, asking everyone to call out the factors which might make someone refer a child to CAMHS or a psychology consultation; what factors made them feel deskilled as a professional; what was the difference between children who needed foster care or residential care; and what made placements break down. 'I wrote all these different words and ideas, tried to cluster them together, and found five themes – Behaviour, Emotion, Relationships, Risks and Indicators of underlying organic or neurodevelopmental conditions. I developed a questionnaire based on those categories.'

'They laid down the gauntlet'

At this time Silver was Chair of a British Psychological Society network – Clinical Psychologists Working with Looked After and Adopted Children (CPLAAC). She reached out to members of the network about which outcome measures were generally used with this population. The group also worked with the CAMHS Outcome Research Consortium (CORC) to speak about outcome measures. 'CORC laid down the gauntlet and said they couldn't recommend measures unless they were properly validated. And I thought, well, I'm never going to get a grant and a research assistant, and the idea of sending out paper copies of BERRI to be returned with anonymised data seemed beyond my horizon at that point.'

Silver turned to her family network – 'I joke that I'm a geek by marriage – my brother's an AI researcher and programmer, my husband's a programmer and my best friends are programmers. I was surrounded by people who had technical skills and I asked them to help me develop a website where if you put in the scores to the BERRI, users could receive a little feedback report that people would like enough to give us their anonymised data.'

In its pilot phase, BERRI received 720 uses by clinical psychologists who also provided feedback. Based on this Silver added in a contextualising life events section at the start of BERRI. 'We were very mindful that when we were using the Strengths and Difficulties Questionnaire, not only was it a very blunt tool with this ceiling effect, but it also has a challenge around what I call background noise. If you're trying to measure the impact of an intervention, but that young person has something stressful going on in their life other than your intervention, you can end up with much bigger effects and struggle to make sense of what's going on in the child's story.'

The residential care provider licensed BERRI from Silver and she was able to develop the website further and start using the tool with the children in their homes. 'Since that time point in 2013 we've gone on and improved it over and over, so that now we've got more than 10,000 uses of BERRI amongst children in care. Now we've got really good norms – our way of individualising reports has got way more sophisticated. We've created a map of if-then rules. So if the child is under this age, and the score is this, and they're in this setting, we can see how far they are from the mean, and recommend the right approach. Now we have really good data and we can compare scores to a mainstream population, to a fostered population, to those in residential care, to supported accommodation, to care leavers. We can even drill down into the data and look by age, by gender, by who's doing the ratings.'

The data Silver has gathered has also shown that the original BERRI factors – behaviour, emotion, relationships, risks, and indicators – are broadly supported by factor analysis, with some additions including two mini factors around sleep/routines and personal hygiene.

A business fitting with ethics

More people began using BERRI and Silver was given the chance to work with Impact Hub – an organisation which helps social entrepreneurs turn their ideas into viable businesses. Sadly, in the same year Silver was involved in a car accident which left her with a serious whiplash injury and other complications. 'I couldn't make the most of my year with the Impact Hub because of this unfortunately. I had to give my notice to the care provider and depart from that.

But I still had a lovely year of support with Impact Hub where I started thinking about how BERRI could be used and how it could be a business while also slowing down to care for myself. I started to understand that I could build a business that fitted with my ethics. I could work in a way where my service could still be free at the point of need for recipients of the service, but it would be funded by the government through local authorities or placement providers.'

In 2019 Silver successfully applied for a local business support grant which gave her confidence that grants could also help to expand her work with BERRI. 'As the pandemic rocked up and services started to think about being remote, I realised we could be part of that … I applied for an Innovate UK grant which gave me £221,000, which was an amount of money that was beyond my comprehension! This was to work with a group of local authorities to see whether using BERRI made their services better and made outcomes for children better.

Silver partnered with the Anna Freud Centre, because she has an honorary senior research fellowship with them. 'They had a research assistant and team to do the evaluation. We also had a partnership with the Commissioning Alliance – a group of 16 local authorities working together to improve commissioning practice.'

Silver commissioned an independent social and economic impact analysis that showed for every pound a local authority spent on BERRI the authority got back £108 over the lifetime of a child. 'That was quite exciting, and we've gone on to apply for a whole set of new grants.

One is going to help us look at how we can enhance BERRI to pick up neurodevelopmental conditions and be a bit more granular. We have another to look at how we can support families at the edge of care – so that if we recognise needs earlier and support families to meet those needs, can that avoid some young people coming into care? The Independent Care Review in England backed up my clinical impression that some families feel they are asking for help and not receiving it, and it's only when a child is in care that they are assessed for autism or a learning disability or a treatable mental health condition.'

Silver has also carried out projects on preventing placement breakdown and helping children 'step down' from residential care into family-based care. 'Helping children re-access families is clearly really good for children and it gives them support post-18 and into their adult life. But also, on average, it saves local authorities £120,000 per year per child.'

A big gap

Silver said she saw the Women in Innovation Grant as a recognition of how far BERRI has come, and the potential of using these types of tools. She said she will use the £50,000 award to develop a version of BERRI for parents who are concerned about the mental health of their children – how to raise concerns with professionals, and ways to support their children in the time between noticing a problem and receiving professional help. 'We feel like this is a big gap. With a direct-to-parent offering we need to work out how we get that to the right people. Do we get some sponsorship? Do we use a buy-one-give-one model where we can give access to someone who can't afford it? Do we launch it on Kickstarter?

Silver says the goal is to reach some of the 2 million children and young people who have an unmet mental health need in this country. 'I'd love in the future to be able to work with CAMHS to use BERRI where young people are being turned away from a service or placed on a waiting list, as BERRI has a really good risk management function – we can see whether a problem is getting worse and help avoid young people presenting at A&E in crisis.'

An important aspect of the Women in Innovation Grant, Silver said, was to be a visible role model for other women who would like to become entrepreneurs. 'I love looking like an overweight middle-aged mum and also being a tech entrepreneur. It gives me the same joy as when I used to go to the gym when I was into weightlifting – the muscle bros would offer to take weights off for me, but I'd pick up the 80kg bar and stack more weights on quite happily! I get joy out of confounding people's expectations and doing something really exciting.'