MHW0051

Written evidence submitted by the Children’s Social Care Department of Portsmouth City Council

Executive Summary

• Feedback on local services and inter-agency working in Portsmouth City Local Authority area.
• Stability required to begin therapeutic work
• Challenges accessing services when children placed Out of Area
• Care leavers' difficulties in accessing services to address issues of mental health and wellbeing.
• Work of Portsmouth Virtual School and set up of Attachment Aware Schools Programme
• Suggestions for improvement of services to address looked-after children's mental health and wellbeing services. 

Introduction

1. Portsmouth Children's Social Care currently has the care of 318 Looked After Children, the majority of whom live in foster placements.  Children looked-after include:

• Children cared for under Section 20 of the Children Act 1989 because they are without friends or family to care for them, (such as Unaccompanied Asylum Seeking Children) - social workers are based across Children's Social Care.

• Children who are the subject of Family Court Proceedings - social workers are based in Court and Protection Teams

• Children who are the subject of Full Care Orders (and possibly Placements Orders) - social workers are based in the Through Care Team.

2. The Through Care Team consists of five pods of social workers with a Practice Leader each:  one adoption pod, three fostering pods and one leaving care pod.

Reasons for submitting evidence

3. Portsmouth Children's Social Care is continually seeking to support children and young people to achieve best outcomes.  It recognises that the mental health and wellbeing of children and young people is a key factor in this. 
4. Portsmouth has a dedicated CAMHS Looked After Children Team which seeks to ensure that children and young people are able to access good quality support; this includes those placed outside the city. Portsmouth City Council would therefore make the following submissions (bold paragraphs are Department of Education points):

5. Having a forward thinking CAMHS strategy around LAC has enabled us in Portsmouth to work very closely with our Social Care and Education partners over the last 10 years and I think this has been demonstrated by the existence of the dedicated CAMHS LAC and Health of LAC service within CAMHS in addition to the general CAMHS/Health provision available to Portsmouth’s children.
    
6. The CAMHS LAC service has provided an Annual Report 2014/15 (Appendix 1) which demonstrates existing on-going work, new initiatives and gaps which are discussed regularly at strategic and front line level so I won’t repeat the initiatives but our aims are:

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.

7. While the guidance sets out clear principles for the care of looked-after children, it does not suggest it is read in conjunction with Department of Education practice guidance for children who are accommodated as Unaccompanied Asylum Seekers.  These children and young people have often experienced significant amounts of trauma and loss but may require careful engagement with mental health services.  In addition there are the challenges of working with these children in terms of the need for interpreting services; there are implications for therapeutic working and costs of interpreting services.

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

8. While the guidance states that "Looked-after children should never be refused a service, including for mental health, on the grounds of their placement being short-term or unplanned", in reality CAMHS services are often reluctant to begin therapeutic work until children are in long term, stable placements.  While social workers acknowledge the clinical thinking behind these decisions, there needs to be a greater flexibility and creativity in how services work with traumatised children.  However in the meantime our local CAMHS service has been set up to support foster carers to response appropriately to these situations.

9. The guidance suggests that when children move out of a CCG area, that arrangements should be made to ensure the continuity of health care.  Unfortunately the experience of accessing services in other CCG areas is mixed.  One of the challenges is the differing eligibility criteria of different CCG areas so while they may provide similar services, ie CAMHS LAC team, they are often only funded to meet the more complex needs of children looked-after from their own CCG area.  Although the guidance recommends liaison between CCGs there is no guarantee that a child will receive a similar service to that in their originating CCG.

10. Children leaving care are acknowledged in the guidance as needing plans to ensure their healthcare continues.  Young people in receipt of a CAMHS service at their 18th birthday can continue receiving a service through to their 19th birthday.  However those young people who have not managed to secure a CAMHS intervention by their 18th birth are unlikely to do so.  Subsequently they are less likely to access any mental health services as the eligibility criteria for adult services are invariably higher.  Many of these young adults have difficulties best understood in terms of 'attachment theory' in childhood (Bowlby J 1969, Ainsworth M and Bell S 1970) and more recently the ongoing implications for adult development and behaviours (Crittenden 2008).  Anecdotal evidence suggests that young adults with attachment difficulties are less likely to fit the criteria for adult services as they are seen to have problematic 'behaviours' rather than a clinical illness.

11. The Care Matters: Time for Change paper (Department for Education and Skills 2007:120) acknowledged that care leavers risk falling "between children's and adult's health services, with neither meeting young people's needs: confidentiality; privacy and communication skills; and knowledge of basic biological and psychological changes of adolescence".  While Portsmouth has a counselling service, Off The Record, for 11-25 year olds, it is those requiring more intensive support for issues for psychological difficulties rather than being mentally unwell which are most vulnerable and may go on to develop more serious mental health difficulties if they do not receive the early help mentioned in the guidance. 

12. While the guidance promotes the idea of timely planning for those leaving care and access to sources of information and advice, it does not seem to reflect the reality of many young people is that their emotional development is often delayed as a result of the trauma they have experienced.  They are, therefore, likely to have more difficulty in asserting their needs for mental health and well-being services.  Within the 'leaving care' period of support, young adults may experience fresh triggers for mental health difficulties; i.e. loss of accommodation, birth of their own children and breakdown of significant, intimate relationships. 

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.

13. In Portsmouth from March 2015 a six month pilot scheme placed a staff member from CAMHS within Children's Social Care teams one day a week.  The idea was to provide 30 minute consultation slots to social workers and education workers about cases from all Children's Social Care teams. 

14. In evaluating this project it was clear that staff appreciated the ready access to expert advice which took place face to face, and was also more efficient in terms of reduced time and paperwork.  The working together built on existing working relationships and increased feelings of mutual respect. The CAMHS advice was considered helpful in terms of finding placements for children/young people as it enabled joined up thinking and an increased likelihood of seamless, co-ordinated care. 

15. While the pilot scheme has been a positive step for looked-after children's services in Portsmouth, there remain a number of challenges in providing appropriate care for children who have experienced significant trauma and loss.  The evaluation acknowledged the challenges of differing IT systems and room availability in a busy civic office building.  While social workers have confidence in the level of care provided by CAMHS, there remain challenges in terms of CAMHS service capacity as evidenced by waiting times for looked-after children to receive services. 

