Introduction

This is a report from an expert working group established by the Department for Education (DfE) in February 2016 to “ensure that the emotional and mental health of children and young people in care, adopted from care, under kinship care, under Special Guardianship Orders, as well as care leavers, would be better met.” The report is available at: https://www.scie.org.uk/children/care/mental-health/report.

The expert working group followed the Department for Education and Department of Health publishing new statutory guidance on Promoting the Health and Wellbeing of Looked After Children in March 2015. The guidance is available at: https://www.gov.uk/government/publications
/promoting-the-health-and-wellbeing-of-looked-after-children–2.

SCIE was contracted by the Department of Health (DH) and the DfE to establish the expert group and support the work.  The expert group brought together a selection of the most committed experts in the field of child and adolescent mental health.  The group included experts by experience as well as evidence from local and national stakeholders.  From the start of the work there was a commitment to co-production.  It was co-chaired by Professor Peter Fonaghy, Professor of Contemporary Psychoanalysis and Developmental Science, University College London, Dame Christine Lenehan, Director of the Council for Disabled Children and Alison O’Sullivan, Past President of Directors of Children’s Services.

The report does consider the wider context of services to support the mental health of all children and young people, but its primary focus is on looked after children.

The expert Working Group commissioned a literature review and held a Call for Evidence of good practice.  These are all accessible through the SCIE link provided above.

The report:

• Established eleven key findings which are the drivers for change;
• Makes sixteen recommendations that address those findings;
• Develops seven quality statements that define outcomes that the recommendations are intended to achieve.

In addition, the report developed a new model which places the young person at its centre, an ‘eco-map’ and decision trees to help children and young people access services.  The eco-map is a representation of the choices that should be available to the young person and or primary caregiver to access the right support and resources.

The report says that “at the core of the model and pathway is the need for:

• Timely intervention and support;
• A system that can be activated by anyone within the child or young person’s network;
• A recognition that mental health is a continuum;
• Support that is responsive to the young person’s needs.”

Context

The guidance published by DH and DfE on promoting the health and wellbeing of looked after children acknowledge that almost half of children in care have a diagnosable mental health disorder and two-thirds have special educational needs. Alongside the publication of this guidance NHS England and DH published ‘Future in Mind’ which set out care pathways and new models of evidence based care to identify and meet the needs of vulnerable children and young people.  Future in Mind is available at: https://www.gov.uk/government/uploads
/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf.

Future in Mind set an expectation that the needs of children in care would be addressed in the delivery of local services.

From the start of the work a fundamental principle of the project was that “recommendations be based on proposals that were supported by the available research evidence, by those directly involved in looking after our most vulnerable young people, and by young people themselves.”   This has meant that co-production has been at the heart of the work with the voices and experience of young people central to the work including the development of the recommendations, models of care and pathways.

The project reflects that young people “… expressed their anger and despair at professionals assuming they did not have the capacity to contribute to decision making.” For example, being presented with child and adolescent mental health services as the only solution.

What is known about the mental health needs of children in care?

The report quotes from research that almost half of all looked after children have a diagnosable mental disorder and that 52% of children in care have low subjective wellbeing compared to around 10% of children in the general population. Looked after children have increased risk of attention deficit hyperactivity disorder and autistic spectrum disorders. Given that the best predictor of psychiatric disorders in adulthood is psychiatric disorder in childhood and adolescence this make a strong moral and practical case for early intervention with children in care.

Practice Examples

The report provides examples from the Call for Evidence. The models, pathways, recommendations and quality statement are based on the evidence from the Call for Evidence, from children and young people, via stakeholder events and from discussion in the Expert Working Group.

What should a good system look like?

The report identifies the importance of caregivers and professionals needing to demonstrate that they have a strong understanding of the children’s feelings thoughts and wishes and that the community around the child needs to share their understanding of the child and their needs regularly.

Understanding of mental health needs should be through timely assessment and that the mental health needs of children in care should be reflected in all care plans and at all stages of the care review and planning process.

