CASPAR Project
The Mental Health of
Looked After Children/Care
Leavers in Northern Ireland:
A Literature Review
AUTHORS:
Christine Mullan & Lelia Fitzsimons
SUPPORTED BY:
Executive Programme Fund for Children
Section
Page
Foreword
Preface
Acknowledgements
i
ii
iii
1
Executive Summary
1
2
Introduction
3
3
The Care System in Northern Ireland
7
4
What current evidence is available regarding the mental health
needs of Looked After Children and Care Leavers?
11
5
How are the mental health needs of Looked After Children and
Care Leavers currently identified, assessed & monitored and how are
referrals made?
17
6
What action is taken to ensure that risk factors and vulnerability
are reduced in the lives of Looked After Children and Care Leavers?
25
7
What action is taken to ensure that protective factors and
resilience are promoted in the lives of Looked After Children/
Care Leavers?
31
8
How are services to meet the mental health needs of Looked After
Children and Care Leavers currently planned, controlled and organised?
41
9
What is the current policy and legislative framework within
which the mental health needs of Looked After Children and
Care Leavers in Northern Ireland are met?
47
10
What services do Looked After Children and Care Leavers want
and what works well?
55
11
How should services develop in Northern Ireland and what is
needed to implement these services?
61
12
Conclusions: Implications of the Review
75
13
References
77
Appendix 1 – Useful Websites
Appendix 2 – Useful Journals
Appendix 3 – Comparison of Studies
87
89
90
The views expressed in this report are those of the authors and do not necessarily reflect those of
the Eastern Health and Social Services Board or Down and Lisburn Trust.
Table of Contents
Table of Contents
Foreword
Foreword
The Caspar Project developed out of a regional multiagency working group involving voluntary and statutory
providers, academics and carers who were deeply
concerned about the need to explore and address the
mental health of children in care. It became evident that
practitioners and carers were working with children with
ever increasing challenging behaviour and that a
continuum of therapeutic inputs and services was
required throughout the system.
No one agency alone can hope to meet the complex,
individual needs of care experienced children and young
people. The Caspar Project recognises the absolute
necessity to work in partnership. With joined up thinking,
creativity and planning, our children can only but
significantly benefit and we will achieve our vision, that every
child in our care grows up feeling good about themselves.
The Caspar Project extends you an invitation to join us in
making the difference.
From the child’s perspective they described coming into
care as one to the most traumatic events in their young
lives only to be matched by the trauma of leaving care.
They enter care having experienced significant neglect
and abuse. In care, they must adapt to rapid changes in
lifestyles, culture and environment, whilst trying to come
to terms with the reasons why they had to come into
care. All these events, children have stated, have had a
huge impact on their mental health.
Vivian McConvey
Director
VOYPIC
As practitioners, carers and policy makers, our job is to
ensure that every child in our care grows up feeling good
about themselves, feels valued, aspires to reach their
dreams, has opportunities and will be able to come to
terms with the issues leading up to their admission to
care. To improve their life chances and provide the
therapeutic services they require we must firstly
understand the impact pre-care and being in care has on
the mental health of children.
This literature review provides the first comprehensive
overview of the literature available between the United
Kingdom (UK) and Northern Ireland (NI) on the mental
health of Looked After Children and those leaving care.
The information presented will provide an invaluable
reference tool for practitioners, carers, policy makers,
academics and students. Our aim is to develop your
thinking and deepen your knowledge. Thus it is hoped
that the literature review will influence the development
of services, which adopt a child-centred, holistic
approach to meeting the emotional, psychological and
mental health needs of one of the most vulnerable
groups in our society; that is care experienced children and
young people.
FOREWORD
i
Preface
Preface
French from Trinity College Dublin. Christine is registered
with the British Psychological Society and hopes to
continue doctorate study in this field of research.
Voice of Young People in Care (VOYPIC) is an independent
regional voice that seeks to empower and enable children
with an experience of care (Looked After Children/Care
Leavers) in Northern Ireland to participate fully in
decisions affecting their lives. Our aim is to improve
their life chances through working in partnership with
Looked After Children/Care Leavers, staff, managers,
agencies and government. We do this through listening
and learning and facilitating change which impacts and
influences legislation, policy and practice. One of the
Agency’s core aims is to record, collate and catalogue
practice experience, training materials, publications, and
research to assist in developing and promoting good practice.
Lelia Fitzsimons:
Lelia is Project Manager for the Caspar Project. She was
previously Senior Manager of Social Care at Bryson House
assuming overall responsibility for the management of all
social care services. In the past, Lelia worked as a Mental
Health Social Worker in North & West Community Mental
Health Team and as a Family Centre Social Worker at
Beersbridge Family Centre. She trained as an Approved
Social Worker, worked as a practice teacher for a number
of years and is registered with Northern Ireland Social
Care Council (NISCC). Lelia graduated with a Masters in
Social Work from Queen’s University, Belfast.
This literature review is the first publication from
VOYPIC’s Caspar Project. The Caspar Project is being
undertaken by VOYPIC in partnership with the Eastern
Health and Social Services Board (EHSSB) and Down and
Lisburn Trust (DLT).
The aim of the Caspar project is to produce an evidence
base which will contribute to the development of a
strategy to meet the mental health needs of Looked After
Children/Care Leavers across Northern Ireland. We believe
that there is a current gap in services that requires a
strategic commitment. The outcome sought by the
project is:
‘That children and young people who live in care
[Looked After Children] and those who have left care
[Care Leavers] have improved psychological, emotional
and mental health and hence improved life chances’.
The project seeks to contribute to these outcomes
through the production and dissemination of the
findings of this review and direct research with Looked
After Children/Care Leavers, foster carers, residential
workers, field social workers and birth parents. We intend
to give clear recommendations at the end stage of the
project (October, 2006) when all this evidence is brought
together. This review therefore is intended to raise
questions and discussion regarding the implications for a
strategy which will help us move towards this end goal.
About the Authors
Christine Mullan:
Christine is the Research Officer for the Caspar Project.
She previously worked in the field of market research, as
a Research Executive with Market and Research Opinion
International (MORI) Ireland and formerly with SIGNAL
Business Growth Centre (based in Stockholm). She
graduated with a BA Honours in Psychology and
ii
VOICE OF YOUNG PEOPLE IN CARE
Acknowledgements
Acknowledgements
We are grateful to:
•
Other members of the Professional Advisory Group
who have provided advice and assistance through
out the project including Colleen Christie
(Fostering Network), Prof Robbie Gilligan (The
School of Social Work and Social Policy, Trinity
College Dublin), Dr Angela O’Rawe and George
Russell (CAMHS Policy Directorate, DHSSPS).
•
Caspar Management group including Marion
Reynolds (Deputy Director, EHSSB) who had
previously acted as a member of the professional
advisory group, Bria Mongan (Operations ManagerChildren’s Services, Down and Lisburn Trust) and
Alan Cowie (Programme Planner, EHSSB). Thanks are
also due to Theresa Nixon for her input into the
group while at the EHSSB.
•
Firstly, all the young people involved in the Caspar
project who painted the canvas for the front cover
and the young people who took part in the
summer art project at VOYPIC and made the
photographs that are included in the document.
This really brings the report to life!
•
The Young people’s advisory group who have
helped with the project as it has been going along.
•
Our funders: The Children’s Fund, The Camelot
Foundation, The Eastern Health and Social Services
Board and Down and Lisburn Health & Social
Services Trust.
•
Dr Rosemary Kilpatrick (Director of the Institute of
Child Care Research at Queen’s University Belfast)
who has provided a key consultative role in the
project and is also a member of the professional
advisory group.
•
Karen Latimer at Queen’s University Belfast Library
who kindly sourced some of the later material on
our behalf.
•
Evelyn Heak for proof reading.
Dr Emma Larkin of the Institute of Child Care
Research at Queen’s University Belfast for her help
with electronic searches.
•
Suzanne Irvine for her work on the referencing.
•
Our colleagues in VOYPIC for their help with
various sections.
•
And, finally thanks to Mike & Annette for all your
help/support/sympathy!
•
•
Dr Ruth Sinclair, Nicola Madge & Natasha Willmott
from National Children’s Bureau (NCB) for carrying
out an initial review which provided a good
starting point for the wider UK evidence.
•
The three independent peer reviewers Dr Roger
Manktelow (School of Sociology & Applied Social
Studies, University of Ulster) , Dr Ann Kilgallen
(Consultant in Public Health Medicine W.H.S.S.B)
and Tony Rodgers (Assistant Director of Social
Services S.H.S.S.B) who carried out a review of the
draft document.
•
Dr Colette McAuley (School of Sociology, Social
Policy & Social Work, Queen’s University Belfast)
who carried out an additional review of the
manuscript. Colette has also provided input as a
member of the Professional Advisory Group.
•
Members of the Professional Advisory Group who
provided direct comments on earlier versions of the
document and useful reference documents
including Cathy Galway (DHSSPS, Childcare Policy
Directorate), John Growcott (Principal Social Worker
NWHSST), Billie Hughes (Clinical Services Manager,
Young People’s Centre), Cathy Jayat (Foster Care
Associates) and Dr Tom Teggart (Clinical
Psychologist Craigavon and Banbridge HSST).
ACKNOWLEDGEMENTS
iii
1
Executive Summary
1
VOICE OF YOUNG PEOPLE IN CARE
Executive Summary
This Review is a comprehensive search of literature
relating to information available within the UK and
Northern Ireland on the mental health of Looked
After Children and Care Leavers.
improve the life chances of Looked
After Children/Cared Leavers. These
should be linked to the Care and Pathway
Planning processes.
The review is divided into thirteen distinct sections
which progressively address the literature in
relation to the care system, the mental health of
young people with an experience of the care
system, risk and protective factors which influence
their lives, assessment of need, structure of
services, the policy and legislative framework and
young people’s views on services.
•
The above points need to be considered regionally
to ensure that any Looked After Child/Care Leaver
will receive the same standard of support, no matter
where they live in Northern Ireland. The vehicle for
moving this forward would be a strategy to meet
these needs.
Several points are of importance when considering
how to develop and improve the mental health of
young people who experience the care system.
While acknowledging the good work which is
ongoing, the literature indicates that there is currently
a lack of a co-coordinated, structured, young-peoplecentred approach in the area of mental health.
A number of projects are highlighted which provide
examples of good practice and elements of these
could be considered in terms of current provision in
Northern Ireland.
The main points are, however, as follows:
•
Young people (Looked After Children/Care
Leavers) need to be listened to and their
views kept central to the development,
planning and delivery of services. They have
clear views on what services they want.
•
Young people’s (Looked After Children/Care
Leavers) mental health should be understood
and assessed within the context of their
lives and a holistic approach, which allows for
the full range of need from support to
treatment, should be adopted.
•
All of those, from professionals to carers, who
are involved in the lives of Looked After
Children and Care Leavers, should have a
shared understanding of need and assessment.
•
Services should be structured in a way that
adheres to clear, agreed and accepted
standards and facilitates co-ordination,
communication, integration and accessibility.
•
Risk reducing and resilience enhancing
actions can be taken on an everyday basis to
1: EXECUTIVE SUMMARY
There is a gap in research, investment and
services which leave Looked After
Children/Care Leavers in Northern Ireland
doubly disadvantaged.
2
2
Introduction
3
VOICE OF YOUNG PEOPLE IN CARE
Introduction
Review Objectives
1:
The purpose of this review is to collect, collate and
summarize current knowledge relevant to the mental
health needs of Looked After Children and Care Leavers in
Northern Ireland with a view to examining the implications
for policy and practice development.
2:
3:
Conducting the review
4:
The literature review has been carried out from January
2005 – May 2006. Evidence for the review has been
collected through a series of electronic and manual
searches conducted by VOYPIC as well as through
informal consultation with colleagues who have
knowledge in the field. It also draws on an initial outline
review which was conducted by NCB (National Children’s
Bureau) prior to February 2005 (all references were then
sourced, read and incorporated into this final review).
While the project scope and timetable did not allow us to
carry out a full systematic review of the literature, we did
carry out a comprehensive search using the following
types of material:
•
•
•
•
•
5:
6:
7:
8:
Listening to Looked After Children/
Care Leavers
Electronic database searches (Including BIDS (Bath
Information and Data Services) Ingenta, Medline,
NCB Child Data, ORB, Psychlit, PubMed, SCIE
(Social Care Institute of Excellence) (including
CareData)) and Google;
Journals (see Appendix for useful journals);
Books;
Websites (see Appendix for useful websites);
Grey literature (e.g. conference presentations,
news articles).
The fundamental premise behind this review is that
Looked After Children/Care Leavers need to be listened
to. We believe that their views are crucial to determining
the nature of any difficulties they may have and in order
to measure the quality of the services received, they
clearly need to be consulted. It is a view that is now
enshrined in legislation, particularly through the UN
Convention on the Rights of the Child (UNCRC), a
message clearly stated in Kilkelly et al. (2004). We also
believe, as Rea (1999) states:
In total, 513 sources were identified and eventually 209
were incorporated into the review. The main inclusion
criteria consisted of sources relevant to ‘mental health’,
‘child and adolescent mental health’ specifically in
relation to Looked After Children and Care Leavers as well
as concepts related to ‘resilience’ or ‘protective factors’.
Where possible we have looked at the wider UK context
but our main focus has been on Northern Ireland and the
sources were selected with this in mind.
“Users have views on their services that pre-exist any
attempt to measure them, and…these views can be
expressed in ways which are lucid and
comprehensible…such views may enable or assist
providers in the task of evaluating existing services
and of prioritising planned services” (p. 169, Rea, 1999).
As an organisation, over the last 13 years, we have been
listening to the views of Looked After Children and Care
Leavers about their experiences of living in care and
experienced first hand their readiness to participate and
the richness of their insights. We have also found some
good examples of work with young people but are
nevertheless shocked to find that in many of the studies
in this review, their views were not sought. Therefore, in
this review, as the initial stage in our project, we will,
where possible, bring these voices to the fore.
A full bibliography (of all sources) is available from
VOYPIC upon request or can be downloaded from the
VOYPIC website www.voypic.org.
The review questions
A number of inter-related question areas frame the review.
These are:
2: INTRODUCTION
What current evidence is available regarding the
mental health needs of Looked After Children and
Care Leavers?
How are the mental health needs of Looked
After Children and Care Leavers currently identified,
assessed & monitored and how are referrals made?
What action is taken to ensure that risk factors
and vulnerability are reduced in the lives of Looked
After Children and Care Leavers?
What action is taken to ensure that protective
factors and resilience are promoted in the lives of
Looked After Children/Care Leavers?
How are services to meet the mental health needs
of Looked After Children and Care Leavers
currently planned, controlled and organised?
What is the current policy and legislative frame
work within which the mental health needs of
Looked After Children and Care Leavers in Northern
Ireland are met?
What services do Looked After Children and Care
Leavers want and what works well?
How should services develop in Northern Ireland
and what is needed to implement these services?
4
Introduction
Introduction
Ethical and Practical Considerations
Although routine assessments of user perceptions are
important, we are committed to ensuring that these
views measure something which has meaning to the user
(Rea, 1999) and believe there is an ethical issue in
ensuring resultant change (Connolly, 2003). Some of
these young people have lived very difficult lives and it is
our experience that even the most general question can
bring up sensitive issues, so researchers should carefully
consider the ethical issues in research. The new Office of
Research Ethics Committees Northern Ireland (ORECNI) is
a vital step forward in protecting this vulnerable group.
Any consideration of research in the field should be
mindful as to how it has been conducted. A discussion of
these issues can be found elsewhere (e.g. Alderson &
Morrow, 2004).
The Review Structure
For the purposes of this review we use the terms
‘children’ and ‘young people’ when referring to the
general population and ‘Looked after Children’/’Care
Leavers’ when referring to those who are care
experienced. If any other terminology is used, this will be
set in the context of the work being described. Generally,
our age-brackets concern Looked After Children/Care
Leavers between the ages of 12-25 years but reference to
other age bands have been retained if part of the age
bracket is included or if the source is seen as applicable
to the review. Our work includes this broad age-range so
as to gain an understanding of the lives of children and
young people while they live in care and young adults up
to the age of 25 years who have left care.
Throughout the review we generally address the wider UK
context before considering the Northern Ireland context.
We will give an initial outline of the care system in
Northern Ireland and the subsequent chapters will look at
each of the review questions in detail. Implications for a
strategy will be summarised at the end.
5
VOICE OF YOUNG PEOPLE IN CARE
Introduction
2: INTRODUCTION
6
3
The Care System in Northern Ireland
7
VOICE OF YOUNG PEOPLE IN CARE
The Care System in Northern Ireland
“There is both an acceptance and expectation on the
part of modern society that children should be valued,
and in doing so the utmost importance should be
placed on their care and protection. In addition those
who are deprived or disadvantaged should be entitled
to the benefits of a support system which will help
their families through difficult periods, or in more
extreme circumstances provide an alternative form of
care and upbringing for the child or children who
cannot remain within the natural family”
(p. 3, DHSSPS, 2003a).
Children accommodated for respite care increased by 45.2%,
from 677 in 1999/00 to 983 in 2004/05 (DHSSPS, 2005a).
FIGURE: 1 - LOOKED AFTER CHILDREN - NI
Base: 2531
(All young people in care at 31 March 2005)
Before looking at the issues impacting on the lives of
Looked After Children/Care Leavers it is important to
start with an understanding of what brings children into
care, what it means to be ‘looked after’ and an
understanding of the current system in Northern Ireland.
A common misconception of young people in care is that
they have come into care because of personal deficit of
character or behaviour (Martin & Jackson, 2002).
However, as Martin & Jackson (2002) point out, most young
people come into care as a result of family circumstances
and through no fault of their own. These precise reasons
will be explained later in the review.
A child or young person who enters the care system can
be referred to as ‘looked after’. A Looked After Child is
any child in substitute (or in public) care, including those
in foster or residential homes and those still with their
own parents but subject to Care Orders. The actual term
‘Looked After’ was introduced under the Children Act
1989 and the Children (NI) Order 1995. There are two
main routes into care, either on a voluntary basis to assist
parents or as the result of a Care Order. Parental
responsibility can then either rest with the parent or the
Trust acquires it (Kilkelly et al. 2004).
Overall rate of 56 children per 10,000-population aged
under 18. Comparative figures in the UK are:
•
•
•
55 children in England
106 in Scotland &
65 in Wales
Source:
Department of Health, Social Services & Public Safety
(2005a). Children Order Statisical Bulletin.
The definition of a Care Leaver, which we shall use in this
review relates to a young person who has ceased to be
‘Looked After’ by the state. Depending on their age and
circumstances, under the new Children (Leaving Care) Act
(NI) 2002, they are still entitled to some support but the
detail of this shall remain outside the scope of this review.
Looked After Children under 12 are more likely to be
placed in foster care (78% of all those in foster care are
under 12) while those 12 or over are more likely to be
placed in residential care (85% of all those in residential
care are 12 and over) (DHSSPS, 2004a).
Fostering Provision
3.1
Looked After Children
in Northern Ireland
Within fostering, placements can be allocated on a
respite, short, medium and long-term basis. Foster care
accounts for almost two thirds of those in care in
Northern Ireland and has been the dominant placement
for Looked After Children since the 1970s. However,
while there has been a rise in the proportion of Looked
After Children placed in foster care, there has not been a
corresponding rise in foster carers (Kilkelly et al., 2004),
giving rise to concern about placement choice (McAuley,
2000). Most fostering takes place on a voluntary basis
At the end of March 2005 there were 2,531 Looked After
Children across Northern Ireland (Department of Health,
Social Services and Public Safety, DHSSPS, 2005a) and
each type of care placement is shown in Figure 1. Most
Looked After Children (56%) at the end of March 2005
were placed in foster care, with 12.5% placed in
residential care and over a quarter (26.6%) placed with
family (DHSSPS, 2005a). The numbers of Looked After
3: CARE SYSTEM NI
8
Care System NI
Care System NI
whereby foster carers are paid an allowance for the cost
of caring for Looked After Children. Nevertheless, some
fostering does take place on a private basis, outside of
Social Services, provided, for example, by Foster Care
Associates and Kindercare. Referrals to private fostering
are received from the local HSS Trusts.
Leavers came from the Eastern Health and Social Services
Board (EHSSB) area (Mooney et al., 2004). Under the new
Children (Leaving Care) Act (NI) 2002, Care Leavers can
move into several different housing options. These may
include: staying on in their current placement, supported
housing, floating support schemes, foyers or their own
tenancy (VOYPIC, 2006).
Residential Provision
At the end of March 2005, there were 52 residential homes
for Looked After Children in NI including 42 statutory, 9
voluntary and 1 private Children’s Home (DHSSPS, 2005a).
These homes provide accommodation for a maximum of 392
Looked After Children at any given time (DHSSPS, 2005a).
The residential sector in Northern Ireland is undergoing
considerable change. Within residential care, some
Looked After Children may be placed in regional care
centres (‘secure’ and ‘open’ units). Secure accommodation
refers to accommodation provided for the purpose of
restricting liberty (under Article 44 of the Children (NI)
Order 1995). A Looked After Child may only be placed in
this type of accommodation if he/she is at risk of
absconding and likely to suffer significant harm or likely
to injure himself or other persons if living elsewhere.
Since November 1996, secure care has been provided for
Looked After Children at the Lakewood Centre in Bangor
(McMaster, 2004). However, a new build of secure
accommodation will be opened in 2006. 49 Looked After
Children were admitted to and 39 were discharged from
secure accommodation during 2004/5 (DHSSPS, 2005a).
‘Open’ units used for ‘young people (both boys and girls)
who present with challenging behaviour and whose needs
cannot be met in mainstream children’s homes’ (p. 18,
McMaster, 2004) are available in Lakewood and Glenmona.
Youth Justice Provision
Some Looked After Children may also progress into the
Juvenile Justice Service and are then placed at the
Juvenile Justice Centre in Rathgael. The centre is part of
the Youth Justice Agency and provides secure custodial
facilities for young people 10-17 years who are referred by
the courts (either on sentence or remand) (McMaster, 2004).
3.2 Care Leavers in Northern Ireland
206 Looked After Children aged 16 years or more (106
boys and 100 girls) left care in Northern Ireland during
the year ending 31 March 2003. Half had been looked
after for over five years and a quarter had been in care
for ten years or more. Almost half of these young Care
9
VOICE OF YOUNG PEOPLE IN CARE
Care System NI
3: CARE SYSTEM NI
10
4
What current evidence is available
regarding the mental health needs of Looked
After Children and Care Leavers?
11
VOICE OF YOUNG PEOPLE IN CARE
What current evidence is available regarding the mental
health needs of Looked After Children and Care Leavers?
While it is widely accepted that Looked After Children
and Care Leavers have mental health needs, it is
fundamental to this review to gather the relating
evidence in Northern Ireland.
10, an internationally recognised classification system
for disorder. The distinction between a Problem and a
Disorder is not exact but turns on the severity,
persistence, effects and combination of features found”.
3) Mental Illness:
“Might be used for a small proportion of cases of
mental disorders. Usually, it is reserved for the most
severe cases”. (p. 13, RMHLDNI, 2005a).
4.1 Definitions of ‘Mental Health’
One of the most used and useful definitions of mental health
is that of the National Health Service (NHS) Health Advisory
Service (HAS) (NHS HAS, 1995). The Mental Health
Foundation (1999) expanded this definition to define
children who are mentally healthy as having the ability to:
• Develop psychologically, emotionally, creatively,
intellectually and spiritually;
• Initiate, develop and sustain mutually satisfying
personal relationships;
• Use and enjoy solitude;
• Become aware of others and empathise with them;
• Play and learn;
• Develop a sense of right and wrong;
• Resolve (face) problems and setbacks and learn from them
(p.6, Mental Health Foundation (1999) based on
the NHS HAS (1995) definition).
4.1.1 Defining mental health problems of
Looked After Children/Care Leavers
Throughout the review, we will argue that there are
further contextual issues in the lives of Looked After
Children/Care Leavers which need to be considered
alongside these definitions. While this review will show
some shocking statistics on the mental health needs of
Looked After Children/Care Leavers when compared to
their peers in the general population, it is necessary to
note that as Coleman (2005) points out we are not
comparing like with like and states:
“These are vulnerable young people, who have endured all
sorts of adverse circumstances relating to mental ill health.
Perhaps we should expect these children and young people
to have some symptoms of internal distress, anxiety,
depression and self-harm” (Coleman, 2005).
One of the strengths of this definition lies in the emphasis
on the broader concept of well-being rather than an
absence of illness, a notion used by the Public Health
Institute of Scotland (2003b). Another strength is the
presumption that mental health is something shared by us
all, as borne out by the ‘Promoting Mental Health Strategy
and Action Plan 2003-2008 by DHSSPS (2003b):
This need to understand the contextual issues has already
been recognised by the World Health Organisation (WHO,
2003). Before steps are taken to diagnose a child or
young person with a disorder, the WHO (WHO, 2003)
cautions that we need to place importance on
understanding their environment; that is their family,
community and nation:
“Everyone has mental health needs, whether or not
they have a diagnosis of mental illness. Mental and
emotional health promotion involves any action to
enhance the mental wellbeing of individuals, families,
organisations or communities” (p. 5, DHSSPS, 2003b).
“Disorders of mental functioning cannot be seen as
static diagnostic labels but rather must be seen as
dynamic responses to social/environmental stressors”
(p. 7, WHO, 2003).
It is also necessary to define mental ill-health. For the
purposes of this review, we will use the definitions outlined
in the recent consultation document for the Review of
Mental Health and Learning Disability Northern Ireland
(RMHLDNI) Child and Adolescent Mental Health Services
(CAMHS) Consultation report (RMHLDNI, 2005a). It defines
three common categories of mental ill-health.
This would seem particularly relevant for Looked After
Children/Care Leavers given the complexity of social and
environmental stress they have experienced in their lives.
As young people progress through their teenage years,
the range of mental health problems they face increases
dramatically but Aggleton cautions that any attempt to
explain mental health problems of Looked After Children
whilst ignoring the fact that a young person is looked
after will be limited (Aggleton et al., 2000). Rather, we
need to look at what can be expected from Looked After
Children. As Pearce, 2000 states:
1) A mental health problem:
“Describes a very broad range of emotional or
behavioural difficulties that may cause concern or
distress. They are relatively common, may or may not
be transient but encompass mental disorders, which
are more severe and/or persistent”.
2) Mental or psychiatric disorders:
“Are those problems that meet the requirements of ICD
4: MENTAL HEALTH NEEDS
“A disorder occurs where the emotional state is of such
12
looked after children and those which have been reported
have concentrated on a particular geographical area and
have relatively small samples” (p. 1, Meltzer et al., 2003).
severity and/or duration that it interferes with
everyday life and is out of proportion to what would
normally be expected in the circumstances taking into
account the young person’s family background, culture
and stage of development” (p. 51, Pearce, 2000).
Recognising this gap in information, the Office for National
Statistics carried out surveys in 2002 of the mental health of
young people looked after by local authorities in England
(Meltzer et al., 2003), Scotland (Meltzer et al., 2004a) and
Wales (Meltzer et al., 2004b). As the first such prevalence
studies in the UK, they are of considerable importance when
analysing the mental health needs of Looked After Children.
The robust design of the studies which accounts for both
symptoms and impact of mental health disorders allows for
more confidence in the findings compared with previous
small-scale studies.
This statement provides some argument for re-examining
the threshold of what would normally be expected from a
young person in care before making a diagnosis. Richardson
& Joughin (2000) caution that diagnoses may not be
helpful in understanding the emotional predicaments and
feelings of Looked After Children. Nevertheless, while there
is much debate on the stigma and labelling of Looked After
Children, as Richardson & Lelliott (2003) remind us, a
diagnosis can bring relief because difficulties are explained
and help can then be sought.