16. To promote a child’s physical emotional and mental health by acting on early signs of health difficulties, providing early intervention and prevention through psycho educational training and longer term therapeutic training, providing direct assessment and treatment for children who present with severe mental illness or are at risk of experiencing a placement breakdown.  All universal practitioners can contact local CAMHS teams for advice, consultation and make a referral if appropriate. In addition we now have an ‘in reach’ service to social care to ensure our children get the right support at the right time. Our response to referrals is within two weeks and we prioritise urgent referrals in one week. We do have an 8 week wait for routine direct work.

17. We have developed a Loss and Bereavement care pathway in 2015 which should be available by December 2015 with 14 Loss and Bereavement companions trained in social care. We are making inroads to identifying the number of 0 to 5 year olds in care and our infant mental health colleague is working closely with Health visitors to prioritise robust consultation to strengthen the attachment relationships of this age group as a preventative initiative. We are proud to highlight that the Local Conference on Loss and Bereavement on Thursday 29th October will focus on the needs of LAC.

18. Portsmouth Children's Social Care currently has a 'Reunification Project' which is reviewing all looked-after children's cases to consider whether the birth family situation has changed enough to explore the possibility of them being re-unified with their family at home.  For those who were accommodated under S.20 of the Children Act 1989, these children are de-accommodated through their return home and are then not prioritised by CAMHS as looked-after children who need a service at a time when they remain vulnerable.  They do receive time limited support from CAMHS as part of the transition plan to return home but they are unlikely to meet the criteria for longer term support for behavioural difficulties.  CAMHS are not commissioned to provide intensive support to these Young People.

19. For those children returning home while remaining whilst under S.31 of the Children Act 1989, the guidance suggest that suitable transition arrangements are put in place to ensure they continue to receive a service.  However it is difficult for CAMHS to provide appropriate support to these children who are technically still looked-after when their operations are based on a fostering placement model.  These children are returning to parents who have struggled previously, and who are likely to find behavioural management of children who need therapeutic parenting a significant challenge. 

20. CAMHS also work closely with our CAMHS YOT practitioner to meet the need of a number of older adolescents who offend and their mental health and well-being is impacted. The conduct issues displayed by this group of young people can impact placement stability and permanence is prioritised as an important issue to prevent further mental health issues.

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.

21. As stated above, Portsmouth Children's Social Care seeks to work closely with colleagues in CAMHS.  In addition the mental health and wellbeing of looked-after children is considered in detail at the Looked After Review meetings.  Strength and Difficulties Questionnaires (DoH 2000) are completed for all looked-after children and used at initial Personal Education Plan (PEP) meetings to provide a context for a young person's behaviours and wellbeing in school.  In addition these are used to signpost children's referral for CAMHS services. 

22. Following the last Ofsted Inspection of Children's Social Care (2014) and HMI of Probation inspect of Portsmouth's Youth Offending Team (2015) there have been closing working between the YOT and the Through Care Team.  A Risk of Offending Screening Tool considers a young person's needs and is used at a triage panel for consideration of preventative work with the Youth Offending Team and other services.  Portsmouth Children's Social Care is aware of the links between offending behaviour and mental health symptoms that may not have been spotted or mis-labelled as anti-social behaviour.  In addition anti-social behaviour and attachment difficulties may mask learning difficulties.  For those looked-after children with learning difficulties there are additional challenges in accessing therapeutic services.

23. However once young people leave the care of the Local Authority there is a reduction in the level of co-ordination between the care system and the health system.  The 'Staying Put' agenda recognises that care leavers have a more difficult start to adulthood due to their past experiences and the absence of a supportive family.  While young people now have the option to remain within their foster placements until age 21 years, the same difficulties do not ensure extended access to mental health services which are expert in young people's issues, ie CAMHS.  Instead they may struggle with issues of mental health and well-being but not meet the criteria for adult services.  Anecdotal evidence suggests that if a young person's mental health and wellbeing issues are unaddressed they are more likely to struggle to maximise opportunities for education, training or employment, are at increased risk of homelessness and are at increased risk of social exclusion.

24. We therefore suggest that this issue could be addressed by a similar process of expanding and extending CAMHS services to care leavers through to the age of 21 years.

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

25. Portsmouth Virtual School have workers who have experience of working with vulnerable children.  They work closely with social workers across Children's Social Care to ensure that schools make necessary adjustments and exceptions for looked-after children who are more likely to experience mental health and wellbeing difficulties.

26. In 2006 Louise Davies, Corporate Parenting Project Development Officer for Portsmouth City Council, contributed to the National Children's Bureau booklet 'Understanding Why' (Ryan 2006), a whole school approach to understanding how attachment difficulties can affect education. 

27. On 30th June 2015 Portsmouth Virtual School built on this by holding a conference entitled 'Learn the Child' to launch their "Attachment Aware Schools Programme".  This was commissioned via Kate Cairns Associates and the main speaker was Brian Roberts, a former Virtual School Head and also a foster carer for Bedfordshire County Council.  The conference was attended by 125 people and included school staff, social workers and foster carers. The feedback from the conference was very positive and all delegates were provided with logins to undertake further training relating to attachment.

28. We are in the process of considering how to increase knowledge regarding Attachment Theory and Practice in schools. From October 2015 school clinics for secondary schools are being offered by the Single Point of Access team in CAMHs and we work closely with the virtual education team for LAC.

29. The Attachment Aware Schools Programme will use Pupil Premium Funding to undertake work with Portsmouth Schools and Academies to promote the importance of school staff being aware of the needs of children who have an attachment disorder.  Many looked after children are in this category and so are other children and we believe this work will benefit school staff in the support they provide for many pupils. 

30. A Psychology and Occupational Therapy resource into the team would enhance early identification of cognitive impairment in children and young people and the impact of sensory issues when working with children and young people presenting with symptoms of complex trauma.

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.

