Failing mental health provision for children in care under review

An inquiry by the education select committee has concluded that mental health services for looked-after children are not good enough.

In a wide-ranging report, MPs identified failings across the system – from assessment of need through to long-term monitoring of wellbeing – and have made a number of recommendations on changes that need to be made to improve the mental health of looked-after children.

The government has responded quickly, setting up an expert group into looked-after children (see box), but mental health experts say action is needed in other areas to improve provision urgently.  

Assessing problems

Although all children entering care should have an initial health assessment by a registered medical practitioner, this focuses on a child’s physical health. There is no requirement for mental health to be evaluated. Looked-after children experts and members of the select committee agree that not enough is being done to gauge the wellbeing of children entering the care system and keep tabs on their mental wellbeing as they grow up.

Local authorities are required to complete a brief emotional and behavioural assessment annually for every child in care – known as the strengths and difficulties questionnaire (SDQ). However, Ofsted has said that these are “rarely” used to maximum effect.

In order to remedy the situation, the select committee recommends that children in care should receive a comprehensive assessment of their mental health and emotional wellbeing – followed up with a plan to support them in the most appropriate way.

“Most people would assume a child taken into care having suffered abuse or trauma would automatically be assessed for their emotional wellbeing and mental health, and steps put in place to help them recover from their trauma,” says Lisa Harker, chief executive of The Art Room, a charity that supports five- to 16-year-olds who are experiencing emotional and behavioural difficulties.

“The SDQ is used in some places, but it’s a paper exercise, a ticking of boxes that doesn’t subsequently result in a treatment plan. Yet these are very vulnerable children and the state is the corporate parent.

“It is incumbent on the state to ensure their mental health needs are met in the same way their physical health needs are met.”

Providing services

Even when mental health problems are picked up, young people often face difficulty accessing specialist services.

One of the concerns is that high numbers of young people are turned away from child and adolescent mental health services (CAMHS) because they do not fit the medical criteria of having a diagnosed mental health problem, or are not in a settled placement.

The select committee said reluctance to assess or treat young people without a stable placement largely stems from “uncertainty” as children and young people move between foster or residential placements, with CAMHS often unwilling to begin therapeutic treatment until they can be sure that a child will be based in the same location for a significant period of time. It says this is no excuse for inaction and has recommended that CAMHS should not refuse to see children or young people without a stable placement or delay access to their services until a placement becomes permanent.

However, Sarah Brennan, chief executive of children’s mental health charity YoungMinds, says CAMHS is under such pressure that it is only able to provide help for around one in four young people in need of support.

“There are a huge number of young people who aren’t getting the help they need at the time they need it because CAMHS is so overwhelmed,” she says.

“They have been forced into a position whereby to manage that demand they have had to raise thresholds. This means young people are getting sicker before they can access any help, something that is borne out by the fact that numbers of young people accessing help by ending up in accident and emergency departments has doubled in the past five years.”

Brennan says the £1.4bn pledged by the government to improve mental health services for young people has the potential to remedy the situation.

“It depends on how commissioners prioritise their funds locally though,” she says. “If they see it as money that can be raided or they reduce other CAMHS funding, it will be impossible to address this. But with the right approach and the right culture, a huge amount could be achieved.”

Prioritising access

Views differ on whether looked-after children should be given priority access to mental health services, even within the government itself. Giving evidence to the select committee, children’s minister Edward Timpson said he is in favour of priority access, but health minister Alistair Burt said he is opposed to it.

Essex County Council is one area that has decided to make looked-after children and young people a priority for accessing support. It says it has done this to ensure that they receive a specialist response as “swiftly and effectively as possible”.

The select committee has recommended that children in care should have priority access to mental health assessments by specialist practitioners, with subsequent treatment based on clinical need. Brennan wants the government to go even further by giving looked-after children priority access to services.

“Young people who have experienced family break-up and have been placed in care may have been through a number of placements and that is very traumatic for them,” she says.

“The trouble is that if they are referred to CAMHS, what they have experienced might not show itself as a diagnosable mental health problem.

“But we know that those traumas have a long-term impact and will show themselves later on.