Among 11-15 year olds, the prevalence of mental disorders
within the three countries’ looked after populations
compared with those in private households was 49%
(compared with 11%) in England, 41% (compared with 9%)
in Scotland and 40% (compared with 12%) in Wales
(Meltzer et al. 2000; 2003; 2004a; 2004b). While patterns of
disorders differed, there were no significant differences in
the overall prevalence of mental disorders in the three
countries apart from these considerable differences between
these rates of disorder and those found for children living in
private households (Meltzer et al., 2000).
Aligned to this point is the fact that different professions
adhere to different models of mental health. Payne &
Butler (2003) stipulated that professionals need to create
a constructive synthesis of ‘social’ and ‘medical’ models
of mental health to provide effective help to young
people. The provision of this help, in their opinion, depends
on the ability to draw on shared aims and responses from
a range of sources and professional perspectives (Payne &
Butler, 2003).
Furthermore, the WHO (2003) encourages the consideration
of broader categories of disorder rather than narrower
disease definitions because this is more readily understood
by professionals and non-professionals without previous
mental health training. The WHO believe that this would
assist understanding and prompt these people to make a
diagnosis and refer for treatment (WHO, 2003):
Many other examples of research which suggest high
levels of need in the Looked After population have been
carried out particularly in the last ten years (McCann et
al., 1996; Philips, 1997; Butler & Vostanis, 1998; Dimigen
et al., 1999; Williams et al., 2001; Minnis et al., 2001;
Royal College of Psychiatrists Research Unit, 2001;
Residential Care Health Project (RCHP), 2004; Blower et
al., 2004). A comparison of these studies is appended
(Appendix 3). Care Leavers are also at known risk of
developing mental health problems (e.g. Richardson,
2002), although the prevalence studies do not tend to
extend into higher age groups taking in young people
leaving care.
“We are well aware of the risks inherent of
medicalization in any discussion of mental health
problems of children and adolescents – or worse, its
‘psychiatrization’ – of problems of normal living and
normal psychosocial development. We are also aware of
the many spurious interests endangering an unbiased,
objective approach to normal developmental issues, that
tend to unduly put many problems of normal living in
the basket of ‘medical or mental disorders’”
(p. 1, WHO, 2003).
4.2
Mental Health Needs
Mental Health Needs
Northern Ireland
Unlike the rest of the UK, Northern Ireland has not
benefited from a large-scale prevalence study to look at
the mental health of the population as a whole, or the
looked after population in particular. Current indicators
are therefore extrapolated from British and international
studies. Some small-scale local studies however, do point
to similarly high levels of need. One example is a study by
Teggart & Menary (2005) carried out in Craigavon and
Banbridge HSST which suggested that up to two thirds of
Looked After Children aged 11-16 years potentially had
diagnosable mental illnesses. Another was the assessment
of need by McMaster (2004) of 52 Looked After Children
The Mental Health Needs of Looked
After Children/Care Leavers
Prior to 2003, there was, regrettably, a lack of information
on the prevalence of mental health disorders among
Looked After Children. Meltzer et al. (2003) note:
“There have been few studies which have attempted to
estimate the prevalence of mental disorder among
13
VOICE OF YOUNG PEOPLE IN CARE
Mental Health Needs
aged 12-18 years accommodated in regional care centres
on a given day. This study found that just over 90% of
Looked After Children experienced some level of anxiety
(sometimes, usually or always), 86% had some degree of
difficulty in coping with life situations and 71% had a
sense of hopelessness (sometimes or frequently) (McMaster,
2004). A further study found evidence of mental health
needs in more troubled Looked After Children in a follow
up study of long-term foster care (McAuley, 2004).
and 10% anxiety. 119 young people aged 11-25 years
were provided with counselling services. Again the top
presenting issues for counselling were relationships
(18%), self-esteem (16%), anger (13%), anxiety (10%)
and family conflict (10%) (YCNI, 2004).
There is some mention that, in general, people in Northern
Ireland may be at greater risk of mental ill-health than
individuals in other parts of the United Kingdom (O’Reilly
& Browne, 20011; NISRA, 2002; McConnell et al., 2002;
O’Reilly & Stevenson, 2003; RMHLDNI, 2005a). O’Rawe for
example mentions that O’Reilly & Browne (2001) estimate
the level of mental health need is 21% higher for men and
29% higher for women in Northern Ireland in comparison
to England (as cited in O’Rawe, 2003, p. 2). Studies at local
levels point to specific reasons for higher rates of mental
ill-health than in the rest of the UK. One example is the
McConnell et al. (2002) study in the District of Derry which
shows high rates of psychiatric disorder in the general
population in the area. This study found that rates of
disorder were even greater than those reported by a
similar study in inner London and were attributed, among
other things, to widespread social deprivation (McConnell
et al., 2002). Similarly, O’Reilly & Stevenson (2003) suggest
that the ‘Troubles’ have significantly impacted on the
mental health of the population of Northern Ireland,
although it is unclear if this is attributable to the violence
itself or other aspects of the Troubles.
Given the lack of information on the mental health of
Looked After Children the review has therefore looked at
the wider population in Northern Ireland and at young
people in particular.
In Northern Ireland, mental health problems in the general
population are among the most common forms of ill-health,
and an attempt to estimate the economic and social costs
of this was made by the Northern Ireland Association for
Mental Health (NIAMH) in 2004. They replicated an earlier
study by the Sainsbury Centre for Mental Health in England,
and estimated that in 2002/03 the economic and social costs
of mental illness in Northern Ireland totalled nearly
£3billion. This figure, they noted, therefore exceeded the
total spend on all health and social care for all health
conditions (NIAMH, 2004).
High rates of mental health problems have been found
in general amongst young people in Northern Ireland as
evidenced in the Northern Ireland Health and Social
Well-being Survey (2001). In this survey, 21% of all those
aged 16+ in Northern Ireland showed signs of a possible
mental health problem (achieving high scores on the
General Health Questionnaire, GHQ12) (NISRA, 2002).
Mental health does concern young people and is one of
the prevailing issues from young people accessing
services such as Contact Youth and ChildLine (YCNI,
2004). The Youth Council for Northern Ireland (YCNI)
carries out a Youth Barometer which compiles and
collates information pertaining to children and young
people aged 0-25 years and the 2004 version provides
up-to-date figures of presenting issues for young people
in Northern Ireland (YCNI, 2004). Between April 2003
and March 2004, 405,430 calls were attempted to
ChildLine (NI) and the most common issues were
bullying, family relationship problems and physical abuse
(YCNI, 2004). During this same period, 4,500 calls were
made to Contact Youth which provides a range of
guidance and counselling services for young people
(YCNI, 2004). Many of the calls related to mental health
issues with 30% being due to relationships, 11% anger
Other evidence appears to suggest that perceptions of
general ‘health’ also seem to differ for young people in
general in Northern Ireland (HPANI, 2001a; Information
& Analysis Directorate, 2004). The Health Promotion
Agency Northern Ireland (HPANI, 2001a) explored the
mental health and well-being of the general population
of young people in Northern Ireland via secondary
analysis of the Health Behaviour of School Children
2
Survey (1997/8) . They found that while most of the
young people who took part in the survey regarded
themselves as healthy, when compared to young people
in other European countries, those in Northern Ireland
had a relatively negative view of their health. Similarly,
the Information & Analysis Directorate reveals that in
2001 fewer people in Northern Ireland self-reported
‘good general health’ (54%) compared to England (in
2000, 76%), Scotland (in 1998, 77%) and in Wales (in
1998, 80%) (Information & Analysis Directorate, 2004).
These figures suggest there is still a gap in perceived
health worthy of consideration.
Commissioning a large-scale prevalence study similar to
1 O’Reilly, D. & Browne, S. (2001) Health and Health Service Use in NI: Social Variations. DHSSPS.
2 The HBSC Survey is a cross-national research study carried out in collaboration with the European Region of the WHO and is administered by the
HPANI in Northern Ireland. Data is collected from a representative sample of 11-15 year olds every 3-4 years regarding their health behaviours
and lifestyle (HPANI, 2001a).
4: MENTAL HEALTH NEEDS
14
that of the Meltzer et al. study has been recommended
on several occasions (e.g. McMaster, 2004; RMHLDNI,
2005a). It is our view that a prevalence study, particularly
a subsequent one for Looked After Children is essential.
Furthermore, consideration for the aforementioned
differences in Northern Ireland should be incorporated
into the design of the study tailored to Northern Ireland.
Despite the lack of information on the prevalence of
mental health problems in Looked After Children and
Care Leavers, we can extrapolate from other studies and
it seems likely that the needs of these populations in
Northern Ireland is at least similar, if not higher than the
Meltzer et al. studies, equating to just under half the
Looked After population. These problems may well
become more pronounced in future years given the
World Health Organisation’s statement that over the next
twenty years, the burden of mental ill-health in general will
grow significantly (DHSSPS, 2004b).
KEY POINTS FOR CONSIDERATION
We do not go into detail in this review about the types of
disorder which can be presented but it would be useful
here to note that a young person moves through
different developmental stages whereby different
disorders are more likely to present. For example, conduct
disorders are more common in the pre-teens, in adolescence
more problems surface such as deliberate self-harm and
suicide and adolescent psychosis may be a precursor to
schizophrenia. It is therefore important for services to be
able to respond to the likely issues which present.
15
•
Lack of information on Care Leavers’
Mental Health.
•
The need for a clear and shared understanding of
the concept of emotional well-being.
•
Mental health is a particular concern for young
people in the general population, and more so for
Looked After Children/Care Leavers.
•
Numbers of calls to ChildLine and Contact Youth
show that many young people, in general, do try
to reach out for help.
•
The general poorer level of mental health in the
Northern Ireland population & the impact of
Troubles may well be significant.
•
The need for an extension of the Meltzer et al.
study in Northern Ireland.
Mental Health Needs
Mental Health Needs
VOICE OF YOUNG PEOPLE IN CARE
Mental Health Needs
4: MENTAL HEALTH NEEDS
16
5
How are the mental health needs of
Looked After Children and Care Leavers
currently identified, assessed & monitored
and how are referrals made?
17
VOICE OF YOUNG PEOPLE IN CARE
How are the mental health needs of Looked After
Children and Care Leavers currently identified,
assessed & monitored and how are referrals made?
It is important to establish how the mental health
needs of Looked After Children and Care Leavers are
currently identified, assessed & monitored and how
referrals take place.
5.1
recommend and develop a health care plan (including
referrals to other services). These recommendations were
discussed with the young person to develop their health
awareness (RCHP, 2004).
Numerous tools to assess the health and mental health of
Looked After Children have been described in the literature
(e.g. Altshuler & Poertner, 2002; Bonnett & Welbury, 2004).
A comprehensive discussion on the merits and criticisms of
such tools as screening instruments can be found in the
Meltzer et al. (2003) study for example. It specifically
discusses screening instruments (Rutter Scales A and B, the
Child Behaviour Checklist (CBCL)), Strengths and
Difficulties Questionnaire (SDQ), diagnostic instruments
(including the Schedule for Affective Disorders and
Schizophrenia (K-SADS), Interview Schedule for Children
(ISC), Child Assessment Schedule (CAS), Child and
Adolescent Psychiatric Assessment (CAPA), Diagnostic
Interview Schedule for Children (DISC) and Diagnostic
Interview for Children and Adolescents (DICA), and the
Development and Wellbeing Assessment (DAWBA).
Identifying and assessing the mental
health problems of Looked After
Children/Care Leavers
Ideally, a full and effective assessment needs to be carried
out to ensure that problems are not missed. However,
there is considerable evidence to suggest that some
Looked After Children fall through the net (e.g. McCann et
al., 1996; Phillips, 1997; Dimigen et al., 1999; Richardson,
2002; Hill & Watkins, 2003; RCHP, 2004). In Hill & Watkins’
(2003) critical assessment of statutory health assessments
for Looked After Children which tracked a cohort of
Looked After Children through the assessment and review
process, recommendations had only been implemented for
just over half of the Looked After Children at the review
stage. These findings (and others) highlight the need for a
system of early assessment and referral. They also suggest
that young Care Leavers may have left the system without
their needs being identified. This obviously has implications
for adult mental health.
Mental health should not be viewed in isolation, but as
interlinked with physical and social health and there is
growing evidence to suggest this interrelationship (Royal
College of Paediatrics and Child Health, RCPCH, 2003). A
good example is that in the general population of 5 to 15
year-olds poorer general health was reported in children
with mental health problems (Meltzer et al., 2000).
In the UK, Williams (2005) recently provided a crude
‘guesstimate’ of the current level of service provision for
the population of children and young people that might be
in more serious need at 10%. He based this on a comparison
of activity figures provided by the mapping exercise carried
out in England for a month in 2002 with the prevalence
data found in the 1999 Office for National Statistics (ONS)
study of disorder (Williams, 2005). Ford et al. (2005) also
carried out a follow up study to the 1999 ONS Study
(Meltzer et al., 2000) to look at service provision. They
found that of those young people identified in the earlier
study as having psychiatric disorders, 58% had been in
contact with services (such as social services, special
educational needs resources, the youth justice system and
mental health services) for emotional, behavioural or
concentration reasons. This percentage included 23% who
had been in contact with mental health services. They note
that the proportion seeing specialist mental health services
exceeds that normally reported in the research literature
(Ford et al., 2005).
This link between physical and mental health has been
addressed among Looked After Children by Hill &
Thompson (2003). They caution that their findings do not
demonstrate causation, rather an association between
these factors and outline three main ways in which Looked
After Children may experience mental and physical health
co-morbidity. Firstly, both may arise from a common
aetiology in the child’s early experiences. Secondly, mental
health problems may occur indirectly as a consequence of
chronic physical ill-health. Finally, the causal path may be
reversed whereby physical health problems are secondary
to a mental health problem (Hill & Thompson, 2003).
Hill & Thompson (2003) suggest that services need to
adopt a holistic perspective representing a movement
away from the traditionally separate disciplines of
physical and mental health. They use the example of a
Behaviour Resource Service to show how this can be
done, given that a named paediatrician has the role of
ensuring that physical health issues are not overlooked.
Mental health assessments can work very well as a
component of a comprehensive health assessment. The
Residential Care Health Project (RCHP) in Scotland set up
an excellent process for identifying and assessing
problems for young people in residential care (RCHP,
2004). Among the key objectives was to carry out a
comprehensive health assessment with a specific mental
health component (rather than a routine medical) and
5: IDENTIFYING & ASSESSING
Others note that statutory assessments work well when
carried out from a health promotion rather than disease
screening perspective and should be delivered by
professionals skilled in addressing diverse health needs (Hill
& Watkins, 2003). An interesting example by Grimes in
18
the US is of a ‘strength-based’ assessment (WHO, 2003).
However, professionals must still consider the potential for
mental health problems:
Identifying & Assessing
Identifying & Assessing
The RMHLDNI does not recommend the use of screening
tools as stand-alone assessments, but rather as a support
for holistic assessments (RMHLDNI, 2005b). The review
concedes that:
“Consideration of formal mental health problems
should be included in the general assessment of
children when entering the looked after system and at
regular intervals thereafter and some standardisation
of assessment and notation across services may be
helpful” (p. 81, Nicholas et al., 2003).
“Commonly used research tools are recognised
to run the risk of identifying disorders where none are
present….there is not evidence to advocate the
widespread use of screening tools”
(p. 37, RMHLDNI, 2005b).
Northern Ireland
There is currently no regional assessment framework in
Northern Ireland (Bunting, 2004; McAuley, in press).
Bunting (2004) acknowledges that the rest of the UK has
benefited from an increased focus on assessment
processes for children in need through the introduction
of the Department of Health (DH) ‘Framework for the
Assessment of Children in Need and Their Families’ (DH,
2000) as part of the Quality Protects Initiative. Neither
the framework, nor Quality Protects have been formally
adopted in Northern Ireland with the result that Health
and Social Service Boards (HSSBs) have been ‘left to their
own devices’ to develop assessment models at a subregional level. She concludes that Northern Ireland would
benefit from a regional, standardized approach to
assessment so that the same information is collected
(Bunting, 2004). Similarly, McAuley (in press) noted that
while in England, Wales and Scotland, the DH Framework
for Assessment of Children in Need and their Families and
the more recent Department for Education and Skills
(DfES) Common Assessment Framework place an
emphasis on assessment for planning and intervention,
no comparable framework has been adopted in Northern
Ireland. She stated however, that the ‘Strategic
Framework for Children in Need and their Families’
currently being developed should bridge this gap
(McAuley, in press).
There is some evidence of unmet need in Northern
Ireland such as the McConnell et al. (2002) survey of
psychiatric disorder which found that only a quarter of
needs for treatment were met. A follow-up study to
Teggart & Menary’s (2005) work mentioned earlier has
been initiated to investigate what services are being
offered to, and used by, Looked After Children in Craigavon
and Banbridge Trust (Teggart & Menary, 2005).
At present, some degree of mental health assessments do
appear to be carried out in the four Board areas. For
example, Sperrin and Lakeland Trust (SLT) in the Western
Board has developed a Therapeutic Service for Looked
After Children (TSLAC). A recommendation for the future
progression of the service is to allow for a comprehensive
assessment on the mental health of Looked After
Children upon entering the care system (SLT, 2006).
Another example is the assessment tool developed by the
Ulster Community and Hospitals Trust (UCHT) in the
EHSSB area as part of the latest set of Service
Improvement Projects (DHSSPS, 2006a). Following a
successful first wave, the second wave of Service
Improvement Projects began in September 2004. The aim
is to improve access for patients and clients by engaging
multi-disciplinary teams in the redesign of services to
reduce waits and delays at all stages of the care pathway.
Prior to the project, there was no robust and
comprehensive system in place to assess the mental
health needs of Looked After Children in the area. The
project identified the main carer as the most appropriate
person to carry out the assessments, e.g. the foster carer or
key worker. A multi-disciplinary clinical group was formed
and tasked with developing an assessment tool which was
then administered by these identified carers. Quantitatively
better information was gathered when the tool was
completed with the child rather than the carer
independently. A learning point was that the carer’s
knowledge and skills within the Looked After Children
system were underused (DHSSPS, 2006a). The tool is still
being used by UCHT and the Eastern Health and Social
Services Board (EHSSB), at the time of writing, had planned
to roll out the tool in the other Trust areas (DHSSPS, 2006a).
5.2
Discrepancies in what Looked After
Children say and how others assess
their needs
Some evidence suggests that the views of Looked After
Children often differ from those of professionals and
caregivers around them regarding whether or not they
have mental health needs (e.g. Williams et al., 2001;
Mount et al., 2004; White & Stancombe, 2004). Williams
et al. (2001) found that carers had significantly less
appreciation of the difficulties young people in their care
had with interpersonal relationships and perceived
greater behavioural problems contrasting with the
parents in a matched control group. Similarly, Mount et
al. (2004) found that carers were four times more likely to
identify Looked After Children as having mental health
needs than Looked After Children were themselves both
19
VOICE OF YOUNG PEOPLE IN CARE
Identifying & Assessing
on an intuitive basis and when using a mental health
screen. Two thirds of the carers were intuitively accurate.
The authors note that 70% of the carers and 20% of the
Looked After Children themselves noted they had mental
health needs which is surprising when compared to
previous studies (e.g. see comparison of studies in
Appendix 3). White & Stancombe (2004) found similar
discrepancies in their study which involved an
assessment of the mental health needs of all Looked
After Children over 7 years in Stockport. Carers
completed the Devereux scales of mental disorder and
Looked After Children completed the Reynolds
depression scale and self-esteem inventory. They found
that whilst carers reported relatively high levels of
depression and antisocial behaviour for 13 to 18 year
olds, Looked After Children themselves neither reported
high levels of depressive symptoms nor low self-esteem.
are to an extent precursors of future beliefs and
attitudes. This would similarly be the case for Looked
After Children/Care Leavers.
Thirdly, these discrepancies may simply demonstrate that
there may always be differences of opinion about
difficulties and their solutions. Mount et al. (2004) gave
several reasons for Looked After Children denying having
a mental health problem. These included preserving selfesteem or considering the ‘symptoms’ as normal in the
context of their lives. They believe it is plausible that
Looked After Children in the study felt it necessary to
normalize their behavior and that their main reference
point for ‘normal’ feelings and behavior is their own
experiences fuelled by a desire not to be perceived as
different from their peers. Further, they note that the
discrepancy could result from an over-reporting of young
people’s emotional expression and difficult behaviour by
carers (Mount et al., 2004).
The fact that these discrepancies exist warrants further
consideration. Firstly, the discrepancies have implications
for service provision. White & Stancombe (2004) argue
that while the established literature makes a strong case
for investment in specialist CAMH Services, contradictory
assessments of mental health needs challenge this
viewpoint. The authors suggest their findings question
the assumption that Looked After Children need
specialist psychiatric services rather than a more
mainstream and cost-effective range of support services
(White & Stancombe, 2004). Similarly, Frankish &
McCrossen (2005) believe good promotion and
prevention services need to be in place, rather than
resources concentrating solely on Tiers 3 and 4 (for
explanation of the 4-Tier system, see chapter 8). The
danger in such an argument is that it may lack
consideration for the very convincing levels of need
expressed by the ONS studies discussed earlier (Meltzer et
al., 2003; 2004a; 2004b) whereby almost half of the
Looked After population were seen as having a
diagnosable disorder. Nevertheless, this half would still
need to access lower level services as well as higher ones.
In this review, we argue that both specialist and
mainstream services are needed.
Finally, these discrepancies may simply raise issues in
relation to the tools and definitions used so we must
ensure that we are comparing like with like.
Similarly, discrepancies may occur in professional
opinions. Phillips (1997), for instance, identified a
mismatch between the decisions of social workers and
child mental health professionals regarding the number
of Looked After Children in need of treatment which
has obvious implications for inter-agency working.
Mount et al. (2004) also suggest that a replication of
the study they carried out with Looked After Children
and carers would be necessary with social workers to
understand their identification of mental health need in
Looked After Children and subsequent referral decisions
to CAMHS.
5.3 Instigating, monitoring and following up
on assessments – the role of Advocacy
The reasons for the lack of instigation, monitoring and
follow-up to assessments can range from instability of
placements to young people being lost at the interface
between CAMHS and Adult Mental Health (AMH)
Services. Polnay & Ward (2000) state that, despite
obligations of the Children Act 1989 to ensure that the
developmental progress of every Looked After Child is
monitored and benefits from an annual medical report,
their mental and physical health problems are often
overlooked or not properly managed. Looked After
Children and Care Leavers is an under-developed area.
Secondly, the discrepancies highlight that assessments
need to be conducted from the perspective of all relevant
parties and should include Looked After Children/Care
Leavers. However, this is not always the case even among
young people in the general population, as Armstrong et
al. (2000) state:
“Research exploring young people’s views towards
mental health is at an early stage of development… both
mental health and the perspectives of children are
relatively under-explored” (p. 60, Armstrong et al., 2000).
This lack of focus on the issues relating to their mental
health causes difficulty, as Looked After Children have no
As the authors note, the views which young people hold
5: IDENTIFYING & ASSESSING
20
real advocate to seek out services on their behalf (DH,
2002). Advocacy can be conceptualised in two different
ways, as the more informal processes used by parents or
frontline workers, or as a formal independent initiative.
Identifying & Assessing
Identifying & Assessing
seemed to be no sense of him ‘owning’ the problem so the
therapist doubted the potential for a therapeutic alliance
but the residential worker insisted. Although Derrick had
not directly asked for help, his worker was able to see
that his earlier experiences had had a profound impact on
his inner world and in Fleming’s words he ‘championed
his emotional health’ and acted as his advocate. Fleming
notes that this type of story is not uncommon, many
Looked After Children do not usually find their way to
psychoanalytic psychotherapy, nor is it seriously
considered. However, he feels that if the referral process is
exposed to the network around the child, those working
closely with Looked After Children may be adept at picking
up the indirect messages from them (Fleming, 2003).
In the general population, most children turn first to
parents with their health concerns (Meltzer et al., 2000;
Madge & Franklin, 2003) and these studies show that
young people in general can rely on competent adults
to recognise their health problems and assist them in
accessing services. Butler & Payne (1997) state that:
“In the case of children living with their own parents,
as we have suggested, the concern with their child’s
health is a primary and primal one. Current practice
would suggest that similar urgency is not felt in
regard to children in public care. Greater awareness
among professionals of the importance of a child’s
health to her or his general well-being would help,
but strong local awareness and advocacy by
those with the day-to-day care of children
would help even more”
(p.34, Butler & Payne, 1997).
The WHO sees formal advocacy as an essential element in
the care of children and young people with mental health
disorders but cautions that it can be fragmented:
“The drawback to current advocacy is the
fragmentation among NGOs [Non-Governmental
Organisations] and others in the development of
co-ordinated systems of care, and discipline
competition” (p. 21, WHO, 2003).
The RCHP (2004) reminds us that young people in
residential care do not have the same network of adults
as their peers (not living in care) to talk to about
sensitive health issues e.g., parents, teachers, a GP
known to the family.
Northern Ireland
In a longitudinal study of young people in long-term foster
care, McAuley (in press) found that foster carers had
encouraged Looked After Children to apply for courses or
used local contacts to assist them in gaining employment.
One creative approach, which could prove useful in the
future, is that used by the RCHP (RCHP, 2004) of
support to residential staff. The RCHP based their
approach on the assumption that in 81% of cases
Looked After Children would approach a unit staff
member if they did not feel well. The project decided to
build on this by developing a training and support role
for these staff delivered by nurses and not dissimilar to
the process a new mother goes through with a health
visitor. This allowed the staff to deal with Looked After
Children presenting with issues they had not previously
encountered. As the project progressed, individual careplanning took over from initial crisis-management.
Alongside this role, the nurses also took on an advocacy
role for the Looked After Children.
The need for advocacy has been highlighted in Northern
Ireland (Kilkelly et al., 2004, Kilpatrick, in press) and at
present VOYPIC operates the only independent advocacy
service exclusively for Looked After Children and Care
Leavers in Northern Ireland. VOYPIC’s definition of
“Advocacy” is providing an independent and skilled
service to represent the rights of care experienced
children and young people. The service is independent of
the Health and Social Services Trusts and brings to the
attention of government and relevant agencies, the
problems existing in the extent and quality of care
provided for young people. VOYPIC campaign for the
improvement in the provision and quality of care services
in Northern Ireland. The job of a VOYPIC Advocate is to
represent young people, give them a voice and consult
with them on issues pertaining to their care. Presently
VOYPIC offers individual advocacy, group advocacy, and
campaign work. It involves helping children and young
people to:
Looked After Children/Care Leavers may also miss out on
services which would assist them because professionals
may not think they will benefit from certain services. A
good example of this was a very honest account given by
a child psychotherapist, Robert Fleming, regarding a
psychotherapy case which benefited the Looked After
Child despite the therapist’s initial reluctance to take on
the referral (Fleming, 2003). When Derrick (a 14 year old
living in residential care) was referred to the
psychotherapist by his residential social worker, there
•
•
•
•
21
Learn about their rights;
Learn about the services to which they are entitled;
Make informed choices;
Ask for services and adherence of their rights;
VOICE OF YOUNG PEOPLE IN CARE
Identifying & Assessing
•
judgements. They were concerned with the finding that
23% of carers did not identify needs which were
subsequently identified by the mental health screen and
provided reasons such as Looked After Children’s ability
to conceal their distress or carer’s potential difficulties in
identifying internalised behaviours. They note that some
Looked After Children are extremely skilled in shutting
themselves off and keeping adults at a distance (Mount
et al., 2004).
Ensure that the services they receive are
appropriate and take account of their age, gender,
race, religion, culture, language, physical or mental
health, or sexual orientation.
The service works in partnership with other professionals,
agencies and individuals to ensure that the child’s views
are taken into consideration and that each work to ensure
a commitment to children’s rights and services.
From December 2004 - November 2005, 107 care
experienced young people were involved with VOYPIC’s
advocacy service. Issues included concerns about leaving
care (particularly accommodation), mental health tribunals,
concerns about placement, lack of contact with siblings
and concerns about education.