31. Portsmouth's LAC CAMHS Team routinely use feedback forms to gain feedback on the service they deliver.  Portsmouth's Children in Care Council is another mechanism which provides feedback on all services delivered to looked-after children.  There was a formal review of the CAMHS service in 2014. 

32. The presentation to the corporate parenting board on the 5th May 2015 clearly outlines the current provision and the service improvements made by Solent NHS which highlights the expansion of CAMHS LAC in 2014/15. This includes working closer through consultation with the Residential Units, Adoption team and Special Guardian Team.

33. In all contacts with the NHS children’s workforce we are raising the importance of our corporate parenting role in early intervention and prevention. We take this responsibility to train and educate all staff when providing a health service to our Portsmouth looked after children very seriously. The health of LAC guidance 2015 has been shared with staff to promote the corporate parenting responsibility.

34. In light of the challenges faced by looked-after children and their carers in terms of accessing mental health services, it would be helpful if there was greater transparency with young people and the Local Authority on decisions about the provision of services from CAMHS, especially when a lack of service may affect young people's social and emotional development.

Recommendations

35. This submission has acknowledged the complexities involved in ensuring that looked-after children can access services to support their mental health and wellbeing.  Portsmouth Children's Social Care would make like to make the following recommendations:

• Funding to expand the capacity of CAMHS LAC teams to reduce waiting times.

• Parity of service for looked-after children being re-unified with their families.

• Care leavers being able to access CAMHS services through to the age of 21 years.

• Extending CAMHS LAC Teams capacity to work with children from outside their CCG, similar to the Virtual School model. Many children with challenging behaviours remain in out of area placements and struggle to access appropriate support.

Bibliography

Ainsworth M, Blehar M, Waters E and Wall E (1978) Patterns of Attachment. Hillsdale, NJ.  Erlbaum

Bowlby J (1988) A Secure Base: parent-child attachment and health human development.  New York.  Basic Books

Crittenden PM (2008) Raising Parents:  Attachment, parenting and child safety.  Cullumpton, Devon.  Willan Publishing.

Department for Education and Skills (2007) Care Matters: Time for Change

Department of Health (2000) Framework for the Assessment of Children in Need and their Families.  Norwich.  Crown Copyright

Ryan M and National Children's Bureau (2006), London, National Children's Bureau.

October 2015

Appendix 1

Child and Adolescent Mental Health Service for Looked After Children

Annual Report 2014-2015

Using words that can be pictured

Contents

Page  3              Abbreviations

Page               4              Aim of Service

Page               4              Strategic Objectives

Page  5              Recommendations from 2013/14

Page  5              Service provision

Page  6              Annual Referral Figures

Page  8              Analysis of Referrals

Page 9              Outcome Rating Scales

Page 10              Session Rating Scales

Page 11              Case Study

Page 13              Consultation             

Page 14              Consultation Feedback

Page 16              Consultation Figures

Page 16              Analysis of Consultation

Page 17              Mental Health Training Programme

Page 18              Attachment Training Evaluation

Page 18              Loss and Bereavement Training

Page 19              Caring for Traumatised Children Training

Page 20              Training Evaluation

Page 21              Co-working

Page 22              Conclusion

Page 22              Proposed work for 2015-16

Page 23              Appendix 1 – CAMHS LAC Interventions

Page 25              Appendix 2 – description of ORS

Page 26              Appendix 3 - Training Course Content

Page 27              Appendix 4 – Qualitative Feedback from Training

Abbreviations

INTRODUCTION

Aim of Service

To promote the mental health and psychological well being of the most vulnerable of Portsmouth’s Looked After Children and Young People and to provide a range of high quality and accessible services that are responsive to needs as they arise and to promote and support placement stability.

Strategic Objectives

The team have two strategic objectives to help us achieve our overall aim. These are in keeping with the most recent National Guidance from both Health and Social Care.[1]

• To focus on partnership working and its role and impact on planning and service delivery, especially in bringing together local agencies and ensuring greater accessibility to relevant services.

• To focus on the impact of the services themselves on children and young people, including increased participation and efforts to empower children and their carers in deciding relevant interventions and solutions.

Wider CAMHS

The CAMHS LAC are part of a wider CAMHS provision that was reviewed during 2014/5. We work closely with CAMHS colleagues in Single Point of Access Team (SPoA), Extended Team, CAMHS LD, IMH, Paediatric Liaison and MST.  Being based and embedded in CAMHS enables the team to represent the needs of LAC, to fast track joint work for those at risk of developing severe mental health difficulties and enables a multidisciplinary approach to those children and young people with complex mental health needs.

(For a full description of interventions offered by the CAMHS LAC Team please see Appendix 1)

Staffing Levels

Staffing levels in 2014/15 were 2.8 Wte

Recommendations from 2013/14
 

• Offer ‘Caring for Traumatised Children’ training package to the Family Placement Social Workers.
• Offer a training package to hostels for older LAC.
• Evaluate and report on our pilot consultation to the residential units.

Reflections on 2013/14 Recommendations

• ‘Caring for Traumatised Children’ training package has been completed with family placement social workers.
• The evaluation and report has been completed for the 9 week training that was offered to family placement social workers.
• Training package to be offered to hostels for older LAC is being assembled.
• The evaluation and report of the consultation provided to the residential units has been completed, informing the decision to offer a further 12 months of consultation for the units.

Gaps in service provision

• Residential resource for children with learning disabilities:  The placement needs of children and young people with a learning disability remain unmet.  Many children with challenging behaviours remain in out of area placements.

• A Psychology and Occupational Therapy resource into the team would enhance early identification of cognitive impairment in children and young people and the impact of sensory issues when working with children and young people presenting with symptoms of complex trauma.

• Feedback from the experience of service questionnaire identified a gap in provision from Portsmouth CAMHS/LAC in Hampshire and the Isle of Wight due to limited resource.

