MHW0022

 

Written evidence submitted by CoramBAAF

 

1.       About CoramBAAF

 

1.1                 CoramBAAF (previously BAAF until 31 July 2015) is pleased to respond to this consultation.  CoramBAAF is the leading charity and membership organisation in fostering and adoption in the UK. We:

 

 

1.2    CoramBAAF’s main activities are the development, promotion and advocacy of best policy and practice; the provision of advice and information to our members and to the general public; and training, consultancy and seminars.  We also publish a quarterly professional journal, Adoption and Fostering, books and guides for professionals, academics, parents and carers and research studies.  The main users of our services are our members comprising local authorities across the UK, voluntary adoption agencies, independent fostering agencies and also individual social care, legal and health professionals, and carers.

 

1.3    Our area of concern is the particularly vulnerable group comprised of looked after children and young people. References to this group also include those who achieve permanence through adoption or other means such as special guardianship, and those who have left care through return to their birth family or transition to adulthood.

 

2.    Introduction

 

2.1               Children’s mental health and well-being is directly related to the quality, security and stability of their family life.  Human beings are essentially social beings centred on their capacity to relate to others, form themselves into social groupings which in turn enables them to procreate, learn and adapt, provide support and resources and enjoy and celebrate.

 

Other factors may influence children’s mental health besides the quality of family life – those that are specific to the child and those that are embedded in the community in which they live - the personal and social capital which influences opportunities and outcomes. 

 

2.2               For children on the edge of care and those who become cared for by the State there are major questions both about the quality of their family life – whether this is with their birth family and/or with alternative forms of family life arranged by local authorities and secured by various legal Orders – Care Orders, Child Arrangement Orders, Special Guardianship Orders and Adoption Orders.  Mental health cannot be adequately considered unless it is considered in the context of family life or the alternative family life the child is living in –its strengths, opportunities, risks and challenges. 

 

2.3               The challenges to local authorities and others in establishing a family life for a child where there are concerns about the quality of that life are significant.  There are major issues in exploring the nature and severity of the originating problems – typically but not exclusively abuse and neglect.  These include;

 

  1. Identifying the challenges faced by the family – drug and alcohol use, serious physical and mental health problems, domestic violence, learning difficulties, criminal activity, financial and practical problems and a likelihood of a history of these issues within the family over time.

 

  1. Assessing the potential for recovery of the birth parents including predicting the likely outcomes of any interventions in the context of providing these interventions within the child’s timescale

 

  1. The problems of establishing a positive working relationship with the birth parents when the local authority has the power to remove the child when there is any sign of ‘failure’.

 

  1. The specific nature of the needs of the child given their age and developmental history.

 

  1. Identifying both short term and long term contingency plans for the child.

 

  1. Securing the evidence for care proceedings when an agreement with the parents about the child’s needs cannot be agreed.

 

2.4   The impact of the working out of these issues can produce uncertainty and significant stress and anxiety for the child, the birth parents and the birth family. These are compounded by the uncertainty of the longer term plan for the child whether this is to return home to the parents, to the wider family or to a ‘stranger’ placement secured by one of a number of available court orders.

 

2.5               Research evidence from the 1980’s onwards has clearly demonstrated the dangers of ‘drift’ and the impact on children when there is an absence of proactive child centred planning within the child’s timescale.  This research has clearly driven the current requirement of agreeing a permanency plan by the time of the second review at 4 months after the child comes into care.  However, research by Sinclair et.al in 2007 also identifies the challenges in establishing a meaningful plan that results in a stable, secure, permanent family life for the child.  In exploring the plans for just under 5500 children in 13 local authorities,  the research identified for the group as a whole that 89% who entered care stayed for at least a week, if they stayed for a week, 90% would stay for 4 weeks, if they stayed for 4 weeks, 89% would stay 12 weeks, if they stayed for 12 weeks, 91% would stay for 26 weeks and if they stayed for 26 weeks, 83% would stay for 52 weeks.  These figures illustrate what has become a well-established picture that if a child does not leave care within 6 months, there is a 60% likelihood of the child remaining in care for 4 years or more.  This is not to say that the quality of that care – typically in foster care - cannot be high but this build of a care population produces heightened risk for these children.  Outcomes for these children indicate high levels of mental health problems, poor educational outcomes, youth offending and unemployment.