The actual criteria for referral and process of referring to
CAMHS may also be difficult. Valios (2002) notes that
mental health problems in Looked After Children are
often difficult to spot and if a professional does realise
they have mental health problems, they may still need to
see a sympathetic GP before referral to a specialised
service. Valios further shows that placement instability
can restrict young people’s access to CAMHS. For this
reason, Callaghan et al. (2004) note that the Looked After
Team, in their study, did not define placement stability as
a prerequisite of referral. Similarly, the actual criteria for
referral should be clear:
A recent development by NICCY should prove informative
through commissioning the University of Ulster to carry
out ‘A Northern Ireland based Review of Advocacy
Arrangements for Children and Young People with
Mental Health Needs who are in Care or Custody’. This
involves consultation with young people, their
parents/carers and professionals working within the field.
The aim of of the review is to find out what advocacy
services are available to these young people, what the
strengths and weaknesses of the current situation are
and what needs to change (NICCY, 2006).
5.4
“Here there are many young people who are emotionally
troubled but not mentally ill, for whom AMHS referral
criteria currently do not apply” (p. 52, RCHP, 2004).
There is a degree of anecdotal evidence to suggest that
the process of accessing CAMH Services is a difficult
process and referral processes are not usually designed to
cope with acute or urgent referrals despite this often
being the type of referral (Kerfoot, 2005). Richardson &
Joughin (2000) also mention the 1999 Audit Commission
report which shows that NHS clinicians are the main
referral route to specialist CAMHS (52% by GPs and 15%
by pediatricians). Kerfoot similarly notes the 1999 Audit
Commission report which suggested that social workers
referred less to CAMHS because these would be routed
through a GP and then on to a waiting list. This is
worrying since nowadays social workers are responsible
for coordinating a number of subcontracted services for
Looked After Children e.g. family centres (Kerfoot, 2005).
They can be the direct referrer or an agent for foster
carers and residential workers to CAMH or AMH services.
Referrals
The approach used by those working directly with Looked
After Children/Care Leavers is a crucial step to meeting
Looked After Children/Care Leavers’ needs through
referrals to appropriate services. In order to be able to
refer, those working with Looked After Children/Care
Leavers need to have a common understanding of what
constitutes CAMHS and Adult Mental Health Services. They
also need to be able to explain and prepare the young
person for the services they will receive:
“Children need to understand whom they are going to
see and why, what will happen and what they might
need to say or to ask. They need to be offered choices
about how, when and whom they see and whether they
go alone or have their foster carer or social worker
with them” (p. 27, Richardson, 2002).
In order to access services, good information is needed on
what these services are and how they can be accessed.
Some movement towards this aim comes from a
comprehensive CAMHS database which has been set up
through a mapping exercise (found on the website
www.camhsmapping.org.uk). Nevertheless, the RCHP
(Scotland) found that often, practitioners are unclear
about what CAMHS has to offer. This, they predict, is due
to lack of contact outside of specific cases and crisis
situations (RCHP, 2004). Conversely, CAMHS staff had
unrealistic expectations of practitioners’ knowledge of
Mount et al. (2004) note that carers (foster and
residential) are relied upon to make intuitive judgments
to initiate the referral process. This is based on their
knowledge of the young person, their understanding of
mental health problems and potential risk factors. They
also tested the systematic use of a mental health screen
for more accurate identification than these intuitive
5: IDENTIFYING & ASSESSING
22
mental health issues. They conclude:
KEY POINTS FOR CONSIDERATION
“Between the sides in this polarisation is a no-man’sland where, given adequate resources, social work and
CAMHS might work together more effectively”
(p. 52, RCHP, 2004).
•
Need for full and thorough assessment of Looked
After Children.
•
Assessment needs to move beyond diagnosis to
look at the Looked After Child/Care Leaver’s
circumstances and the impact of this on his/her
emotional well-being.
•
Need to understand Looked After Children/Care
Leavers’ views of mental health and ill-health.
•
Need to include multiple perspectives, in particular
those of Looked After Children/Care Leavers in all
aspects of assessment. If discrepancies occur, it is
necessary to try to explain why.
•
Need for proactive and ongoing support for
Looked After Children in relation to assessments or
care plans.
•
How is health information currently stored/tracked
in Northern Ireland?
•
Need to develop awareness of what services are
available among those working directly with
Looked After Children/Care Leavers. Are there plans
for a mapping exercise in Northern Ireland?
Northern Ireland
This view, that those working directly with young people
need to have knowledge of Looked After Children/Care
Leavers’ mental health needs and know how to refer to
the appropriate services, has been highlighted in
Northern Ireland through the RMHLDNI CAMHS
consultation report (RMHLDNI, 2005a) but would be
equally applicable for AMH Services.
There may be a need in Northern Ireland for more priority
for Looked After Children in CAMHS. Some suggest that
Looked After Children can be particularly disadvantaged
when needing referral to CAMHS because they move
around a lot due to placement instability. McAuley &
Young (2006) suggest:
“Direct referral from senior social work staff
responsible for planning the care of looked after
children, coupled with more flexibility surrounding child
referrals across authorities, might well reduce some of
these problems” (p. 98, McAuley & Young, 2006).
23
Identifying & Assessing
Identifying & Assessing
VOICE OF YOUNG PEOPLE IN CARE
Identifying & Assessing
5: IDENTIFYING & ASSESSING
24
6
What action is taken to ensure that risk
factors and vulnerability are reduced in the lives
of Looked After Children and Care Leavers?
25
VOICE OF YOUNG PEOPLE IN CARE
What action is taken to ensure that risk factors and
vulnerability are reduced in the lives of Looked After
Children and Care Leavers?
genetic factors, or environmental factors (Kerfoot, 2005).
Latest statistics on Looked After Children who started to
be looked after in England during the year ending 31
March 2004 reveal various reasons for the need to be
looked after. The main reason was abuse or neglect
(48%), followed by family dysfunction (13%), family in
acute stress (11%), absent parenting (11%), parental
illness or disability (8%), socially unacceptable behaviour
(6%) and disability (3%) (DfES, 2005).
There are many factors that may place some Looked After
Children/Care Leavers at greater risk of developing
mental health difficulties than their peers in the general
population. These factors have sometimes been described
as the three “Ps” (i.e., predisposing, precipitating and
perpetuating factors) and were identified by the Clinical
Psychology Speciality Advisory Committee (SAC) (2002)
as follows:
• Predisposing factors may include genetic
influences, low IQ, developmental delay,
communication difficulties;
• Precipitating factors may include overt family
conflict, family breakdown, inconsistent parenting
and so on; and
• Perpetuating factors involve socio-economic
disadvantage, hopelessness, and living in conflict
(Clinical Psychology SAC, 2002).
There is also evidence to show that Looked After Children
coming into care are from atypical families (Bebbington
& Miles, 1989). Bebbington & Miles found that only a
quarter of Looked After Children were from two parent
families, only one in five lived in owner-occupied
housing, half lived in poor neighbourhoods and three
quarters were in receipt of income support (Bebbington
& Miles, 1989).
A difficulty arises when one or other of the problems are
not identified and as already outlined, there is some
evidence of the risk of Looked After Children and Care
Leavers’ needs not being met. Some have found that
physical issues can go largely unnoticed in residential
units where health was a low priority given all the other
crises workers had to deal with (RCHP, 2004) so it is
hardly surprising that less obvious mental health issues
similarly remain undetected.
An often-cited study to reveal the vulnerability of this
group is that carried out by Dimigen et al. (1999) among
Looked After Children aged between 5 and 12 years at
the time of entering care. The study revealed that a
‘considerable proportion’ of these participants had a
serious psychiatric disorder when entering care but were
not referred for psychological help.
Steps that can be taken in response to parenting failure
before the point of a child coming into care (Rutter,
2000). Rutter proposes that the care system may fail to
provide what is needed or make things worse. He states
that society needs to consider what can be done to make
the provision of care better than it has been up to now
(Rutter, 2000).
Since risk factors have been well documented in the
research literature, in this review, we will concentrate on
discussing the main developmental stages the child in
care goes through during which different risk factors
present and the extent to which these are met.
Subsequently, we will briefly discuss the way the young
person may choose to cope with these risk factors.
Northern Ireland
6.1
Three stages of vulnerability in relation
to Care Experience
In Northern Ireland, there has been some movement
towards the establishment of early intervention initiatives
such as Sure Start. However, the level of investment in the
area is much less than in England and Wales.
For the purposes of this review, we suggest that every
child in care goes through three main stages of
vulnerability: pre-care experience, the experience of care
itself, and then ultimately leaving care. Each of these
stages can heighten the number and severity of risk
factors impacting on the young person’s mental health
and will be discussed briefly below. However, many young
people go through these three stages a number of times
with intermittent periods at home.
Predominantly, in Northern Ireland, Looked After Children
come into care due to neglect associated with alcohol
addiction of one or both parents (McAuley & Bunting, in
press). This was also shown in the 1999 Social Services
Inspection of Care Planning for Looked After Children the
subject of Care Orders. It was found that both parents had
longstanding problems with alcohol/drug use in 85% of
cases (as cited in DHSSPS, 2004b).
Stage 1) Pre-Care Experience
Winter & Connolly (2005) analysed referral data in
Northern Ireland at ward level from 1998-2000 and
found a strong relationship between measures of
deprivation and referrals to family and child care teams.
Life before care and the very reasons for entering care
can increase the risk and vulnerability to mental health
disorders and can be either intrinsic to the child, due to
6: ACTION - RISK FACTORS
26
Action - Risk Factors
Action - Risk Factors
relationships, school, feeling good about themselves,
feeling cared for), they often have problems associated
with their living circumstances, they feel a need for
someone to be ‘on their side’, and can feel a lack of safety
(Houston, 2005). While in care, Looked After Children can
also experience stigmatizing attitudes from others,
particularly in the school environment, directly as a result
of their care experience. Some participants in the study
carried out by Stanley (2002) for example experienced
hostility from other children as a result of their lookedafter status.
While they acknowledge that more research is needed in
this area in the UK in general, they stated that if they
knew the multiple deprivation score for a particular
ward, they would be able to predict the number of childcare concern referrals with 91.4 per cent accuracy. In
other words, deprivation is likely to increase the chances
of referral to Social Services. The DHSSPS 2005-2025
vision ‘A Healthier Future’ also recognises the link
between deprivation and health status (DHSSPS, 2004b).
This link is important to acknowledge since families in
more affluent areas may be better able to curtail or
contain the adverse effects of actions e.g. alcohol misuse
which can be harmful to young people’s mental health.
Ritchie (2005) has recently questioned the benefits of the
care system:
There may also be issues for some Looked After Children
who come from cross-cultural backgrounds. In a
prevalence study of Looked After Children across
Northern Ireland, McCay & Sinclair (1999) found an overrepresentation of children from cross-community
backgrounds in the care system in Northern Ireland.
Compared to 5.6% of cross community relationships in
the population as a whole, 17.3% of their sample came
from such a background (McCay & Sinclair, 1999). Kelly
& Sinclair (2005) later demonstrated how meeting the
identity needs of the Looked After Children is now a
statutory duty yet the majority of social workers had not
received training in this respect. They note that:
“[This paper] tentatively suggests that it is time to say
what we know: that there is no evidence that public
care reduces risk of significant harm, that there is no
evidence that child protection procedures save lives and
that the past 125 years of history of inquiries and
legislation suggest that little will improve”
(p. 765, Ritchie, 2005).
However, there is evidence to show that the quality of the
experience of care has important effects on behavioural
outcomes (Rutter, 2000).
Berridge (2005) believes we can underestimate the nature
of problems Looked After Children face given the huge
sense of loss they experience when their family breaks
down, or when they are separated from their families. He
concedes that we cannot be sure we fully understand the
social and psychological effects of that.
“Religious identity is directly linked to cultural and
community identity in Northern Ireland. It impacts on
where children can live safely, attend school, socialize
and develop relationships. Therefore, asking about
religious identity cannot be discarded by social workers
as simply a personal matter where they should not
intervene. Social workers have a legal duty to meet the
religious and cultural needs of children and must
actively consider the impact of placement decisions on
the lives of looked after children from cross-community
backgrounds” (p. 337, Kelly & Sinclair, 2005).
Northern Ireland
Pinkerton & McCrea (1996) recognise that the young
person’s day-to-day experience with the formal care
system sets the context and provides the resources they
use when growing up. Furthermore, the findings of
Pinkerton & McCrea (1996) show the importance of the
family throughout the young person’s time in care, which
acts as an informal support:
Stage 2) The Experience of Care
Looked After Children/Care Leavers may suffer additional
problems as a result of living in care (DH, 2002) in that
care itself may fail to repair and protect health, and
potentially exacerbate problems. As Madge & Willmott
(2005) point out, becoming looked after brings
disruptions to family and other social relationships with
perhaps the loss of friends at school and in the
community. Houston (2005) recounted issues Looked
After Children presented when calling ChildLine
Scotland. First and foremost, she noted that they often
present with very similar problems and concerns as their
peers not living in care. However, they do have long
histories of difficulties in a short life (e.g. with
“Both the informal and formal systems contribute to
providing the context and resources for the majority of
the young people in their coping with the life tasks of
adolescence. This is crucial to making sense of leaving
care” (p. 149, Pinkerton & McCrae, 1996).
One element of corporate parenting where more work
could be done may be on the concept of ambition for the
Looked After Children/Care Leavers’ future, highlighted
recently by the DHSSPS:
“When Health and Social Services take on parental
27
VOICE OF YOUNG PEOPLE IN CARE
Action - Risk Factors
responsibility for children we must make every effort
to provide them with stability, protect them from
further harm and be ambitious for their futures”
(p. 74, DHSSPS, 2004b).
by Mooney et al. in 2004. These reveal a fairly bleak
outlook for Care Leavers compared to school leavers in
the general population (Mooney et al., 2004). The
authors’ note of caution must be kept in mind when
making these comparisons: Care Leavers tend to be older,
and the base numbers each year are relatively small
(Mooney et al., 2004). Although these are the main
source of information on Care Leavers for the moment,
the authors caution that further collections of information
will facilitate more reliable estimates from a larger pool of
data (Mooney et al., 2004).
The care system can struggle to provide a similar life to
family life as Teggart (in press) states:
“Despite the best of intentions the care-system cannot
emulate the constancy and security of family life, and
many young people in care have been so disturbed by
their experiences that the activities and requirements
of recovery may seem beyond their grasp”
(p. 15, Teggart, in press).
The Mooney et al. (2004) findings demonstrate that the
level of educational achievement for Care Leavers was
much lower than school leavers generally; Care Leavers
were 10 times more likely than school leavers in general
to leave with no qualifications at all which translates to
51% of Care Leavers compared to 5% of all Northern
Ireland School Leavers (Mooney et al., 2004). Similarly,
economic activity levels were much lower whereby 57%
of Care Leavers (whose economic activity was known)
were in education, training or employment compared to
91% of all 16-18 year olds in the population.
Unemployment rates were also high among Care Leavers
with 30% being unemployed compared to 5% for school
leavers in general (Mooney et al., 2004).
Stage 3) Leaving Care
Care Leavers have also been found to be vulnerable to the
development or exacerbation of mental health problems
because of the difficulties they face when leaving care.
These difficulties include poor educational attainment,
unemployment, teenage pregnancy, entering the prison
population, homelessness (e.g. Biehal et al., 1995; Social
Exclusion Unit (SEU), 2003). Nevertheless, if they are
given the help and support they need, education, training
and employment can be improved (Martin & Jackson,
2002; Harker et al., 2004).
There also seems to be limited research findings on Care
Leavers in Northern Ireland but work such as The
Northern Ireland Leaving Care Research Project (NILCRP)
set up by Queen’s University Belfast (QUB) (Pinkerton &
Stein, 1995) contributes to a growing field of
information. What emerges from the literature is two
different pathways summarised below regarding the
transition into adulthood of a young person in the general
population and a young person leaving care.
Most young people (in the general population) leave
home in their twenties and there is evidence that the age
is increasing. Usually, they can return home over a
considerable period of time assisted by what Mendes &
Moslehuddin (2004) call a safety net of extended
support. For Care Leavers the picture is rather different
with a severe lack in support as Minty (1999) states:
Young person leaving family:
“There is a strong case for arguing that discharging
some of our least-educated, worst-skilled, and most
emotionally and socially disadvantaged young people
into the community in mid-adolescence, and without
adequate support, is a recipe for disaster”
(p. 996, Minty, 1999).
“This transition to adult citizenship involves successfully
shifting from a childhood status characterised by
dependency on family, school, friends and
neighbourhood to an adult status based on choices such
as building intimate relationships, becoming a parent
and setting up a new family, becoming a householder,
finding employment and choosing a locality in which to
live, work and develop leisure pursuits”
(pp. 697-698, Pinkerton & Stein, 1995).
He argues that better outcomes are associated with the
later discharge of Care Leavers but also earlier admission
(rather than postponing admission and Care Leavers
oscillate between home and short-term placements)
(Minty, 1999).
Young person leaving care:
Northern Ireland
“Many have to leave care and live independently at a
much earlier age than other young people leave home
– and they are more likely to move regularly and
experience homelessness; they have lower levels of
educational attainment and lower post-minimum
A similar picture has been found in Northern Ireland.
Work is currently being undertaken to profile the current
population of Care Leavers, however, the most up-todate statistics on Care Leavers in Northern was compiled
6: ACTION - RISK FACTORS
28
Action - Risk Factors
Action - Risk Factors
rather than let it build up to the point where he or she
can no longer cope” (p. 67, Pearce, 2000).
school-leaving age participation rates; they have
higher unemployment rates, more unstable career
patterns, and higher levels of dependency on
welfare benefits; and many (in England and
Northern Ireland) enter parenthood earlier”
(p. 243, Stein et al., 2000).
In order to comment on the coping mechanisms of
Looked After Children/Care Leavers, it is necessary to bear
in mind what is ‘normal’ for young people of the same
age in the general population. Drugs, for example, are no
longer considered the province of a deviant minority and
show signs of becoming statistically normal (Davies,
2000). Adolescence is a time of great change and we need
to bear this in mind when looking at the coping
behaviour of Looked After Children/Care Leavers:
An interesting study of outcomes for Looked After
Children in long-term foster care in Northern Ireland by
McAuley (2004) was carried out with 16 Looked After
Children in a ten year follow-up study. The young people
were aged 17-24 years at the time of interview and the
author categorised them as being ‘more troubled’ or ‘less
troubled’. Findings from the more troubled group showed
that they were all assessed by their social workers as
having low or very low self-esteem although no evidence
in the case files demonstrated work being carried out to
address this. Also, the more troubled group were very
isolated, compared with the majority who had supportive
networks. The author found little evidence of life-story
work despite young people having many unanswered
questions about their identity. There were also gaps
regarding social and emotional development in their
files. However, she noted considerable achievement in
either educational or vocational qualifications
demonstrating that the majority were in full-time
employment (11) or full-time education (2) (McAuley,
2004). It should be noted however, that these outcomes
are more positive than other findings probably due to the
long-term stability these Looked After Children have
experienced compared to the general leaving care population.
“Because of the rapid emotional, social and
psychological changes occurring during adolescence,
together with pubertal changes in growth and strength,
a number of problems may become apparent which
may earlier have been ‘masked’ ” (p. 18, RCPCH, 2003).
Studies therefore are strengthened if they draw direct
comparisons between Looked After Children/Care Leavers
and their peers in the general population. One general
study which is of interest related to young people talking
about how they responded to negative feelings, in
particular anger and sadness (Armstrong, 2000). In
responding to anger, young people would take it out on
inanimate objects, on siblings or, sometimes on other
young people. However, they reacted to sadness and
depression by internalising their feelings (Armstrong,
2000). All the young people participating in the research
identified talking as an effective means of coping with
negative feelings.
In a recent survey by the HPANI (HPANI, 2001b), the
majority (79%) of 16-25 year olds in the general
population said they felt ‘OK’ or ‘optimistic’ about their
future. While this was a quota-drawn sample and
therefore cannot be indicative of the whole population,
research into the corresponding feelings of Looked After
Children would be insightful.
6.2
3
In the Looked After population, a study by Street 1999
has shown a shift from withdrawn, internalising
difficulties to more overt out-of-control and aggressive
behaviours among Looked After Children referred to
residential provision (cited in Kerfoot, 2005).
Nevertheless, Callaghan et al. (2003) talk of a veil of
secrecy which some Looked After Children draw around
them, something which the professionals around them
interpreted as a coping strategy, and one which they as
professionals had to respond to skilfully and sensitively.
Coping mechanisms
Rutter notes that it is striking how differently people
respond to apparently the same situation and further
attaches importance not so much to what coping
strategies people use but to the existence of the coping
process in the first place (Rutter, 1985). A useful
definition of coping mechanisms is:
Looked After Children/Care Leavers exhibit a variety of
other coping mechanisms relating to underlying issues
and these vary from severe to less severe. Self-harm has
received extensive press coverage recently and much
work has been undertaken on the subject, not least in the
new Suicide Prevention Strategy soon to be completed in
Northern Ireland which has specific targets to deal
“The young person needs to find a way to reduce stress
3 Street, C. (1999) Providing residential services for children and young people: a multidisciplinary perspective. Aldershot: Ashgate.
29
VOICE OF YOUNG PEOPLE IN CARE
Action - Risk Factors
with self-harm. There is evidence to show that self-harm
is largely treated medically, and Looked After
Children/Care Leavers are rarely admitted to acute
CAMHS beds either because of lack of capacity or they
are not seen as having mental health problems (RCPCH,
2003). However, the same authors state that:
“Management of these patients requires good links
with CAMHS liaison services including social work,
strong nursing skills/training in mental health issues
and effective community follow-up”
(p. 42, RCPCH, 2003).
KEY POINTS FOR CONSIDERATION
•
The need to understand, in more detail, the actions
taken to reduce the likelihood of young people
coming into care.
•
What priority is given to early intervention
schemes?
•
Need to understand what further actions can be
taken to equip a Looked After Child with the day
to day experiences in care which encourages
ambition for their future.
•
What actions are taken to reduce risk factors
while in care?
•
Need to find creative ways of enhancing the
normality of the day to day experiences of Looked
After Children while in care.
•
It would be interesting in Northern Ireland to find
out how Looked After Children and Care Leavers
regard the stress with which they are faced and
how they choose to cope with it.
6: ACTION - RISK FACTORS
30
7
What action is taken to ensure that protective
factors and resilience are promoted in the
lives of Looked After Children/Care Leavers?
31
VOICE OF YOUNG PEOPLE IN CARE
What action is taken to ensure that protective factors
and resilience are promoted in the lives of Looked
After Children/Care Leavers?
problems and continuing difficulties. The review
identified several models situating these factors. We will
discuss these general models first before providing a
synopsis of protective actions which can be taken. First it
is necessary to define what we mean by protective
factors, as stated by Rutter (1985):
To enable conclusions to be drawn on what needs to
change, it is essential that we consider what actions
could be taken to ensure that protective factors are
identified and resilience developed and promoted in the
lives of Looked After Children/Care Leavers.
Despite increased risk of developing mental health
problems, there is clear evidence that not all Looked
After Children/Care Leavers have problems. Buchanan
(1999) for example analysed adult satisfaction among
Care Leavers. Basing her findings on the National Child
Development Study (NCDS), she asserted that members
of the sample had been at greater risk of psychological
problems compared to children who had not been in care.
However, the same author identifies protective factors for
Looked After Children against later mental health problems.
“Protective factors refer to influences that modify,
ameliorate, or alter a person’s response to some
environmental hazard that predisposes to a
maladaptive outcome” (p. 600, Rutter, 1985).
7.1 Models of Protective Factors/Resilience
There is evidence of efforts to provide protective factors
and resilience in the lives of young people in the general
population. A good example is the work of Hawkins &
Catalano over the last 30 years in the US regarding
protective factors that can reduce anti-social behaviour
(www.channing-bete.com). They mention a number of
factors such as bonds and connections, hopes and dreams,
rules and discipline, raised self–esteem, developing skills,
activities, positive values and strengthened communities.
Another example comes from Armstrong et al. (2000) who
carried out a small-scale qualitative study on a range of
young people’s perceptions of mental health, and in
particular, positive mental health. The participants
identified four main factors as contributing to positive
mental health; family and friends, having people to talk to,
personal achievements and feeling good about themselves.
The factors are often interlinked. Factors, which impinged
on mental health, were parental problems, bereavement,
peer rejection and bullying. A further approach by
Communities that Care (1999) also maps a series of risk
and protective factors for young people’s health and
behaviour (in the general population). The main protective
factors are clear standards (know consequences of
unacceptable behaviour), social bonding (strong
attachments with those who set standards), opportunities
for involvement (feel involved in their families, schools and
communities), social and learning skills, recognition and
praise (incentive to continue positive behaviour).
The following Figure (Figure 2) creates a useful starting
point for discussion, presented by Brigid Daniel at the
British Psychological Society (BPS) Conference hosted by
the Faculty of Children and Young People in September
2005. It shows a shift in perspective from aspects of
Looked After Children/Care Leavers’ lives pointing to
vulnerability and adversity towards a focus on protective
factors and resilience. While we approach this section
with the realisation that Looked After Children/Care
Leavers do experience more adverse life events than their
peers, we acknowledge that we have to look at the
individual person and the context of their lives to
understand resilience. A good way of summarising the
concept is: “Resilience is about doing better than expected
when bad things happen” (p. 105, Gilligan, 2005a). This will
be the starting point of our discussion.
FIGURE: 2 - PROTECTIVE FACTORS & RESILIENCE
Buchanan (1999) as mentioned earlier, also identified
protective factors for Looked After Children today
against later mental health problems. These included
achieving a qualification, help finding employment, help
cutting down on smoking and drinking and more
controversially, help developing successful partnerships.
She asserts that all these will increase life satisfaction,
something which is linked to out-of-family and out-ofwork activities. For Buchanan, it is therefore a case of
developing outside interests as Looked After Children/
Care Leavers grow up, a notion which parallels the ongoing
work of Daniel and Gilligan.
Source:
Daniel, 2005
A number of factors appear to protect some Looked After
Children/Care Leavers from developing mental health
7: ACTION - PROTECTIVE FACTORS
32
protective factors, stating that there are three core areas
which influence our mental health, healthy structures
(e.g. unemployment, poor housing, inequality of
income, discrimination, having choice and control,
education), citizenship – social world (social support,
strong support networks, sense of integration and
social inclusion) and emotional resilience (how people
feel about themselves, interpret events and cope with
stressful or adversarial circumstances).
For this review, one of the most useful models of resilience
for Looked After Children or Care Leavers is contained in
the six domains outlined by Daniel, Wassel & Gilligan
(1999). A thread running through each is their shift in focus
away from problems towards strengths, a fundamental
principle in the resilience-based approach. We will discuss
each of these in turn considering them from the viewpoint
of Looked After Children/Care Leavers.
Firstly, a secure base is needed for Looked After
Children/Care Leavers to have stability and this acts as a
springboard to the wider social world (Daniel et al., 1999).
They suggest that within the theory of resilience, there is
an emphasis on building up a support network from all
available sources including professional support as
required. Secondly, educational expectations need to be
reasonable but not too high. They need to be based on an
up-to-date educational assessment and incorporate the
child’s perception of school. The authors maintain that we
must work from the assumption that:
7.2
Specific actions that can ensure
Protective Factors
We have drawn up a list of four actions that can be
taken to ensure that protective factors are in place in
the lives of Looked After Children/Care Leavers. This has
been drawn from three sources: from the above
concepts of protective factors and resilience; through
VOYPIC’s work with Looked After Children/Care Leavers;
and through other sources in the literature. Each factor
will be dealt with in turn:
“Children naturally have an interest in the world, but
that in some this interest has been thwarted and
disregarded” (p. 9, Daniel et al., 1999).
