Dr Martina Paglia

Counselling Psychologist

Overview

Children looked after by local authorities in England experience higher levels of educational difficulties, psychopathology and neurodevelopmental disorders (Ford et al., 2007; Meltzer et al., 2003)

The National Institute for Health and Care Excellence (2010) provides a figure of 60% of LAC in England having mental health problems

Many foster children exhibit difficulties with attachment to caregivers (Dozier et al., 2001); post-traumatic stress disorder (PTSD)-like symptoms (Morris et al. 2015); difficulties relating to peers (Hodges & Tizard, 1989); attention and conduct problems including oppositional defiance, and difficulties with sexual behaviour (Milburn et al., 2008); high-risk trajectories towards substance abuse and criminal behaviour (Johnson-Reid & Barth, 2000)

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Aims and Objectives

The primary aim of this project is to provide a platform of knowledge that can inform professionals involved in delivering services to LAC in TH.

Key aspects include:

1. To assess the capacity of the SDQ parent version for children aged 4-17+ to capture mental health problems in LAC in comparison to non-disadvantaged children.

2. To make recommendations as to a wider range of outcome measures can be used to aid in the identification of LAC’s mental health needs.

3. To recommend alternative ways of providing services and care to looked after children placed out of borough.

4. To map the implementation of outcome measures across agencies involved in the delivery of services and care to looked after children.

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1. SDQ scores and the mental health needs of LAC in TH

It is recommended that the SDQ be used alongside the BAC to

capture a fuller picture

Statistically significant differences were found

between the mean scores of the norm group and the study population on all but

one SDQ subscale (Emotional Symptoms)

Where a statistically significant difference was

found the direction of difference represents lower

adverse performance by the looked after population

The incidence of mental health difficulties, as reflected in SDQ

‘Total Difficulties’ ‘Slightly Raised, ‘High’ and ‘Very High’ ratings of

respectively 17.9%, 8.5% and 16%, for a total figure of 42.4% (n = 45) is

congruent with the most comprehensive surveys conducted in the UK to date (Ford et al., 2007;

Meltzer et al., 2003)

Statistically significant variances between the

target population’s scores and the norm group’s scores on SDQ scales

suggest multidimensional difficulties.

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2. Outcome measures for LAC

Widely used in CAMHS

Normed on UK population

Translated into 80+ languages

Research found evidence that the SDQ parent version is a genuinely dimensional measure of mental health in LAC and provides accurate estimates of disorder prevalence

Research suggests that the use of both the self-report and parent versions of the SDQ could improve the sensitivity of the SDQ from 54% and 71% respectively to 93% for both together.

Not suitable as a frequent / session by session measure

Since it was not developed for LAC, the SDQ cannot on its own provide a retrospective, comprehensive view of the mental health needs of the looked after population. It would be best used as a tool within a wider, holistic assessment.

The Strengths and Difficulties Questionnaire (SDQ; Goodman et al., 1997) Multi-informant brief screening questionnaire for 2-18+ year olds

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2. Outcome measures for LAC

Specifically designed for LAC

Not too long - the format is comparable to the SDQ

Flexible - can be used for screening, as part of a clinical assessment, as a treatment-outcome measure, as a research tool

It can be used by children’s agencies without oversight by a CAMHS clinician.

Not suitable as a frequent / session by session measure

Normed on NZ population of looked after children

The Brief Assessment Checklist (BAC; Tarren-Sweeney, 2013) 20 items carer-report rating scales for 4-17+ years old LAC

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3. Improving access to CAMHS for TH LAC placed out of borough

Method: A qualitative approach was employed with social workers to explore their views and experiences on access to CAMHS for looked after children in Tower Hamlets placed out of borough.

Participants: The online survey received 31% response rate. 76 responses of the 245 expected were received from 31 Social Workers.

Results: Social workers have concerns around mental health needs for 38.2% (n = 29) of the looked after children. Of this figure, only 13 children (44.8%) were referred to local CAMHS. Of the 16 (55.2%) children that were not referred to local CAMHS, 10 (62.5%) were offered support by TH CAMHS and 2 (12.5%) by another service provider, while 4 (25%) children had an unmet need for mental health care.