Service Provision 2014/15

The year 2014-15 has been a year of many developments in the CAMHS LAC Team.  Sarah Tollast, Advanced Nurse Practitioner in Loss and Bereavement joined the team and has expanded the training provision we offer to include training for professionals and carers on Loss and Bereavement, a significant impact on mental and emotional health for all Looked After Children. Kathryn Hammond Advanced Nurse Practitioner is joining the team in July 2015.  Kathryn previously worked in the CAMHS Infant Mental Health Team and has a expertise in promoting attachment between infants and their parents/carers. 

We have increased our offer of training and consultation to the Adoption team, Special Guardianship Social Workers and Care Leavers up to the age of 25years.

In addition we began providing in-reach to all Social Care staff, by basing ourselves in Civic Offices one day a week.  In this way we are providing consultation to all Social Care staff who have a mental health concern about a looked after child or young person, who may or not be open to our team.  This provision began in March 2015, following consultation between CAMHS and Social Care and the Integrated Commissioning Team. This input will be formally evaluated in October 2015.

We no longer have a psychology assistant in the team which has meant clinicians have taken on more statistical analysis and report generation, taking some time away from clinical input. Positively, following a re-structuring of the admin staff in CAMHS, the quality and efficiency of team admin has improved.

ANNUAL REFERRAL FIGURES

There were a total of 61 referrals to the CAMHS LAC team between April 2014 and March 2015. This shows an increase of 19% on 2013/14 figures.  The majority of the increase has been in the 10-16 age group.  Referrers ranged from Social Care to Health professionals. The split between boys and girls has remained two thirds and one third respectively.  The group with the most referrals were boys aged between 13 and 16 years, followed by boys aged between 5 and 10 years.  These two groups were the most referred children/young people in 2013-14 as well.

There were referrals from a range of residential locations such as Hampshire, Portsmouth, IOW and West Sussex. The majority of referrals were for children and young people in the Portsmouth locality (See chart below).

Children and young people referred to the team were living in a number of difference placement types. The majority of referrals were from children placed with Portsmouth City Foster Carers (See below)

Referral Details

A total of 12 young people (20%) referred were from a Black or Minority Ethnicity (BME)

Untoward Incidents

There was one incident of a letter being sent to the wrong address. The letter was returned unopened as this incident was quickly identified and all affected parties were informed. There were no adverse repercussions for the young person or their family. Learning includes highlighting up to date information with admin staff and admin staff to check addresses prior to sending out to the family. This has been shared with wider children’s services through information governance and actions taken in relation to demographic data.

Snapshot of Caseload
 

Between April 2014 and March 2015 the CAMHS-LAC team held on average 59 cases a month. These were distributed between Active and Inactive Cases. The Active cases were being seen for a range of interventions; Assessment, Consultation and Therapy. The remaining cases were on an Inactive list for monitoring or prior to discharge.

Direct work

50% (30) children and young people referred to CAMHS LAC received direct work, either individually or with young people’s carers.  Direct work is offered when the young person asks for help managing their thoughts or behaviour, when the young person’s behaviour is such that their functioning in 3 or more areas of their life is adversely affected. (Home relationships - family relationships - peer relationships - self-esteem - academic progress). This indicates appropriateness of referrals in that 50% of referrals require direct therapeutic work.

Young people who self-harm, are suicidal and/or indicate that they may be experiencing mental illness are also offered direct work – as long as they are within manageable travelling distance to Portsmouth.

The other 50% (30) of referrals received input to the network including network focusing on systemic and environmental factors.

Analysis of referrals

61 referrals represent approximately 20% of children and young people looked after by Portsmouth City Council at any one time.

The figures show that the majority of referrals are made by the CLA Health team, at initial LAC medical.  Gauging the underlying causes of emotional distress and underlying mental health issues at this point of a child’s experience of being in care is, at times, difficult as we would expect a child or young person to show distress following a massive change in their circumstances.

In order to analyse whether the difference between number of girls and boys referred is significant we would need to know the ratio between them within the LAC Social Care system as a whole.

With regard to placement moves there has been an increase in both planned and unplanned moves.  Looking at the unplanned moves in more detail 2 moves are for the same young person who had moved from fostering to residential to family and moved again following a corroborated allegation of abuse by a parent.

3 moves were due to concerns about carers’ capacity to look after children/young people as they needed. 3 moves were due to placement breakdown.

A number of the breakdowns have been with IFA carers.  Working with these carers and family placement social workers is possible and can be positive, however we feel that the close relationship we have with Portsmouth foster carers and their Social Workers, makes communication and liaison more straightforward, particularly as we have good working relationships with Portsmouth Social Care teams and are able to offer training with consultation to PCC carers.

OUTCOMES

Outcomes for Direct Interventions

CAMHS LAC have continued to use the Outcome Rating Scale (ORS) and Session Rating Scale (SRS).  This system analyses cases that have had CAMHS LAC input and have been discharged. (See Appendix 2 for a description)

The ORS assesses client functioning that are widely considered to be valid indicators of successful outcome. Please refer to pre and post scores below:

Outcome Rating Scale (ORS)

Pre-treatment score (overall ORS score) 26.6

Post-treatment score (overall ORS score) 35.6

LAC Team Closed Cases (N=16)

There was a significant difference in the total reported ORS scores pre-intervention (M=26.6) and post-intervention (M=35.6). The average raw change was 6.1. The pre-post effect size was 0.8.

Analysis of ORS on discharged cases

The average scores for children and young people show that overall there was an improvement in their mental health and wellbeing. 

These averaged scores will include data from young people who improved dramatically during the time frame as well as those that deteriorated or stayed constant.  Some young people who were discharged did not complete pre and post questionnaires, or declined to complete the ORS during therapy.

Session Rating Scale (SRS)

At clinic appointments, clinicians ask their clients, whether they are working directly with the young person, their parents or their whole family, to complete a Session Rating Scale (see appendix). A strong therapeutic alliance is a good predictor of outcome across different types of therapy, so the SRS is designed to identify the strength of the relationship between therapist and client and highlight any areas of weakness. Receiving real time direct feedback about the session allows the client to feel empowered, promotes collaboration, identifies and addresses any adjustments that need to be made to the therapeutic relationship and enhances outcomes.

