The mental health needs of looked after children:

1

• 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

2
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
3
A preface- the history of alternative care

• The kindness of strangers
• The first Poor Law (1531) apprenticeship for
  children
• Voluntary care Children Act 1948
• Looked after children - Children Act 1989
• The Foundling Hospital (1857) boarding out to
  families

Caring for complex children 11.06.09 Centre
for emotional development
4

• 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.

5
(No Transcript)
6
For the year ending 31.03.08

• 59.500 children looked after
• Abuse or neglect 62 (little change over the
  past 5 years)
• 3500 unaccompanied asylum seeking children
  (numbers are increasing)
• 71 in foster care, about 10 in childrens homes
  (28 in 1981-ONS)
• 30 placed outside of their local authoritys
  boundaries
• (Department of children, schools and families
  2008)

Caring for complex children 11.06.09 Day
conference - Centre for emotional development
7
Mc Cann et al 1996

• All Adolescents (13-17) looked after in
  Oxfordshire (88 responders- 66)
• 2 stage design
• 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
8
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)
• Among 5- to 10-year-olds
• - 42 compared with 8
• Among 11- to 15-year-olds
• - 49 compared with 11

Caring for complex children 11.06.09 Day
conference - Centre for emotional development
9
Sempick et al 2008

• At the point of entry into care
• Difficulties recorded by social workers
• No previous experience of care
• Almost 20 of boys and girls under 5
• About 70 of children between 5 and 15 years of
  age

10
Are looked after children different?

• Entering care (Sinclair et al 2007)
• Abuse and neglect
• 65 of those first in care under 11
• Chronic adversities
• Parental substance misuse and domestic violence
  in 41 of those first in care under 11
• 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
11
Are looked after children different? Abuse
whilst in care

• Hobbs et al 1999
• (133 children in foster/residential care involved
  in 158 incidents)
• Children in care are more likely to be assessed
  by a paediatrician for suspected abuse
• (7-8 times FC, 6 times RC)
• Confirmed cases- 42 physically abused, 76
  sexually abused, 15 both

Caring for complex children 11.06.09 Day
conference - Centre for emotional development
12
Are looked after children different?

• Moves and placement breakdown
• 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)
• 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
13
Psychiatric disorder among British children
looked after by local authorities comparison
with children living in private households (Ford
et al 2007)

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

Caring for complex children 11.06.09 Day
conference - Centre for emotional development
14
Measures (Same measure in the 4 surveys)

• Strengths and difficulties questionnaire
• (Goodman 1997)
• Teachers report
• Social workers and carers report
• Development and Well Being Assessment
• (DAWBA- Goodman et al 2000)

Caring for complex children 11.06.09 Day
conference - Centre for emotional development
15
(No Transcript)
16
SeverityNational In-patient Child and
AdolescentPsychiatry Study

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

Caring for complex children 11.06.09 Centre
for emotional development
17
Questions (true or false)

• Research evidence suggests that
• 10 of young people who have been in care go on
  to become young prisoners
• Looked after children are 10 times more likely to
  be excluded from school than their peers
• Of young women leaving care, 25-30 are parents
• Young people leaving care have a 1 in 10 chance
  of becoming homeless
• Studies of care leavers show that
• 8 had a long term mental disorder
• 20 had self harmed since the age of 15

Caring for complex children 11.06.09 Centre
for emotional development
18
Looking at care leavers-mental health

• (Saunders and Broad 1997)
• 16.6 had a mental health disorder
• 35 had engaged in self harm since the age of 15
• 60 had felt suicidal
• 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
19
Looking at care leavers-social exclusion

• 50 will be unemployed on leaving care and 20
  will be homeless within 2 years of leaving care
  (Biehal et al 1995, Broad 1999)
• 26 of all prisoners and 40 of prisoners under
  21 (The national prison survey 1991 main
  findings, 1992)
• 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
20
Looking at care leavers-parenthood

• On leaving care 1 in 7 young people already have
  or are expecting a child (Dixon et al 2006)
• On follow up (10 months) this is risen to 26
  (35 of females and 15 males) (Dixon et al 2006)
• 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)
• 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
21
Looking at care leavers-substance misuse

• (Ward et al 2003)
• Cannabis use- 73 have smoked it, 52 in the last
  month, 34 report daily smoking
• One-tenth had used cocaine within the last month
• 15 have used ecstasy within the month

Caring for complex children 11.06.09 Centre
for emotional development
22

• The state makes a rotten parent
• (Sergeant 2006)

23
Children on the edge of care

• In and out of care
• More than one period of care
• 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
24
Prevention

• 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)
• NICE/SCIE guidance on parental mental health and
  child welfare (July 2009)
• Multisystemic therapy approach
• National academy of parenting practitioners

Caring for complex children 11.06.09 Centre
for emotional development
25
The policy and legislative context

• Every child matters
• Care Matters white paper (2006)
• National CAMHS review (2008)
• Children and young persons Act 2008
• Guidance on promoting the health and well being
  of looked after children (DH consultation draft)
• 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
26
Improving access for looked after children

• Problems accessing mainstream CAMHS
• (Callaghan et al 2004)
• narrow referral criteria,
• non-detection of mental health problems,
• referrers reluctance to pathologize childrens
  behaviour,
• childrens mobility and engagement
• Services need to adapt
• (Richardson and Lelliott 2003)

Caring for complex children 11.06.09 Centre
for emotional development
27

• Establish targeted/dedicated CAMHS that
  appropriately prioritise children in care
• (Care matters- time to deliver for children
  in care 2008)
• 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
28
(No Transcript)
29
(No Transcript)
30
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_at_oxleas.nhs.uk
• carmen.pinto_at_iop.kcl.ac.uk
• ingrid.king_at_acamh.org.uk