“We need CAMHS to understand that these young people must receive some help to prevent or reduce the development of mental health problems later on. There needs to be fast-tracking of those young people and staff need to be trained to sensitively decipher what has gone on in that young person’s life.”

Harker says the decision to take a child into care should trigger an automatic entitlement to therapeutic support. She wants the government’s Adoption Support Fund – worth £21m in 2016/17 – to be extended to all children in care to ensure they can receive tailored support short of CAMHS involvement.

“Some looked-after children are eventually adopted. Many aren’t. But their needs are very similar. It makes sense to extend that fund,” she says. The fund supports a wide range of provision – it is not a case of one size fits all. There is a whole spectrum of possible interventions available in the voluntary and statutory sector that young people ought to be able to access according to their needs.

“With the right therapeutic support, children who have experienced adversities in their lives can be helped to thrive and given a second chance to have the childhood they deserve.”

In numbers

• 69,540 children in local authority care
• 45% have a mental health disorder
• 80% have mental health problems
• £1.25bn allocated to improve children’s mental health services by 2020

Source: 1. CoramBAAF; 2 & 3. NICE; 4. Future in Mind


‘We must use evidence of best practice to find better ways of addressing the needs of children in care’

By Alison O’Sullivan and Peter Fonagy, co-chairs, the expert working group for looked-after children

As the Children and Young People’s Mental Health and Wellbeing Taskforce has previously set out, the picture for mental health services for looked-after children is very variable. In some areas there is good practice, but there are other areas where arrangements are pretty poor.?

The education select committee is right to say that looked-after children are not getting the support they need. These children have often had troubled journeys, with many traumatised by abuse.

As a result, their level of need is higher than the general population. If you listen to the experiences of these children and their carers and families, you get a rich picture of their needs. Some get the right care, support and treatment, but others tell stories that are worrying.

They speak of not being able to get help when they need it. They say that the understanding of their experiences among the workforce is not as developed as it could be. We need to find better ways of meeting the needs of those children and young people guided by best evidence.

The core business for the expert group will be to pull together what is known about the needs of children and young people in care and identify best practice in supporting them and addressing those needs. We want to develop a picture of the kind of help and range of help young people in care should get access to in order to inform the offer for their carers and families.

It will be about bringing together the expertise of what works with the planning of how implementation best works – in other words a care pathway. There is good support from the government for this, both from health minister Alistair Burt and children’s minister Edward Timpson, and the government has allocated significant money towards improving young people’s mental health.

In most locations, mental health services for children are being transformed to provide better integrated, more responsive care. This is the best shot we are going to get at this, so we have to get it right now.

It will likely take longer than a year to come up with our full recommendations, but we will not wait until the end of the work if there are things that can be implemented along the way that can shape and influence the journey of young people.

We want to establish a framework that will become the baseline for how things should operate and will raise the bar and expectations, and be for the long-term.

We are clear that the voice of young people and their carers must guide this work. And it's important that we don't over medicalise the challenges that children and young people face during the course of growing up. A lot of young people we talk to want support and help addressing their problems but do not want to be labelled as 'cases needing treatment'.
 
We know that there are many ways in which young people can support each other and develop their own personal resilience to deal with the ups and downs of life, all of which helps them to deal with periods of adversity. And it's vital that families and carers are supported to understand and support young people in distress. So finding the best ways of providing access to a wide range of help and helping people to care for themselves will be part of the mix.
 
We want to make sure there is a good range of support available not just from specialised services but also embedded within better equipped universal and support services. And of course while schools have a particularly important part to play we all have a role in achieving this.
 
Raising awareness and understanding of mental health issues will be important, as will ensuring that the right training is in place for all of those dealing with mental health issues. As new models are developed we need to make sure that the right range of professionals with the right skills will be in place.
 
And it will be vitally important that all of this informs the commissioning of services for the future. Ensuring that commissioning is informed by sound knowledge of best practice as well as information about what works will be essential to make sure that better ways of working are embedded in a sustainable way for the long-term. Addressing well the particular needs of children in care is not only vital for the well-being of those young people but also for the sustainability of our communities in the longer term.