 

 

 

2.6               A study by Meltzer et.al published in 2003 strongly indicates the heightened presence of an identifiable mental health diagnosis affecting over 45% of the sample of all looked after children.

 

2.7               Identifying causation and origins of these mental health problems is complex.  It is important not to take a simplistic view of this – that being in care causes mental health problems.  The quality of many children’s experience is likely to be good and for some, that experience transforms their lives but the heightened risk especially in the absence of high quality secure, stable and loving child centred foster care and support services does need to be acknowledged and addressed.

 

2.8               There are a number of factors that need to be taken into account in understanding the contributory factors to these increased rates of mental health difficulties.  Firstly, there are enhanced genetic and epigenetic risk factors.  Then there are risks from poor ante natal care resulting from malnourishment, increased likelihood of exposure to legal and illegal drug use, alcohol and smoking and increased risk of significant prematurity.  The risk of neuro-developmental disorders is high including foetal alcohol spectrum disorders, autism spectrum disorders, learning difficulties and a range of other developmental challenges. These may be combined with other health disorders such as infant drug withdrawal, and a range of other health conditions or disabilities that present themselves immediately or over the course of the child’s development.  At a time when there needs to be strong commitment from parents in ensuring the child receives appropriate care from the parents themselves – and the significance of this cannot be underestimated – as well as full support from health and other services, the child is subject to a mixture of neglect and/or abuse and significant uncertainty when they are taken into care to be cared for by strangers.

 

2.9              While the focus here is on babies and very young children, the working out of these issues over time produces a complex picture of care experiences. Sinclair identifies a model that groups children in one of 6 categories with one group under 11 years of age and the others over 11.  Adolescent graduates are those children who started their care experience under the age of 11 as Young Entrants and continued after they reached 11 years.  The other groups started their care experience when they were over the age of 11.  Altogether 43% of the care population in this sample were under 11 with 57% over the age of 11.

 

2.10              The diversity of need and experience are one of the striking features of this model, stretching as it does across different ages and stages of a child’s development.  For many of these children, a mixture of risk, disadvantage and deprivation moderated by a stable, secure fostering placement, high quality services delivered both universally and specifically and care planning that is compliant with statutory requirements and best professional practice is key to their wellbeing and development.  For some children, genetic and epigenetic risks and early developmental trauma will persist.   For others there may be developmental recovery.  For other children, there will be the emergence of new developmental issues or risks.

 

 

 

based on Sinclair (2007)

 

2.11 There are four key issues that must be available for all children who become looked after.

 

  1. A comprehensive assessment of development that is specifically designed for the child’s age range or identified conditions must be undertaken.  There are issues that must be taken into account in the design of assessment protocols. For instance children under 5 must have an assessment of their emotional, social and cognitive development, yet these may be ignored because the child is seen as too young for such an assessment.  For adolescents, there may be issues of engagement in appropriate assessments because of a fundamental loss of trust in adults and services and a resistance to engagement in any such process.  Assessments must also be comprehensive across all relevant domains of the child’s development.

 

  1. Assessments and services must have a preventative focus to them.  Looked after children are a vulnerable group and services must proactively identify the needs of the child without waiting for problems to emerge or problems to escalate to a level of seriousness that requires radical intervention.

 

  1. Assessment and services must recognise the multi-dimensional nature of the child’s needs.  Strong arguments have been formulated by some researchers on the specific issues resulting from child maltreatment and their presentation during different stages of the child’s development.  (Tarren-Sweeney, 2010a, 2010b)

 

  1. Assessments and services must be delivered in ways that maximise the child’s involvement, listens to their perspective, and recognises that building trust and engagement may take time.   While family should be the primary advocate for the child, some children may require independent advocacy to secure the help that they need.

