The mental health needs of - The Centre for Emotional Development

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					    The mental
   health needs of
     looked after
       children:
    an overview
Dr Anto Ingrassia
Consultant Child and Adolescent
Psychiatrist
Greenwich CAMHS
           “Caring for complex children” – 11.06.09
                Centre for emotional development
              Outline
Part 1. What do we know about the mental
   health needs of looked after children?

Part 2. What happens after leaving care?

Part 3. What are we doing?



                             “Caring for complex children” – 11.06.09
                                  Centre for emotional development
          A preface- the history of
              alternative care
o The ‘kindness of strangers’
o The first Poor Law (1531) – apprenticeship for
  children
o Voluntary care – Children Act 1948
o Looked after children - Children Act 1989



o   The Foundling Hospital (1857) – boarding out to
    families
                                     “Caring for complex children” – 11.06.09
                                          Centre for emotional development
In 1739 Thomas Coram, with the
   help of the artist William
   Hogarth and the composer
   George Frideric Handel
   established a “Hospital for
   the Maintenance and
   Education of Exposed and
   Deserted Children” which
   looked after more than
   27,000 children until its
   closure in 1953.
For the year ending 31.03.08:
o   59.500 children looked after
o   Abuse or neglect – 62% (little change over the past 5
    years)
o   3500 unaccompanied asylum seeking children
    (numbers are increasing)
o   71% in foster care, about 10% in children’s homes
    (28% in 1981-ONS)
o   30% placed outside of their local authority’s
    boundaries
(Department of children, schools and families 2008)
                                                     “Caring for complex children” – 11.06.09
                                          Day conference - Centre for emotional development
          Mc Cann et al 1996
o   All Adolescents (13-17) looked after in
    Oxfordshire (88 responders- 66%)

o   2 stage design

o   Total prevalence of psychiatric disorders was
    67%
    - 96% of those in residential units
    - 57% of those in foster care
                                    “Caring for complex children” – 11.06.09
                                         Centre for emotional development
   The prevalence of any mental
      health disorder in LAC
The mental health of young people looked after by local authorities in
   England (Meltzer et al 2002)


o Among 5- to 10-year-olds
- 42% compared with 8%

o Among 11- to 15-year-olds
- 49% compared with 11%

                                                    “Caring for complex children” – 11.06.09
                                         Day conference - Centre for emotional development
         Sempick et al 2008
o   At the point of entry into care
o   Difficulties recorded by social workers
o   No previous experience of care

o   Almost 20% of boys and girls under 5
o   About 70% of children between 5 and 15 years
    of age
                  Are looked after
                 children different?
Entering care (Sinclair et al 2007)
o   Abuse and neglect
≠   65% of those first in care under 11
o   Chronic adversities
≠   Parental substance misuse and domestic violence in 41% of
    those first in care under 11
o   Interaction of biological and
    environmental factors
≠ Chronic adversities related to poor health outcomes
≠ 17.7% considered ‘disabled’ by their social worker

                                          “Caring for complex children” – 11.06.09
                                               Centre for emotional development
    Are looked after children different?
           Abuse whilst in care
Hobbs et al 1999
(133 children in foster/residential care involved in 158 incidents)
o   Children in care are more likely to be assessed
    by a paediatrician for suspected abuse
    (7-8 times FC, 6 times RC)

o   Confirmed cases- 42 physically abused, 76
    sexually abused, 15 both

                                                 “Caring for complex children” – 11.06.09
                                      Day conference - Centre for emotional development
             Are looked after
            children different?
Moves and placement breakdown
o   Minty 1999 - breakdowns of 20-50% in long
    term foster care
 large variation between timescales and different authorities
 A number of placement considered barely adequate (about
  10%)

o   Sinclair et al 2007 – 17% of the sample had
    had 6 or more placements
                                         “Caring for complex children” – 11.06.09
                                              Centre for emotional development
Psychiatric disorder among British children
looked after by local authorities: comparison
with children living in private households
(Ford et al 2007)


 o   Comparison between looked after children and
     children living at home from deprived and non
     deprived background
 o   Data combined from 3 surveys of looked after
     children (England, Scotland, Wales)
 o   ONS sample of children living at home (Meltzer el
     al 2000) from the child benefit register
 o   Age 5-17

                                         “Caring for complex children” – 11.06.09
                              Day conference - Centre for emotional development
                 Measures
         (Same measure in the 4 surveys)

o   Strengths and difficulties questionnaire
(Goodman 1997)
o   Teacher’s report
o   Social worker’s and carer’s report

o   Development and Well Being Assessment
(DAWBA- Goodman et al 2000)


                                         “Caring for complex children” – 11.06.09
                              Day conference - Centre for emotional development
                        Odds                      Prevalence (%)
                        ratio
                                Children        Disadvantaged     Remaining private
                                looked after by private household household sample
                                local           sample
                                authorities
Statement of special            23             4.5                 2.9
educational needs
Neurodevelopmental              12.8           4.5                 3.3
disorder
At least one
psychiatric diagnosis   4.92 46.4              14.6                8.5
(ICD 10)
Any anxiety disorder    2.09    11.1           5.5                 3.6
Depression              2.28    3.4            1.2                 0.9