The SRS translates what is known about the alliance into four visual analogue scales (see appendix) to assess the clients’ perceptions of:

• Respect and understanding
• Relevance of the goals and topics
• Client-practitioner fit
• And overall alliance.

These four scales yield a total score out of 40. The literature suggests that any score below 36 indicates a need to discuss how the session can be improved. The table and graph below show the average session ratings for 2014-2015 for the LAC Team.

Analysis of SRS on discharged cases

Overall the scores identify that children and young people are satisfied with the quality of the relationship, the goals, topic and approach to treatment received.

The lower overall score express an uncertainty about seeking treatment form a mental health team. Many children and young people in care express an anxiety about being labelled with a mental health diagnosis. Given their early childhood experiences some emotional distress displayed is normal in relation to early childhood adversity. Given this there is often a discrepancy between carers, social worker and young person’s perception of mental health issues. Please note that some children and young people declined completing the ORS and SRS and this is respected.

Case Study

J first came into care at the age of nine and was with one carer between the ages of nine to fourteen. The placement ended as J was displaying controlling behaviours which his foster carer felt she was not able to manage due to her own personal reasons.  J moved to a new placement, with relatively new carers and after a settled period of time and his behaviour began to escalate. J was offered Art Psychotherapy and met with a clinician however decided that he did not want to engage with this. Our team also offered consultation to his carers which including sharing information about his previous history before coming into care and some practical strategies.

J behaviour continued to escalate to a point where it became unsafe for him and his foster carer and it was decided that he would be moved to respite care while a new placement was found.

Our involvement was targeted at stabilising his placement however when it became apparent that this would not be possible we worked at supporting respite carers and then his newly identified long term placement. This involved at first holding a network meeting with J new carer, their social worker and his social worker. Later we involved other professionals who had worked with J and his carer.

J placement has remained stable even during some significant changes involving contact with his birth family. Our team continues to support his carer and school and as a service we continue to monitor his medication and emotional wellbeing on a regular basis.

J carer has a relaxed approach however has put in place clear and firm boundaries, she is very direct with J about the behaviour she does not like and the behaviour she would like to see more of, and uses playfulness to defuse situation. She works closely with other agencies and is also in contact with J original carer which has promoted the attachment to continue even though they are not living together.

The plan is for J to stay with his current carer until he is eighteen, he is planning on attending college in September to gain skills in multi trades with the plan of becoming a carpenter. J view on his previous placement was that he was not happy in the placement although he says he did not feel able to put this into words at the time. Instead J stated that he increased his difficult behaviour to try and end the placement. J’s memory is of the things he was not able to do in the placement and how this turned into a battle in different areas.

Reflection on Case Study

My experience of working with J and his different carers is that there is always interplay between being able to support and up skill carers and their personality being the right match for the child or young person. Even though carers and young people may appear to be a good match it is not known until the young person is in the placement how they will live and interact together. In J case his first carers identified their own reasons why they felt unable to manage J even though they were experienced carers who had been given support from the CAMHS LAC team and other professionals. His second set of carers looked as if they would be a good match J however once he moved to live with them it was apparent that they were not the right personality fit for J. In J current placement he appears relaxed and settled and states he is happy, likes his carers and especially likes the food!

CONSULTATION PROVIDED BY THE CAMHS LAC TEAM

The CAMHS LAC Team provide consultation to many professionals and carers working with Looked After Children.

There are monthly consultation meetings to Beechside, Tangier Rd and Skye Close, the adoption team based at Hester Rd, Special Guardianship Social Workers.

In addition we provide ad hoc consultation to

• Any foster carer of a Portsmouth Looked After Child.
• Consultation to all Social workers, the LAC Education Team, Fostering Support Team through our ‘In Reach’ at Civic Offices.
• Consultations to adopters, family and friends carers, SGO carers and foster carers who attend our training.
• Consultation to CLA Health Team, Educational psychology and schools.
• Consultations to staff and Care Leavers living in hostels.

The feedback from carers and professionals on this service is as follows….

CHI Experience of Service Questionnaire feedback

Copies of the CHI-ESQ questionnaire can be found at http://www.corc.uk.net/resources/measures/parent/

15 carers and 10 professionals completed this questionnaire.

Professional feedback

This year there was a response from 10 professionals which is an increase of 7 from last year.

What was really good about our care?

Respondents of a professional capacity felt that staff were very helpful in sharing knowledge regarding behaviours and thought patterns of young people. It was felt this enabled young people to engage and increased confidence in the support we facilitate to school and pupils which is invaluable.

The atmosphere created is calm and welcoming with good facilities which promote sensitivity and a feeling of being listened to. Working with a team with such a huge knowledge base and understanding of issues that are so prominent to young people, provides a good learning experience; broadening knowledge, skills and tools.

Excellent tips, advice and approaches add to the level of confidence in the service.

What needs improving?

Much of the feedback received about the service was positive. The main need highlighted was a wish for further collaborative time and opportunities to develop more of a service for staff and adopters. Access to more of the CAMHS Clinicians time would provide a useful enhanced consult ion with adopters/parents/schools, etc.

Any other feedback about the service?

The support received continues to be outstanding and invaluable. An excellent service but limited in terms of what is offered in Hampshire and the Isle of Wight.

Carers

This year there was a response from 15 carers which is an increase from 4 from last year.

What was really good about our care?

The advice given was helpful, practical and consistent. Service users felt listened to with their concerns understood, felt supported and seen promptly.  The advice, knowledge and experience instantly made them feel at ease. Support and guidance is always available and there is confidence that the team can help to overcome issues.

What needs improving?

Most of the feedback was positive, although it was felt that there were some difficulties in young people independently getting to the service.

Any other feedback about the service?

It was felt that this is a crucial service for young people in Portsmouth.

Consultation figures

During the year April 2014 to March 2015 there were a total of 511 consultations given by the CAMHS LAC team to carers and workers of Portsmouth Looked After Children. 

Some of these consultations were to professionals involved with children and young people open to the CAMHS LAC team, who did not need to be open cases to the CAMHS LAC Team. These consultations were through ad hoc contact and consultation meetings.  Those seeking consultation included Carers, Social Care staff, Health and other professionals including schools, LAC Education Team, Educational Psychology, commissioners and specialist services such as YOT and court teams.   In addition to these consultations we provided training to foster carers and residential staff, part of which was consultation to the carers individual child in placement. 