•
Thirdly, friendships take on an importance, not just in the
ability to make friends but also in the types of friendships
made. A fourth domain is talents and interests which is linked
to self esteem and should be encouraged. The fifth domain,
positive values are seen by the young person’s behaviour
towards others and the authors feel situations need to be
created to encourage caring for other people and empathy.
One particular area of discussion was in the human qualities
of workers. The authors encouraged the assumption that:
•
•
•
Ensuring placement choice, stability & continuity
of care (a secure base)
Encouraging and facilitating contact with family
and wider support networks
Encouraging and facilitating education and
work progression
Encouraging and facilitating the development of
interests/hobbies
7.2.1 Ensuring placement choice, stability
& continuity of care (a secure base)
“Everyone has the potential to behave pro-socially and
that no matter what traumas have been experienced, all
young people can learn to control anti-social behaviour”
(p. 12, Daniel et al., 1999).
A fundamental safeguard for Looked After Children is
choice of placement, a key recommendation of The
Utting (1997) Report. Another key recommendation to
this end was the maintenance of spare capacity. The
rationale was that the type of care placement can have
an influence on the outcome for Looked After
Children/Care Leavers. Kerfoot (2005) acknowledges
that there is increasing evidence to show better
outcomes for those adopted or fostered than those
4
placed in residential care .
The final and sixth domain, social competency, is one with
which Looked After Children/Care Leavers who have often
been deprived of secure early attachments need considerable
support through developing social skills (Daniel et al., 1999).
Again, the authors acknowledge that expectations of
troubled young people’s social skills may not be high.
There is also evidence to indicate/suggest that Looked After
Children of different ages are suited to different types of
care placement. Delfabbro et al. (2002) compared Looked
After Children entering care between Australia and the
Northern Ireland
The HPANI (1999) database specifically mentions
4
Action - Protective Factors
Action - Protective Factors
Direct references used by Kerfoot were:
Quinton, D., Rutter, M. & Liddle, C. (1984) Institutional rearing, parenting difficulties and marital support. Psychological Medicine, 14,
pp. 107-124. Triseliotis, J. & Russell, J. (1984) Hard to place. London: Heinemann.
St Clair, L. & Osborn, A.F. (1987) The ability and behaviour of children who have been ‘in care’ or separated from their parents. Early Child
Development and Care, 28, 3, (Special Issue).
Cheung. S.Y. & Buchanan, A. (1997) Malaise scores in adulthood of children and young people who have been in care. Journal of Child
Psychology and Psychiatry, 38, pp. 575-580.
33
VOICE OF YOUNG PEOPLE IN CARE
Action - Protective Factors
5
comparative cost of using other initiatives (citing examples
such as transport between placements and previous school,
re-arranging access, direct time of social workers). However,
the area needs further study (Delfabbro et al., 2002).
UK using Farmer’s (1993, 1996) distinction between two
types of Looked After Children. Firstly, they identified
disaffected Looked After Children (adolescents placed on
longer-term orders with a history of unstable placements
and more mental health and behavioral problems) and
secondly, protected Looked After Children (younger Looked
After Children on short-term orders due to parental
incapacity, abuse or neglect). They found that different
policies, services and interventions were needed for the two
groups of Looked After Children. The older group needed
something other than family placements (e.g. mentoring,
residential units and supported accommodation whereby
they could live independently with other adolescents); the
younger group needed more focus on their own parents and
work on reunification with parents (Delfabbro et al., 2002).
Continuity of care is also important not only to detect
and act upon mental health problems, but also because it
provides a ‘better’ service to Looked After Children
themselves (Madge & Willmott, 2005). A good example is
that Looked After Children in a study carried out by
Stanley (2002) highlighted consistency and continuity of
care as key components of good services.
Stability and continuity of care are key elements of the
Leicestershire Partnership Trust’s young people’s team – now
a beacon NHS service (Hopkins, 2002). The scheme was
established to work positively with traditionally difficult to
engage groups including Looked After Children. It achieves
continuity through a target response time of two weeks
based on the assumption that there is little point seeing
young people at all if they are not seen immediately given
that so much can change in their lives in a couple of months.
They also see continuity of care as equally important for Care
Leavers and ensure this by following Care Leavers through
the transition to adulthood working with them up to the age
of 18 years (Hopkins, 2002). The team benefits from
psychologists and psychiatrists as full-time team members.
Hopkins (2002) concludes that:
Stability has a protective influence in the lives of Looked
After Children/Care Leavers (Dumaret et al., 1997;
Koprowska & Stein, 2000; Stein et al., 2000; Meltzer et al.,
2003). For example, Meltzer et al. (2003) demonstrate that
in England, Looked After Children’s general health seemed
to improve when placements became more secure (Meltzer
et al., 2003). Dumaret et al. (1997) interviewed adults
who had lived in stable care placements (for at least 5
years in foster families) to determine the long-term impact
of adverse childhood experiences. They summarised the
interview data using an overall social integration score
based on a scale ranging from 3 (-) to 12 (+) points. This
scale covered general health (as defined by the WHO),
professional situation and financial self-sufficiency,
private and home life, social relations with family/parents
and/siblings as well as outsiders, relationship with the
foster family and general psychological state. Dumaret et al.
(1997) found that half the adults were well integrated socially
and 68 per cent were well integrated or average. Stable
placements have been found to be linked to positive outcomes
during care and after care regarding relationship skills,
educational attainment, and employment outcomes (Koprowska
& Stein, 2000). This was also shown by Stein et al. (2000):
“This imaginative model of service, well-funded,
integrated and targeted, shows how things needn’t be
the same way again” (p. 2, Hopkins, 2002).
One area where continuity can be difficult to achieve is
in education (Fletcher-Campbell et al., 2003). The authors
discuss in detail the role of a dedicated teacher6 and the
ensuing difficulties when handing responsibility over to
the Leaving Care Team.
Northern Ireland
“For those young people who did achieve educational
success this was closely linked to placement stability,
more often achieved in foster care placements, combined
with a supportive environment for study. And without
such stability and encouragement, post-16 employment
and career outcomes were likely to be very poor”
(p. 244, Stein et al., 2000).
Maintaining spare capacity and ensuring a choice of
placement, as recommended in the studies above,
unfortunately does not seem to be always feasible in the
Northern Ireland Care System and McAuley (2000) argued
that placement choice has been a major challenge in
Northern Ireland for some time. Further concerns were
raised by Mooney & Fitzpatrick’s (2003) findings that only
22% of respondents considered current arrangements for
Looked After Children in Northern Ireland to be working
‘well’ or ‘very well’.
It may be that there is a higher cost of placements breaking
down compared to the cost of maintaining placement
stability. Delfabbro et al. (2002) speculated on the
5
6
Direct references to Farmer’s work from Delfabbro are:
Farmer, E. (1993) Going home - what makes reunification work? In: P. Marsh & J. Triselotis (Eds), Prevention and reunification in child care. London: Batsford.
Farmer, E. (1996) Family reunification with high risk children: Lessons from research. Children and Youth Services Review, 18, pp. 403-418.
A ‘designated teacher’ is a teacher who understands about care and the impact of care upon education. Each school decides the most
appropriate person to fill in this role (DfEE & DH, 2000).
7: ACTION - PROTECTIVE FACTORS
34
The factors that influence choice of placement and the
extent to which factors other than professional judgement
of assessed needs of Looked After Children determine
placement choice in Northern Ireland has been studied by
Mooney & Fitzpatrick (2003). Just over a third (37%) of
respondents cited ‘Assessed need’ as the most important
factor influencing the decision to admit a child into
residential or foster care. It seems that there are a number of
other factors influencing decision-making as outlined in
Figure 3 below.
They see stability as follows:
Action - Protective Factors
Action - Protective Factors
“Stability is not just about the issue of achieving stable
placements, but about providing continuity in the
child’s family and social relationships through
maintained contacts, continuity of education through
undisrupted schooling and equality of access to after
school activities appropriate to the child’s age,
continuity of health and social care and ensuring that
the placement continues to meet the child’s needs”
(p. 71, Monteith & Cousins, 2003).
FIGURE: 3 - MOST IMPORTANT FACTOR
IN THE DECISION TO PLACE A CHILD IN
RESIDENTIAL OR FOSTER CARE
It is hoped that in Northern Ireland, the implementation of
the new Leaving Care legislation will serve to provide more
continuity for Care Leavers, particularly through pathway
plans and personal advisors and there is also a drive
towards the securing of stability of those in care.
Another promising development for stability could be private
fostering provision. A recent study by Foster Care Associates
(Foster Care Associates, 2006) randomly selected 360 Looked
After Children in foster care in England and Wales and
tracked their placements for 12 months. They found that
99% of the participants experienced no moves within the 12
months of the study, a rate which compares very favourably
against statutory fostering (Foster Care Associates, 2006).
Source:
7.2.2 Encouraging and facilitating contact
with family and wider support networks
p. 65 YCNI (2004) Barometer (adapted from Mooney & Fitzpatrick)
While the Information & Analysis Directorate (2004) stated
that Looked After Children in Northern Ireland seemed to
benefit from greater placement stability than their
counterparts in England or Wales in 2001/2, concern has
still been expressed by policy makers regarding placement
provision and stability as reported in Kilkelly et al. (2004):
A secure relationship is regarded as a crucial protective
factor (Rutter, 1985) and having someone to talk to is a key
factor in young people’s mental health (Armstrong et al.,
2000). Family contact is important in the lives of Looked
After Children and efforts normally are and should, where
possible, be made to preserve family ties. Contact is
complicated because it exists in many forms from receiving
information from a third party through to having regular
face-to-face visits and stays. The manner in which contact
occurs is important, as Gilligan states:
“Placement instability appears to have become an
accepted feature of provision for looked after children
yet it is not accurately recorded and is not the subject
of regular enquiry” (p. 71, Kilkelly et al., 2004).
Placement instability has been linked to difficulties in
placing adolescents with more complex needs, with the
likelihood that these young people would be placed in
residential care (Kilkelly et al., 2004).
“Contact does not have to follow some dull dreary
format involving tedious, stilted and predictable sessions
in often ill-suited locations. Instead these sessions can
be organised around activities of mutual interest to
parent and child” (p. 109, Gilligan, 2005a).
Both stability and continuity of care are linked to longterm planning as Monteith & Cousins (2003) point out:
Support networks, for the purposes of this review consist
of those stable relationships around the Looked After
Child/Care Leaver which help and support them in their
lives encompassing a much wider web of relationships than
the parental or family context. Gilligan emphasises the
importance of the extended family such as grandparents
(Gilligan, 2005a). Gilligan (1999) also outlines five main
adults who play a supportive role in the young person’s life,
“Irrespective of whether children are to be looked after briefly
or for the longer term, there is a need to plan for longer than
their immediate placement if stability and continuity is to be
achieved in their lives. This means building in contingency
plans for when things go wrong or do not work out as
planned” (p. 63, Monteith & Cousins, 2003).
35
VOICE OF YOUNG PEOPLE IN CARE
Action - Protective Factors
it seems that Looked After Children gain from wellestablished positive relationships with their birth family.
McSherry et al. (2004) note that 33% of the Looked After
Children in their study had returned to their parents in
2003 and suggest that a ‘sizeable’ percentage of parents
would be amenable to a programme of support geared
towards maintaining the integrity of the family unit.
However, caution should be exercised when contact with
birth parent(s) brings further dysfunctional interactions.
the caregiver, the social worker, the advocate, the
counsellor and the mentor.
Mentors can be a source of positive relationships in Looked
After Children/Care Leavers’ lives and can lead to positive
outcomes especially if it lasts for a longer period. Koprowska
& Stein (2000) suggest that mentors may act as the
protective secure relationship identified by Rutter (1985).
Young people interviewed by Clayden & Stein (2005)
thought the mentoring relationship was a good source of
practical advice and help with relationship problems, thereby
helping their confidence and emotional well-being.
Relationships in all contexts are of key importance to
young people. Houston et al. (2000), in a small-scale
quantitative study of presenting behaviours and
problems in children’s homes in the Greater Belfast Area
of Northern Ireland, found that relationships were a key
feature in Looked After Children’s lives. They found that
there was a relationship component to all the problem
areas identified in their study and concluded that:
Gilligan (1999) provides an different concept of mentoring
referring to encouraging and supporting a young person’s
talents, interests and leisure activities by a committed
adult. His definition of mentoring is a common interest or
enthusiasm, which is shared with the young person and this
would preferably be informal. He outlines six potential
sources of mentors including the young person’s own social
networks, the caregiver and caregiver’s social networks,
neighbourhood organizations (church, school, workplace,
voluntary social service groups), special interest
organisations (sport, culture, outdoor pursuits, etc.),
individuals with relevant knowledge of youth needs
(former foster carer, youth worker, etc.), advertising to
general public (p. 194, Gilligan, 1999). Gilligan’s (1999)
definition of desirable qualities in a mentor is:
“The complex interplay between the psychological
inside and social exterior of the problems outlined in
this study might be understood better in the context of
nurturing, ambivalent or rejecting relationships”
(p. 18, Houston et al., 2000).
Despite the realisation of the importance of these
relationships, previous evidence has shown that
encouraging contact with this wider social support
network is neither promoted by frontline workers nor by
the planning and review process (Horgan & Sinclair, 1997).
In their review, Horgan & Sinclair found that:
”A deep interest in the young person, enjoying their company,
having an enthusiasm which they enjoy sharing with the
young person, an understanding of and respect for the young
person’s cultural background, a sensitivity to the impact of
negative experiences on the young person’s confidence, mood
and behaviour, and an awareness of the proper boundaries
of responsibility and behaviour” (p. 194, Gilligan, 1999).
“Review preparation forms from all providers ask about
family contact since the last review. Over half the
forms, however, ask about parental, rather than family
contact and no prompt is given about links with other
family members” (p. 49, Horgan & Sinclair, 1997).
He cautions that adults need to nurture such mentoring
relationships, rather than forget them in the current
climate of formal child protection, employing decision
making akin to a prudent parent (Gilligan, 1999). However,
one note of caution in this interpretation is that the parent
may not be dealing with children with complex needs.
McAuley (2004) notes that social workers should assist
young people who are about to leave care to build up
these supportive networks.
The mentoring relationship put forward by Gilligan (1999)
is quite different from formal mentoring services such as
the “U” Choose Mentoring project in VOYPIC. Referrals to
the VOYPIC service do not come solely from the young
person’s social worker but can also be received by young
people self-referring, or from fostering link social workers.
The separation of this relationship from the social worker
can also be beneficial such that the service is seen as more
independent. In some ways the definition used by Gilligan
could be seen as befriending more so than mentoring,
because perhaps the latter tends to be more goal focused.
The four main aims of the “U” Choose project are to create
and build a social support network outside of the care
system for young people aged 12-18 years currently in care,
Northern Ireland
Looked After Children think a lot about their parents even
when placed in long-term care, illustrated by a study of
planned long-term foster care by McAuley (1996) which
found that even after one year in a foster placement, most
of the Looked After Children were still thinking and
dreaming about their birth parents often or very often.
Further, McAuley (in press) showed that the less troubled
participants in her ten year follow-up study had regular
contact with birth parents and/or siblings throughout
their time in care (McAuley, in press). From McAuley’s work
7: ACTION - PROTECTIVE FACTORS
36
to improve the self-confidence and self-esteem of young
people in care, to reduce and combat feelings of isolation,
loneliness and social exclusion and to increase social skills,
empowering young people to get more involved in
decision making. Promoting the building of the mentoring
relationship can also help build other relationships.
Action - Protective Factors
Action - Protective Factors
school…………Children and young people living at home
receive their information and guidance on health
matters primarily from their parents, supplemented by
the school curriculum and their peers. Looked after and
accommodated children are therefore doubly
disadvantaged” (p. 3, RCHP, 2004).
Richardson (2002) specifically mentions several initiatives
relating to education and employment which have an
impact on Looked After Children’s mental health. Health
action zones have local strategies to improve health in
deprived areas through partnership working and can
include other areas such as employment which have an
impact on health. Similarly, Richardson (2002) mentions
education as playing a crucial role in preventing mental
health problems. Personal Education Plans (PEPs) provide a
record of the young person’s developmental needs, progress,
achievements and aspirations. Furthermore, Educational
action zones ‘aim to raise pupil attainment and tackle
educational disadvantage in deprived areas, through
partnership-working’ (p. 30, Richardson, 2002). Another
initiative is the Connexions Service which gives advice and
support to young people aged 13-19 years regarding
personal development and has a particular emphasis on
vulnerable young people. Social Services, in their
management action plans, must show their links with the
Connexions’ service planning structure (DH, 2000).
7.2.3 Encouraging and facilitating
education and work progression
Education, for many, is pivotal to Looked After Children/Care
Leavers’ development. The reasons behind this view have been
well summarised by RCHP (2004) in relation to residential
care, but are equally applicable to Looked After Children in
other placements and Care Leavers. Education, according to
the RCHP (2004) normalizes their disrupted lives, reduces
unstructured leisure time (and therefore time available for risk
behaviours), provides exposure to a wider peer group, access
to health screening, preventative measures and health
promotion and a chance to get out of the cycle of deprivation
and disadvantage (p. 19, RCHP, 2004). This opens the door to
future job prospects which is encouraging given findings that
employment protects both adults and teenagers from mental
health problems (Koprowska & Stein, 2000). Linked to this,
Gilligan (2005b) introduces the concept of childhood industry.
His interpretation of this is that Looked After Children have
the capacity to be active on a range of levels which may
well have an important pay off. These include part-time
work, household chores, school achievement and
extracurricular activities.
Factors which seem to enhance the educational progress of
Looked After Children include the availability of support
and encouragement for educational progress as well as the
acknowledgement of young people’s achievements (Harker
et al., 2004). In this study by Harker et al., Looked After
Children participating in a follow-up stage were asked
about elements of the Taking Care of Education project that
had taken place in their authority. The participants reported
greatest awareness and involvement with activities relating
to schemes to acknowledge and encourage achievement
e.g. awards ceremonies and rewards for revision scheme
(Harker et al., 2004). Similar findings were revealed in a
study of 38 high achievers who had spent at least 1 year in
residential or foster care by Martin & Jackson (2002). The
participants highlighted the importance of foster carers,
residential workers, social workers and teachers in their
provision of support and encouragement for their academic
achievement (Martin & Jackson, 2002). One promising
advance is the Guidance on the Education of Children and
Young People in Public Care (DfEE & DH, 2000) which aims to
raise standards of expectation.
While it is necessary to increase expectations, these need to
be realistic as outlined earlier. There are very real problems
for Looked After Children such as more difficulties with
reading, mathematics and spelling as revealed in the Meltzer
et al. study in England for example. Approximately 60% of
all Looked After Children were assessed by their teachers as
having these difficulties (Meltzer et al., 2003). In the present
review there was little evidence of childhood industry
regarding part-time jobs for Looked After Children.
Of particular significance to this review is the role
education plays in providing Looked After Children/Care
Leavers with valuable information regarding their health,
encompassing both physical and mental health
(Richardson & Lelliott, 2003). A number of concerns have
been raised regarding the accessibility of this
information to this group with low school attendance
(Mental Health Foundation, 2004; RCHP, 2004). In
particular the RCHP states that:
Factors hindering Looked After Children’s educational
progress have also been discovered (Martin & Jackson,
2002; Harker et al., 2004). Harker et al. (2004) found that
peers are the most frequent cited source of hindrance on
Looked After Children’s educational progress,extent, social
workers. In Martin & Jackson’s (2002) study a third of the
“Our system of delivery of health promotion, preventive
health services and screening centres around the
school health service once children are of school age,
so assuming that all children will attend
37
VOICE OF YOUNG PEOPLE IN CARE
Action - Protective Factors
participants reported that the main obstacles to their
educational success were the negative stereotypes and low
expectations for Looked After Children among professionals
and care providers. Indeed this worry stems from the fact
that schooling is frequently missed and truanting tolerated
(Martin & Jackson, 2002). A further difficulty is the lack of
basic necessities such as a quiet place to do homework
(Martin & Jackson, 2002; Harker et al., 2004).
focus on positive aspects, rather than negatives which
have been the main focus in the past (a clear finding in
the study) (McLaughlin, 2002). The project is now
operating in its third phase (LACE III) and has developed
training materials to enhance the core curriculum in
schools (VOYPIC, 2004).
A major obstacle to achieving their full potential was
changing school and the study found that three-quarters
of the participants had changed school (McLaughlin, 2002).
Similarly, education instability can be linked to placement
instability as demonstrated by McAuley (in press) who
found that the 16 participants in her follow up study
collectively experienced 56 primary schools. She also notes
a link between school and social relationships and positive
interests (McAuley, in press). McAuley & Trew (2000) discuss
the attitude of schools towards Looked After Children and
reiterate Fletcher-Campbell’s (1997) evidence that some
schools more readily exclude Looked After Children.
Northern Ireland
There is some evidence that there is a better recognition now
of the need to improve the life chances of Looked After
Children and Care Leavers through the promotion of their
education. Mooney et al. (2004) state that this is evidenced
in the Children Order (NI), Children Matter (1998), and the
new Children (Leaving Care) NI Act as well as in short and
long-term targets by the DHSSPS. In particular they note
that the Northern Ireland Programme for Government
(2002-2005) aimed to increase by 15% the number of Care
Leavers with recognised educational and vocational
qualifications (Mooney et al., 2004). They further note this
commitment in the ‘Priorities for Action 2004/5’ in its
interim target of achieving an attendance rate of at least
85% for Looked After Children (Mooney et al., 2004).
Another development is the commitment in the consultative
document for the Northern Ireland Suicide Prevention
Strategy and Action plan to promote the inclusion of
coping/life skills in the school curriculum (DHSSPS, 2006b).
As Heenan (2004) points out, mental health is largely ignored
in the Northern Ireland curriculum in schools and calls for
local and global citizenship to deal explicitly with mental
health issues. However, there is evidence that young people
in regional adolescent inpatient units do not benefit from a
dedicated education service (O’Rawe, 2003).
For Care Leavers, there would similarly need to be an
emphasis on some form of vocational training or personal
development. This is also the case for those with mental
health problems. NIAMH (2003) noted that those with
mental health problems should be given the opportunity to
engage in ‘meaningful’ activities such as vocational training
or personal development courses as well as job coaching and
supported employment. Further priority should also be given
to their social networks.
7.2.4 Encouraging and facilitating the
development of interests/hobbies
There are numerous examples of the benefits to Looked After
Children of participating in pursuits such as sport, cultural
activities or caring for animals (Gilligan, 1999). Chambers
(2004) also notes the area of play arts as a way of enhancing
resilience. Looked After Children/Care Leavers do seem to be
interested in leisure activities, for instance the RCHP (RCHP,
2004) found that 81% of Looked After Children in residential
care enjoyed sports, and 50% expressed a desire for more
access to sports and leisure facilities.
Some research has taken place at a regional level regarding
the education of Looked After Children. The LACE (Looked
After Children in Education) project was carried out by Save
the Children, First Key and VOYPIC (McLaughlin, 2002). It
involved 52 semi-structured interviews of Looked After
Children aged 9-17 years. Similar to the findings in the
wider UK research, the LACE project found that the support
Looked After Children received in education played a
pivotal role in their progress. While Looked After Children
in foster care responded positively to foster carer’s support,
those in residential care felt staff focused more on their
attendance at school rather than attending to what they
did while they were at school (McLaughlin, 2002).
Three of the important adults mentioned earlier from
Gilligan’s (1999) work are noted by the authors as
providing support directly relevant to leisure interests.
The caregiver can help in practical ways, the social
worker by securing resources and the mentor provides
personal attention and encouragement. While the
mentoring role is key to the actual nurturing of leisure
interest, he views the social worker as responsible for
ensuring this can happen (Gilligan, 1999) through three
vital roles. These include prioritising the encouragement
of interests and talents by placing it high on the agenda
for the caregiver as well as the care review and planning
The LACE findings also suggest that by the time they
realised the importance of education it was potentially
too late, suggesting that they had not listened to adults
because it was not properly explained to them. The focus
on education in LAC reviews also plays a role. The LACE
project recommended that there should be more of a
7: ACTION - PROTECTIVE FACTORS
38
process, identifying and recruiting a potential mentor
and helping ‘nurse the relationship into life’ and finally
supporting the mentor (Gilligan, 1999).
We should all strive for the entrance into care being a
protective factor in itself as noted by Richardson & Lelliot
(2003) by ensuring physical safety, better living conditions,
fair and consistent rules to live by and an understanding
and acceptance from caregivers. A key to this is attending
to the nature of risk and protective factors and the
interaction between them, comprehensively documented
by Rutter in 1985. In fact, the WHO states that policies,
plans and specific interventions relating to child and
adolescent mental health should be designed with the
reduction of risk factors and enhancement of protective
factors in mind (WHO, 2005).
The focus on hobbies and interests is linked to the notion
of ‘normalisation’ of these Looked After Children’s lives.
Martin & Jackson (2002) in their study of high achievers
found that nearly all the participants stressed the
importance of ‘normalization’ in Looked After Children’s
day to day lives. This was possible through the freedom,
support and finance for participation in outside hobbies
and interests. The participants believed this helped them
gain confidence in socialising for example (Martin &
Jackson, 2002).
Essentially all these protective factors (and others in the
literature) should be addressed in the LAC Review Process and
care planning of Looked After Children. Richardson (2002)
points out that health assessments pave the way for a health
care plan which is integrated into the overall care plan.
Northern Ireland
McLaughlin (2002) in the LACE project found that
achievements for Looked After Children were much more
than exam results, they talked of success in sports, art or
music. By being supported and encouraged, they became
more involved and did better in school (McLaughlin, 2002).
Improving outcomes for Looked After Children/Care
Leavers in their adult life has been a focus in the UK since
the Children Act 1989 and through initiatives like Quality
Protects and Choice Protects (McAuley, in press). Mendes &
Moslehuddin (2004) note a movement to more substantial
provision for Care Leavers since the mid seventies. It began
with small-scale quantitative and qualitative research
studies then followed by longer, empirically-based studies.
Certain consumer groups in the UK in general such as the
Who Cares Project and the National Association of Young
People in Care sprang up and voluntary organisations like
First Key demanded reforms and more services.
VOYPIC’s ‘Making Connections’ project is an example of a
specific project to encourage the participation of Looked
After Children and Care Leavers. Making Connections
allows children and young people with an experience of
care to connect with their peers, VOYPIC staff and other
relevant professionals and agencies. It delivers a number of
activities including: the production of a newsletter, website
design
(www.bawareofwatsncare.co.uk),
personal
development and entrepreneurship programmes, creativity
workshops (e.g. dance, drama, photography), groupwork
residentials and training as well as a Young Reps
programme (a peer group of volunteers representing care
experienced young people across Northern Ireland).
Through these activities, the project provides the young
people with the keystones to make successful life changes
and gain opportunities through participating and trying
out new experiences and interests.
Stein et al. (2000) show that positive contributions are
achieved for Care Leavers through leaving care schemes
and formal preparation and support. They specify that this
relates to accommodation and self-care skills and also
contributes to furthering social networks, developing
relationships, and building esteem.
Frankish & McCrossen (2005) however, caution that
practical issues can take priority in Pathway Plans and
emotional needs can be neglected. While the Children
(Leaving Care) Act 2000 has been introduced and
implemented in the UK, Mendes & Moslehuddin (2004)
still note concerns about the potential continued
variation in the provision of income support as well as the
level of other provision such as ongoing support with
accommodation and mental health. Mendes &
Moslehuddin (2004) point out a concern that mental
health and other support needs may still not be met.