The report found that many caregivers feel they do not get the support they need in an effective or timely way due to high thresholds or exclusion from key meetings.

Commissioning and Multi-agency Collaboration

The expert working group were concerned about the number of individuals and organisations that can be involved in a child’s care, poor multi-agency collaboration and the capacity of the system to support children and young people with the most complex needs. These problems are reflected in weak commissioning systems and practice. These problems are system wide but most acute for children and young people with the most complex needs.

The weakness in how children and young people with complex needs get the help they need was a main driver for one of the reports central recommendations. This is the development of a virtual mental health lead. This role would be modelled on the success of the virtual school head for looked after children with the same principles of championing children’s needs, monitoring progress in local areas and intervening where necessary to promote good practice but with a focus on mental health and wellbeing. The Expert Working Group thought the post should be located within the NHS with the lead having “sufficient mental health expertise and professional credibility to communicate with other health professionals”.

Corporate Parent

The Expert Working Group identified that within the dual role of corporate parent of provider of services and ‘parent’ the former role is given priority over the latter. The Expert Working Group want to see the ‘parent’ role given priority. They hope that with the implementation of the Children and Social Work Act 2017 with its principle that corporate parents must act ‘in the best interests of and promote the health and wellbeing of children and young people in care’ this will increase local areas’ commitment to the role.

Child and Adolescent Mental Health Service (CAMHS) Provision

The report identifies the need to improve provision at local and national level. The increased funding for CAMHS is welcomed but the report says it is too early to say what difference this will make and that if all it does is replace funding that has been withdrawn then this will not deliver improvement to services.

Stable Placements and Relationships

Young people said stability is the most important aspect of their experience of care. Placement instability is identified as both a cause of mental health conditions and an effect of the placement itself. The importance of support to carers in reducing placement instability is highlighted. The report quotes the Children’s Commissioners latest report on vulnerable children and the stability index which says:

“When children in care have to change their placement, it can lead to relationships with trusted adults being broken.”

Assessment

The Expert Working Group said:

“Done correctly, assessment can be the foundation for providing a comprehensive strategy of support and services, developed in partnership with children and young people and their care givers.”

The group did not think the Strengths and Difficulties Questionnaire (SDQ) was an effective way to measure the mental health and emotional wellbeing of young people. Their view was it needs to be used in conjunction with other assessment methods.

In discussion of approaches to assessment the Expert Working Group recognised the importance of identifying strengths as well as challenges and that assessment needs to go beyond diagnosis.  An important element of this is how assessments are undertaken which needs to reflect the development of a relationship with the child or young person.

Contemporary Challenges

The Expert Working Group were concerned about the wider influences on mental health and wellbeing of young people including:

• Growing up in a digital age;
• Increased societal inequality;
• Failure to develop coherent support or children’s mental health.

Children and Young People’s Recommendations

These recommendations came from young people who were experts by experience.  They are:

• Young people need love and kindness;
• Not everything is an issue or problem;
• Don’t judge us;
• Don’t leave us waiting for help or without information on decisions that affect us;
• We need time;
• We are still young people;
• Don’t treat us differently;
• Remove barriers;
• Let young people be involved;
• Social workers should be trained in life story work, talking therapies and anger management;
• If a young person has more complex needs, they should have access to more advanced therapy.

Key Findings

The report identifies eleven key findings, summarised as follows:

1. A needs based model is the best way to support and respond to young people.
2. Young people and front-line professionals expressed frustration at the conventional linear approach to describing pathways. Young people’s journeys are not linear, and neither are their needs.
3. Initial and continuing assessment of mental health status is essential for monitoring and meeting needs.
4. How an assessment is completed was more important than by whom to young people. Young people were keen to recommend the importance of trust and getting to know each other first as part of any assessment.
5. Statutory services must ensure they allow those who have key relationships with the young person to contribute to decision making.
6. Caregivers need to be fully aware and informed of what statutory and non-statutory services are available.
7. Children and young people want choices outside of CAMHS.
8. There need to be stronger mechanisms of accountability within existing systems.
9. A similar oversight role to that of the virtual school head, a virtual mental health lead is needed.
10. It is only by collaborating with young people that we can move beyond services ‘done to’ to services ‘done with’.
11. In relation to mental health assessment a key process recommendation is to shift control back to the child and young person including a strengths based approach focusing on enhancing resilience.