Main Findings: The study concluded that there is not a consistent strategy in place to support LAC placed out of borough.

Recommendations: To explore options to develop an out of borough strategy to offer mental health support to children in care placed out of borough.

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4. Considerations for implementing outcome measures across services

The decision points involved in screening were outlined, including:

what to screen for

whom to screen

how to implement outcome measures (which to use and when)

and how to deal with service users who meet the clinical threshold

In each step, standard operating procedures (SOPs), instructions and recommendations are provided. The out of borough strategy is also addressed.

The steps are:

1) Regular Mental Health Screening

2) CAMHS Consultation

3) CAMHS Intervention Monitoring

Proposals will be reviewed on the 19/09/2016

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4. Considerations for implementing outcome measures across services

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STEP 1 - Regular Mental Health

Screening

Two options using existing resources

Key Decision Points for Screening Tools

Implementation within Health: Measures to be completed at initial and

review health assessments

Key Decision Points for Screening Tools

Implementation within CSC: Measures to be

completed at initial and review health assessments

Two prospective solutions that require to explore

alternative commissioning arrangements for CAMHS

provision of a mental health screening and assessment

service for TH LAC

Option to appoint a Specialist Mental Health

Clinician to provide comprehensive psychological health assessments of all CYP

new into care in TH

Option to trial a LAC triage service for CYP who stay in care for more than 4 weeks.

Recommended Outcome Measures for

MH Screening

SDQ - to be completed by FCs, KWs and YP aged ≥ 11 BAC - to be completed by FCs and KWs on all LAC

4. Considerations for implementing outcome measures across services

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Recommended Outcome Measures for CAMHS Indirect Work with LAC CORC Consultation feedback questionnaire - to be completed by social workers on all consultations.

The Carer Questionnaire - to be completed by foster carers and key workers on all consultations. Can be found at www.cplaac.org.uk/tools/

STEP 2 - CAMHS Consultation

CYP meets the BAC and/or SDQ threshold at STEP 1

CAMHS in Social Care Team to offer consultation

or series of consultations to SWs and FCs

CYP meets the criteria for CAMHS Tier 2

threshold at STEP 2

CYP can access CAMHS in TH

CAMHS in Social Care Team to offer a direct intervention to CYP

CYP cannot access CAMHS in TH

CAMHS in Social Care Team to offer support to

SWs in the referral making process to local CAMHS to

the CYP’s placement

4. Considerations for implementing outcome measures across services

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Recommended Outcome Measures for CAMHS Interventions with LAC

The SDQ, RCADS, BAC, GBOS and CORS - to be completed by service users to capture change pre and post treatment. The CGAS - to be rated by clinicians to capture change pre and post treatment. The CHI-ESQ - to be completed by service users for evaluating the experience of service. An adapted version for LAC can be found at www.cplaac.org.uk/tools/

This list is not exhaustive. For a complete list of standard outcome measures used in CAMHS please refer to the COOP Document (Law and Wolpert, 2014). It is crucial to be clear about the purpose of collecting data and choose the most appropriate set of tools according to their information-providing focus.

STEP 3 - CAMHS Intervention Monitoring

The CAMHS in Social Care Team to implement a system of routinely

collecting patient outcomes to guide on-going interventions and evaluate

patient experience of service.

Conclusion

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• This mixed methods research project involved the review of pathways and screening measures for LAC in TH.

• Data from the quantitative study concluded that the SDQ be used alongside the BAC, a screening tool designed to gather clinically meaningful difficulties experienced by LAC, to capture a fuller picture.

• A qualitative study explored social workers’ experiences on access to CAMHS for TH LAC placed out of borough and concluded that there is not a consistent strategy in place.

• Guidelines for mental health screening, CAMHS consultation and intervention monitoring were outlined and a prospective out of borough strategy was addressed.