Analysis of Consultations

It can be seen that the number of consultations offered from the CAMHS LAC team have increased by approximately 150%. This data is now being collected in a more systematic way. In this way we are providing mental health input to a wider group of professionals in order to promote early intervention emotional health strategies across children’s services. This also fits with current evidence based practice regarding prevention of complex trauma and is considered as a first phase treatment approach (The National Child Traumatic Stress Network, 2003).

Analysis of Consultations to Residential Units

The evaluation of monthly consultations to Beechside, Tangier Rd and Skye Close was reported on in April 2015 and discussed with unit managers and Kate Freeman, Looked After Children Commissioning Manager.

Recommendations

• Management to encourage staff to use telephone consultation from CAMHS LAC.
• All staff who completed a feedback form agreed they would like monthly sessions to continue.
• Consultation will be actively promoted by managers.
• This has been a successful project and agreed a review will be appropriate in 12 months (April 2016).
• Consultation to continue, managers to share the review with staff.  CAMHS to join this process. 

CAMHS LAC MENTAL HEALTH TRAINING PROGRAMME

In total 110 carers and 41 professionals attended training provided by the CAMHS LAC team in the year 2014/15.

Helping Children Form Good Attachments

The CAMHS LAC Team also provided four 2 day training courses ‘Helping Children form Good Attachments’. Training was completed in April 2014 for social care staff, June 2014, November 2014 and March 2015 for Foster carers, SGO carers and Adoptive parents.

All attendees strongly agreed or agreed that the training had met the objectives

The most common comments focussed on the useful strategies provided, increased awareness of the emotional health of the child and how this impacted upon their attachment relationship.

Combined 2 day Attachment Training Course Evaluation

Below is a snapshot of the comments received

“Useful strategies to put into practice and the issues faced by LAC”.

“Remembering impact on caring for traumatised children has on carer’s and ensuring support provided reflects this. I won’t be as hard on myself about the level of change I can effect and will value what I have done more”

Please refer to Appendix 4 for a full report on feedback

Loss and Bereavement Training

A total of 24 carers and 14 professionals attended 1 day training on Loss and Bereavement in the year 2014-15.

Feedback for this course is qualitative and was universally found to be helpful.

The most common comments focussed on the helpfulness of the handouts, the increased confidence in talking to children about loss and the greater understanding of how grief changes through time.  Staff from the adoption team commented on how they were more likely to acknowledge the loss for adopters.

Caring for Traumatised Children Training

Following the successful training programme ‘Caring for Traumatised Children’ for foster carers and residential carers that ran in 2012/13, the training was repeated for Family Placement Social Workers from September 2014-December 2014. The total number of staff who attended the training was 14.

(See Appendix 3 for course content)

Outcomes

Individual Session Ratings

The individual session evaluations were completed at the beginning and end of each session.  It asks participants to rate their understanding and ability to manage children and young people with the above mental health issues.  All participants rated greater understanding for every session, between 1.6 points increase for Trauma and Neuroscience to 2.9 for Sensory Integration and Play. 

PCC course satisfaction questionnaires

All participants agreed or strongly agreed to the questions.

Qualitative feedback

Participants were asked to comment on the ways in which they intended to develop or change their practice as a result of the learning. See word cloud below:

…………… and how the course could be improved

The 9 week training will continue to run in 2015-2016.

Caring for the Traumatised Child - Booster Session

In order to consolidate the knowledge and skills gained from the 9 week training programme, a ‘booster session‘ was offered to foster carers in July 2014. The participants were 9 foster carers and 2 professionals.

Awareness Training

The CAMHS LAC Team also provided three, 1 hour slots contributing to the team around the foster child training for new foster carers. These sessions aimed to inform new foster carers about the LAC Team, how to contact the service if necessary and what therapeutic work may be offered for appropriate referrals.

Analysis of Training – benefits to young people

CAMHS LAC are pleased with the feedback from all the training and plan to continue in the year 2015/16.  We adapted the training to meet the needs of attendees and feel that training being presented by experienced clinicians, who know the joys and stresses of working with Looked After Children, enhances the training environment, allowing attendees to be open and honest about their experiences, which in turn, leaves them feeling understood and valued by CAMHS LAC. 

It is these qualities we aim to promote between carers, professionals and Looked After Children - and are necessary for secure attachments and stable placements - we like to practice what we preach! 

CO-WORKING WITH SOCIAL CARE COLLEAGUES

Safer Care Policy

Along with Portsmouth Council Learning and Development Team and representatives from the Family Support Social Work Team and Children Looked After Team, CAMHS LAC have been contributed to rewriting the Safer Care Policy for Portsmouth City Council.  This is now in final draft, having been sent for consultation with Social Workers and Senior Managers within Social Care.

This has taken place to increase delegated responsibility for foster carers.  Safe care is crucial to all positive placements and integral to developing healthy attachments between carers and children in longer term placements.  This is an area in which the social care agenda and mental health services for LAC need a shared view as it is often anxieties around safer care that cause most stress to carers – Is it OK to cuddle when a child is distressed?  How do I teach my LAC to keep himself clean? 

The new guidance is sensible and straightforward, designed with the day to day life and relationships between carers and traumatised children and young people in mind.  It will hopefully address the issues that arise in homes and support carers to meet the child’s needs safely and empathically.

Health of Looked After Children Group

CAMHS LAC has been actively involved in this working group since 2011/2 -   contributing to the health needs assessments of LAC, discussion on how to measure health and emotional well being outcomes for LAC, presenting to the Corporate Parenting Board and developing policies and agendas that promote the health of LAC in Portsmouth City Council.

CONCLUSION
 

This year has been very productive and efficient in providing effective clinical training, consultation and direct therapeutic work with foster carers/young people/children. The ‘Caring for the Traumatised Child’ training has continued to demonstrate its efficacy in providing family placement workers with further skills and knowledge in managing carers with children with complex mental health difficulties. Consultation has continued to be valued by the residential units, and the evaluation of this programme demonstrated its efficacy. On-going consultation to practitioners and carers to embed the training is crucial to a change in practice.