The report develops from the findings seven quality statements with a total of sixteen recommendations grouped by the quality statement they relate to.

What the quality statements cover together with their linked recommendations are set out below:

1. Commissioning and accountability:
   1. Ensuring Joint Strategic Needs Assessment by Clinical Commissioning Groups addresses the mental health and wellbeing of looked after children and care leavers;
   2. Local Safeguarding Children Boards, Corporate Parenting Board and Health and Wellbeing Board give priority to ensuring the mental health and wellbeing needs of looked after children and care leavers are met;
   3. Ofsted, Care Quality Commission and Her Majesty’s Inspectorate of Prisons should review their regulatory frameworks to ensure equal weight is given to mental as physical health;
   4. Each statutory review of the child’s care plan should include whether mental health needs have been met.
2. Leadership:
   1. Establish a virtual mental health lead role modelled on the virtual school head role;
   2. Every school should have a designated teacher with training and competence in identifying and understanding the mental health needs of pupils who are looked after;
   3. Ministers at DH and DfE should work together to ensure children in care and leaving care have access to services provided for their mental health and wellbeing.
3. Workforce – Knowledge and skills in recognising and responding to children and young people’s mental health needs:
   1. Caregivers need to be informed of which statutory and non-statutory services are available. This should be included in each areas local offer.
4. Workforce – Recognition and valuing of carers:
   1. Caregivers should receive support for their own mental health and wellbeing;
   2. Everyone working directly with looked after children should receive training on children and young people’s mental health.
5. Voice:
   1. A needs based model is the best way to support and respond to young people;
   2. Existing mechanism for capturing direct views of young people should be integral to planning and commissioning arrangements;
   3. Self-help, peer mentoring and community initiatives should be considered before referral to more formal CAMHS.
6. Pathway:
   1. Formal services should be more flexible in who they will allow to support the young person.
7. Assessment:
   1. The SDQ should be supported by a broader set of measures which can trigger a comprehensive mental health assessment;
   2. Assessments should focus on understanding the individual’s mental health and emotional wellbeing in the context of their current situation and past experiences, rather than focusing solely on the presenting symptoms.

The report sets out a model that champions the mental health needs of the young person. Then model is framed as a series of “I” statements. It places the child or young person at its centre with what is needed for positive mental health in terms of relationships, community support, hobbies, education, health and home with the enablers for these identified.

The Expert Working Group developed an eco-map and linked decision trees to reflect the pathways by which children and young people should be able to access the support and help which delivers what is in the model of good mental and emotional health care.

At their heart the model and pathway identify the need for:

• Timely intervention and support;
• A system that can be activated by anyone within the child or young person’s network;
• A recognition that mental health is a continuum;
• Support that is responsive to the young person’s needs.

Decision trees have been developed to cover prevention and accessing support.

Conclusion and Comment

The report makes a number of useful recommendations for Government local and national, NHS bodies and for practitioners. The model for promoting children and young people’s mental and emotional health is easy to grasp and helps ensure a systemic and whole person approach to thinking about children and young people and how we can help them have positive emotional and mental health.

The eco-map and decision trees help provide a clear framework for pathways to services which should help commissioners and practitioners improve access to services and provision. Their straightforward structure with the child at their centre gives them clarity.

The idea of a Virtual Mental Health lead could help with reducing barriers to access to service and provide a champion for children in care within the complex framework of CMAHS. Whether it can work will depend whether it is adequately resourced, services to help meet need are available and those appointed are given the mandate to act with authority to improve the mental and emotional wellbeing of children in care.