Dr Matt Woolgar.

Q176 The Chair: Good afternoon and welcome to this public evidence session of the Select Committee looking at the Children and Families Act 2014. I remind everyone that this session is being broadcast online and a transcript will be taken.

I am very pleased to welcome Dr Matt Woolgar. Before we start our questions, would you briefly introduce yourself and your role?

Dr Matt Woolgar: I am a consultant clinical psychologist at the National Adoption and Fostering Service at the Maudsley. I am also an academic looking into attachment and parenting, which interacts nicely with both the clinical work I do and, hopefully, what we are going to be talking about today.

Q177 The Chair: I am conscious that mental health was not written in as a big part—or, indeed, any part—of the Act we are looking at, but in looking as we have across adoption, family justice, special educational needs, the role of the Children’s Commissioner, et cetera, mental health has emerged as by far the biggest cross-cutting issue. That is really why we are having this session and we have had various other sessions related to children’s mental health.

I want to kick off by asking you—and I am conscious it is a very big question—for your take on the cause of the substantially increased prevalence of mental ill-health among children and young people.

Dr Matt Woolgar: It is a big question.

The Chair: It is a big question, I know.

Dr Matt Woolgar: I will give only a partial answer. My specialism is with adopted and looked-after children in particular, and children with behavioural problems, so I would probably think about the answer in that context.

From the research, we know that it will not be a single factor. There will be multiple factors feeding into the emergence of mental health problems across a lifespan. Perhaps we are better at identifying issues now, as people often say, but the increase that you are talking about has been over a relatively short period, which suggests that it is not just about measurement issues but is probably a real increase. So, yes, it is a real increase, and some of that is possibly to do with the Covid impact.

If I think about the cases I see in my clinic, the adoption and foster cases in particular, a theme I will keep going back to is that people are different and individuals vary. We found with that high-risk group that some have done rather well through Covid. Being out of school settings that were not well fitted to them, and being in different contexts, they have done quite well, bucking the trend perhaps. There are also quite a lot of children who have done rather badly because they have missed out on the socialising aspects of peer relationships and normal engagement with other children. We have seen a diverse picture as regards the impact of Covid restrictions on the particular cohort we look at. That is a partial answer to your question, I think.

The Chair: I am afraid that my follow-up question is equally wide-ranging. We have received a lot of evidence about the pretty parlous state of CAMH services. Indeed, recently the committee conducted an online survey, and the responses and quotes that have come back about problems accessing CAMHS are really concerning, and harrowing in places, because they include children and young people who seem to have very serious mental health needs. Again, could you give us your take on why CAMH services are in what many have described as crisis, and what is needed to improve that situation?

Dr Matt Woolgar: It is a really interesting question. Again, our clinical service is a national service and we do not have local commissioning. We see a different picture from local communities. We see a lot of children from a variety of CAMHS. We get a picture of the kinds of things that are happening across the country. We are located in London but it is not restricted to London at all. We see lots of problems with children getting access to the right kinds of services in CAMHS early on, absolutely.

What are the problems with that? Funding will be at least part of that, I am sure. It has probably always been the case that it has been underresourced even more compared with adult mental health. That is part of the problem.

Again, if I think about my special interest group of adopted and looked-after children and children on the edge of care, for example, their complexity makes it quite difficult. That is probably true for other children in birth families. With more complex presentations, it is much harder for a stressed system to have the resources to look at the variety and diversity of presentations in those complex kids. That will stress any system. One way people try to cope with those problems is to simplify the services, and that means, again, that some of those more risky, complex children get squeezed out and do not get ready access.

The Chair: To follow up on that point, how would you characterise the relationships, the join-up if you like, between CAMHS and the more specialist services, say, that you provide or, indeed, that other voluntary sector organisations provide?