Our strengths as a CAMHS LAC team are that we value and develop positive multi-agency relationships. We emphasise the importance of discussing emotional and psychological concerns in easily understood language that holds in mind a child’s day to day life experiences.

The CAMHS LAC service continues to offer a value for money service and we are creative in using our limited resources to maximise the positive outcomes of Portsmouth LAC, through addressing and managing mental health difficulties.  We believe that by being embedded in the wider CAMHS service we continue to develop an expertise in the specific needs of traumatised children.  Our location enables us to offer multi-disciplinary mental health assessments with CAMHS colleagues, raise awareness of NICE guidance for children in care and hold a strong voice for LAC within CAMHS.

Proposed work for 2015/16

• Offer ‘Caring for Traumatised Children’ training package to additional healthcare professionals and hostel staff.
• Re-evaluate the efficacy of the consultations provided to the residential units.
• Evaluate in reach to Civic offices.
• Evaluate consultation to SGO SW’s, Adoption Social Workers, Care Leavers.
• Audit requests for one off mental health screening to Care Leavers.
• Continue Loss and bereavement training.
• Develop care pathways on NICE Attachment guidance, PTSD, Trauma, Loss and bereavement, 0-5 years.
• Pilot a group for children identified as presenting with Sensory Integration difficulties.
• Increasing young people’s participation in service development.

Appendix 1

Interventions offered by the CAMHS Looked After Children Team (CAMHS LAC).

Specialist assessments.

We provide a specialist mental health assessment to individual children/young people. The assessments inform further therapeutic work and or highlight significant issues for discussion within the wider network. These could be in relation to the child/young person or their placement needs.

Prior to arranging an assessment we will have met with carers/school/social workers and depending on age, the young person themselves, to get a full picture of the history and context of the difficulties. In the assessment we will be looking at the relationship young people have with their carer/s, the way stress and trauma is currently managed, the meaning and function of behaviours and the extent to which they are caused by circumstances or internal factors.  We may suggest alternative management strategies or tasks for the carers or network.

Additionally, we may complete a school observation and talk to birth parents to gather a comprehensive developmental history. A full report is written for each assessment, including recommendations for improving the young person’s mental health.

Direct Therapeutic Work.[2]

For young people who have been assessed and are able to engage in therapeutic work, we offer sessions through assertive outreach and at Falcon House.  Where possible and appropriate we include the carer in this work in order to help develop a strong and trusting attachment/relationship between carer and young person.

When it is suited to the young person we will see them on their own.  These sessions focus on helping children and young people to reflect on their experiences and the impact this has had on them and to help them make choices and relationships that improve their mental health as they grow older. In our therapeutic work, we draw upon several psychological models, depending on the need of the child/young person e.g. attachment theory (PACE), trauma (bereavement work, DBT), systemic theory (solution focused) and CBT etc.

Training on Understanding and Working with Traumatised and Attachment Disordered Children and Young People.[3]

Training was provided to enhance the quality of care that children and young people receive from foster and residential carers, by supporting and educating carers on the impact of trauma on attachment formation and the implications for longer term mental health. This training was also offered to family placement social workers, in order to enhance their confidence, skills and knowledge on various aspects of mental health, which they could use when providing support to carers in developing their relationships with the children/young people and in managing their complex needs.

Consultation and support.[4]

Consultations to carers can be an ongoing intervention in itself.  For example, when younger children who are living with a great deal of uncertainty about the future whose difficulties are related to change, we are more likely to offer consultation to the carer to promote thoughtful and responsive care.  This intervention also minimises the number of professionals the child sees.

Short term and ad hoc consultations are available to professionals and foster carers for any Portsmouth Looked After Child.  The child does not need to have been referred to the CAMHS LAC Team.  We offer bi-monthly consultation slots for professionals, as well as being available for telephone consultation. 

Consultation to the Portsmouth residential units, to discuss any young person in their care, is currently taking place once a month to each unit.  The usefulness and sustainability of this intervention was assessed in October 2014, and the feedback suggested that although attendance was low, those who were able to attend felt the sessions were very beneficial. Therefore, it was agreed that the monthly consultations to the residential units would continue for another 6 months 

Thinking Networks[5]

Network meetings can be a part of other interventions offered by the CAMHS LAC Team – assessment or therapeutic work – and can also be an intervention in itself.

The purpose of these meetings is to strengthen the ‘team around the child’ and to ensure good communication and shared understanding of the needs of the young person.  These meetings usually include Social Workers, Carers, Education and where possible, family contact supervisors.  Other agencies such as Youth Offending Team, missing person police or educational psychology are involved as appropriate.

Appendix 2

Description of Outcome Rating Scale (ORS)

Outcomes have always been important in CAMHS; to monitor progress in clients, provide evidence that interventions are working and to give information to commissioners about our service.

In October 2013 CAMHS LAC started using the Outcome Rating Scale and the Session Rating Scale with clients undertaking any treatment in CAMHS. The graphs below represent forms completed by 25 young people and carers.  The ORS was offered to all clients who were old enough and/or able to reflect on their experience of attending CAMHS appointments. 

• Outcome Rating Scale – measures client and carers feedback on progress on a session-by-session basis
• The Session Rating Scale – measures client and carers feedback on the clinicians responsiveness to the client (again on a session-by-session basis)

Advantages of using these measures:

• Completion, explaining and interpreting these measures is brief, making them easier to use for clinicians, whilst providing comprehensive outcome measure of the therapeutic intervention that the service provides.
• The ORS and SRS give young people and their carers an opportunity to describe their experience of the service, and this feedback can be used to adapt the therapeutic intervention to suit the style/need of the client.
• A number of studies support the efficacy of using the ORS and SRS as a client feedback intervention across various treatment approaches
• Research on the ORS and SRS demonstrate impressive internal consistency and test-retest reliability.
• ORS and SRS show moderately strong concurrent validity with longer, more established measures of treatment outcome and therapeutic alliance.
• Feasibility (i.e. the degree to which it can be explained, completed, and interpreted quickly and easily) of the ORS and SRS is high as they are brief.
• Over 3000 young people participated in the four year validation study of the ORS with adolescents aged 13 -17, and the Child ORS for children aged 6-12. The ORS and CORS significantly correlated with the Youth Outcome Questionnaire (YOQ 30), and both showed robust reliability, validity and feasibility.
• Four studies, including three Randomised Controlled Trials, support the efficacy of using the ORS and SRS as a client feedback intervention across various treatment approaches.