To enhance interests and activities, mentoring schemes could
also prove useful. In Northern Ireland, VOYPIC delivers the
“U” Choose mentoring project which is specifically and
exclusively dedicated to Looked After Children. A number of
voluntary agencies also run mentoring projects which
include Looked After Children (e.g., Mulholland After Care
Services (MACS) and EXTERN) and the Northern Ireland
Association for the Care and Resettlement of Offenders
(NIACRO) also operates a befriending and independent
visitor scheme. In the future, it could be interesting to find
more synergies between leisure-related organisations and
Looked After Children/Care Leavers.
7.3
Action - Protective Factors
Action - Protective Factors
Northern Ireland
In McAuley’s longitudinal study of outcomes of young
people who had lived in long-term foster care, she later
acknowledges that being accepted within the family was
Good Care - Reducing risk factors
and promoting resilience
39
VOICE OF YOUNG PEOPLE IN CARE
Action - Protective Factors
one of the striking elements of young people’s accounts.
This sense of feeling they were wanted meant much to
the young people (McAuley, in press). She further
mentioned that some of the foster children were offered
continuous support from foster carers after leaving care
thus echoing the continued support parents give their
own children when leaving home (McAuley, in press).
particularly isolated from some of the above protective
factors is when they are placed in secure accommodation
(Kilkelly et al., 2004; Kilpatrick, in press). Independent
representatives who participated in the Kilkelly et al.
(2004) research were concerned about restricted leisure
facilities and associated health issues, noting an increase
in mental health issues for young people placed in secure
accommodation. This echoes earlier concerns made in the
report on secure accommodation by the Social Service
Inspectorate and the Education and Training Inspectorate
which also highlighted a lack of education provision (SSI
& ETI, 2002). A priority area stemming from the Kilkelly
et al. (2004) research is that ‘urgent steps should be
taken to bring the operation of the Independent Review
mechanism into line with international standards
specifically Article 5 ECHR’ (p. 82, Kilkelly et al., 2004).
The care planning process in Northern Ireland is similar to
the UK. As part of the Children Order, all Looked After
Children should have a regular review which looks at the
progress, development, health, education, and placement
needs of the child/young person. This is a formal meeting
which includes the Looked After Child and all those who
are involved in his/her care (Children (NI) Order 1995,
part 4 section 45, Reviews and Representation). The
Northern Ireland Commissioner for Children and Young
People’s (NICCY) office has been carrying out research on
Child Centred Planning and the report is due out in 2006.
The report will address care planning in Northern Ireland.
Similarly, in in-patient care, these protective factors still
need to be attended to. Street (2004) talks of an earlier
7
study by Street & Svanberg where young people gave their
opinion on the services they received. Of relevance to the
present discussions of protective factors is the importance
they placed on regular daily activities to prevent boredom,
education provision within the unit and support after
discharge (Street, 2004).
Similar forms of political action for Care Leavers happened
in Northern Ireland, with VOYPIC being established in 1994.
Pathway plans for Looked After Children moving out of
care are now necessary under the new Children (Leaving
Care) Act (NI) 2002 (DHSSPS, 2005b). Most recently, VOYPIC
has delivered a programme of conferences to prepare
senior managers, practitioners and Care Leavers and
launched a new young person’s guide to Leaving Care,
funded by the DHSSPS (VOYPIC, 2006).
KEY POINTS FOR CONSIDERATION
Under the new legislation, a needs assessment is carried
out before the young person leaves care so as to ensure
they have appropriate support and services to meet their
needs. This assessment takes in such aspects as support,
education and training, independent living, family,
friends and relationships, money issues, job options and
health and growing up (VOYPIC, 2006). It is the starting
point for the pathway plan which differs from the care
plan in that it is more detailed regarding the Looked
After Children’s future. The plan will include all those
aspects identified in the needs assessment such as
accommodation, education, training or employment
needs and any financial or practical help the young Care
Leaver is entitled to, relationships with family and
friends, any practical skills they need and how to get
them, any personal support they need, and the names of
a personal advisor and the people who will help get them
the support they need (VOYPIC, 2006).
•
Need for enriched understanding of how Looked
After Children feel about being in care or Care
Leavers feel about having lived in care.
•
A number of actions can be taken to protect
Looked After Children and Care Leavers from mental
ill-health. These include maintaining stability and
continuity in their lives, ensuring contact with their
family and wider social network and supporting
them in their education, hobbies and interests.
•
Need for a more in-depth understanding of how
well the care planning and the LAC Review
processes are aligned to these factors. How
has practice progressed since Horgan and
Sinclair’s Review?
•
The promotion of these protective factors offers
a way forward for practitioners.
One area of care where Looked After Children can be
7 The Study’s full reference is Street, C. & Svanberg, J. (2003) Where Next? New directions in in-patient mental health services for young people.
Report 1. Different models of provision: facts and figures. Young Minds.
7: ACTION - PROTECTIVE FACTORS
40
8
How are services to meet the mental health
needs of Looked After Children and Care Leavers
currently planned, controlled and organised?
41
VOICE OF YOUNG PEOPLE IN CARE
How are services to meet the mental health needs of
Looked After Children and Care Leavers currently
planned, controlled and organised?
“One of the best ways we can improve the health and
wellbeing of the population is by improving the health
and wellbeing of children and their parents”
(p. 71, DHSSPS, 2004b).
develop service networks to support those working with
these children and young people. Most CAMHS in the UK
are structured within the Four-Tiered model (Richardson,
2002). Figure 4a below outlines the presenting difficulties
at each Tier followed by Figure 4b which outlines the
services to meet the needs at each Tier. Across the Tiers,
presenting difficulties increase in severity and the level of
specialist services needed increases.
Although we have looked at ways of reducing risk and
promoting and protecting the mental health of Looked
After Children/Care Leavers, we also need to look at the
specific services which are designed for mental health
and the current framework within which they are
organised. We will look at these services through the
frameworks of Child and Adolescent Mental Health
Services (CAMHS) and Adult Mental Health (AMH)
Services which may be used by Looked After
Children/Care Leavers aged 12-25 years. We outline
Tiered approaches from mild to severe need from both
service perspectives. Our choice to begin directly with
these services stems from our earlier definition of mental
health as a broad concept. In recognising that we all have
needs, to different degrees, these services are meeting
the needs of these young people. We do not deal with
primary care services explicitly but as an element of
services within these Tiered models. The focus of this
review extends right across the Tiers and is therefore not
weighted towards the higher Tiers.
8.1
FIGURE: 4a - THE 4-TIER MODEL FOR CAMHS:
PRESENTING DIFFICULTIES
Child and Adolescent
Mental Health Services
Source:
HAS Together we Stand 1995
(Adapted from a presentation by Jeffs 2005)
By looking at the literature, it becomes clear that there
are major regional and international differences in
CAMHS but O’Rawe (2003) notes the US Surgeon
General’s admission that all CAMHS are in varying
degrees of crisis. Across the world there is a need to
develop CAMHS at a national policy level illustrated in
the following quote by the WHO (2003):
FIGURE: 4b - THE 4-TIER MODEL FOR CAMHS:
“The development of child and adolescent mental
health services in the absence of specific national
policy leads to: 1) fragmentation of services,
2) inefficient utilization of scarce resources, 3) inability
to provide effective advocacy for priority concerns,
4) lack of constituent participation in program
development and 5) an inability to incorporate new
knowledge in a systematic fashion” (p. 14, WHO, 2003).
The Four Tier Model
CAMHS in the UK had been developing in a fashion not
unlike that explained in the above quote until the advent
of the Four-Tiered model outlined in the influential
“Together We Stand” report (NHS HAS, 1995). This model
was aimed at providing a comprehensive service for
children and young people as an integrated whole, and to
8: CURRENT SERVICES
Source:
HAS Together we Stand 1995
(Adapted from a presentation by Jeffs 2005)
42
Current Services
Current Services
that service users, their carers and advocates have a
greater say in how these services are planned, delivered
and monitored, a trend toward community solutions,
increased difficulty in recruiting and retaining staff and
limited alternatives to acute admission (EHSSB, 2004b).
The RMHLDNI is currently reviewing CAMHS in Northern
Ireland and produced a consultative document in
December 2005. Although the final report will not be
available before the publication of this review, we feel it
is important to mention some of the detail in the
consultative document with the proviso that some things
may not remain in the final report. That said, it is unlikely
that the rather bleak picture of overall services will
drastically improve before its publication in the near
future as outlined in the following quote:
While this Tiered model greatly influenced the
development of CAMHS in the UK, there are many other
areas of good practice which can be embraced. Attention
has been paid to those incorporating a holistic model of
child health. O’Rawe (2003) notes that the ‘National
Service Framework for Children, Young People and
Maternity Services’ (DH & DfES, 2004) was the first
inclusion of CAMHS planning into a planning document
in England following extensive lobbying by Young Minds
in particular. In 1998, 24 CAMHS Innovation Projects
were set up by the Department of Health with the aim of
stimulating innovation, inter-agency partnerships and
developing services for children and carers whose needs
were not well met by existing services. A number of the
24 projects chose to work with Looked After Children and
their carers (James, 2002).
“The over-all quality, consistency and accessibility of
services is so inadequate that urgent strategic action is
needed to tackle the shortages in CAMH Services in NI”
(p. 9, RMHLDNI, 2005a).
There are many good examples of special designated
services across the UK. One example is a mental health
service set up in Birmingham in 1995 specifically for
Looked After Children to provide assessment, brief
psycho-social interventions and referrals to longer term
services. Additionally, it supports and advises staff and
families working with Looked After Children including
help for foster carers (Butler & Vostanis, 1998). Butler &
Vostanis (1998) found that the system at the time failed
to provide stability and nurturing to Looked After
Children with often very high levels of need; highlighting
the potential for services like the one in Birmingham
which would overcome such problems.
In the review, Teggart & Linden (2005) carried out a userconsultation. They concluded that a number of areas
could be improved including:
“Increasing capacity at all Tiers of service, developing
collaborative models of practice, developing public
knowledge about child and adolescent mental health
and establishing meaningful structures for increased
user participation in the planning and monitoring of
CAMH Services” (p. 2, Teggart & Linden, 2005).
Another initiative is described by Callaghan et al. (2004)
through the evaluation of a mental health team
established to provide support to Looked After Children
aged between 4 and 17 years. The team, structured
according to the NHS HAS 1995 Tiered Model of Service
Provision had a combination of skills including primary
mental health work, psychology and psychiatry. It offered
assessment, treatment, consultation and training to carers,
residential staff, and others. Positive outcomes were observed
after the first five months of the project in terms of the
children’s mental health as well as client satisfaction on the
part of both carers and children (Callaghan et al., 2004).
From this consultative document, it became clear that the
Four-Tier model has not been formally adopted by
Northern Ireland as a whole although specialist
professionals do currently use the concepts of the model
(RMHLDNI, 2005a). The review examined a number of
potential service delivery systems and concluded that the
Four Tier Model would be the most effective in Northern
Ireland. This means that relationships between other
services providing CAMH Services (e.g. projects established
by Social Services departments), youth services of the
Education and Library Boards and the voluntary sector) and
specialist CAMH Services need to be developed (RMHLDNI,
2005a). A good example of this already working in Northern
Ireland is in Homefirst Trust which has drawn up a poster of
all the available services for referrals. The consultative
review document also recommends that a mapping exercise
similar to that in England needs to be carried out on an
annual basis by an independent research institute to include
provision by voluntary, community and statutory services
(RMHLDNI, 2005a).
Specialist provision must be balanced against the work
that needs to be carried out at the lower Tiers as stated
earlier (White & Stancombe, 2004).
8.1.1 The Development of CAMHS in
Northern Ireland
It is useful to look at the context in which specialist
services are developing in Northern Ireland, as outlined
for example in EHSSB (2004b). This includes growing
demands on all mental health services, an expectation
8.1.2 Current Provision in Northern
Ireland across the Tiers
43
VOICE OF YOUNG PEOPLE IN CARE
Current Services
There appears to have been limited development at the
lower Tiers as outlined in the RMHLDNI Consultative
document (RMHLDNI, 2005a) which argues that a
number of community services effectively contribute to
Tiers 1 and 2. These include early intervention
programmes e.g. Sure Start, statutory and voluntary
family centres, voluntary and community providers (e.g.
befriending, advocacy services), education departments
providing pastoral care and school based counselling, more
specialist support teams (e.g. educational psychology,
educational welfare officers, emotional and behavioural
support teams) and youth justice services. However,
many of these services do not see themselves as CAMHS
providers and this may raise issues of responsibility
(RMHLDNI, 2005a). It also highlights a potential barrier
of the stigma attached to mental health and may show
the need for more professionals to adopt a wider
definition of mental health as was stated earlier. In order
to be an accessible and responsive service, this barrier
needs to be overcome. Gilliland et al. (2005) further note
that while a number of professionals are operating at Tier
1, there are structural problems with limited staff
development or clinical support.
also mentions operational and recruitment difficulties at
Forster Green, Copeland and College Gardens which
restrict bed availability and young people can find
themselves admitted to acute adult wards (SLT, 2006).
Further inpatient provision is currently located at
Muckamore Abbey Hospital (Assessment and Treatment
Provision) delivered by North and West Health and Social
Services Trust (NWHSST) for children with severe learning
disabilities and challenging behaviour (RMHLDNI, 2005a).
Other provision includes outpatient services
commissioned for example by the EHSSB from Down and
Lisburn Trust and UCHT for their localities (EHSSB,
2004a). In Belfast, there is the Royal Belfast Hospital for
Sick Children (EHSSB, 2004a). Appropriate in-patient
provision is currently restricted geographically to Belfast.
Looked After Children can also enter secure
accommodation, and Kilkelly et al. (2004) state that
demand for secure accommodation outstrips supply
whereby every person who is offered a place results in three
being refused and little is known about what happens to
those not placed (Kilkelly et al., 2004). The new build of
secure accommodation was due to be completed in
December 2005 but is still not complete. VOYPIC was
invited to assist with the design and development of the
new regional secure unit so young people have been
involved in the process (and reported feeling that their
views were seriously considered) (VOYPIC, 2004).
At Tier 2, Gilliland et al. (2005) list a number of common
professionals working at this level including community
paediatricians, health visitors with particular training in
behaviour therapy, staff in family centres, educational
psychologists, education welfare officers and those
working in Youth Justice.
It can happen that some young people are placed in Out
of Area placements such as St. Andrews or Roycroft. Mc
Master (2004) noted that at the time of his review, the
EHSSB had 7 young people in such placements with one
case pending, the total annual cost of which was
estimated at £1.3m. He notes that:
It appears that Tier 3 provision is now available in each
of the Boards in Northern Ireland although there is wide
variation on a number of factors including age limits,
mode of referral, waiting times, support services, referral
management/coordination system, clinical networking,
directorate placed in and day hospital services (RMHLDNI,
2005a). Gilliland et al. (2005) also note that there are now
specialist CAMH teams in each Community Trust but these
are hindered by extensive waiting lists.
“While accepting such expenditure will not always be
avoidable this does raise the question of whether
additional investment in local services, thus allowing
early appropriate intervention, would better meet the
needs of young people, improve their long term
psychosocial outcome and prevent some of these Out
of Area treatments” (p. 43, McMaster, 2004).
It took some time to piece together current Tier 4 CAMHS
provision for the review. A crude overview is that when
the day and inpatient system is functioning as it should,
younger Looked After Children (under the age of 14)
requiring day patient or inpatient admission would be
admitted to the Forster Green site (regional child
psychiatry services inpatient unit). Older Looked After
Children (aged 14-16/17) would be placed in the
Copeland & College Gardens Young People’s Centre (YPC)
(Adolescent Regional psychiatry service). The RMHLDNI
Consultative document, however, notes that no day
places are available at the current base in Knockbracken,
but there is a planned new build for Adolescents at the
Forster Green site (RMHLDNI, 2005a). Another local
review, carried out by Sperrin and Lakeland Trust (SLT)
8: CURRENT SERVICES
Other types of provision such as assertive outreach, 24 hour
emergency cover to general hospital Accident and
Emergency (A&E) departments and crisis intervention which
have been embraced in England and Wales cannot be
currently provided in Northern Ireland (RMHLDNI, 2005a).
8.2
Interface between Child and
Adolescent and Adult Mental Health
Generally, those under the age of 16 years are the
responsibility of CAMHS and those over the age of 18
44
Current Services
Current Services
found this particularly useful for this review because it
mirrors the similar model for CAMHS.
years are the responsibility of the AMH Services (SLT,
2006). However, a number of Looked After Children/Care
Leavers do not fit easily into CAMHS or adult services
which results in a gap in provision for those aged in the
range between 16-19 years. This has been acknowledged
in the RMHLDNI CAMHS Consultation document which
mentions 16-17 year olds in particular and recommends
that CAMH Services should ideally be provided for children
and young people up to their 18th birthday (RMHLDNI,
2005a). There is also a belief that the needs of this group
would be better met within CAMHS rather than Adult
services which tend to deal more with specific psychiatric
disorder and the placement of young people in adult wards
is generally considered as unacceptable by the Royal
College of Psychiatrists and the Irish College of Psychiatry
(as cited in SLT, 2006). Nevertheless, there is evidence to
show that young people are being admitted to adult wards
in Northern Ireland, with an estimated 90 children and
young people being admitted to adult wards across the area
in 2001/2002 (O’Rawe, 2003). This figure is proportionately
five times higher than that in England and Wales.
There are also implications for the type of service these
young people receive due to staff having little or no
training in child and adolescent mental health or
paediatrics (O’Rawe, 2003).
The Western Health and Social Services Board (WHSSB)
has been particularly active in reviewing the best way
forward for this group. One proposal is to have an early
intervention service for first episode psychosis sitting
within present CAMH Services (SLT, 2006). The Child and
Adolescent Service in Omagh (SLT), which was set up in
1995, is currently setting up a protocol to ensure that
young people experience a smooth transition between
child and adult mental health services (SLT, 2006).
8.3
Adult Mental Health (AMH) Services
Care Leavers aged 18 years and over are referred to
AMH services. In its final Review of Adult Mental
Health, the RMHLDNI (2005b) calls for consideration of
the needs of younger people to be included in service
plans for Adult Mental Health (recommendation 21).
This would involve substantially developing plans for
those with a psychotic illness which may require
lifelong care, adults with developmental disorders (e.g.
autistic spectrum, learning disability and attention
deficit hyperactivity disorder) and adults with mental
health problems relating to adverse childhood
experiences (in particular abuse).
The Eastern Board has identified a Four-Tier model as a
framework for how AMH Services could be managed
(EHSSB, 2004b) as outlined in Figure 5 and we have
45
VOICE OF YOUNG PEOPLE IN CARE
Current Services
FIGURE: 5 - PROBLEM TIER
Source: EHSSB, 2004b (using a framework from
Northumberland Mental Health National Service Trust
An example of good practice is the Windsor First Episode
Service based at Belfast City Hospital which provides a
multi-disciplinary, multi-agency service to young people
aged 18-30 living in the South Belfast catchment area
experiencing a first episode of psychosis (p.171,
RMHLDNI, 2005b).
KEY POINTS FOR CONSIDERATION
•
CAMHS in Northern Ireland is seriously
under funded.
•
Current CAMHS provision needs to be enhanced
across the Tiers.
•
Need to highlight stronger links between CAMHS
and Looked After Children services.
•
It would be useful to know more about what types
of interventions are offered in Northern Ireland e.g.
psychoanalysis, systemic family therapy.
•
Adult services need to be sensitive to the needs of
Care Leavers.
8: CURRENT SERVICES
46
9
What is the current policy and legislative
framework within which the mental health
needs of Looked After Children and Care
Leavers in Northern Ireland are met?
47
VOICE OF YOUNG PEOPLE IN CARE
What is the current policy and legislative framework
within which the mental health needs of Looked After
Children and Care Leavers in Northern Ireland are met?
9.1
The Wider Picture
common targets across organisations in different sectors.
She placed particular hope in the ‘National Service
Framework for Children, Young People and Maternity
Services’ (DH & DfES, 2004) in England to make a difference
by setting targets across organisational boundaries.
At a global level, there has been a drive to establish a Global
Child and Adolescent Mental Health Action Plan (WHO,
2003). Some aims of the plan are directly relevant to
Looked After Children/Care Leavers including increasing the
capacity or initiating national plans for Child and
Adolescent Mental Health, identifying models of good
practice, disseminating information via an updated registry
and setting up a webpage as a world-wide focal point.
A useful document is the DH ‘Promoting the Health of
Looked After Children’ (DH, 2002) because it provides a
commitment to many of the protective elements included
in this review including the need for mental health to be
part of a holistic assessment as well as the importance of
education and interests and hobbies. It also recognises the
lack of advocates to seek out services for Looked After
Children and the instability of their placements as the key
barriers to the achievement of their good health. Prior to
assessment, information on the young person needs to be
collated and the guidelines outline a number of ways in
which this can be done (DH, 2002). Since this is time
consuming, an administrative post has been set up to
undertake this activity (DH, 2002). It further recognises that
health assessments need to refer to Looked After Children’s
mental health and that GPs, education professionals, social
workers and carers will need training on mental health.
The WHO (2005) also gives guidance on writing up Child
and Adolescent Mental Health Policies and Plans and a
crucial element is that they are intersectoral:
“Because children’s and adolescents’ well-being is
apparent in and influenced by their participation in
multiple sectors of society, mental health policy should
foster collaboration between the different sectors
concerned, such as education, welfare, religion,
housing, correctional services, police and other social
services” (p. 30, WHO, 2005).
The United Convention on the Rights of the Child (UNCRC)
1989 is particularly useful when situating the rights of
Looked After Children/Care Leavers in the context of the
rights of their peers. Although it has currently no statutory
force, O’Rawe (2003) notes that all parts of the UK are bound
by international law to ensure that the terms of the treaty
are honoured. The three key principles are directly relevant:
non-discrimination (2); best interests of the child (3); and
children’s voice (12) (UNCRC, 1989). There are some rights in
particular which relate to key messages from the present
review including the right to maintain contact with parents
(9), regard to continuity in a child’s upbringing (20), access to
health and medical services (24), education and its aims of
developing personality and talents and preparing the child
for an active life as an adult (27, 29), leisure, recreation and
cultural activities (31), and rehabilitative care (39). These and
others were summarised in the Office of the First Minister
and Deputy First Minister (OFMDFM, 2001) paper for
appointment of a Northern Ireland Commissioner for
Children and Young People (pp. 70- 73, OFMDFM, 2001).
9.2
In the document, the Department of Health outlines the
responsibility of foster carers and residential staff to
ensure Looked After Children’s health needs are met (DH,
2002). These are all directly applicable to our broad
definition of mental health and include:
• An understanding that achieving optimum health
starts early and includes the provision of good quality
care which starts in infancy and which provides a child
with a positive sense of identity and self-esteem;
• Encouraging and supporting each child in achieving
optimum health and in particular exercising the
corporate parent’s responsibility as health educator;
• Providing a home environment which actively
encourages and supports a healthy lifestyle;
• Ensuring the child attends health appointments
and clinics as necessary;
• Contributing to the child’s health plan and care plan;
• Ensuring and facilitating contact and
communication with the child’s parents and family
in accordance with agreed plans;
• Ensuring that the child or young person makes
maximum benefit from education and broader
experiences offered by leisure activities, hobbies
and sport (p. 36, DH, 2002).
The Current Legislative and Policy
Framework in the UK
Across the UK, there has been a legislative and policy drive
to prioritize the mental health needs of Looked After
Children/Care Leavers such as the CAMHS Innovation
Projects set up in 1998, the Quality Protects programme,
treatment and assessment plans as well as targeted
investment in CAMHS (Richardson & Joughin, 2000).
Despite all these advances, Richardson later (2002)
acknowledged that more needs to be done to introduce
9: POLICY & LEGISLATION
The need for access to a broad range of CAMH services
across the Tiers was outlined as well as the fact that
leaving care services need support from CAMHS and
adult mental health professionals, particularly in relation
to prevention and access to referral (DH, 2002).
Another significant development is The ‘National Service
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Policy & Legislation
framework for services in this area. This legislation is,
however, broad-based and gives little direct guidance in the
case of children and young people (although it does
mention legal responsibilities for Looked After Children).
The Order led, in turn, to the Mental Health Commission
and the Mental Health Review Tribunal. At the moment, the
RMHLDNI is reviewing this legislation.
Framework (NSF) for Children, Young People and Maternity
Services’ (DH & DfES, 2004) which demonstrates the degree
of attention government departments are paying to
children’s mental health and recognises that service
provision is not the sole responsibility of one service or
agency (Lindsey, 2005). Lindsey (2005) believes that the
Children’s NSF recognises the psychological well-being of
children and young people as an integral part of their
healthy emotional, social, physical, cognitive and
educational development.
A vital step forward in the provision of services in Northern
Ireland is The Children (NI) Order 1995, which came into
force in 1996. This order places a statutory duty on Trusts to
provide a range of services for children in need and
introduced a systematic approach to individual assessments
of Looked After Children making written care plans a
requirement (SSI, 1999). The SSI was authorised by the
Children (NI) Order to inspect services for children (Article
149). The need for the Children (NI) Order was well
summarised by SSI (1999):
9.3 The Current Legislative and Policy
Framework in Northern Ireland
Generally, legislation in Northern Ireland is very close to
legislation in England and Wales. The Children (NI) Order
1995 mirrors the Children Act (1989) and the recent
Children (Leaving Care) Act (Northern Ireland) 2002
closely follows The Children (Leaving Care) Act 2000
previously introduced in England. Stein et al. (2000)
demonstrate that while the Children (NI) Order 1995
mirrors the Children Act (1989), the main differences
took account of the unique structure of Health and
Social Services Boards in Northern Ireland at the time:
“Research in the 1980’s identified major gaps in
decision-making for children in public care. Findings
indicated that there was insufficient attention given to
meeting the needs of children in respect of their health,
education, contact, identity, preparation for leaving
care, religion and culture. There is now a statutory
requirement for all these matters to be considered
within each child’s Care Plan” (p. 7, SSI, 1999).
“These were set up at the time of Direct Rule when a
number of key responsibilities, including housing and
education, were removed from local government which
had been a site of many of the grievances over religious
and political discrimination” (p. 237, Stein et al., 2000).
It has been noted (DHSSPS, 2003a) that the Children (NI) Order
enacts much of the progressive thinking in the 1976 Black
8
Report , including the recommendation that services should
be based on an assessment of need and tailored to meet the
identified needs of each Looked After Child (DHSSPS, 2003a).
Usually the legislation in Northern Ireland follows several years
after that in England and Wales which has the advantage that
we can learn from the application of it; the main disadvantage
is that it leaves major gaps in provision until it is implemented.
It will be interesting therefore, to see how Northern Ireland
follows on from the new Children’s Act in 2004.
A further development came about in 1998 with The Children
(1995 Order) (Amendment) (Children’s Services Planning)
Order (Northern Ireland 1998). This amendment made it a
requirement for each HSS Board to produce a Children
Services Plan (CSP). These provide for a range of services to
meet the assessment needs of each Board’s child population
structured in such a way that residential care was seen as
inter-dependent with family support and foster care. April
1999 saw the introduction of the first Children Services Plans.
Gilliland et al. (2005) note that they could be influential in
the development of CAMH services as outlined below:
For the purposes of this review, we have looked at
legislation and policy with elements directly applicable to
Looked After Children or Care Leavers, mental health and
young people in general. This is not an exhaustive
overview but simply draws relevant elements from each
of the sources for the review.
“Children’s Services Planning offers a template within
which an integrated, strategic approach to the planning
and commissioning of CAMH services can be taken
forward. The complexity of CAMHS in organisational
terms will provide a significant challenge to the
9.3.1 Legislation
A good starting point is the 1986 Mental Health
(Northern Ireland) Order which provides the overall
8 The full reference for the Black Report is:
Children and Young Person’s Review Group (1979) Legislation and Services for Children and Young People in NI: Report of the Children and Young
Person’s Review Group. HSMO.