Dr Matt Woolgar: The bit of good news on CAMHS is that a process that has been going on for the last 10 or 11 years is the Children and Young People’s Increasing Access to Psychological Therapies and now CYP mental health. This has been a really positive framework in which to try to integrate CAMHS, third-sector organisations and social care with input into children’s mental health. I am slightly biased because the other half of my job is on CYP mental health, so I declare my interest there. However, I think it has been a really positive way to try to promote a shared understanding.

The key issue, we think, is probably the shared understanding, and the difficulty of reaching a shared understanding between the different stakeholders, particularly with more complex children. There are different ways of understanding presentations within different CAMH services, within social care, within education and within different cohorts of parents. It is those different understandings that we struggle to accommodate.

We have done some research with adoptive parents on their opinions on CAMH services. It probably will not come as a surprise to you that they were overwhelmingly negative in their feedback on those sorts of things. Their main concern was a lack of collaboration and a lack of shared understanding. In effect, I guess, it is about listening to what their perspectives are and making sure that those are carried through in the services that get delivered. I could spin off into a big answer but I will perhaps pause there.

The Chair: That is very helpful. That collaboration point is extremely important and other colleagues may well wish to pick up on it.

Q178 Baroness Bertin: I think it is probably related. As to early intervention and how helpful that is to prevention, presumably, the collaboration could try to help that early intervention happen faster.

Dr Matt Woolgar: Yes, it would be really good to get early intervention working. Early intervention is an interesting topic in its own right. I am sure you have heard lots of submissions on early intervention. It is understanding first off what that means. For example, early intervention in psychosis goes up to age 65. That is not what we are talking about here, I think. We are thinking about the early years and early intervention, possibly. I do not know. Am I answering the right question?

Baroness Bertin: Definitely. How early is early? For example, are nurseries around the country tooled up to spot things? Is there a question mark? Perhaps it is slightly different with cared-for children, but for children in a big system it takes a long time to spot and it is whether the system is actually working. The healthcare system is such a mishmash of community services, health visiting and no join-up, as you say. Do you think the system needs to be looked at?

Dr Matt Woolgar: It is the joining up between these different stakeholders. It goes back to the idea of getting a shared understanding. We often find there are silos or narratives around children’s mental health that exist within different stakeholders and do not link together. Trying to get linked-up services when you believe different things about a child is incredibly difficult. We need to make sure that there is real clarity around terminology. I do not know entirely how you go about doing that, although I have some ideas. Getting clarity and a shared understanding will be really important for that.

As well as early intervention in the early years, we know that early intervention is more effective when it is directed towards a targeted or indicated group when problems are starting to emerge rather than when they are universal. Keeping hold of that sense of early intervention would be important to think about. People being able to identify and then target is more effective than rolling it out to everybody, if that makes sense.

The Chair: Thank you very much.

Q179 Baroness Wyld: You have answered a lot of my question, which was going to be about children who have been adopted or who have left care under special guardianship. You talked about the complexity of cases, with the caveat that everybody is different.

I would find it really helpful if you could walk me through an example of where you think people hit obstacles. You talked a bit about CAMHS and you talked a bit about a lack of collaboration. From the individual perspective, if somebody comes out of care or they are adopted or under special guardianship, and they start to display mental health problems, how does their journey pan out?

Dr Matt Woolgar: It varies from place to place and person to person. That is not a cop-out; it is a recognition that there is such diversity in what happens. There is also diversity in presentation. We would expect one child who has been in the care system to not necessarily look like another child who has been in the care system. We would expect diversity and difference to be a biological priority or imperative. They will be quite different. You have to hold in mind the fact that this child’s problems may not be the same as other children’s. There are lots of narratives that tend to say if you are adopted or fostered you have one of one or two general problems, but the data and research do not really support that.

The first problem is someone identifying that this child who is adopted has a mental health issue of form A, B or C, and for that child to be understood not just as, “Well, they were adopted. What do you expect? This is part of the process. Leave it a few years and let’s wait and see what happens”. That can sometimes be a problem.