Client Feedback

At clinic appointments, clinicians ask their clients, whether they are working individually with the young person or the session includes carers, to complete a Session Rating Scale (see appendix). A strong therapeutic alliance is a good predictor of outcome across different types of therapy, so the SRS is designed to identify the strength of the relationship between therapist and client and highlight any areas of weakness. Receiving real time direct feedback about the session promoted service user-led systems, allows the client to feel empowered, promotes collaboration, and identifies any adjustments that need to be made to the therapeutic relationship to enhance outcomes.

Appendix 3

Caring for Traumatised Children

Objectives

1. To provide training to family placement social workers.
2. To enhance the knowledge and skills of these professionals when managing the emotional and behavioural needs of their carer’s Looked After Child, including those with additional Learning Disabilities.

Training Programme

The 9 week training programme included the CAMHS LAC team core teaching block on attachment and the impact of trauma on emotional behavioural and neurological development as well as a wider range of Mental Health modules.

The Sessions:

1. An Overview of Attachment
2. Neuroscience and Trauma
3. Social Learning Theory
4. Reinforcement - Application of Social Learning Theory
5. Learning Disability and Risk
6. Understanding Children With Sexually Harmful Behaviour & Risk Assessment
7. Understanding and Managing ADHD
8. Sensory Integration and Creative Play
9. Summary, Feedback and Action Planning

Participants attended three hourly training sessions each week for 9 weeks. The sessions included Microsoft PowerPoint presentations, group and individual exercises and the opportunity for group discussion on the theory or their own experiences and practice examples. All groups were encouraged to share ideas and thoughts about the young people they worked with throughout the sessions to facilitate an atmosphere of ‘collaborative consultation’. Regular breaks were timetabled into each session and refreshments were provided.  

The final week of the training programme involved a summary presentation and action planning. Throughout the 8 weeks training the facilitators made note on some of the themes that were arising in the participants’ discussions, these were presented to them in the final session in addition to an overview of the previous 8 weeks of training, residential managers were invited to attend the relevant group for the purpose of assisting participants in planning how they intended to implement the training in their practice.

Appendix 4

Comments from training

Which part of the course was most useful?

“It was useful to have a refresher on the overall impact of attachment has on a child’s development. Ways in which you can support a child through trauma was helpful”.

“All very relevant to my current work and future as a foster carer”

“Exploring impact of trauma on the brain and considering the child’s perspective”.

“The videos and examples of cases made the theory very good”.

“All aspects – slides/DVD’s in particular”

“DVD’s and reflection on own practice bought it to life. Reading references to use after training, practical ideas for activities, resources to use to strengthen attachment”.

“Some of the videos were very informative and refreshing. All content was useful. Tips on how to work better/support building attachments with clients was useful”.

“Strategies for building attachment, development processes”

“Tips on building relationships with teen mums who appear to have no attachment to their own child, such as commenting on what they are doing well”.

“Looking at theory of development”.

“Child’s view point”

“Group tasks to think about strategies”.

“Current research on developmental trauma”.

“Direct work with children and families to form good attachments, recognising your own attachments”.

What was the least useful?

“Training at the Civic makes it difficult to step out of work mode”

“More information surrounding how to get support for children that come into care for short periods but need continued CAMHS support”.

“Everything was useful, although lots to take in and process”.

“All was useful”.

“Nothing”

“Examples being based around foster carers and LAC children. So how to transfer to children living with their actual parents”.

“Some of the group exercises”

“Statistics”.

“Heavy emphasis on LAC so sometimes difficult to relate to direct work with families”.

In what ways do you intend to develop or change your caring as a result of your learning?

“I shall consider attachment patterns to inform interventions with the young people who I work with, I shall increase my curiosity by reflecting what I see to the young people at the time to aid my and their understanding and development”.

“Putting what I have learnt into practice and using it more in my interactions with parents”.

“Use the resources suggested to support future cases on an individual basis”.

“Virtual schools to liaise with LAC CAMHS in hope of incorporating information into training for schools. Reference reading materials to schools and carers, ideas of strategies/resources/activities for schools/carers”.

“Look at training opportunities for school staff to share this useful learning. Discuss course content at team meeting. Use suggestions within direct work”.

“To feel more confident in understanding the issues faced by LAC and to be able to pass onto carers and schools”.

“I will think much harder about the reasons and traumas behind certain behaviours. Really very impressed with the course”.

“I will input what I have learnt into my assessments particularly my analysis to establish the impact trauma may have had on that child”.

“I will be able to focus and keep in mind child perspective. Also dealing with adults with PTSD, impact of their childhood trauma still present in adulthood even though they are parents themselves.

“Increased reflection on behaviour of children in their family homes and foster care”.

“Increase in awareness of direct work and an understanding of my cases attachments”.

If you were the training officer designing this course, how would you improve it?

“Some time spent doing some activities you could do with a child to help you feel more confident in doing so”.

“Consider if aspects of the course could be more interactive, I would have liked more practical ideas of what I could do”.

“Put more case studies to do as groups”.

“Handouts to be given before so notes can be added during discussion”.

“It was perfect”

“It was fantastic”

“Excellent pack to take away”.

“Trainers amazing at offering advice”

“Develop for all service users”.

“Learning emotions behind certain behaviours, understanding more reasons behind certain behaviours. I found being in a confidential setting alongside professionals and other foster carers a really helpful learning experience from people in similar positions to ourselves actually living with attachment issues and personal experiences”.

“The practical ways that promote attachments are formed”

“Why children act out the way they do because of previous experiences”