 

3.       Previously Published Evidence

 

3.1  The BAAF response to the Select Committee Review of CAMHS held in March 2014 published in the House of Commons Health Committee: Children’s and adolescents’ mental health and CAMHS, Third Report of Session 2014-15 is highly relevant. It describes the mental health needs of looked after children, difficulties with current CAMHS provision, need to develop specialist workforce capacity and specialist dedicated services, and the barriers which need to be addressed. (The response can be read here).

 

3.2  The May 2015 BAAF response to the British Youth Council Inquiry into Mental Health Issues – UK, addresses the role of schools in promoting good mental health and assisting children and young people of all ages to develop resilience, and highlights the role of CAMHS in addressing the mental health difficulties of looked after children and adopted children so that they can access education, and outlines the need for specialised training within education, social care, health and CAMHS. (Please see Annex A to read the response).

 

Response to consultation questions

 

  1. Whether the Department for Education and Department of Health guidance on promoting the health and wellbeing of looked after children published in March 2015 is sufficient to ensure that mental health and wellbeing are prioritised for children in care and care leavers

 

4.1  It is the view of our members that this guidance is not sufficiently strong in specifying the level of provision of mental health and well-being services for this particularly vulnerable group of children. The provision should be addressed in more detail within this guidance, as outlined in 2.11, with more explicit recommendations to commissioners regarding the breadth and capacity of comprehensive services required for this provision within CAMHS, as well as development of the role of social workers, medical advisers and specialist nurses for LAC at lower tiers of services.

 

4.2  While the recommendation to complete an SDQ on the child is a starting point, the SDQ tool is limited in identifying difficulties with attachment, phobias and effects of trauma, which are prevalent in this group of children. In addition, a significant number of our members report that completion of the SDQ is a paper exercise as the information is collected but not used clinically.  Some areas lack dedicated specialist CAMHS services and others have these services but capacity is very limited. Furthermore, this does not address the needs of the large population of looked after children under four, where the SDQ cannot be used. Yet this is a critical age group for both early intervention when problems are identified, and promoting attachment, resilience and wellbeing, to prevent later difficulties, and the guidance should address this. 

 

 

  1. The extent to which the aims articulated in the guidance are being implemented at a local level

 

5.1               Most if not all areas struggle with implementing the health guidance, and particularly with regard to mental health assessment and provision, due to the increasing financial constraints within the NHS. Commissioners are meant to be advised by the Designated Doctor and Nurse, who have strategic oversight, yet many areas have not appointed to these posts. In occupied posts, the influence of designated health professionals is often constrained as they may not sit within the relevant structures, may not be given sufficient authority, or within the safeguarding arena the emphasis may be on acute child protection issues, which receive more resources.

 

 

  1. The extent and quality of dedicated mental health and wellbeing services provided for looked after children and care leavers, including training and support for carers and social workers

 

6.1              We endorse the findings of the Health Committee’s Third Report of Session 2014–15 that “There are serious and deeply ingrained problems with the commissioning and provision of Children’s and Adolescents’ Mental Health Services”.  Our members frequently report a lack of understanding within CAMHS of the needs of looked after and adopted children and a consequent lack of effective services. As detailed in our referenced reports, CAMHS provision is inconsistent with many areas lacking dedicated mental health and wellbeing services, and in those areas which have developed these services there have often been cutbacks due to economic restraints, so that overall there is a severe lack of capacity.  Many post adoption services are being developed outside of CAMHS, but CAMHS should be the main national provider of services for looked after and adopted children.

6.2              Aside from issues related to capacity, many areas report difficulties in accessing CAMHS.  Service provision is highly variable, and these children often do not meet threshold criteria for a specific psychiatric diagnosis corresponding to DSM-5 or ICD-10 criteria, despite well recognised emotional and behavioural difficulties, so are refused access.