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demonstrated that many vulnerable under 16 year olds
were being discharged from care. As previously mentioned,
this legislation is broadly similar to that in the UK and as
such, it targets preparation and planning for leaving care
including core concerns such as housing, education and
employment, finances and social support. The new legislation
should also help to lessen the number of risk factors
presenting at this stage in young people’s lives because it
serves to prepare Looked After Children for leaving care and
explicitly sets in place new supports such as personal
advisors, pathway plans, support for young people in
education up to 25 years, and support for young people up
to 21 years in general. A needs assessment will take place to
inform a pathway plan to guide supports which should
replicate what responsible parents would provide for their
children. The DHSSPS issued ‘Leaving and After Care:
Guidance and Regulations’ in 2005 (DHSSPS, 2005b).
effectiveness of the children’s services planning model.
However, the framework, involving as it does key agencies
and disciplines in the voluntary, community and statutory
sectors, provides a potentially viable mechanism for
progressing the agenda” (p. 55, Gilliland et al., 2005).
In the same year (1998) The European Convention on
Human Rights (ECHR) was incorporated into domestic law in
the United Kingdom (UK) through the Human Rights Act
(1998) (Kilpatrick, in press). The UNCRC and the ECHR
promote both the individual rights of children and young
people within the family as well as promoting an active
partnership between children, their carers and the state
(Kilkelly et al., 2004; Kilpatrick, in press). Kilpatrick (in press)
also states that this partnership approach is supported in the
guidance and regulations of the Children (NI) Order 1995.
Another relevant development was The Northern Ireland
Act 1998 following the Good Friday Agreement. The New
Targeting Social Need (New TSN) was re-launched as part
of the Act. This is a long-term strategy to tackle social need
and social exclusion. Three core elements are a focus on
unemployment and employability, tackling social need in
other areas, and promoting social inclusion (DHSSPS,
2004a). The Act also introduced key equality legislation
through its Section 75. This Section has required since
January 2000 equality of opportunity in relation to nine
key dimensions: persons of different religious belief;
political opinion; racial group; age; marital status; sexual
orientation; men and women generally; persons with a
disability and persons without; and persons with
dependants and persons without (DHSSPS, 2004a). O’Rawe
(2003) demonstrates how the Act may be violated by
failing to meet children’s needs:
A further significant change has been the Health and
Personal Social Services (Quality, Improvement and
Regulation) Order (Northern Ireland) 2003 which
established the Northern Ireland Health and Social Services
Regulation and Improvement Authority and made provision
for the registration and regulation of certain establishments
and agencies. It makes provision regarding the quality of
health and personal social services, adoption and fostering.
Across this legislative context it is important to mention
that in October 2003, Northern Ireland’s First Children and
Young People’s Commissioner (the late) Nigel Williams was
appointed, sponsored by the OFMDFM. The Commissioner’s
principal aim is “to safeguard and promote the rights and
best interests of children and young persons”. His powers
can be grouped under three main areas of work:
promoting children’s rights; complaints and legal action;
and research and inquiries. While the Commissioner’s remit
includes children up to the age of 18, it extends to those
leaving care, up to the age of 21. In a recent submission to
the United Nations Committee on the Rights of the Child,
NICCY called for a review of the specific mental health
needs of Looked After Children and the provision of
adequate services to meet the needs identified.
“Failure to represent and address the specific needs of
children under current legislative provisions, policy and
funding potentially violates the S75 duty under which
authorities are obliged to have due regard to the need to
promote equality of opportunity” (p. 33, O’Rawe, 2003).
A more recent legislative development has been the
Implementation of the Children (Leaving Care) Act
(Northern Ireland) 2002 which took place in 2005. The
aim of the legislation is to improve the life chances of
Looked After Children as they leave care and make their
move to independent living (VOYPIC, 2006). It is important
to mention the context of the legislation. The need for
such a legislative commitment was clear from the
findings of the SSI Report ‘Promoting Independence. A
9
Review of Leaving and After Care Services’ (2000) which
9.3.2 Policy
A number of policy documents have put forward key
themes for looking after the mental health of Looked
After Children/Care Leavers.
The Social Services Inspectorate has carried out numerous
9 Social Services Inspectorate (SSI) (2000) Promoting Independence: A Review of Leaving and After Care Services. Belfast: DHSSPS.
9: POLICY & LEGISLATION
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Policy & Legislation
inspections, adopting a Standards based approach to
Inspections in 1994. Standards papers were issued for
residential care “Quality Living Standards for Services: Children
Who Live Away From Home” (SSI, 1995a) and subsequently
those in a family placement who are fostered “Quality
Standards for Services: Children Living in a Family Placement”
(SSI, 1995b). New standards should be released in 2006. In
1997, SSI carried out the first large-scale examination of
fostering services in Northern Ireland to establish a baseline
against which to benchmark future practice in fostering
services (SSI Fostering in Northern Ireland, 1997).
approach which promotes good health, prevents mental illhealth and ensures early intervention when mental health
problems do occur. This approach, similar to our earlier
definition, accepts that everyone has mental health needs
irrespective of whether or not they have a diagnosable illness.
It works at three levels: strengthening individuals (promoting
self-esteem, life and coping skills); strengthening
communities (increasing social inclusion); and reducing
structural barriers to mental health (promoting access to
education, meaningful employment, housing). This also falls
in line with the New TSN Policy by promoting social inclusion.
The Strategy and Action Plan aims to encourage policy
development and support emotional/mental health in two
ways. The first is improving life circumstances through
providing social and physical environments which assist
people in obtaining help and resources to support them
through challenges or crises. The second is improving life
skills through enabling and empowering people to improve
their own mental health by promoting positive well-being
and self-esteem (p. 8, DHSSPS, 2003b).
Another very important piece of work followed closely after
that; Children Matter (1998) at the DHSS request. Children
Matter was a crucial step in the provision of services and
McAuley (2000) classed it as “Probably one of the most
clearly written and hard-hitting reports emanating in recent
years from SSI” (p. 49, McAuley, 2000). Children Matter (SSI,
1998) recommended that immediate action was needed
either to bring the existing stock of children’s homes up to
standard or to commission new property. One crucial
element was that a range of differentiated and specialist
residential services was seen as necessary, according to
assessed need (SSI, 1998). The Children Matter Taskforce was
established in 2000 (DHSSPS, 2003a). Implementing Children
Matter was the 4 Board’s response to Children Matter and set
out a five-year programme (DHSSPS, 2003a). Further
developments will include a Children Matter Leaving Care
Subgroup and a Secure Care Subgroup.
One of the targets of the Strategy and Action Plan is to
reduce the rate of potential psychiatric disorder by one and
a half percentage points from 21% in 2001 (as measured by
NISRA, 2002) to 19.5% in 2008. This compares to the earlier
target set by Investing for Health. This clearly recognises the
importance of the mental health of children:
“Since childhood mental distress is strongly predictive of
poor mental health and social outcomes in adult life,
preventive interventions for children have clear potential
to bring long-term psychological, social and economic
benefits” (p. 23, DHSSPS, 2003b).
In its 1999 Planning to Care document, the SSI found
inconsistencies in Looked After Children’s Care plans
particularly in relation to their content, detail and quality (SSI,
1999). They cautioned that care planning could be driven by
resources rather than assessed need. They found that the LAC
Review process lacked adequate consideration of the young
person’s emotional health and well-being needs (SSI, 1999).
Each Health Board area in Northern Ireland is committed to
the Strategy and Action Plan and progress has been made
both in Board areas and regionally, for example, through
ASSIST (Applied Suicide Intervention Skills) training (DHSSPS,
2003c). Some of the work is particularly noteworthy, for
example the Southern Board’s 2003 Conference on ‘Young
People and Positive Mental Health’, its regional resource for
young men’s mental health ‘Right in UR Head’ as well as the
development of directories of mental health services
(DHSSPS, 2005c). While progress has been made to promote
mental health, it does seem that further consideration,
however, needs to be given to the accessibility of this
information to Looked After Children/Care Leavers excluded
from mainstream education and employment.
McAuley (2000) welcomed the announcement that the
DHSSPS would adopt a Quality Protects Initiative tailored
to local organisational arrangements but we found no
formal adoption of this Initiative in the review.
Several strategic documents are important in this review.
The first is the DHSSPS ‘Investing for Health’ strategy for
improving public health and reducing health inequalities
introduced in 2002. Many subsequent developments have
been linked to this strategy. The DHSSPS identified mental
health as a priority within this strategy, for example by
setting a target of reducing the rate of potential psychiatric
disorder by one tenth by 2010 (p.60, DHSSPS, 2002).
A useful document for the current review is the DHSSPS
‘A Healthier Future’ 2005-2025 (DHSSPS, 2004b). The
overall aim of this twenty-year vision is to “improve the
physical and mental health and social well-being of the
people of Northern Ireland” (3.1, p. 38, DHSSPS, 2004b).
This vision specifically states that it will focus on those
‘least able to protect themselves, including looked after
Another key strategic development is the DHSSPS
(2003b) Strategy and Action Plan 2003-2008 for
Promoting Mental Health which relates to all age groups
from 18 to 65 years. It outlines a health improvement
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also delivers numerous physical activity training
programmes (DHSSPS, 2004c).
children’ (3.2, p. 38, DHSSPS, 2004b). An interesting aspect
of this strategy is the focus on engaging users in flexible
ways such as through the use of IT. They give an example of
how text-messaging reminders before an appointment can
reduce missed appointments by half.
Information provision in mental health has also been
highlighted in the 2004 Inspection of Social Work in
Mental Health Services. Recommendation 8.7 is:
Some outcomes are relevant to Looked After Children/Care
Leavers. One key outcome is to improve the life chances of
Looked After Children initially by ensuring that they are
placed in an appropriate setting and that this is reflected by
continuity of care (measured by a reduction in movements
between placements). While a stable environment will have
immediate benefits, they suggest that the longer-term
benefits will lead to 95% of Looked After Children
experiencing no more than three placements during any
one continuous period in care (DHSSPS, 2004b).
“Trusts should conduct an audit of all published information
that is currently available to ensure that service users,
carers and all relevant agencies are fully informed about
mental health services, including social work services. Any
gaps in information provision should be identified and
remedied. Trusts should actively engage service users and
carers in this process” (p. 68, DHSSPS, 2004d).
As previously mentioned, each Board area has Health and
Well-Being Investment and Action Plans and these may
make some reference to Looked After Children/Care
Leavers. The latest EHSSB Health and Well-Being
Investment Plan (2005/8), for example, has earmarked
funds for Child and Adolescent Mental Health to develop a
‘First On-Call Rota” as well as additional funding to assist
with the new requirements under the Children Leaving
Care Act in relation to personal advisors and additional
funding for residential Children’s Homes to develop a pilot
Intensive Support Unit in Glenmona (EHSSB, 2005).
The vision also aims for the proportion of young Care Leavers
in education, training or employment at age 19 years to be
at least 75% of the level for all 19 year olds (DHSSPS, 2004b).
Other key outcomes relate specifically to mental health
as follows:
• Between 2001 and 2025 - to have improved the
mental health and well-being of young people
aged 16 - 24 years by a fifth as measured by the
General Health Questionnaire (GHQ) 12 score
(baseline was 15% of males, 25% of females in 2001);
• By 2005 to have ensured that 75% of children and
young people requiring in-patient hospital
treatment will receive their care and treatment in an
age-appropriate setting;
• By 2015 no more than 25% of those on child and
adolescent psychiatry waiting lists to be waiting
for 3 months or longer for a first appointment at
the end of each quarter;
• By 2025 all children requiring specialised CAMH
Services will be able to access them in 3 months or less
(pp. 71-72, DHSSPS, 2004b).
The need for joined-up working has been embraced, for
example, in the EHSSB (2004) Strategy for Adult Mental
Health Services in the area (EHSSB, 2004b). The Strategy
endorses the wider definition of mental health in the sense
that it recognises that Mental Health problems do have a
social component. It appreciates the need for Trusts to
work with local communities and others in creative ways
which may not necessarily involve Mental Health
professionals but will seek to promote better Mental
Health (EHSSB, 2004b). It aims to:
• “Develop, in partnership with the Education and
Library Boards, arrangements for the delivery of
Mental Health awareness training to staff and
pupils in all schools within the Board’s area”
• “Provide improved information about Mental
Health services to local Social Security offices”
• “Review liaison arrangements between the PSNI,
the Ambulance Service and Health and Social
Services with a view to exploring the need for the
delivery of training in the management of Mental
Health crises”
• “Initiate an evaluation of the extent to which
mainstream leisure, training and employment
opportunities are available to people attending
day centres and pre-vocational training and
employment schemes”
(p. 80, EHSSB, 2004b).
The vision will be reviewed every five years in conjunction
with a regional implementation plan and supported by
area health and well-being plans.
Developments relating to physical health may also be
noteworthy such as the DHSSPS Investing for Health
consultative document on the Five Year Physical Activity
Strategy and Action Plan (DHSSPS, 2004c). It outlines two
actions which are directly relevant to this review. Action 5
aims to make physical education a mandatory element of
the education curricula. This however, as earlier noted, may
not be applicable to those Looked After Children who do
not attend mainstream education. Action 6 aims to further
develop policies and programmes to promote physical
activity, taking account of the specific needs of children
and young people and those in care settings. The HPANI
9: POLICY & LEGISLATION
In November 2005, the Secretary of State outlined plans for
52
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Policy & Legislation
a major re-organisation of public administration in
Northern Ireland to re-shape the local government made
up of 26 District Councils to a new configuration of 7
Councils. As part of that review (but not dependent on it)
Shaun Woodward (The Minister for Health, Social
Services and Public Safety) announced his proposals for
Health and Social Services on the same day (Woodward,
2005). His announcement sets in place significant
changes to the current configuration of Health and
Social Services Trusts in Northern Ireland which he
claimed would take effect from early 2006. Woodward’s
reforms take on board the conclusions of an earlier
independent review in 2005 carried out by Professor
Appleby of the King’s Fund. This review concluded that
the system lacked clarity despite the efforts of excellent
staff in Health and Social Services, and despite the
additional resources invested in these services
(Woodward, 2005).
At the heart of Woodward’s motivation, is the need to
put the patient first which he aims to do in a number of
practical ways (Woodward, 2005). He has questioned the
previous configuration of 4 Health and Social Services
Boards and 19 Health and Social Service Trusts. His vision
is a health system with a single Health and Social
Services Authority to replace the four Boards, and seven
Local Commissioning Groups to map against the
proposed areas of the 7 District Councils. He then
envisaged that the five new Trusts will replace the 18
existing Trusts (with the Ambulance Service remaining
unchanged). A Patient and Client council will also be set
up and there will be some changes and sharing with a
number of agencies providing support services. A
performance management body will also be established
which will go hand in hand with inspection, regulation
and improvement (Woodward, 2005). These new changes
will undoubtedly have an ensuing effect on services to
Looked After Children/Care Leavers.
KEY POINTS FOR CONSIDERATION
•
To what extent is current legislation being met in
Northern Ireland?
•
How well does the legislation and policy fit the
needs of Looked After Children and Care Leavers?
•
Since the overview has highlighted a number of
similar goals, how can cooperation be enhanced to
achieve these goals?
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9: POLICY & LEGISLATION
54
10
What Services do Looked After Children and
Care Leavers want and what works well?
55
VOICE OF YOUNG PEOPLE IN CARE
What Services do Looked After Children and Care
Leavers want and what works well?
A vital component in this review is understanding what
services Looked After Children and Care Leavers would be
happy to take up. We have tried to decipher what works
already in engaging with them and what would encourage
the uptake of services particularly for this group.
the Looked After Children had some concern about their
health at the time (12 of the 18 young people
participating). The participants also spoke of the
difficulty of arranging off-site visits to doctors and other
professionals as appointments were set up by care staff
or permission needed to be sought to be off-site even if
he/she set up the appointment personally (Bundle, 2002).
10.1 What services do Looked After Children
and Care Leavers want?
Another major concern is confidentiality (RCPCH, 2003;
NCB, 2005) and young people in general were
particularly wary of GP services including reception staff
in respect of this (NCB, 2005). Many Looked After
Children also felt angry at the failure of health
professionals to respect the confidentiality of their
health information (Ward et al., 2002). This was also seen
as important in the sharing of information and the limits
to this being clear (Stanley, 2002).
Young people in general have quite strong views about
what kind of services they want (NCB, 2005) and this is
similarly the case for Looked After Children (Ward et al.,
2002; Stanley, 2002) and Care Leavers. We will examine
both the general perceptions of young people and then
look at the particular case of Looked After Children or
Care Leavers.
NCB recently completed a review on children and young
people’s views on health and health services. A key issue
emerging was communication whereby young people
wished that all service providers would be good at talking
and listening to them (NCB, 2005). Another study of
young people in general stressed the importance of the
overall friendliness and non-judgemental approach of
the professional and other staff (RCPCH, 2003).
Further issues for Looked After Children in particular
include the need for better information (Ward et al.,
2002; Bundle, 2002). A qualitative study of the views of
Looked After Children aged 12-16 years in a mixed
residential children’s home in England revealed that they
wanted more information, especially on mental health
issues (Bundle, 2002).
Looked After Children also called for better support
(Ward et al., 2002; Stanley, 2002). Stanley (2002) found
that Looked After Children wanted workers to spend time
with them or to be able to talk to someone who had
personal experience of similar problems. A suggestion for
service planning was to provide formal training
opportunities for Care Leavers to enable them to support
younger people in the looked after system through
counselling and care work (Stanley, 2002).
Use of services by all young people could be encouraged
with the provision of a choice of style of service (RCPCH,
2003). This view was also held in the study by Stanley
(2002) whereby Looked After Children also wanted a say
and to be allowed the power to choose the type of help
they might receive from a range of provision (including
voluntary provision) (Stanley, 2002).
Young people generally attach importance to the
physical environment in making them feel comfortable
(NCB, 2005) and the RCPCH (2003) document
highlighted the need for sensitivity to the privacy/visibility
of the visit. Similarly, Looked After Children wish to avail of
services which are user- friendly, accessible, flexible and
discreet and welcome being able to consult these services
without the knowledge of care staff or other
professionals (Blower et al., 2004)
Other messages emerged from an exploration of young
people’s attitudes about the delivery of health care to
Looked After Children and how it might be improved
(Ward et al., 2002). First, it seemed that young people
valued seeing and keeping their own health records.
Second, their experiences of medical examinations were
negative on the whole, and they often found the process
impersonal, lacking explanations, and without recognisable
outcomes for them.
Young people in general would like services which are
accessible, aided by the timing of surgeries and
accessibility with public transport and being able to
access information in other ways than face to face with
doctors (RCPCH, 2003). This accessibility of services is
also extremely important for Looked After Children/Care
Leavers. In Bundle’s (2002) study, young people talked
about their reluctance to request appointments, feeling
that they were not encouraged to ask questions about
personal health during medical examinations. This is
juxtaposed against the same study’s findings that most of
10: WHAT YOUNG PEOPLE WANT
A recent study by Harris & Broad (2005) identified factors
leading to positive outcomes for young people leaving
care after the implementation of the Children (Leaving
Care) Act 2000. It explored the views of service managers,
staff and young people regarding policy and practice in
three East Midlands local authority areas. They found
that Leaving Care services which were popular were
those which cultivated a clearly distinct identity from
Looked After Children Services and outlined five key
points for practice relating to transition (Harris & Broad,
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What young people want
What young people want
2005). These included the presentation of the service as
independent, the swift and flexible allocation of personal
advisors, the time to develop this relationship between
the personal advisor and Care Leaver prior to leaving
care, paying special attention to goodbyes and
introductions and the lengthening of transitions by a
later transference of case responsibility combined with a
long changeover period (Harris & Broad, 2005). A further
point they noted was that the success of the process was
often related to the Care Leaver demonstrating a real
sense of ownership of their plans as evidence of their
progress and ambitions (Harris & Broad, 2005). A final
point is their suggestion that services treat Care Leavers as
adults through the use of adult settings and having high
expectations of them.
Over the last few years VOYPIC has carried out numerous
consultations with Looked After Children/Care Leavers
and there are common recurring themes that are
pertinent to their mental health (as we define it in this
review) as summarised by McAuley & Bunting (in press):
Northern Ireland
In this report, McAuley & Bunting examine the findings
of 18 consultation projects carried out by VOYPIC
between 2002-2005. The report will be published later
this year and provides in depth suggestions from Looked
After Children/Care Leavers in relation to services.
•
•
•
•
•
•
In Northern Ireland some work has been carried out with
young people in general for example by the Southern
Area Health Promotion Consortium (2001). It carried out
a study of the emotional and mental health needs of
students in Year 11 (predominately 14-15 year olds) in
the area and found that the participants were very
selective in who they could confide in. Key traits they
sought were confidentiality, approachability and being
non-judgemental. Although this study was not of the
care population, this would probably remain equally or
perhaps more important to this group.
To feel wanted by their carers;
To get placements which meet their needs;
Placements where they can stay longer-term;
To be kept informed about what is happening with
their birth family;
To have a long-term social worker with whom they
spend time (e.g. on activities) outside of when in crisis;
To have someone to talk to about their feelings
(p. 95, McAuley & Bunting, in press).
A recent study by Santin (2006) demonstrated the
significant psychological impact VOYPIC’S Advocacy
service has on the development of decision making
attributes in care experienced young people. Results
indicated that care experienced young people who had
been a user of VOYPIC’S Advocacy service had developed
significantly greater decision making and critical thinking
attitudes compared to other care experienced young
people. Further analysis demonstrated that selfconfidence to critically think is a significant
psychological predictor of decision-making attitudes.
Santin (2006) identifies the components of VOYPIC’S
Advocacy practice that empowers young people to
become competent decision makers: being listened to,
working in partnership with young people, providing an
open disclosure policy, providing opportunity to express
views and conducting action to problems that young
people agree with.
Users’ and carer’s views of CAMHS in Northern Ireland
were investigated by Teggart & Linden (2005). The area of
most dissatisfaction was service presence and
responsiveness. The participants wanted to see prompt
acceptance of referrals, shorter waiting lists, more
flexible working practices (e.g. appointment times and
travel distances).
There is growing evidence in Northern Ireland regarding
the views of Looked After Children. The LACE project for
example, highlighted the need for social workers and
carers to know more about future courses and careers
and teachers to be trained in understanding what it is
like to live in care, to assist in this supportive role
(McLaughlin, 2002).
10.2 What services seem to work well with
Looked After Children/Care Leavers?
At a general level, it seems that all young people
accessing services would benefit from workers developing
a specific style of engaging with them, particularly
focused on building good relationships. The RCPCH
(2003) review of health care for adolescents cautioned
that by failing to develop good relationships with young
people (in general), professionals may be setting a future
pattern of poor use of services. Throughout the
document, they emphasise a need for a different
professional style and service for young people, with the
possibility of some professionals in larger hospitals
The relationship between young people and social workers
has also been found to be important. McAuley (in press)
notes that young people want to feel valued and
respected by their social workers and the chance to
establish a relationship with them (by spending time with
them, getting to know them and having fun together). If
this was not achieved, the young people regarded
questions as an intrusion or lack of genuine interest
(McAuley, in press). This can be threatened by staff
turnover (McAuley, in press).
57
VOICE OF YOUNG PEOPLE IN CARE
What young people want
developing particular expertise with young people.
many of the Looked After Children voluntarily requested
a health assessment. They found that some Looked After
Children needed to gain their trust first. Their approach
was seen as successful because the young person was
encouraged to become curious about their health and
take control of it. Of the 134 Looked After Children in the
target population, 105 were assessed and 103 of the 105
Looked After Children assessed were assessed in their
own units (RCHP, 2004). This response rate contrasted
favourably with previous findings where the uptake and
interest was low with only a quarter of Looked After
Children medicals being performed despite this being a
formal requirement and not a ‘formal service’ (Butler &
Payne, 1997).
Armstrong et al. (2000) recommended that parents and
professionals wishing to discuss mental health with
young people should use vocabulary which mirrors the
young person’s own or carefully identify what they
mean. Gilligan (2005a) claims that the key to working
well with Looked After Children and positively
influencing them is to actually enjoy their company.
Services which seem to work with Looked After
Children/Care Leavers are closely aligned with their
specific needs. An interesting national survey of the
links between social services and CAMHS in Great
Britain (GB) was carried out by Kerfoot et al. (2004).
Regarding preferred models of working, 63% of Social
Services Department staff wanted a service that was
more closely aligned to the needs of Looked After
Children but contained within the existing
‘comprehensive’ framework (Kerfoot et al., 2004).
There appears to be a particular problem of uptake of
CAMH Services either because the young person may be
uncertain about their diagnosis and the reason for
contact with mental health teams, some even denying
their illness (Rea, 1999), or because Looked After Children
are unwilling to attend. It may also be that Looked After
Children are not encouraged or welcomed as referrals to
CAMHS (Kerfoot, 2005). Kerfoot (2005) puts forward
several reasons for this. Firstly, Looked After Children
have complex problems which may seem intractable.
Secondly, they have a complex service history and
previously tried interventions may have failed. Finally,
Looked After Children have disrupted placement histories
and changes in placement and social worker will further
disrupt their uptake of services (Kerfoot, 2005).
The CAMHS Innovation projects provide a useful
starting point for areas of good practice when working
with Looked After Children and a useful learning
resource is the evaluation carried out by Kurtz & James
in 2002. They evaluated all 24 Innovation projects, nine
of which focused on the needs of Looked After
Children, their parents and carers. These projects
offered rapid access to mental health assessment and
intervention, support consultation and training for
carers, creative approaches to engaging children and
consultation and training for social workers, residential
workers and other professionals (Kurtz & James, 2002).
Findings suggested that there was increased selfawareness among Looked After Children of their
strengths and difficulties (Northamptonshire),
improvements in engagement with education
(Liverpool, Sheffield) and better-planned and more stable
placements. All in all, the projects seemed to succeed in
increasing involvement with specialist CAMHS, greater
inter-agency working and better engagement in
education (seen as particularly important for a successful
outcome) (Kurtz & James, 2002).
An example of good practice to encourage Looked After
Children/Care Leavers to take up services comes from a
CAMHS team in Nottingham (Frankish & McCrossen,
2005) whereby the CAMHS worker is based in the Leaving
and After Care Team for part of the week. Self-referrals
are made often via text to the worker and the number of
self-referrals are rising. They believe this is happening
because the worker is based in the team, she gets to
know the young person which breaks down the barriers
of entry. Another success factor is that she advocates the
use of flexible contact methods, in particular mobile
phones, and does not attend a meeting unless the young
person has responded to her text. This means that the
‘three times and you are out’ scenario does not arise.
Frankish & McCrossen (2005) feel that traditionally there is
more of an emphasis on diagnosis rather than the
emotional needs of Looked After Children/Care Leavers.
Another major consideration from the Innovation
projects working with Looked After Children is how best
to engage with young people who may well feel there
are too many adults in their lives (James, 2002). To
achieve engagement, they stress that persistence and
flexibility are crucial, and have developed many ways of
ensuring this such as using leisure facilities, creative
therapies and engaging with carers (James, 2002).
The actual building or environment is again an important
element which has the capacity to cloud the Looked
After Child/Care Leavers’ impression of the services
(Callaghan et al., 2003) and flexibility in the location can
be important. Kerfoot et al., (2004) found a general
perception that CAMHS treatments are largely inaccessible
to Looked After Children and Care Leavers:
In the Residential Care Health Project (RCHP, 2004), when
some Looked After Children were reluctant to take up
services, they would make short visits until gradually
10: WHAT YOUNG PEOPLE WANT
58
What young people want
What young people want
“There were frequent examples cited of failed clinic
appointments because young people were resistant to
attending ‘psychiatric settings and CAMHS staff often
saw youngsters being discharged from Care as ‘poorly
motivated’ or ‘uncooperative’. The prevailing view was
that the special vulnerability of children with mental
health problems who are also being looked after by the
local authority needed to be recognised through the
provision of special treatment resources. These would
be different to conventional CAMHS by being provided
in neutral non-health settings where fears of labelling
would be reduced” (p. 165, Kerfoot et al., 2004).
simply some rethinking or a more sensitive approach
by social workers or their managers. Others
need investment of time and finance”
(p. 98, McAuley & Bunting, in press).
