'We need a rethink, to support young families'

This is Ruby, my daughter by adoption. Adoption is essentially an optimistic act. It is founded on the belief that the effects of whatever trauma, neglect and abuse adopted children have suffered in their early years can be overcome by experiencing security, love and nurture in a new family. This is what my husband and I believed, or possibly hoped, when we adopted our four girls 20 years ago. We were optimistic people, determined to make a family of our own by offering our home and love to children who needed it. Our optimism has been profoundly shaken, however, by the death of our Ruby, who took her own life on 23 July last year at the age of 23.

Ruby was joyous – loving, so funny, super-smart and a brilliant human being. We, her sisters, her partner and her friends are devastated and miss her terribly. Her death has not only altered my view of the world as a place where love and persistence win through but has caused me to reflect on the way we as a society treat and manage mental health problems.

A lifecourse of adverse events

Ruby was a frequent user of mental health services. She and her three sisters, all of whom we adopted, had and have mental health vulnerabilities of longstanding. Their birth parents died in separate accidents linked to their own mental health issues, by which time all the sisters had spent time in care. Ruby our youngest daughter was 3 years old when she came to us and her oldest sister was 10. 

Poverty, early life trauma, abuse and neglect make children highly susceptible to later mental ill health. This knowledge is the basis of pieces published in The Psychologist as part of the BPS's excellent 'From Poverty to Flourishing' campaign. We have known for a long time that mental health issues are the product of a lifecourse of adverse events but we, as a society, choose to do very little to address this. We focus our attention on treating rather than preventing mental health problems.

The difficulty with this approach is that we have few really effective treatments for mental health problems and the growing scale of mental illness means in our society that mental health services in the UK are, and will always be, under-resourced. A report produced by the LSE in 2011 demonstrated clearly that, quite apart from the social cost, the UK economy is unable to cope with the consequences of treating mental health problems as they are predicted to rise (Mental health promotion and mental illness prevention: the economic case - LSE Research Online).

In contrast, we know quite a lot about how to prevent mental health problems. We know that adverse early life events cause many later mental health problems. The trauma Ruby suffered as an infant and toddler were entirely preventable and her life did not have to end in this way. As a society, we need to rethink. She would still have a future if we made different decisions about how we spend money on mental health issues. We need fundamentally to redirect attention and resource to supporting young families. 

Poverty puts huge stresses on families, and aggravates associated issues of violence, parental addiction and mental ill health. No child should grow up in poverty in a society as rich as ours. All young families should have access to the practical and emotional support they need. Programmes such as the Nurse-Family Partnership show what can be achieved by investing in young families. Studies have shown that providing an unconditional, basic income for all in high and middle-income countries can produce big improvements in terms of hospital admissions and adult and child mental health. The time from conception to the second year of life – the so-called first 1000 days – is a critical period of development for a child. One during which the functioning of all organs and systems, including the brain and nervous system, are set-up for the rest of life. Consequently, we know that investments early in life – starting before birth – have the greatest return in terms of improving lifelong health and well-being.

A surer start

Sure Start as it was originally conceived was an initiative that recognised the importance to both society and the economy of investment in young families and in early life. Sure Start Children's Centres (originally Sure Start Local Programmes) provide a range of support services to families from disadvantaged and low-income populations, with the express purpose of enhancing the health and development of children under four years, and so preventing the transmission of inequalities in health, poverty and social exclusion.

In 2006, when as researchers we spent a lot of time in Sure Start Centres, listening to women talk about how they managed their lives, we heard many humbling stories of struggle and ingenuity. Much of what we heard was from women feeding and caring for their children on ridiculously small amounts of money, with little support from family or partners and often at the expense of their own health. Many of these stories stay with me even today 15 years later. (Here's an analysis of what we heard).

Most of the women we spoke to had been referred to Sure Start by Social Services. Many because of their vulnerability to domestic abuse and drug and alcohol problems. These were women who struggled in the same way as the mother of my own children. Sure Start Centres were a crucial source of emotional, social and economic support but with breath-taking short sightedness on the part of government, these services and Sure Start Centres have been steadily eroded since their peak in 2010. This is despite the Institute for Fiscal Studies finding that when high levels of service were being offered by the Centres, the NHS experienced £5million of direct savings from reduced hospital visits caused by infections in and injuries to children. Reductions were particularly seen in areas of high poverty. I often wonder whether, if Sure Start services had been available to the birth parents of my children, they would have come up for adoption. My husband and I might never have met them or had the privilege of loving and caring for them for the last 20 years. 

Tragically for Ruby, her lifecourse of trauma did not stop when she and her sisters became our children. She was violently raped aged just 13. Though a terrible thing to happen to anyone, the timing of this event was particularly terrible for Ruby and her mental health. We know that adolescence – now defined as the period from 10 to 24 years – is a second critical period of development in addition to the early years; it is a time when 'the quality of the physical, nutritional and social environments may change trajectories of health and development into later life'. Early adolescence is an important time for social and emotional development; changes in brain structure and reorganisation of brain function mean that trauma and disruption during this period may have life-long consequences for mental health.

It was Ruby's particular misfortune that she was attacked at this moment in her life. Psychiatric opinion is that the rape would have had not additive but multiplicative impacts on Ruby, triggering memories and sensations of early trauma and abandonment, reinforcing her feelings of worthlessness and 'fixing' these into patterns of response that she took forward into her adult life. From the age of 13 to the time she finally succeeded, she tried multiple times and in a variety of ways to end her life. Along the way she experienced, and overcame, anorexia and episodes of deep depression.  

Again, I suggest that investment in mental health treatment services would not have saved Ruby. Actually what we need to do is to safely support young people in their search for independence or 'agency'. As a society, we need to find ways of allowing them to be heard and to make a contribution. Earlier this year, in the context of the Coronavirus pandemic, the WHO, UNICEF and the medical journal the Lancet joined forces to call for 'worthy investment in children and adolescents goes beyond formal education and encompasses community engagement and participation. The responsibility now falls to adult policy makers to … extend the scaffolding, and to replenish the commitment to ensuring that the future for children and adolescents is worthy of them'. Young people are the citizens of tomorrow and the parents of the next generation. They are our future and deserve our protection and respect.

Giving voice to children and young people

We know the huge economic costs of not addressing abuse and neglect in childhood and adolescence. I believe that if we had a more just and less inequitable society that gave voice to the needs of children and young people, my much-loved daughter would still be alive today. For me, there is little solace in knowing that Ruby is no longer suffering, because my other children and millions like them continue to struggle. They continue to struggle because we as a society choose to focus on treatment rather than prevention of mental health problems. If we go on choosing to ignore what we know, we condemn every future generation to the traumas suffered by my daughters, with the inevitable and devastating consequences for their long-term mental health.  

Love you, my Rubes! See you again in the long run …

- Dr Mary Barker is a Chartered Psychologist and Professor of Psychology and Behavioural Science, University of Southampton. [email protected] 

If you want to help make a difference, please donate here at the GoFundMe page we have set up to support a project run by Mind in Ruby's name (Fundraiser by Mary Barker : Running for Ruby (gofundme.com)). Thank you!

If you are affected by suicide or you are worried about someone, Samaritans is available 24/7 on 116 123 or via email [email protected].

World Suicide Prevention Day is 10 September. 

Find more in our archive on suicide, including our recent special feature and interview with Professor Rory O'Connor.

In partnership with the Mental Health Academy, the British Psychological Society is running a suicide prevention summit on 11 September.