Written evidence from Dr Matt Woolgar (CFA0140)

HOUSE OF LORDS CHILDREN AND FAMILIES ACT 2014 SELECT COMMITTEE INQURY

•  A) What is the cause of the substantially increased prevalence of mental ill health amongst children and young people? 

• Many different causes, no one or two factors, as mental health driven by multiple and varying factors. But Covid restrictions likely.
• In the cohort of adopted children were work with, the impact of Covid has been diverse.
• Some children flourished away from a school that was a poor fit for their needs, then returned to smaller classes with better focus on them.
• Others had a terrible time during lockdown with few social encounters, stuck at home, increasing family stresses
• Others coped with lockdown, but experiencing challenges on returning to school & social life, perhaps because they have not had the usual developmental social experiences.

B) Why is CAMHS in crisis? What is needed to improve outcomes? 

• Partly it is funding, of course. But the CYP-IAPT/MH projects have been very helpful and refocussing & restructuring CAMHS provision – but still not always a great fit between what is needed and what is available – but the emphasis in these programmes on, for example collaboration & ROMS steps in the right direction.
• But especially for CYP with high levels of complexity & severity, where response needs to be more intense and more personalised – that is more difficult for services to manage inclusively and effectively.

• It is not all bad in CAMHS, at least for those who make it to services…Friends & Family Test test shows a) >85% positive nationally in April/May 2022 & b) pre-covid in Dec 2019 >88%... so high levels of satisfaction through the last few years [and higher than a lot of the NHS more generally, which was about 70% during same periods]
• More interesting are the areas where it is very low, e.g., a survey we conducted with adoptive parents found their FFT responses at 13% positive when the CAMHS comparison at that time was 86% - this, some cohorts, such as for complex & severe adoption cases, expressing much lower satisfaction with CAMHS, and needs exploring.

• Care experienced CYP in general have high levels of needs and high levels of diversity in needs & presentation which makes them especially unlikely to fit with standard models of service delivery.
• Dr Robbie Duschinsky [Cambridge] and colleagues [including myself] will be looking at mental health service issues for CYP with social workers [CYPcSW] in a series of studies – looking at what is being delivered using case records, data linkage studies; and also voices of CYP & other stakeholders.
• But still desperately need epidemiological research which has not been done [see below].

2. What is the role of prevention and early intervention in supporting young people’s mental health? Is the mental health system currently able to provide this early intervention? 

• Early intervention is everyone’s wish, yet there is not huge evidence for it in CAMHS – but needs a clearer definition & understanding to avoid wishful thinking
• Colleagues in adult services may think of early intervention as much later than we do in CAMHS, e.g., for psychosis defined as up to 65 years
• Is the early intervention target i) intervention early in life course; ii) intervention early in development of symptomatology; (iii) intervention early in the problem that is at the root of the symptoms?
• Need to balance targeted [i.e., not universal] provision with treatments of known efficiency for the target issues to selected / indicated groups against retaining sufficient services for the currently very ill, who already have higher risks, impacts & costs.
• Definitely avoid redirecting limited resources to early interventions that have yet to show robust effects; and away from high need, high risk CYP who need intensive interventions now.
• And for it to be clear what the intervention is for; who it is for; how/why it will work; and thus what outcomes will demonstrate that for the individual [and the service], as per CYP-IAPT / CYP-MH principles.

•  3. What are the mental health problems that children and young people in care and those who have been adopted or left care under a special guardianship order face? 

• It has been known for a long time that there will be many different presentations, and that diversity is the norm and this the issue & the challenge for effective services.
• UK research in 2002 [Meltzer 2003; Ford 2007], showed elevated rates across all common disorders for LAC, and more than in high-risk groups. But no recent data.
• One or two ‘top-down’ general issues such as attachment and/or trauma are not helpful because there is a diversity of issues [individuals are different; and early adversity leads to diversity in outcomes, quite predictably].
• Thus these children need structured assessments, not restricted to one or two favoured presentations, with careful differential diagnosis and personalised formulations, as recommended in guidance back in 2005/6 [e.g., APSAC, Chaffin] - but which has been largely ignored. 
• A focus on early issues can miss impact of development. Different issues are likely to be more salient at different ages. CYP, especially those with complex needs may need repeated, longitudinal assessment.
• We frequently see teens languishing on old, developmentally inappropriate issues, and they need a refresh in thinking for the here and now…
• As children progress, say from birth family, to foster placement[s], to pre-school adoption, to starting school, to teens etc… there are good biological & obvious social reasons why issues could well change.
• We have research that shows, for example, adopters’ concerns change over time from initial placement – but are services open to reflecting these changes and reformulating?

• Importantly, there has never been a UK epidemiology for adopted children and the epidemiology for UK LAC is now 20 years old – yet we know that [question 1] mental health issues have increased rapidly even recently.
• Thus, we do not know what the specific issues currently are in the UK for this vulnerable cohort - but they are likely to be more severe based on the direction of travel in CYP mental health more generally, and possibly more complex, than what was identified 20 years ago for UK LAC.

• As we do not know for sure what the specific issues are or how severe, it is hard to assert what is needed. This is especially true for the Adoption Support Fund – adopted children have never had epidemiological clarity about the range of issues or their severity, yet £400million has been committed to supporting their needs, which is a lot of money to invest in a cohort with no formal knowledge about the extent or severity of the issues.
• A decent epidemiological study clarifying these issues might cost as little as 0.1% [one tenth of one percent] of the figure invested.