The Experts by Experience group in the RMHLDNI Adult
Strategic Framework (RMHLDNI, 2005b) stated that:
“There is consensus within the group that if only one
element could be changed we would wish it to be the
prevailing attitudes of those who engage with us…we
need all professionals in the mental health field to have
specific training in the person-centred approach
as part of their overall learning”
(p. 208, RMHLDNI, 2005b).
Creative approaches appear to be important in
overcoming the reluctance of young people to
acknowledge these needs. This reluctance casts doubt on
their likelihood to take up services (Mount et al., 2004).
What can work instead, according to Mount et al. (2004)
is to adopt creative approaches to enhance engagement
such as mentoring schemes involving Care Leavers as
paid volunteers who have been trained to engage other
young people at a non-pathologizing, activity-based
level. They note that this is already happening with
young people being involved as co-researchers in the 24
CAMHS Innovation Projects (Mount et al., 2004).
The uptake of CAMHS is similarly an issue in Northern
Ireland. A recent review has shown that only 52% of 1316 year olds are happy to re-attend Child and Adolescent
Services in Omagh after the initial assessment, and SLT
have responded by recommending a focus group to
explore ways of attracting adolescents to attend the service
(SLT, 2006). Fleming et al. (2005) similarly note the low
uptake of statutory medical assessments in Northern Ireland.
Again, the environment in which services are offered is
important and should be as child friendly as possible and
non-stigmatising. To achieve this, the RMHLDNI
recommends that they are located on the same site as or
as near as possible to other children’s services (RMHLDNI,
2005a). NIAMH similarly raised issues such as user
preference for care/treatment outside the psychiatric
hospital (NIAMH, 2003).
Specific leaving care schemes can also be successful for a
number of reasons (Stein, 1997). These include being able
to target so-called core needs of Care Leavers (e.g.
accommodation, social support, finance and careers) in
different ways, being able to engage and involve young
people in important decisions in their lives, being able to
work with other agencies (e.g. housing providers, benefit
agencies, employment and training agencies) to meet the
core needs, being able to influence policy at a local level,
and finally operating within a management and policy
framework with clear objectives.
One question which arises from the review is that perhaps
Looked After Children/Care Leavers are not offered the
type of therapeutic support which could enable them to
understand and reconcile their past histories. It may also
be that there is a lack of individual work with Looked
After Children, in general, and in CAMHS. Systematic
Family Therapy approaches predominate at present, but it
may be the case that other approaches could be used.
Being able to explore their personal history is an
important protective factor for Care Leavers and is linked
to a positive self concept (Biehal et al., 1995). Gilligan
(2005a) also states that a good ingredient for enhancing
resilience is “helping the child to have and hold a story
about their unfolding life that brings coherence and
meaning” (p. 111, Gilligan, 2005a).
Northern Ireland
Evidence in Northern Ireland seems to raise similar issues.
Again, relationships are important. Sensitivity and
understanding are key elements to an effective approach
with Looked After Children/Care Leavers. McAuley &
Bunting (in press) in their summary of VOYPIC’s work
state that:
“Some of the issues raised (by young people) require
59
VOICE OF YOUNG PEOPLE IN CARE
What young people want
KEY POINTS FOR CONSIDERATION
•
What approaches are used?
•
How flexible are working patterns?
•
What processes are in place regarding confidentiality?
•
How welcoming are the physical environments
within which Looked After Children/Care Leavers
access services?
•
How accessible are these services in reality?
•
Could some of the creative approaches outlined in
the review be adapted in Northern Ireland?
•
How much one-to-one work is carried out with
Looked After Children/Care Leavers?
10: WHAT YOUNG PEOPLE WANT
60
11
How should services develop in
Northern Ireland and what is needed to
implement these services?
61
VOICE OF YOUNG PEOPLE IN CARE
How should services develop in Northern Ireland and
what is needed to implement these services?
emerging from this review is that, irrespective of statutory
responsibility, the responsibility for promoting the mental
health of Looked After Children and Care Leavers is broadly
based. The securing of protective factors and reduction of risk
factors is not the sole responsibility of Social Services (an
argument that has already been made in Investing for Health)
or those with day-to-day and statutory responsibility for
Looked After Children/Care Leavers, but, it is the responsibility
of everyone linked to Looked After Children/Care Leavers. A
good example of shared responsibility is found in
Communities that Care (1999) which states that:
The review has looked at mental health, how it is
identified and assessed, actions which are taken to
reduce risk factors and promote protective factors, direct
services, the legislative and policy context and at young
people’s views. Having done so, we are now in the
position to look at the future of service development in
Northern Ireland, and what is needed to implement these
services. The outline of the chapter is as follows:
1. How should services develop in Northern Ireland?
• Shared Responsibility
- Engaging with carers and staff in the Looked
After Child/Care Leaver’s existing network
- Joined-up/Inter-professional/
multi-agency working
• Development of a range of services based on
assessed need
2.
•
•
•
•
•
•
“By mobilising whole communities behind an holistic,
multi-agency approach, Communities that Care
ensures that prevention ceases to be the
responsibility of a few, specialist organisations”
(p. 1, Communities that Care, 1999).
What is needed to implement these services?
Providing structure to CAMHS in Northern Ireland
Recruitment and Retention of a well-trained work
force in Northern Ireland
Improved Information and Training
Research and Evaluation
Adequate Funding
A Legislative, Policy and Practice Commitment
This is also acknowledged by the DHSSPS:
“Health and wellbeing is the responsibility of everyone
and not only the health and social services. Individuals,
families, communities, the business sector and
Government all have a role to play. We must also be
more aware of the needs of vulnerable people and
accept collective responsibility for their protection and
care while promoting their independence and inclusion
in society” (p. 12, DHSSPS, 2004b).
11.1 How should services develop in
Northern Ireland?
In Northern Ireland, the main responsibility for Looked
After Children and Care Leavers is held by the DHSSPS.
However, a number of other departments also hold
responsibility for aspects of children and young people’s
lives which have an impact on Looked After Children/Care
Leavers. A few examples include the Department of Culture,
Arts and Leisure (DCAL) through the unlocking creativity
strategy, the Department of Education (DE) through
revising the school curriculum to meet educational needs,
the Department for Education and Learning (DEL) which
provides further and higher education services, careers
education and guidance, and vocational training, and the
Department of Enterprise, Trade and Investment (DETI)
which prepares young people for business and provides
legal protection for children and young people at work
(OFMDFM, 2003). While there will be some restructuring
through the new reforms in public administration, the
functions of these bodies will still have to be met.
There may be limitations of organising mental health
provision for Looked After Children around both social care
and medical models, discussed by Teggart (in press) which
brings to light earlier work carried out by Street & Davies
10
(2002) . The author notes that Street & Davies conceive
the Four-Tier CAMHS Model outlined earlier as organised
around needs ‘described in the presence of symptomatology’.
He further outlines Street & Davies model based on
health/developmental approaches (integrating the theory
of childhood problems) and argues that such a model may
be essential to address the complex realities of Looked After
Children. This model can still exist from within a CAMHS
structure (Teggart, in press) which would therefore fit well
with the RMHLDNI’s (RMHLDNI, 2005a) conclusion that the
Four-Tier Model is appropriate for Northern Ireland.
Presumably this would equally apply to adult mental health
in the case of Care Leavers whose complex histories need to
be understood contextually.
It is each service provider’s responsibility to advertise
what they do, equally important at the lower Tiers and in
adult services. The need for this in CAMHS was summed
up well by Mount et al. (2004):
11.1.1 Shared responsibility
The main element of the future organisation of services
10 Street, E. & Davies, M. (2002) Constructing child mental health services for looked after children. Adoption & Fostering, 26(4), pp. 65-75.
11: DEVELOPING SERVICES
62
Developing Services
Developing Services
“A coordinated multidisciplinary interagency response
demands CAMHS professionals to take responsibility to
educate other agencies about mental health issues and
to advertise the services they provide”
(p. 379, Mount et al., 2004).
managers in the area and the North Glasgow Community
Adolescent Mental health team developed a dedicated
mental health service for Looked After Children (Van Beinum
et al., 2002). There were two key developments in the service,
the change from a ten-bed unit to smaller units for at most
four young people and an ‘Open Door’ project providing a
wide range of services to young people as well as training and
specific support for frontline workers. This enabled frontline
care staff and managers (who were recognised as having
‘informal expertise’) to work more effectively with young
people. An independent evaluation by the Scottish Health
Feedback for Greater Glasgow Health Board was positive.
Staff were more confident and were able to work through
their own anxieties rather than acting them out. They were
encouraged to come up with insights into why the child was
acting in a particular way (Van Beinum et al., 2002).
This should be a welcome message because it reduces the
sense of one party being overwhelmed with responsibility.
Daniel et al. (1999) admitted that they had mixed success
in designing a system to map resilience but further work
was possible in the area. They note that social workers
should not feel overwhelmed with the responsibility for
this but that the aim is to locate a network of people
capable of addressing the different aspects.
There are two sides to sharing responsibility which we
discuss here: the way in which there is joined working with
carers and staff in the child’s existing network and the
degree to which there is multi-agency working.
The second is the Residential Care Health Project (RCHP,
2004), which found that in their supportive role to
practitioners in residential care, consultations were
requested because staff were having problems dealing with
behaviour. Instead of staff feeling overwhelmed by this,
they were encouraged to discuss the young person’s history
and try to find an explanation. Normally one consultation
was enough to come to a conclusion.
Engaging with carers and staff in the child’s
existing network
The value of involving carers and staff to improve the mental
health of Looked After Children has been demonstrated. A
number of the CAMHS Innovation projects have, therefore,
taken steps to ensure that services engage with the networks
of adults around Looked After Children (James, 2002).
Richardson & Joughin also support this work:
“[Challenging behaviour] may place adult carers under
severe pressure. We can think of this as an attempt by
a child or children to test out whether these adults are
any more reliable and consistent than those they have
previously experienced; we can also think of this
behaviour as an attempt to communicate to other
people what it has been like for the child in the past”
(p. 5, Richardson & Joughin, 2000).
Similarly, work in England has some interesting
developments. One example is in Lincolnshire where
dedicated CAMHS support was directly provided to adults
who care for Looked After Children (Prince, 2002). This
support was provided both to carers in residential and foster
care. Each children’s home benefited from a weekly visit from
a CAMHS specialist nurse. Staff used this service in various
ways ranging from training sessions, nurses taking part in
staff meetings, discussions regarding the behaviour and
management needs of particular Looked After Children or
the nurses helping staff to decide on appropriate referral to
specialist Tier 3 CAMHS. Foster care, which was the
predominant type of care in Lincolnshire at the time,
benefited from an additional scheme because the 250 carers
were scattered across a large rural population. Two specialist
community mental health workers were appointed within
two CAMHS clinical bases. They supported all foster
carers in the area through a telephone advice line service
available every Thursday as well as visits to carers at home
or discussions with carers at CAMHS offices (Prince,
2002). The author concludes that:
Much work has been done in Scotland and it would be useful
to outline two examples whereby these principles can be put
into practice. The first is a pilot project in East
Dunbartonshire to implement the ‘Looking After Children in
Scotland’ materials and system of care planning that
underpinned them. This system aimed to provide care which
resembled more the care experienced by young people
growing up at home in their families. Residential childcare
“CAMHS support to the adults who care for looked
after children 24 hours a day, 7 days a week is proving
to be very important, not only in improving placement
stability, but in ensuring that the mental health needs
of children in public care are identified at the earliest
opportunity, and that referral of LAC to Tier 3 CAMHS
for specialist assessment and treatment is an effective
and appropriate process” (p. 11, Prince, 2002).
“It is possible to support the network around the child by
means of consultation, offering an understanding of the
problem and strategies for management, so that the
carers and professionals work together consistently to
alleviate the difficulties” (p. 9, Richardson & Joughin, 2000).
Richardson & Joughin (2000) call for an understanding of
the child’s circumstances:
63
VOICE OF YOUNG PEOPLE IN CARE
Developing Services
The importance and value of joined-up, inter-professional
and multi-agency working to meet the mental health
needs of Looked After Children is well documented in the
research and policy literature. When it works well, links
between Social Services and CAMHS, for example, can
result in good knowledge transfer with Social Services staff
remarking on the skills and knowledge gained from regular
co-working and consultation with CAMHS (Kerfoot et al.,
2004). There is also a need for a common language whereby
professionals understand how to manage problems rather
than being confused by jargon (Callaghan et al., 2003)
Another area of good practice is a model of specialist
psychological support to foster carers (Golding, 2004). It
allows them to consult with a specific project team including
a clinical or educational psychologist. Results show that
carers change their perceptions of the Looked After Child
following the consultation and find this useful. They usually
perceive the Looked After Child as having more severe
problems following the consultation. However, they caution
that collaborative discussion can be hindered by the
perception that the psychologist is more expert (Golding,
2004). This kind of collaboration is important given findings
that foster carers are a particularly isolated and stressed
group and can feel that they deal with the Looked After
Child every day but information is withheld from them
which would help with the situation (Callaghan et al., 2003)
Nevertheless, Richardson & Lelliott (2003) pointed to the lack
of ‘joined-up government’ whereby targets set for one
agency do not apply to another. They also note the lack of
cohesion among front-line workers who are unaware of the
targets their Trust or authority are trying to meet which can
result in resistance to changing practice, something they hoped
the ‘National Service Framework for Children, Young People
and Maternity Services’ (DH & DfES, 2004) would assist with.
A final example is the Leicestershire Partnership Trust’s
young people’s team which has a primary mental health
worker who states that 70% of her work is providing
consultation with foster carers, residential staff, link workers
and social workers. The worker believes that by helping the
foster carer for example to understand the issues around the
child, this will not only help with the child in question but
the training and experience will result in the carer being
more equipped the next time (Hopkins, 2002).
Joint working between education and social services could
be particularly important in the future. Steps have been
taken in the UK through the Guidance on the Education of
Children and Young People in Public Care (DfEE & DH, 2000)
which recommended that schools should identify and ensure
that a ‘designated teacher’ is in place in each school to act as
an advocate for Looked After Children. Fletcher-Campbell et
al. (2003) examined the role of the school in providing
support for Looked After Children and found that most
designated teachers engaged in multi-professional dialogue,
some finding it easier than others. One area of potential
concern voiced earlier by Fletcher-Campbell (2003) related
to continuity whereby at 16 years responsibility for the
Looked After Child switched to the Leaving Care Team.
Northern Ireland
This need to engage with the networks around the child
has been recognised in the RMHLDNI:
“Clinical aspects of Looked After Children (LAC) should
include the liaison with and consultation to the
network surrounding the child, comprehensive
assessment of need, intervention with the child and
carers, supervision and training, audit, research and
evaluation” (p. 56, RMHLDNI, 2005a).
Another important area of joint working is between CAMHS
and schools, examined by Pettitt (2003) in England with a
view to providing areas of improvement. Key advantages of
joint working included the ability to access children (not
specifically Looked After Children) who would not normally
be reached, to identify children’s problems earlier, overall
improvements in children’s happiness and well-being,
increased awareness and learning between health and
education staff and CAMHS workers highlighted that they
received more appropriate referrals. Disadvantages however,
included the fact that joint working was time-consuming,
they encountered management difficulties, duplication of
work due to lack of effective coordination, difficulties in
sharing information between the different agencies and also
being inundated with referrals.
Supporting carers, particularly in their understanding of
the child, may also serve to enhance placement stability,
as McAuley & Trew (2000) demonstrate:
“How the foster carers perceive the child is much more
likely to be related to whether the placement continues
or not as most placements conclude at the request of
the foster carers” (p. 103, McAuley & Trew, 2000).
Although the attachment of CAMHS professionals to
Children’s homes similar to models in England or
Scotland would be a positive development, one thing to
bear in mind is that a much higher percentage of the
Northern Ireland workforce in residential care are
professionally qualified.
One shining example of good multi-disciplinary working is
the Residential Care Health Project (RCHP, 2004) which
essentially linked together Looked After Children in
residential care with existing services in order to meet their
Joined-up/Inter-professional/multi-agency working
11: DEVELOPING SERVICES
64
Developing Services
Developing Services
needs. A key element is that new services were not
necessarily created; rather that existing ones were
redirected. The project team made links with many
agencies and where health initiatives were successfully
underway, did not duplicate effort.
area will need to engage in discussion about their
differences, with a view to developing shared accounts
of the young person’s needs and negotiation of the
most appropriate paradigm for interventions”
(p. 14, RMHLDNI, 2005a).
Northern Ireland
A recommendation for the development of specialist CAMHS
in the review by SLT is to bring multi-disciplinary staffing
levels in line with the Royal College of Psychiatry guidelines,
particularly regarding the appointment of Primary Mental
Health Care Workers (SLT, 2006). They further note that
deliberate self-harm necessitates a speedy response with a
mutually agreed protocol between CAMHS, accident and
emergency departments and paediatric services (SLT, 2006).
From the review, and in particular the policy overview, it
appears that the needs of Looked After Children/Care
Leavers have been recognised within a range of policy
documents issued by government departments. The
question remains, however, regarding how much linkage
and cross-working occurs.
In 2002, the Clinical Psychology Speciality Advisory
Committee (SAC) issued a consultation document to the
DHSSPS which examined services to meet the psychological
and mental health needs of Looked After Children in
Northern Ireland (Clinical Psychology SAC, 2002). This
noted the need for a specific mental health service for
Looked After Children and outlined that such a service
would require partnership and sustained collaboration from
the main stakeholders including service users, frontline
carers, education services, social and health care services
managers, child and adolescent services and voluntary
sector agencies (Clinical Psychology SAC, 2002).
11.1.2 Development of a range of services
based on assessed need
A range of services need to be developed across the
CAMHS Tiers (McAuley, 2004) and O’Rawe (2003)
cautions that this needs to be a balanced development to
avoid the creation of service bottle-necks since Tiers are
not discrete entities. O’Rawe (2003) suggests closer and
more effective connections between practice and the
supportive resources available from children’s natural
networks and environment. Future services will benefit
from a number of new builds and developments. One
development in CAMHS will include the rebuild of
inpatient adolescent provision as well as regional specialist
units for social/emotional/psychological provision.
There may be room for progression in Northern Ireland of
more joined-up working with voluntary agencies. The
RMHLDNI acknowledges the pioneering work in the broad
CAMHS field by voluntary organisations. It listed examples
of good practice including Belfast Central Mission,
Barnardos, Contact Youth, New Life, NI Association of
Mental Health, NSPCC, Opportunity Youth, Extern (Turning
Point), STEER, Threshold and VOYPIC. The review notes
however that funding can prevent long-term planning of
services and there can be problems of communication so
that service users are not always aware of what is available
to them (RMHLDNI, 2005a). In a study by McCrystal &
Fleming (1999) there was evidence that limited
partnerships had developed at the time of writing in 1999
between the voluntary and statutory sectors for the
provision of services for children in need following the
introduction of the Children (NI) Order. Since this was in
the early stages of implementation, we should hope that
more partnerships have been developed and enhanced.
Similarly, assessments of need are required, on which to
base services (O’Rawe, 2003):
“The ambivalence towards providing a comprehensive
CAMHS is perhaps most apparent in the regional lack
of monitoring data, particularly with regard to needs
assessment. This must be addressed as a matter of
priority” (p. 7, O’Rawe, 2003).
The consultative document for the RMHLDNI also cautions
that the number of inpatient places should be based on a
comprehensive, multi-agency needs assessment taking into
account the known prevalence and incidence of mental
health problems and local demographics (RMHLDNI, 2005a).
On a more positive note, McTernan (2003) outlines that
among the key priorities in Children’s Services Plans are
Looked After Children, Care Leavers and Child and Adolescent
Mental Health. He sees a progression in planning:
There is also scope for cross-working with education. The
RMHLDNI also recommends that the Department of
Education and DHSSPS should set up an interdepartmental group and that training for educational
practitioners should address young people’s mental health
needs (RMHLDNI, 2005a). The Review cautions that:
“We are moving away from planning on the basis of
activity analysis and historical patterns of service
delivery (in other words, ‘what did we do last year?’
and we will tweak it a bit) to an emphasis on the
assessment of need” (p. 202, McTernan, 2003).
“Practitioners both within teams and across each local
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He outlines the needs-led planning work the Western Area
Children and Young People’s Committee has carried out to
create a database which he says uses language understood
across community, professional, cultural and organisational
boundaries (McTernan, 2003).
11.2
Further elements which emerge from the consultative
document by the RMHLDNI include the lack of
development of the link worker concept, lack of strategic or
operational planning in a phased manner, the need for
CAMH Services to be addressed across health, social
services, education and youth justice, the need for the
development of a managed clinical network (MCN) through
CAMH Services in Northern Ireland facilitated by a regional
development worker (RMHLDNI, 2005a). It appears that
these things will be key issues in the future.
What is needed to implement
these services?
11.2.1 Providing structure to CAMHS
in Northern Ireland
The Review of Public Administration will undoubtedly
have implications for CAMHS provision, possibly in the
opportunity to consolidate services which have been
dispersed up until now.
“The goal of CAMHS is to promote mental health and
treat mental health problems amongst children and
adolescents and in so doing, in collaboration with the full
spectrum of professionals both within and beyond the
wider CAMHS, to keep children and their families together,
to support parents in strengthening their families whilst
helping their children to overcome their difficulties and
supporting them at school, and to keep children and young
people out of care, young offenders and child protection
systems. If we are sincere in achieving this goal – we must
have a practical and coherent regional CAMH programme
controlled by a single accountable body – and adequate
resources to fund it” (p. 31, O’Rawe, 2003).
11.2.2. Recruitment and Retention of a welltrained workforce in Northern Ireland
There are various levels of crisis in relation to recruitment
and retention of foster carers, residential staff, social
workers and those working in adolescent mental health in
Northern Ireland.
The decision to cease fostering may happen for a number
of reasons, but a particularly worrying one is if foster carers
are dissatisfied with the relationship with their social
worker (Sheldon, 2004). Sheldon notes his earlier work in
2002 whereby carers aspired to being treated as partners in
the process of caring for children. He therefore
recommended that South and East Belfast Trust moved
away from an ad hoc relationship with foster carers to an
acknowledgement of them as partners.
Management, coordination and accountability in CAMHS
appear to be major issues in Northern Ireland and will need
to be addressed in the future (O’Rawe, 2003; Gilliland et al.,
2005; SLT, 2006; Teggart, in press). O’Rawe (2003) sees a
lack of accountability and coordination in NI CAMHS and
feels that there is ambivalence towards establishing a
comprehensive CAMH Service. Her answer is that “NI
CAMHS does not need a structural review or reform – it
needs a structure” (p. 13, O’Rawe, 2003) and she suggests
this can be done by appointing a dedicated CAMHS
manager within each Board. A local review carried out in
SLT reiterates the Audit Commission (1999) argument that
the management of CAMHS is a key quality indicator and
recommends a management structure within their Child
and Adolescent Services to include the appointment of a
dedicated senior manager (SLT, 2006). To provide
integration across the Tiers, Gilliland et al. (2005) note one
response by the NHS HAS ‘Together we Stand’ report (1995)
for the development of primary mental health workers. Two
recommendations by Gilliland et al. to this end include:
Regarding the crisis in recruitment of foster carers, the
recent call for 350 more foster carers in Northern Ireland
(Fostering Network, 2006) will hopefully be met with more
success than a previous call in GB. In 2001, a government
recruitment campaign in GB coordinated by the National
Foster Care Association yielded 1,200 contacts instead of
the 7,000 expected (ADSS, 2002). The call in Northern
Ireland is prompted by the reality that around 1,400 Looked
After Children live with 1,300 foster families on a given day
in the area which is 350 short of the number needed
(Fostering Network, 2006). Some hope comes from the
planned investment of £6m over the next two years which
Hain (2006) announced will be aimed at increasing the
number of foster carers in Northern Ireland.
“Coherent organisational structures with clear
managerial arrangements, a robust governance
framework and transparent clinical and managerial
accountability” and “integrated planning and
commissioning processes informed by a regional
dimension, facilitating needs assessment and linking
service development priorities, implementation strategies
and resource base” (p. 60, Gilliland et al., 2005).
11: DEVELOPING SERVICES
The development and recruitment of a well-trained
workforce in CAMHS will increasingly be an issue for the
future (RMHLDNI, 2005a; Gilliland et al., 2005). Gilliland
et al. (2005) note the particular training needs of staff at
the various Tiers. They believe Tier 1 staff have support
and developmental needs which can be difficult to
address. Tier 2 staff require specialist consultation and
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prompted new calls for training for social workers and
foster carers. He backs up this assertion by similar calls
from Young Minds, the Fostering Network and the British
Association of Social Workers. Stanley et al. (2005) state
that there is a particular need for the training of social
workers given their pivotal role:
support from Tier 3 and the same authors report that
“the development of the Tier II system arguably offers
a considerable challenge for service providers in the
near future” (p. 54, Gilliland et al., 2005). However, this
is set against the pressures of long waiting lists at Tier
3 (Gilliland et al., 2005). Some of these early
recommendations in the RMHLDNI CAMHS
Consultation document are to develop the workforce
along the Four Tier Model and in particular to expand
the role and complement of primary mental health
workers, family therapists, child psychotherapists,
speech and language therapists and occupational
therapists in CAMH Services in Northern Ireland
(RMHLDNI, 2005a). Gilliland et al. (2005) recommend:
“As the professional group most likely to be providing
substantial intervention to looked after children and
their carers, social workers require relevant training in
identifying and responding to mental health needs”
(p. 239, Stanley et al., 2005).
In its consultation with the wider network working with
young people, The Scottish Needs Assessment Programme
(PHIS, 2003b) found that a lack of training and readily
available support were major concerns. A total of 900
replies were received from this network which included
social workers, residential child care workers, foster
carers, teachers, police, children’s hearing reporters,
children’s hearing members, health visitors, general
practitioners, school nurses, paediatricians and voluntary
sector workers:
“A workforce strategy embracing uni-professional and
multi-professional training requirements, recruitment,
retention and opportunities for innovation in relation
to practitioner and management grades. In this
regard, the development of Primary Mental Health
workers appears to offer particular benefits”
(p. 60, Gilliland et al., 2005).
There has also been some work to show the particular
11
pressures the Troubles have had on the working life of
social workers in Northern Ireland. Campbell &
McCrystal (2005) found that high proportions of social
work staff (working at the time in, or associated with
mental health settings) received minimal agency
support and training to be adequately prepared to deal
with the ‘Troubles-related’ problems they faced. The
main problems encountered by participants were traffic
disruption, bombs and sectarian harassment and the
authors note that:
“The SNAP survey clearly indicates that across the
network of people who work with children and
young people, many practitioners recognise mental
health need amongst young people and are looking
for ways to develop their own capacity to make a
difference. There is a need for formal learning
opportunities which will support that aspiration
and lead to enhanced capacity”
(p. 18, PHIS, 2003b).
The training needs of various stakeholders such as social
services staff, foster carers and residential workers, were
examined through focus groups by Callaghan et al.
(2003). A number of training needs were identified by the
participants including understanding trauma and the
psychological impact of abuse and neglect, working with
Looked After Children with behaviour problems,
counselling skills, understanding what mental health is
and being able to identify mental health difficulties
experienced by Looked After Children. There was also a
need to understand how services worked for example
through knowing the steps after a referral is made, the
interventions available, and how children in therapy
could best be supported.
“These types of problem are unlikely to have
been experienced with such intensity by
social workers elsewhere in the UK”
(p. 186, Campbell & McCrystal, 2005).