Alternatively, the problem might be, “Well, you’re adopted. Then we have this service. We have this way of working with adopted children. We have this on hand, so let’s give this to you straightaway”, and maybe not thinking about what the individual child has. One of the first challenges is a child being seen as an individual child and that child’s difficulties being understood as things that are specifically related to that child. For me, that is one of the biggest barriers. That goes back to effective assessment, and I am not sure that happens routinely.

Baroness Wyld: Do you see any particular areas where that is problematic? Say I was the parent and I ended up at a GP surgery. Is the GP likely to say, “Well, they’re adopted”, or say I am at school and my child gets some early intervention, will they be treated differently? Is there any particular hole in the system? I know that is a big question and a sweeping one.

Dr Matt Woolgar: It is a really important one. It is really interesting to think about where these barriers emerge and what they are. As a national service, we see children nationally, and we see different kinds of narratives and services existing in different areas. It is like a postcode lottery but it is probably more than just a postcode lottery. There will be some services where they have very “on it” schools, which are very tuned into these things, but the school next door is not at all. Social care might be open and engaged in thinking about the complexity and diversity of presentation; others will perhaps be more led towards doing what they usually do. There are clusters of good practice in any region. If you are lucky, your child fits into that good practice; if you are unlucky, your child does not and you really struggle to get effective help because you do not fit with what is available in that area.

I am saying that, but some GPs are excellent. We have some very helpful, thoughtful, reflective GPs, but their ability to commission services and find them locally is impaired in its own right.

Baroness Wyld: Are there any specific tools that need to be given to different parts of the system? Is there any guidance or commissioning guidance that needs to be altered in the context of the challenges that you have identified?

Dr Matt Woolgar: It is difficult to say “training”. So much training goes on in this area with parents and social workers that people are drowning in training. I am not sure that more training is the right idea, and certainly not more content-based training, but perhaps training in the way of approaching and thinking about these cases could be quite useful. If it was less about content and more a way of thinking about things, that could help.

Something cheap and cheerful and readily available, but which is often maligned, is the Strengths and Difficulties Questionnaire (SDQ). That is all right at what it is good at. It is not everything but it is something. There are some things out there that people could access that children are routinely assessed on that could be better used in practice. Schools, GPs and social care—all sorts of people—could use some fairly basic instruments to obtain a better understanding.

Baroness Wyld: That is really helpful, thank you.

Q180 Lord Brownlow of Shurlock Row: Looking post adoption, what additional support is needed for both CYP and families? What can we do to ensure that that support is sustained in the long term?

Dr Matt Woolgar: That is a really good question. I am very interested and will try to give a succinct answer to that. It is really important. Perhaps I will start with families, partly because we have just been doing some research looking at adopted families’ experiences of something called secondary trauma. This is the idea of caring for a child whose care experience can bring challenges and risks in its own right. We found that adoptive parents—and our previous research has found it in foster carers as well—present with secondary trauma. These are traumatic symptoms when they have not been primarily involved in a traumatic event but they occur secondary to that; for example, from caring for someone who has been traumatised. Those sorts of rates are about the same as for paramedics. There are quite high rates of stress and trauma in adoptive parents and foster carers that occur as part of the job or role of looking after challenged and compromised children.

Some of that research also suggests that part of that comes from relatively high levels of child to parent violence that can occur in adoptions. CPV—child to parent violence—is quite an important issue in thinking about post-adoption support, both for the families who experience it and for the child. There are some pretty good interventions for child aggressive behaviour. In fact, they are some of the best evidenced and supported interventions that we have. There are things that could be done about that, but whether they are being done I do not know.

What is needed to support these adoptive families, and the children in particular, going forward? We have the Adoption Support Fund, which has been fantastic but complicated as well. It has opened up a degree of access for families to get support and is being evaluated independently by various people.

