Improving mental health support for our children and young people
Expert Working Group final report
Published: November 2017
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As a society, we trust the state to provide the best possible care to all children who cannot be looked after by their birth families. In their journey through care, the meaning we can give to the life of the young person whose wellbeing rests in our collective hands, the speed with which we respond to the distress of children in care, and the resources we make available to support them in their time of need, all speak to our capacity as a society to safeguard the most marginalised.
The mental health of young people is a focus in our society as never before, and we welcome the government commitment that by 2020 there will be system-wide transformation of the local offer to children and young people. Work has begun with principles of service integration across health, education, justice and social care now feeding into sustainability and transformation partnerships (STPs) and Local Transformation Plans (LTPS) across the country.
However, through our Expert Working Group meetings, stakeholder events and Call for Evidence we have learned that too often we are failing these children and young people. Multiple testimonies highlighted that some looked after children and young people are not accessing services when needed, or are being told that their mental health need does not meet service thresholds.
Other evidence in this report highlights that we must change our approach to children and young people’s mental health and ensure that services are accessible, flexible and child-centred. The report also highlights the urgent need to transform how we commission, collaborate and work together in local areas to give children in care the same level of support, care and opportunity that we would wish for our own children. We need to build a community both around the child and those caring for them, to ensure that this group of young people are supported to reach their potential.
In February 2016 the Department for Education (DfE) minister announced that an Expert Working Group would be created to ensure that the emotional and mental health needs 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. It was proposed that, by October 2017 the following would be developed:
- care pathways: focusing on the young person’s journey
- models of care: how services ensure appropriate interventions
- quality principles: measures that set out markers of high-quality care
- implementation products: to support those working in the field.
The charity Social Care Institute for Excellence (SCIE) was contracted by the Department of Health (DH) and the Department for Education to establish the Expert Working Group to support this work.
We believed that it was absolutely essential that our work was co-produced with children and young people, and over 80 contributed their experience and evidence to the project. We also heard from those looking after young people and approximately 100 professionals including looked after children nurses, doctors, birth parents, social workers, residential key workers, foster carers and adoptee parents. All of these groups attended our stakeholder event in April 2017.
The Expert Working Group gathered evidence from a review of literature about what the mental health needs of looked after children were, and held a Call for Evidence of good practice. The group also considered what a good system to support the health and wellbeing of looked after children would look like, and described its key features.
One of the key issues that we recognised was that good quality ongoing assessment must be the foundation of a comprehensive strategy of support and services. The feedback from young people, stakeholders and the Expert Working Group itself was that the Strengths and Difficulties Questionnaire (SDQ) by itself is not an effective way of measuring the mental health and emotional wellbeing of young people.
One of the strongest views of the Expert Working Group was that local areas need to be able to provide consistent care and support for a child, with an understanding that their diagnosis and therefore the type of support services they need can change. Therefore, assessment and services must be responsive and flexible. Mental health is a continuum and cannot be seen as a one-off diagnosis.
For one of our consultations we met 35 children and young people who had accessed provision from across health services including specialist in patient care (‘Tier 4’ provision). We asked them to create recommendations to include in our report, so that their voice was clear and strong. We present their 11 recommendations here, before our own, because their voice is the context in which our work should best be understood.
Views of children and young people who are experts by experience,
From the evidence base that we have assembled, the work of the Expert Working Group, the views of children and young people who are experts by experience, professionals and those looking after young people, we have:
- established 11 key findings, which are the drivers for change
- made recommendations that address those findings and will improve the mental health and wellbeing of looked after children
- developed seven quality statements that define the outcomes that our recommendations are intended to achieve.
Change needs to happen now, and it is our hope that this report provides a platform for that change and the necessary call for action.
We recommend that:
- Building on the success of the virtual school head (VSH), a similar oversight role of a virtual mental health lead (VMHL) is established. This is to ensure that every child and young person in the system is getting the support they need for their mental health and emotional wellbeing.
- The Strengths and Difficulties Questionnaire should be supported by a broader set of measures which can trigger a comprehensive mental health assessment. There are a range of tools in use that could support the assessment depending on the need of the young person.
- 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 solely focusing on the presenting symptoms. The young person, their caregivers, family (where appropriate) and professionals’ viewpoints should be included. Young people should be able to share who they would like to accompany them to assessments, and where possible those wishes should be accommodated.
- Caregivers should receive support for their own mental health and wellbeing.
- Caregivers need to be informed of which statutory and non-statutory services are available when support is needed for the child or young person. This should be included in each area’s local offer. It is crucial that services are funded to support caregivers’ training and development.
- Everyone working directly with looked after children should receive training on children and young people’s mental health so they are equipped with the appropriate skills.
- A needs-based model is the best way to support and respond to young people. This model places the young person at the centre of decision-making and where appropriate lets them exercise choice as to how and what support they access. This allows appropriate support to be generated by need, rather than diagnosis.
- Formal services should be more flexible in who they will allow to support the young person, acknowledging that support can come from a range of services and places. Health, education and social services need to work collaboratively to achieve this recommendation.
- Ministers at the Department for Education and Department of Health should work together to ensure children in care and leaving care have access to services provided for their mental health and wellbeing.
- Ofsted, the Care Quality Commission (CQC) and Her Majesty’s Inspectorate of Prisons (HMIP) should review their regulatory frameworks linked to registration to ensure that equal weight and attention is being given to mental and physical health needs.
- The statutory review of a child’s care plan by the independent reviewing officers (IROs) must include at each meeting a review of whether mental health needs have been met.
- Every school should have a designated teacher with the training and competence in identifying and understanding the mental health needs of all their pupils who are looked-after.
- Existing mechanisms for capturing direct views of young people should be integral to planning and commissioning arrangements. Local Health Watch services should monitor the effectiveness of mental health care arrangements for children and young people who are looked after, and report their findings to Health and Wellbeing Boards at least annually.
- Self-help, peer mentoring and community initiatives should be considered (if a young person expresses this is their preference) before a referral to more formal child and adolescent mental health services.
- Clinical Commissioning Groups should ensure commissioning is informed by a Joint Strategic Needs Assessment (JSNA) which addresses the mental health and wellbeing needs of looked after children and care leavers. This should be reflected in Local Transformation Plans.
- The Local Safeguarding Children Board, Corporate Parent Board and Health and Wellbeing Board should give appropriate priority to ensuring that the mental health needs of children and young people in care and leaving care are met.
Placing the young person at the centre
The Expert Working Group developed a new model which places the young person at the centre. The model is based on ‘I statements’ supported by enablers. The model highlights what good, holistic support for mental health and wellbeing looks like from the perspective of the young person, and what needs to be in place to make it happen.
Alongside this model, one of the major findings from our evidence is that the journeys taken to access support are often not linear. For example, a child in care may have a social worker who has the statutory responsibility of referring to child and adolescent mental health services, but their trusted relationship may be with another professional or their main caregiver. In this instance, there would be benefit to the young person being able to utilise their trusted relationship to access support together.
To support our findings, we then developed an eco-map, to be used in conjunction with the accompanying decision trees.
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 decision trees represent our recommendations for a responsive pathway that places the child or young person at the centre, and include those that know them in the decision-making, as appropriate.
At the core is the need for
At the core of both our 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.
Pathways for prevention and accessing support
- the people raising a concern
- who they raise the concern to
- how that person decides what the level of concern is
- what they do in response to this concern
- ongoing monitoring and responding to need.
The roles and responsibilities presented in Appendix 3 of the full report are those that the child or young person can expect to support them as they journey through the pathways.