3B) How well does CAMHS address them? What more should be done to support this group? 

• The diversity and variability of presentation makes adequate service delivery for all LAC/adopted CYP very difficult at a local level.
• Usually, mental health services are organised by disorder-based pathways, but this cohort is high need, high variability and does not fit into single disorder pathways well, but needs to fit across multiple pathways if using existing structures - how services respond to that can lead to gaps & mismatches. 
• The intrinsic diversity of need/presentation also means that it is hard to meet all the individual needs within a single LAC/adoption pathway because “LAC/adoption” is not a single disorder with a clear evidence base [as one commissioner said to me “adoption is hardly an illness, is it?”, when declining funding, which is true, but…], rather LAC/adoption is a demographic high-risk indicator for a range of diverse mental health issues.
• Where local services have set up specific LAC/adoption teams the challenge is how to manage a cost-effective service, for a) a relative small number of high need, complex, and diverse individuals, and to do that with b) what is likely to be a small and relatively low cost team [reflecting the relative small number of cases relative to the general population]
• Can lead to the appeal of one or two "generic" labels/approaches and then try to fit an individual CYP into the limited service offer, not offer a service that fits the individual CYP needs – such an approach is likely to help some CYP, perhaps very well, but also not be likely to help others. We must acknowledge that some services offer very good services, of course – but not for all CYP.

• We have data on CYP coming to our service with non-specific labels/descriptions and on assessment, they have a complex, but personalised mix of specific disorders, that implies a totally revamped social/educational understanding and mental health treatment – consistent with the guidelines from 2005/6.
• We have evidence that adopters are very disappointed with CAMHS services – and that needs to be better understood; the reasons are likely to be complex and possibly bi-directional, and especially around collaborative agreements.
• There is a need for research into the epidemiology of issues in LAC & adopted/SGO cohorts [either updated from 20 years ago or for the first time ever, respectively], but we must also find out how that relates to what families [and other stakeholders] want and expect – there is a likely mismatch, due to different narratives.
• Then to find a way to reconcile an evidence-based approach with stakeholder wishes/expectations; all of which is practical and achievable research if carefully planned.
• Else we will likely continue to find high levels of dissatisfaction and services not being terribly effective.

• 4. What post-adoption support is needed for both children and young people, and their families? How can we ensure this support is consistent and long-term?

• The diversity of presentation and the variation that further occurs through development means that - people are different & things change over time.
• The right support is the right one for the specific child, at the right time [e.g., for current issues].
• Services need to be prepared to repeat & reformulate. We frequently see teens with disorders really meant for much younger children. 
• There is currently pressure for top down categories based on attachment and/or trauma. But while either or both of these can be issues [although there is no data to suggest they are the main ones, and indeed quite a lot to suggest they are not], two categories are too restrictive to take into account the diversity of presentation.
• While the Adoption Support Fund has been a good thing, the restriction around the unevidenced focus on attachment and trauma has led to unintended consequences; and especially that CYP get crammed into attachment and trauma conceptualisations that do not fit their needs or presentation, because that is how they can access funding for treatment
• , i.e., there can be a drive to describe an issue that is not really at all about attachment & trauma as either or both of those in order to access funded treatment for that child, which sets up a series of unintended consequences for that individual’s care and more broadly service delivery.
• And again, there is no epidemiological data on what adopted/SGO CYP mental health needs are [and the LAC data is 20 years old].

•  5. What are your reflections on the use of experts in the family courts? Are they used appropriately and afforded sufficient protections and support?

• Most of the children we see in our clinic have had expert reports, sometimes several, and the best that can be said is that from an evidence-based perspective the quality is highly variable – and sometimes extremely poor.
• Perhaps the right answer, but for the wrong reasons?
• Questions arise how often they would stand up to retrospective scrutiny from an evidence-based perspective.
• And even what was once correct at age 18 months in a birth family, may have little relevance to a CYP who is 4 or 5 years – especially if caregiving context has changed.
• We worked with the IAAM social impact bond [Jim Clifford & CVAA colleagues] to help address some of these issues for hard to place children freed for adoption.
• I am aware of one attempt to assess the quality of a sample of expert reports in Family Courts, but the findings were more or less controversial to different stakeholders, for variably valid reasons, which is a shame as there is a need for this quality assessment.
• Something very similar could be redone, in an open way, to get consensus on the methodology and frameworks amongst stakeholders – it could tell us a lot about the extent to which the quality of opinion is consistent, and relatable to the evidence base.
• We see that not every expert follows the evidence base, and that does not appear to be picked up, and is perhaps not a concern. 
• For example, a recent case referred to our clinic had had several expert reports, which led to a judge recommending an unevidenced-based treatment for a disorder that does not formally exist.
• Our clinic rarely does expert opinions as we find there is a poor fit between the evidence-base and a) the typical Letters of Instruction questions b) the approaches of the other experts involved. They also do not cover NHS costs.
• In terms of protection & support, my concern would be that the CYP in particular needs the most protection, by ensuring high quality, transparent and evidence-based reports; rather than experts who ought to know what they are doing and have the capacity to cope in Court based on their professional expertise and practice.

Dr Matt Woolgar

Consultant Clinical Psychologist, National Adoption & Fostering Service Michael Rutter Centre, South London & Maudsley NHS Foundation Trust, DeCrespingy Park, London SE5 8AZ

http://www.nationaladoptionandfosteringclinic.com/

October 2022

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