Hyperkinesis            3.9     8.7            1.3                 1.1

Any behavioural         7.53    38.9           9.7                 4.3
disorder
                Severity
      National In-patient Child and Adolescent
                  Psychiatry Study

12% of inpatients were looked after
o Higher than young people presenting
  to CAMHS in general - 9%
o Much higher than found in the general
  population - 0.5%


                                    “Caring for complex children” – 11.06.09
                                         Centre for emotional development
      Questions (true or false)
Research evidence suggests that:
o 10% of young people who have been in care go on
  to become young prisoners
o Looked after children are 10 times more likely to be
  excluded from school than their peers
o Of young women leaving care, 25-30% are parents
o Young people leaving care have a 1 in 10 chance of
  becoming homeless
Studies of care leavers show that:
o 8% had a long term mental disorder
o 20% had self harmed since the age of 15

                                   “Caring for complex children” – 11.06.09
                                        Centre for emotional development
          Looking at care leavers-
              mental health
(Saunders and Broad 1997)
o   16.6% had a mental health disorder
o   35% had engaged in self harm since the age
    of 15
o   60% had felt suicidal
o   31% had self referred to mental health
    services (of whom 77% did not find services
    useful)

                                 “Caring for complex children” – 11.06.09
                                      Centre for emotional development
            Looking at care leavers-
               social exclusion
o 50% will be unemployed on leaving care and
  20% will be homeless within 2 years of leaving
  care (Biehal et al 1995, Broad 1999)
o 26% of all prisoners and 40% of prisoners
  under 21 (The national prison survey 1991: main findings,
    1992)
o   23 % of adult prisoners and 38 % of young
    prisoners are care leavers (Department of Health,
    1999)

                                       “Caring for complex children” – 11.06.09
                                            Centre for emotional development
            Looking at care leavers-
                 parenthood
o On leaving care 1 in 7 young people already have or
  are expecting a child (Dixon et al 2006)
o On follow up (10 months) this is risen to 26% (35% of
  females and 15% males) (Dixon et al 2006)
o The children of women who have spent time in care
  are themselves two and a half times more likely to go
  into care than their peers (Sergeant 2006)
o By age 20- one quarter of young people in care are
  parents and 40% of women were mothers (Department of
    Education and Skills 2006)
                                    “Caring for complex children” – 11.06.09
                                         Centre for emotional development
      Looking at care leavers-
         substance misuse
(Ward et al 2003)


o   Cannabis use- 73% have smoked it, 52% in
    the last month, 34% report daily smoking
o    One-tenth had used cocaine within the last
    month
o   15% have used ecstasy within the month

                               “Caring for complex children” – 11.06.09
                                    Centre for emotional development
The state makes
 a rotten parent
(Sergeant 2006)
                Children
          “on the edge of care”

o   In and out of care
o   More than one period of care
o   Children in need as a result of abuse or
    neglect (around 30% will enter care during
    their childhood)


                                “Caring for complex children” – 11.06.09
                                     Centre for emotional development
                        Prevention
o   The new CPA guidance
“the needs of the parent, the child and the family are
  assessed routinely at each stage of the care pathway
  from referral to review”
(CPA Briefing: Parents with mental health problems and their children – DoH
   2008)
o   NICE/SCIE guidance on parental mental health
    and child welfare (July 2009)
o   Multisystemic therapy approach
o   National academy of parenting practitioners
                                                  “Caring for complex children” – 11.06.09
                                                       Centre for emotional development
    The policy and legislative context
o   Every child matters
o   Care Matters white paper (2006)
o   National CAMHS review (2008)
o   Children and young persons Act 2008
o   Guidance on promoting the health and well being of
    looked after children (DH consultation draft)
o   The physical and emotional health and wellbeing of
    looked after children and young people (NICE/SCIE
    expected 2010)

                                     “Caring for complex children” – 11.06.09
                                          Centre for emotional development
                 Improving access for
                 looked after children
Problems accessing mainstream CAMHS
(Callaghan et al 2004) :
o narrow referral criteria,
o non-detection of mental health problems,
o referrers’ reluctance to pathologize children’s
  behaviour,
o children’s mobility and engagement


“Services need to adapt”
(Richardson and Lelliott 2003)

                                    “Caring for complex children” – 11.06.09
                                         Centre for emotional development
o   Establish targeted/dedicated CAMHS that
    appropriately prioritise children in care
    (Care matters- time to deliver for children in care 2008)


o   PCT are required to ensure that:
 A child is never refused a service on the grounds of their
  placement being short term or unplanned
 There are referral pathways that are understood and used by
  all agencies that come into contact with the child
 CAMHS provide targeted and dedicated services to looked
  after children where this is an identified local need
    (Guidance on promoting the health and well being of looked after
    children- DH consultation draft)

                                                    “Caring for complex children” – 11.06.09
                                                         Centre for emotional development
    ACAMH Special interest group
A multi-disciplinary special interest group
  trying to bring together, through its
  membership, a network of professionals
  working with looked after children

≠   antonina.ingrassia@oxleas.nhs.uk
≠   carmen.pinto@iop.kcl.ac.uk
≠   ingrid.king@acamh.org.uk