What we can say, as a clinical service that takes quite a lot of commissioning based on the adoption support fund, is that there is a cap on how much money is available to provide for assessment and treatment of these children. The cap is there to increase accessibility by way of a fair access limit. I understand that and that makes sense. However, in any cohort of children with mental health issues, there will be a smallish number—and perhaps it is a biggish small number—of adopted children with very extreme and very severe and marked problems, and their difficulties are perhaps not adequately resourced in the context of fair access limit. You will find a lot of services providing treatments for adopted and looked-after children, but especially adopted and special guardianship order children, will tell you that. A lot of families will tell you that as well. It is about how we step up. We do not have a mechanism at the moment that reliably enables parents and children to access more support when they need it. So that is tricky.

To make it more accessible from a limited pot, the fair access limit is very sensible, but from the point of view of recognition that there are some children who are extremely troubled and will cost the taxpayer an awful lot of money, we do not have a mechanism to step up. There is matched funding, but that means social care has to match it, and social care is not awash with funds, so that mechanism is not terribly effective. Sorry, I may have gone off on my own special interest.

The Chair: Thank you very much.

Q181 Baroness Prashar: Could you share any reflections you have on the use of experts in family courts? From your point of view, are they used appropriately and given the right protection and support?

Dr Matt Woolgar: Working with adopted and fostered children, we see a lot of children who have had a number of expert reports at some point in their life. As an introductory statement, I would say that very rarely would we find those expert reports sufficient for thinking about what next for that child, for various reasons. Part of that would be because, and this is probably the best thing you can say, there is a high level of variability in the quality. As somebody who is interested in understanding children and young people’s presentations, there is huge variability in the quality of expert reports.

You may know that there was an attempt to quantify that empirically some years ago. Professor Jane Ireland did a study that ended up being a bit controversial. I think the approach was right, which was to try to assess the quality of expert opinion in these written reports to see whether they were fit for purpose. That study came out with some very negative and alarming findings, some of which I can relate to, clearly, in what we see. I would say that expert opinion is extremely variable.

You ask whether experts are sufficiently protected. I am probably more concerned about the children and young people and the families. In a lot of the expert opinion we see I wonder whether, if it was looked at again with a different set of eyes, it would have been sufficient, for example, to get the child removed, in the sense you may have the right result for the wrong reason, because sometimes the opinion is very low quality.

I am thinking about a case that came to us recently. Several expert opinions had already been engaged and the judge was directing an un-evidence-based treatment for a disorder that does not formally exist but doing that on the basis of expert opinion. We cannot help with that because we need to work with things that are evidence-based and conditions that are formally recognised. There are quite significant problems with it. Perhaps I am answering it in a different way from what you are asking.

Baroness Prashar: What can be done to improve the quality of expert reports?

Dr Matt Woolgar: There have been various attempts to improve the regulation of it. The problem is that it is already quite hard to commission expert opinion other than from people who are engaged largely in providing expert opinion. A service such as ours almost never does it because it is a bit complicated. It also does not pay NHS costs sufficiently. We cannot supply expert opinion in most cases because it costs too much. It is difficult to improve it if there is not going to be more funding to ensure that you are getting a different pool of experts. Some experts are fantastic, clearly, and we see some brilliant reports, but there is this variability, and I do not know what we do about it. I am sorry to be a bit vague.

Baroness Prashar: Are you able to send us a copy of the report that you did?

Dr Matt Woolgar: Of the one that was done by Jane Ireland, who looked into that? I can send you that, but, as I say, it was quite controversial and caused quite a lot of upset. It led to an HCPC hearing at which she was completely acquitted, so it looks as though a lot of the problems were not substantiated. I can definitely send you that. If I did, I would also send you some of the criticisms of it because I think it is important to get a balanced view.

Baroness Prashar: We have also heard that there are not enough experts around. Is that an issue too?