 

6.3              Additionally and as previously stated there is a widespread need for specialised training within CAMHS so that these professionals understand the unique needs of looked after and adopted children and their families, and in particular their life-long needs, in order to develop services which address their needs. The current CAMHS model of focusing on short term interventions, most commonly cognitive behavioural therapy, and rapid symptom resolution, utilising checklists as measures of ‘effectiveness’, does not work and is inappropriate for these children and their families.   Services instead need to offer bio psychosocial assessment and intervention in the form of stable committed support from CAMHS over a 'developmental' timescale, even when there are not specific 'symptoms' to be addressed.  

 

6.4              Provision for care leavers is similarly problematic in far too many areas, with inconsistent services and inadequate support at the time of transition to adult services. Many care leavers in receipt of CAMHS do not meet criteria to access adult services, right at the time when they have an even greater need for support as they negotiate greater independence. There is a need for training within adult mental health services to increase understanding of this vulnerable group to facilitate development of services which can meet their needs. 

 

6.5              The identified problems are often compounded for those children placed outside of the boundaries of their local authority, as services and thresholds may differ, children are denied services while commissioners negotiate services, and communication between professionals is more difficult.

 

6.6              Training and support for carers and social workers is also inconsistent and affected by shrinking budgets, yet they have a crucial role to play in training and support of the highest quality will benefit children.

 

 

  1. The level of coordination between relevant elements of the education system, the care system and the health system in supporting the mental health and wellbeing of looked after children and care leavers, and how this can be improved

 

7.1              Despite the aims of co-ordinated multi-agency working, our members report increased fragmentation between these services, and attribute much of this to increasing workloads and lack of capacity. Working with these children, whose needs are complex, takes a great deal of time, yet resources are increasingly limited.

 

 

8.              The contribution that schools make to supporting the mental health and wellbeing of looked after children alongside services such as CAMHS

 

8.1              The role of schools is critical, both to understand the needs of individual children and overcome the barriers which prevent accessing education, and to promote mental health and wellbeing for this group.  This should start with high quality training for teachers and provision of programmes which build resilience and promote emotional wellbeing in children and young people. However, there is a lack of consistency in offering training to teachers and in provision of such programmes throughout the key stages. The promotion of emotional well-being, the development of resilience and the conditions that contribute to good mental health are as important as specific programmes of specialised intervention.

 

 

  1. How young people and their carers can be more involved in designing mental health and wellbeing services for looked after children, including when making the transition to adult services when leaving care

 

Some areas have set up forums to involve children in care, their carers and care leavers in development of services, but these are by no means universally present.  It can be a challenge to engage these children and young people, due to their complex circumstances and placement moves, and persistence is required. Wider representation to include adopted children and their families should be encouraged.

 

 

 

 

Tarren-Sweeney, M. (2010a). Concordance of mental health impairment and service utilization among children in care. Clinical Child Psychology and Psychiatry, 15(4), 481-495.


Tarren-Sweeney, M. (2010b). It’s time to re-think mental health services for children in care, and those adopted from care. Clinical Child Psychology and Psychiatry, 15(4), 613-626. doi:10.1177/1359104510377702

 

 

 

 

 

October 2015


Annex A

BAAF response to the British Youth Council

Inquiry into Mental Health Issues – UK

May 2015

 

  1. Executive Summary

 

 

  1. About BAAF

 

The British Association for Adoption and Fostering (BAAF) is pleased to respond to this consultation.  BAAF is the leading charity and membership organisation in fostering and adoption in the UK. We:

 

 

  1. BAAF’s main activities are the development, promotion and advocacy of best policy and practice; the provision of advice and information to our members and to the general public; training, consultancy and seminars; child placement services including Be My Parent online and the Department for Education contract to run the Adoption Register in England.  We also publish a quarterly professional journal, Adoption and Fostering, books and guides for professionals, academics, parents and carers and research studies.  The main users of our services are our members comprising local authorities across the UK, voluntary adoption agencies, independent fostering agencies and also individual social care, legal and health professionals, and carers.