Dr Matt Woolgar: I think that is right, yes. It is quite hard if you are, for example, running a busy clinic to step out and do court-based work. If we do it in our clinic—as I say, we do it very rarely—I always insist that we get involved in the letter of instruction, because what we find with letters of instruction is that they sometimes ask questions that are unanswerable. I understand why people want those questions answered. They are just not questions that can be answered, other than by wishful thinking. People want to get what a particular child will be like in 10 years’ time. We do not know. If you are sticking to the evidence, there are only certain things you can say, reliably. It is quite challenging to step into the arena of giving expert opinion if you are wedded to the evidence base and if you are not able to work with the way in which the questions are framed in the legal system. Does that make sense?

Baroness Prashar: It does. Is there a need for guidance and support?

Dr Matt Woolgar: Of professionals? It is not something that has ever occurred to me. I think the most important thing would be to make sure that people are qualified to do it and have real expertise, so it is not just a case of, “I have done hundreds of reports”, but it is, “I am qualified in these areas and I routinely do these kinds of things in my practice”. If we ensure that the people are qualified and expert in the ordinary sense of expert to do the job, perhaps they do not need protection. I am not sure what the protection is that they would need.

Baroness Prashar: Not only protection but guidance. Do you think there is room to create a pool of people who have expertise and who could be given guidance that could be drawn from, rather than the hit-and-miss poor quality and high quality?

Dr Matt Woolgar: That could work. It would be quite nice to have a pool of experts. I know that some other countries have a fixed set of assessments that they do if they are engaged in the family court system. That is a possibility. I wonder how easy it would be to populate that pool and keep them working on a project, but that could be a possibility.

Q182 The Chair: As we get to the winding-up stage, could I ask what sort of community services you would like to see being available for children in the care system?

Dr Matt Woolgar: On community services, again, I will try to be succinct and say only two things. First, there are already some fantastic services. We have to recognise that there are some brilliant services. One issue there will always be with a community service is that it will be relatively small, because the number of children in a trust who are coming to it will be relatively small, but that relatively small cohort of children will have a wide diversity of problems. I hope the key message from my evidence today is that the children tend to be quite diverse and different. It is quite hard to have a small team that is able to deal with wide-ranging complexity.

A community team that recognises what it can do well and is reflective about what it would need help on for other areas, and knows what it does not know, would be really good. The different ways in which community teams are structured will mean that they necessarily have different expertise compared with the next community service, which will have a different mix of people, with different expertise. Ideally, you would fit the child to the service rather than the service to the child. If the service was able to reflect on the bits that it needs help with, that would be great. It sounds simple, but I think in practice it is quite difficult.

The Chair: Finally, could I check my understanding of a point that came up a bit earlier? We have had a lot of evidence about the need for greater parity of esteem and services available for parents who are formally adopting and those who are involved through special guardianship orders, kinship care and all that. There just is not the same degree of support services available for the latter category. Do you have any thoughts about what can be done to even up the current imbalance? I am thinking particularly about the support needs that those children have after they leave care, irrespective of through which route they leave.

Dr Matt Woolgar: Someone from social care may be able to answer this better than I can, but we certainly see that the places where special guardianship order children are situated within social care vary greatly. Sometimes they are in with the adoption services. That means you can have an almost seamless conversation with people who are expert on adoption and accessing the adoption support fund, and you can do that as well for special guardians and their families. That is quite a nice way of working. In other situations, SGOs are hived off into different areas and then it is more complicated to find the appropriate support.

I believe the adoption support fund is trying to increase parity of esteem between SGO and adoptive families, but I still think there are different ways in which that is organised within social care. Because social care tends to be the commissioning organisation, even for mental health, that is quite important.

Another issue we are not going to talk about today is whether social care is the best source of commissioning for complicated mental health issues, or whether that should be done much more in partnership with people with a mental health background. I wanted to sneak that in, sorry.

The Chair: You have raised the very interesting issue of the commissioning of mental health services, but I think we will have to pursue that separately. It is 5 pm. We have covered a lot of territory. Thank you very much indeed for coming to the committee and giving up your time and sharing your expertise. As I said at the beginning, the whole issue around mental health support has become such a key issue for us as a committee. Thank you very much indeed.