 

  1. This response is being submitted on behalf of the BAAF Health Group, which is also a special interest group of the Royal College of Paediatrics and Child Health (RCPCH), in consultation with social care professionals. The Health Group was formed to support health professionals working with children in the care system, through training, the provision of practice guidance and lobbying to promote the health of these children. With over 500 members UK-wide, an elected Health Group Advisory Committee with representation from community paediatricians working as medical advisers for looked after children and adoption panels,  specialist nurses for looked after children, psychologists and psychiatrists, the Health Group has considerable expertise and a wide sphere of influence.

 

  1. Our area of concern is the particularly vulnerable group comprised of looked after and adopted children and young people.

 

Previously Published Evidence

 

  1. The BAAF response to the Select Committee Review of CAMHS held in March 2014 published in the House of Commons Health Committee: Children’s and adolescents’ mental health and CAMHS, Third Report of Session 2014-15 is highly relevant. It describes the mental health needs of looked after children, difficulties with current CAMHS provision, need to develop specialist workforce capacity and specialist dedicated services, and the barriers which need to be addressed. The response can be accessed here.

 

Education

 

  1. Looked after and adopted children and young people have backgrounds of health inequalities, abuse and neglect, high levels of mental health difficulties, and are known to have a high prevalence of identified clinical conditions – attachment disorders, learning difficulties, autism spectrum disorders, conduct disorders, inattention and hyperactivity, foetal alcohol spectrum disorders, depression, self-harm and psychosis.  All of these factors can lead to difficulties accessing education, and schools need to have additional training to understand these conditions, manage challenging behaviour, provide appropriate environments which facilitate learning and offer a range of support tailored to the needs of the individual child.

 

  1. There is considerable stigma around having difficulties with mental health and emotional well-being, whether this is concerning the children themselves or the adults who care for them.  There is considerable need for improved education in schools on mental health for children and young people of all ages, and this must begin with high quality training for teachers and provision of programmes which build resilience and promote emotional wellbeing in children and young people. In addition, for those children with an identified need, there should be access to timely and tailored CAMHS provision in schools.

 

  1. There is also a need for specialised training for social care and health professionals (such as social workers, health visitors, school nurses and specialist nurses for looked after children) who come into contact with these children and families.  The promotion of emotional well-being, the development of resilience and the conditions that contribute to mental health are as important as specific programmes of specialised intervention.

 

 

Services

 

  1. Research has consistently demonstrated that the population of children on the edge of care, in care or discharged from care has much higher levels of emotional and mental ill health and difficulty than the general population. Recognition of the large numbers of children and families requiring some type of support and / or intervention is an essential prerequisite to the provision of adequate services, and planning for appropriate increases in skilled and experienced workforce.

 

  1. There is increasing recognition that young people need ongoing support in the transition to adulthood and adult services, yet in practice there are considerable difficulties with the transition to adult mental health services for young people approaching leaving care.  The difficulties which looked after and adopted children experience in accessing CAMHS, described in the referenced BAAF response, continue to be present for care leavers.  Although their mental health issues are significant, they often do not correspond to the dominant medical diagnostic and treatment models, and thus don’t meet the thresholds for access to mental health services, or fit with current business models. There is an urgent need to invest in development of accessible services which truly address the recognised needs of this vulnerable population.

 

 

Conclusion

 

  1. CAMHS are a vital part of the service provision for children separated from their birth families.  Much remains to be done to develop CAMHS services appropriate to the needs of looked after and adopted children, their carers and care leavers. This will involve identification of good practice in service structure, addressing problems of access and the provision of effective interventions, including promoting good mental health and resilience.  Schools have an important role to play in education on mental health for all children, and in addressing the barriers which prevent many looked after and adopted children from successfully accessing education. Critically, it will require considerable investment in specialised training within education, social care, health and CAMHS in order to build sufficient workforce capacity.