11.2.3 Improved Information & Training
The need for information and training on the mental
health needs of Looked After Children recurs in the
literature (e.g. Valios, 2002; PHIS, 2003b; Callaghan et
al., 2003; RCHP, 2004; Martin, 2004; Stanley et al.,
2005). Martin (2004) states how the confirmation of
mental health needs in the looked after population by
the Meltzer et al. studies (2003; 2004a; 2004b)
The single most pressing area in which residential staff
expressed the need for support in the Residential Care
11 Campbell & McCrystal state that the term the ‘Troubles’
“Has been used to describe the history of violence in the north of Ireland before and after the partition of Ireland in 1921. In the subsequent 80
years Northern Ireland experienced periods of sectarian conflict between Catholics and Protestants, often leading to death and injury.
The current Troubles began in the late 1960s and have resulted in over 3,600 deaths and tens of thousands of injuries [Fay et al., 1999]’
(p.188, Campbell & McCrystal, 2005).
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Health Project was regarding mental health issues (RCHP,
2004). Furthermore, the work highlighted a need for less
focus on crisis intervention and more focus on the
underlying causes of mental and emotional ill-health in
Looked After Children (in residential care) (RCHP, 2004).
Those working closely with Looked After Children need to
have enough information and be trained to deal with the
12
issues they are presenting with. Street’s 1999 work with
residential workers highlights problems for residential carers
regarding the quality and quantity of information they receive
from different sectors (outlined in p. 335, Kerfoot, 2005).
Looked After Children/Care Leavers and professionals
need to know about what the issues are and what
services are available. Information availability is a key
issue in Northern Ireland, linked to the procedures in
place in the Trusts.
Some work has been undertaken to improve information
provision in Northern Ireland. One good example is the
Action Mental Health (AMH) MensSana project,
established in 2002. The project provides advice and
information services for parents and key workers
regarding mental health issues and services relating to
young people with mental health needs. A recent
recommendation has been to develop information
provision by designing a CD ROM directory of potential
agencies/resources both statutory and non-statutory
which work therapeutically with children and young
people with mental health needs (SLT, 2006). From this
review, it will become clear that such a directory is
needed specifically for Looked After Children/Care
Leavers for both therapeutic and other relevant services.
Another way of ensuring public and professional
awareness was put forward by SLT (2006) which was to
create a child-friendly and accessible website for their
Child and Adolescent Services. The HPANI has also
compiled a useful database of interventions and
initiatives that are intended to promote mental health in
1999 (HPANI, 1999). Although very few of the initiatives
relate directly to Looked After Children/Care Leavers, a
number are evidently relevant. These might involve dropin and/or counselling facilities, referral programmes,
suicide prevention strategies, or school projects. An
update of this publication would prove very useful for
the future.
Lindsey (2005) notes the development of a child and
adolescent workers’ training matrix which was developed
through the NSF recommendations:
“All community workers in the statutory health, education
and social services and voluntary sector who work with
children (known as Tier 1) need, amongst other
requirements, to acquire the basic skills of communication
with children, a grasp of child and family development,
knowledge of child protection, of risk and resilience and
the promotion of mental health, sensitivity to cultural and
ethnic differences, and an awareness of referral pathways
for specialist help” (p. 227, Lindsey, 2005).
Some training materials have already been developed
which have components of, or relate specifically to, mental
health. Examples include Hudson et al’s (2003) training
materials ‘Learning with Care’ for teachers, social workers
and carers involved in the education of Looked After
Children in Scotland, Gilligan’s (2001) resource guide
‘Promoting Reslience’ for working with Looked After
Children, and Young Minds’ training resource pack on
mental health for professionals caring for and working with
Looked After Children (Talbot, 2002).
McTernan (2003) outlines the database created by the
Western Area Children and Young People’s Committee
which defines need using existing information from
social services, health, probation, police, housing, social
security and education. It has pulled together
information about the agencies that supply services
stating what services they provide and who they target
across the statutory, voluntary and community sectors.
Importantly, McTernan uses the Hardiker model to show
that Looked After Children, although they are at level 4
in this model, are also dependent on access to effective
services at the earlier levels (McTernan, 2003).
Other examples of training include the RCHP (2004) which
provided training on topics including general mental illness,
mental health services and how to access them, adolescent
development, staff dynamics, and how young people made
workers feel. Minnis et al. (2001) also evaluated a training
programme for foster carers and the impact this had on
Looked After Children (aged from 5 to 16 years). While
participants perceived the training as beneficial, there was
only a small but not significant effect on their high levels
of psychopathology. The authors noted that the group
could warrant more intensive interventions.
Another useful resource which could be implemented in
Northern Ireland is an update of the FOCUS project by the
Royal College of Psychiatrists’ Research Unit which brought
together a Who’s Who in CAMHS (Joughin et al., 1999). The
Northern Ireland
Information Provision
12 Street, C. (1999) Providing residential services for children and young people: a multidisciplinary perspective. Aldershot: Ashgate.
11: DEVELOPING SERVICES
68
authors noted that it would be a useful resource for new
CAMHS managers, professionals who liase with staff in the
field, trainees and students and parents of children likely to
use services. The document outlined information on the
background, training and key responsibilities of
professionals who work in the field. This included clinical
child psychologists, educational psychologists, mental
health nurses in CAMHS, child and adolescent psychiatrists,
child psychotherapists, social workers, family therapists,
speech and language therapists, occupational therapists,
art therapists, drama therapists, music therapists, other
professionals (specifically paediatricians, general
practitioners, health visitors, counsellors, juvenile probation
services, school nurses and teachers) and voluntary
organisations (Joughin et al., 1999).
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(McMaster, 2004). However, they sought more collaboration
with training providers to address these highly specialised
demands and believed specialist input was needed at a
number of different levels. These ranged from advice and
consultation for staff, through to directly being involved
with young people and if necessary with admission to a
psychiatric inpatient unit (McMaster, 2004). McMaster
(2004) recommends that mental health issues are
included in the Training Framework for all staff within
regional care centres.
SLT also highlight a need for specific training to those
working in their Child and Adolescent service to enable
them to respond comprehensively to the needs of children
and young people. They recommend this should include
training in behavioural therapies, cognitive-behavioural
therapies, family therapy, individual psychodynamic
psychotherapy and group therapy (SLT, 2006).
The need for training
It is vital that those who are at the first point of contact
for Looked After Children/Care Leavers are well informed
and supported in knowing how to address the issues they
present with (AMH, 2005). The focus of the MensSana
project carried out by Action Mental Health (AMH) was
on the needs of the key contacts of young people aged
16-25 years in the general population. These contacts
included specifically parents or guardians and relevant
professionals. One of the recommendations was that
young people’s key contacts require:
A commitment to training
Any training can be benefited by using Looked After
Children/Care Leavers in the design of the material. The
Northern Health and Social Services Board (NHSSB), for
example, used direct consultation with such young people to
help prepare, plan, design, deliver and evaluate training for
residential child care workers (Green, 2001). Wilson et al.
(2005) also note significant changes in the Northern Ireland
ASW (Approved Social Worker) course whereby users and
carers are more involved in direct teaching (which has been
positively evaluated) and the new curriculum includes,
among other things, the mental health needs of children and
the interrelationship between child and parental mental
health (Wilson et al., 2005). VOYPIC provides input to the
BSW (Bachelor of Social Work) degree at QUB (in relation to
Looked After Children), as well as input to the Social Work
Department in the University of Ulster (on developing good
practice guidelines for service user involvement in social work
training). Similarly, the LACE (Looked After Children in
Education) research outlined earlier has been implemented
by Include Youth, Save the Children, the DHSSPS and
Department of Education. It has produced training materials
for social work staff, teachers and young people through the
core curriculum in schools (VOYPIC, 2004).
‘Regular training and the provision of information to
enhance their knowledge of mental health issues and
services and develop the skills to support young people who
are experiencing mental health problems’ (p. 96, AMH, 2005).
In the case of Looked After Children, it appears that staff
and carers need to be adequately trained to work with
their ever-complex problems and challenging behaviour.
Sinclair (2005) notes that training of foster care should
be realistic and allow for additional ongoing training in
handling stressful placements. Kilkelly et al. (2004) also
show that challenging behaviour necessitates training and
support, particularly in residential settings.
The need for training in complex behaviours is particularly
apparent in the regional care centres outlined in
McMaster’s (2004) study. Staff acknowledged this and
some suggested a ‘grow your own’ approach to training
social workers whereby employees would be seconded in to
train and return to the centre when qualified. It was noted
that this had already been successful with a psychologist in
Lakewood. Unanimously, social work staff in the study
agreed that social work training does not adequately
equip staff for the demands of residential settings. A
programme of internal training has already begun in the
centres incorporating drug awareness, counselling skills,
mental health awareness and interventions skills
One note of caution is that consulting service users should
not be tokenistic or an afterthought. The Experts by
experience group in the RMHLDNI Adult Strategic plan
felt that they were ‘brought in at a late stage to validate
or respond to agreements already in train” rather than
being central to the review from the outset (p. 207,
RMHLDNI, 2005b).
Crucially, those who come into contact with Looked After
Children/Care Leavers with mental health problems are
not always trained in mental health e.g. GPs and other
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health professionals (RCPCH, 2003). However, to share
responsibility for the mental health of Looked After
Children and Care Leavers, more training is needed for all
those working with these young people. The RMHLDNI
suggests that undergraduate courses in disciplines such
as occupational therapy, speech therapy, family therapy,
play therapy, art therapy, drama therapy should include
awareness and foundation training in child and
adolescent mental health (RMHLDNI, 2005a).
children and young people as an area of practice they
needed in their refresher training (Wilson et al., 2005).
Some developments in the review and regulation of social
work are worth mentioning here. The Central Council for
Education and Training in Social Work (CCETSW) was set up
in 1971 with the aim of regulating a common social work
training qualification for the first time replacing a plethora
of other awarding bodies. Its duties were then taken over
by the Northern Ireland Social Care Council (NISCC) from
1st October 2001. This council not only registers and
regulates the workforce and draws up codes of practice but
also has responsibility for developing, promoting and
regulating education and training (DHSSPS, 2003a).
Another relevant organisation is the Social Care Institute
for Excellence, an independent ‘not for profit’ organisation
to review and determine what works well both in social
work and in social care practice (DHSSPS, 2003a).
Links between training and education
There is a need for the development and strengthening of
links between academic institutions and operational
services (RMHLDNI, 2005a). A more developed career path
in line with the developments in CAMHS provision would
also enhance recruitment and this is directly linked to the
creation of academic posts (RMHLDNI, 2005a). To do this,
an academic department of child psychiatry was seen as a
priority in this consultative document.
11.2.4 Research and Evaluation
Although the review has been able to access pockets of
evidence in Northern Ireland to inform services to meet the
mental health needs of Looked After Children/Care Leavers,
Teggart (in press) notes that research in general on the
needs of this group has only developed over the last two
decades. Richardson & Lelliott (2003) state that there has
been little research about this group of vulnerable young
people and attribute this to a number of factors. There are
difficulties in reaching this hard-to-research group due to
numerous placements, the conflicting use of terminology
between sectors, poor systems of data collection and the
complexity of problems experienced by Looked After
Children thus making evaluations of mental health
difficult. Therefore, there is still a strong need for research
into this vulnerable group.
Kilkelly et al. (2004) note that recent research shows
encouraging findings that higher levels of staff qualifications
and morale in residential care staff have been found in
Northern Ireland compared to England. The DHSSPS (2003a)
also recognised that the ‘Hughes 6 recommendation’ to
improve the status of residential work specifically in relation
to the calibre of workers was adhered to particularly well in
Northern Ireland. It recognises that there have been
advancements in education and training:
“Since the 1990s there has been a recognition of the
need for investment in training for the whole social care
workforce with a particular emphasis on residential child
care staff and foster carers” (p. 185, DHSSPS, 2003a).
Current educational provision for social work in Northern
Ireland does involve some input regarding mental health
and Looked After Children. Regarding training on the
mental health needs of Looked After Children, McAuley
& Young (2006) state that:
The need for longitudinal studies to inform policy and
practice has been suggested (e.g. Koprowska & Stein,
2000; Teggart, in press) although some work has been
done in this area in Northern Ireland (e.g. Monteith &
Cousins, 2003; McAuley, 2004). However, there is still a
need to know how many Looked After Children are
referred to CAMHS, go on to enter AMH Services or
suffer major mental health disorders later in life
(Koprowska & Stein, 2000) at a regional level. Future
service planning will also need to consider Richardson’s
(2002) suggestions to account for differences in gender,
minority ethnic groups and different faith groups. The
latter would seem to be potentially more relevant to
Northern Ireland.
“Given that many newly qualified social workers are
working with looked after children, there would also be
a strong argument for its inclusion in qualifying social
work training. Identifications of need is a crucial
starting point for accessing services for these children”
(pp. 99-100, McAuley & Young, 2006).
This message is clearly stated in a recent study by Wilson
et al. (2005) on Approved Social Work training in
Northern Ireland which highlighted a need for improved
training. They found that 43% of Approved Social
Workers were dissatisfied or very dissatisfied with the
training they received regarding the mental health needs
of children. The Approved Social Workers outlined
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Another area already gaining momentum, where there is
need for further research is in ways to promote resilience
and coping skills among Looked After Children/Care
Leavers (Gilligan, 2000; Richardson 2002; Richardson &
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project will serve as a first step to inform this assessment.
However, further research is needed to detail the prevalence
of the needs in this group. The Meltzer et al. (2003; 2004a;
2004b) studies have helped establish an information base
on the type and prevalence of mental health problems of
Looked After Children in England, Scotland and Wales
respectively, but this has yet to be done in Northern Ireland.
However, Teggart (in press) points out that many studies
have focused on the presence of symptomatology and
diagnosable disorder rather embracing a wider definition
of mental health (the NHS HAS (1995) definition as
outlined earlier in the overview of mental health) so we
should bear this in mind when commissioning needs
assessments. The RMHLDNI also calls for a systematic and
comprehensive assessment of mental health needs in the
general population, both in its Strategic Framework for
Adult Mental Health Services (RMHLDNI, 2005b) and in
its CAMHS consultation report (RMHLDNI, 2005a) to aid
the planning of services.
Lelliott, 2003). This would foster a new understanding to
inform new and creative interventions or the more
appropriate application of conventional ones. There has
been relatively little research on high achievers (Martin &
Jackson, 2002) despite the potential to transfer the
understanding of why some children experience good
outcomes in the face of adversity to help wider numbers of
children (Gilligan, 2000). Importantly, Gilligan notes that it
is that part of resilience which is due to social experience
and how it is processed that is susceptible to influence
(Gilligan, 2000). He highlights the potential of enhancing
school experience and spare time activities in particular
because they can be neglected and may further be more
susceptible to professional influence than home life
(Gilligan, 2000).
A greater focus on assessment and evaluation by users
and carers is also critical to ensure effective provision:
“The SNAP survey found that few of the NHS specialist
mental health services were involved in any service
research. It was also reported that few were involving
young people or parents in formal evaluation of their
experience of these services. These are matters for
early attention” (p. 24, PHIS, 2003b).
In Northern Ireland, there is a need for more CAMHS
specific research (SLT, 2006). Recent small-scale studies
have indicated that satisfaction with CAMH services
when accessed is reasonably positive (RMHLDNI, 2005a;
SLT, 2006). However, more research is needed in this area,
particularly since 90% of the comments in the RMHLDNI
expressed a negative view or experience of some aspect
of CAMHS. Common criticisms centred on waiting times
and absence of specialist services (RMHLDNI, 2005a). The
review also called for more consultation with carer
groups. Such work has been initiated with VOYPIC’s
Caspar project and AMH MensSana (AMH, 2005).
There appears also to be a need for more research on the
value and outcomes of different treatments and
therapeutic approaches (Richardson, 2002).
Northern Ireland
Many of the above areas for further research are equally
applicable to Northern Ireland although there are also a
number of specific areas requiring more research and
evaluation. Two recommendations by McAuley et al. (2006)
are relevant here: the need for substantial investment in
research into effectiveness of social care interventions;
and the need to build stronger links between research,
policy and practice. This is summed up well in their
concluding remarks:
Echoing Richardson’s (2002) call for more research on
therapeutic skills, there is a need in Northern Ireland for
such information. We have not in this review looked at the
range of therapeutic services available in Northern Ireland,
although McAuley (2004) did highlight a serious concern
regarding the lack of available appropriate therapeutic
services for the more troubled Looked After Children in
her study who had been subjected to extreme forms of
abuse and neglect prior to coming into care.
“Clearly, evidence-based policy and practice needs to be
underpinned by a body of knowledge generated from
rigorous research. To obtain this, substantial investment
in programmes of research into effectiveness is required.
Building stronger links between research, policy and
practice should also ensure that the evidence base leads
to the commissioning of services for children and families
which really do make a difference to enhancing the wellbeing of vulnerable children and young people and
improving their outcomes” (p. 331, McAuley et al., 2006).
There is a need for more studies of Care Leavers in Northern
Ireland, which should be helped by the establishment of
the Research and Information Group (R&I Group) in
November 2005 relating specifically to leaving care, (R&I
Group, 2006). The group will ensure that the needs of
Care Leavers will be in the forefront in the future and the
twin goals of the R&I group are:
“To ensure that the necessary range of different types
and levels of research and information are identified
and shared to promote and monitor best practice and
good outcomes during the 3 year implementation
period [of the New Children (Leaving Care) NI Act
First and foremost, there is a need for a comprehensive
regional assessment of the mental health needs of
Looked After Children and Care Leavers. VOYPIC’s Caspar
71
VOICE OF YOUNG PEOPLE IN CARE
Developing Services
“To promote recognition of the importance of research
and information to all those involved in
implementation, across sectors and levels i.e., individual
young people, frontline staff, operational management,
Trust level equivalent management, Board level
equivalent management, Departmental level policy
makers and planners” (R&I Group, 2006).
interventions, a lack of systematic evaluations of
interventions in a rigorous way: thereby pointing to an
inconclusive evidence base and although a number of studies
involved user views, these same studies lacked objective or
standardised outcome measures. Among other observations
were a lack of longitudinal evaluations and, at times, a lack of
theoretical basis.
The present review has shown that research needs to
incorporate the perspective of young people, echoing earlier
concerns (Stanley, 2002; Berridge, 2005), although we have
found that this perspective is not often sought. A great deal
of understanding is still needed regarding how young people
view their lives and what they think services need to provide.
The Caspar project seeks to bridge a number of gaps
highlighted in this review to gain an understanding of young
people’s needs as they see them. It will also examine their
coping mechanisms and gain an idea of how services can be
improved through areas such as training and support.
Finally, and importantly, research needs to be grounded
in a sense of realism, summed up well in the following
quote by O’Rawe (2003):
“Researchers and policy makers have traditionally been
quite good at telling professionals throughout the health,
social services and education fields explicitly and implicitly
what needs to be done with, and on behalf of the young
person with mental health needs, and to a lesser extent
why, but it is not so clear that they received so much
guidance in terms of how to do that is expected of
them…The question of how arises both in the context of
techniques required to deliver on certain expectations or
guidance, secondly the cumulative time demands of doing
all that needs to be done and in addition is the need for
realism in the face of bright ideas for already overburdened
practitioners to implement” (pp. 18-19, O’Rawe, 2003).
Research is important, but the sharing of research is equally
important. Research that is user-orientated both in its
planning and implementation has received interest (NISSC,
2002). The Northern Ireland Social Care Council (NISSC)
differentiates between social work and other clinical
disciplines in that it does not have a tradition of practitionerbased research. They acknowledge that the more
academically prestigious a journal is, the less likely
practitioners will be to read it. The solution, they propose, is
to make findings more accessible, and secondly practitioners
need to read and be exposed to more research (NISCC, 2002).
11.2.5 Adequate Funding
Despite the UK benefitting from much more substantial
funding than Northern Ireland such as a modernisation fund
grant of £85m awarded in 1999 for three years (Richardson,
2002), some suggest additional resources would have been
beneficial. Michael Leadbetter, president of the Association
of Directors of Social Services (ADSS) stated that:
One very important development in the dissemination of
research relating to children and young people has been
the establishment of the Child Care Research Forum (CCRF)
set up by the QUB Institute of Child Care Research in
Belfast. The forum acts as a vehicle for the sharing of
information on research relating to child care policy,
practice and research and is supported by the R&D Office.
The forum formally launched the Online Research Bank
(ORB) Children’s database in December 2005 through
ARK (the Northern Ireland Social and Political Archive)
(www.ark.ac.uk/orb/child). The database is sponsored by
the Children and Young People’s Unit in the Office of the
First Minister and Deputy First Minister. This is an important
instrument to use regarding research in Northern Ireland. A
similar UK-wide Youth Research Forum was officially
launched on 1st February 2006. Another mental health
research Network for the UK is also now in place for largescale studies (www.mhrn.info). Initiatives like these
encourage wider dissemination of research findings.
“Many believe that, had the 1989 Children Act been
implemented with additional resources, future
generations of children may have been kept out of
the care system” (foreword, ADSS, 2002).
This does not inspire hope in Northern Ireland where
specialist mental health services, particularly CAMHS, are
seriously under-funded. O’Rawe (2003) states that the
present practice of short-term, project-oriented funding
undermines the development of capacity and limits the
ability to strengthen pilot projects. She sees a need for
longer-term funding in order to maintain all the qualified
staff it needs to undertake this work (O’Rawe, 2003). A good
example of under-funding is evident in SLT (2006) whereby
despite the fact that SLT spends more per head of population
on mental health than any other Trust in Northern Ireland,
only 3.7% of the total mental health budget in 2004/2005
was allocated to specialist CAMHS. This is even lower than
earlier reported figures in England and Wales of 5% (Audit
Commission, 1999 cited in SLT, 2006).
McAuley et al. (2006) outline a number of lessons which
can be learned from evidence they compiled between the
UK and USA. In the UK, in particular, the authors note a
lack of research on the effectiveness of core child11: DEVELOPING SERVICES
72
Developing Services
Developing Services
safeguard that empowers these young people to make
their own decisions, develop their own strategies, define
their own agenda and speak for themselves”
(p.8, Hain, 2006).
In general, mental health services do not benefit from
comparable levels of funding as the rest of the UK, the need
for which was outlined by NIAMH (2003). This seems
particularly urgent given the aforementioned higher levels
of estimated need in Northern Ireland, the economic and
social costs of mental illness and the evidence of need for
Looked After Children/Care Leavers. This situation reflects
the lack of expenditure on childcare services in general
which is just half of the English figure per head of the
under 18 population (NHSSC, 2003). Services for Care
Leavers are similarly under-funded and the new Leaving
Care Legislation is being implemented amidst a lack of
monetary backing. This is particularly worrying as outlined
in the following quote by Broad (2005):
VOYPIC welcomes Mr. Hain’s focus on advocacy and
mentoring as the only independent advocacy service solely
for care experienced children and young people in Northern
Ireland at present. As such, VOYPIC has been campaigning for
the provision of mainstream advocacy services for the last four
years in line with the principle of parity underlying policy and
practice between the UK and Northern Ireland. This has been
based on the Government’s Quality Protects programme and
13
recommendations following the Waterhouse Inquiry .
One further element of this funding package which is
relevant is that it will strengthen CAMHS provision through
providing £0.5m in 2006/7 and £1.0m in 2007/8 for the
establishment of 2-3 Child and Adolescent Crisis Response
Teams in Northern Ireland, and aims to address the issue of
inappropriate placements in adult mental health wards
through 1.6m (of which £1.2m is recurrent) to the provision
of adolescent inpatient facilities (Hain, 2006).
”Based on the evidence available to date, this author
has serious reservations about the extent to which the
health and well being needs are placed sufficiently high
enough on wider social inclusion funding agendas
compared with the social inclusion rhetorical agendas
to make the differences required within the timescale
demanded” (p. 135, Broad, 2005).
Urgent investment is needed in both CAMH and AMH
services for Looked After Children/Care Leavers.
11.2.6 A Legislative, Policy and
Practice Commitment
Recently Peter Hain (Secretary of State) announced a new
Children and Young People funding package (as part of the
2006-8 Priorities and Budget process) which, he believes,
demonstrates a clear commitment by the government to
address the most pressing needs of children and young
people (Hain, 2006). The package, in total, will target more
than £61 million over the next two years, an element of
which will be directly used to provide better services for
Looked After Children (Hain, 2006). He states that
underpinning this package is greater co-operation between
Departments and their agencies. Through the funding,
additional educational support will be provided, Care
Leavers who are not ready for independence will be able
to remain with their former foster carers and an
independent advocacy and peer mentoring service for
Looked After Children/Care Leavers aged up to 25 years
will be set up (Hain, 2006). In summary:
A number of developments are currently taking place or
due to take place in the near future which should
enhance the commitment to improving the mental health
of Looked After Children and Care Leavers across
legislative, policy and practice boundaries. Crucially, the
Review of Mental Health and Learning Disability (NI) will
shape future services. The Review is currently taking place
(sometimes referred to as the Bamford Review), with the
strategic framework for AMH Services already being
published in June 2005 and the CAMHS report released
for consultation in December 2005. The review’s draft
CAMHS vision is informed by a number of principles.
These include that:
• Children should have access to a comprehensive
array of services;
• These should be individualised (taking in a holistic
view of the context of their lives and be develop
mentally appropriate);
• Operate within the least restrictive and most
normative environment clinically possible;
• Be family focused encouraging the family/
surrogate family to participate as a full partner in
relation to services;
• Be organised by case management or similar mechanisms;
• Support early identification and intervention
“This package of measures will improve the stability
and continuity of care for the young people, empower
carers to engage competently with the education
system, reduce the social exclusion of looked-after
children, improve educational outcomes and levels of
school attendance and contribute to better long term
outcomes in terms of employment, health and
wellbeing. Importantly there will be an independent
13 The New Labour Government initiated a ‘Quality Protects Programme’ in an attempt to improve and monitor service delivery from Government
agencies. See also TSO (2000) Learning the Lessons, The Government’s Response to Lost in Care: The Report of the Tribunal of Inquiry into the
Abuse of Children in Care in the Former County Council Areas of Gwynedd and Clwyd Since 1974, Cm 4776, June 2000 and Child & Community
Care Directorate and Social Services Inspectorate (2001), The Waterhouse Inquiry Recommendations: A Northern Ireland Response, April 2001.
73
VOICE OF YOUNG PEOPLE IN CARE
Developing Services
•
•
•
for mental health needs;
Guarantee a smooth transition into the adult
system when they reach the age for adult services;
Have the skills to recognise and respect the values,
beliefs, customs and language of the diverse
population of Northern Ireland;
Be an inclusive service irrespective of physical,
mental or developmental ability
(Source: pp. 11-12, RMHLDNI, 2005a).
but consideration needs to be given to how standards and
packages are to be implemented at a local level within the
worker’s perceptions of what is important for their practice
(Watson, 2003). He recognises from his study that:
“[Staff] may not have the power to create, but they
undoubtedly have the power to resist change that does
not fit into their experience of what would constitute a
quality service” (p. 76, Watson, 2003).
Another influential development should be the Children and
Young People’s Unit of the OFMDFM 2006 Strategy for
Children and Young People in Northern Ireland, soon to be
released. The Draft Strategy was put forward for consultation
from November 2004 to February 2005 and the final strategy
is due out in 2006. It is hoped that the strategy will put the
rights of children and young people at the heart of policy
development. It will set out a common vision with specific
targets and outcomes over a ten-year period and will act as
Northern Ireland’s implementation plan for the UNCRC.
NICCY will have a key role in the independent monitoring of the
strategy. The Strategy will pay particular attention to young
people who are vulnerable to social exclusion (OFMDFM, 2003).
A Mental Health Strategy for Looked After
Children/Care Leavers
The need for a strategy to meet the mental health needs
of Looked After Children and Care Leavers has been
recommended before this review, (Clinical Psychology
Speciality Advisory Committee, 2002; RMHLDNI, 2005a).
We hope, however, that this review and the future strategic
recommendations from the next stage of the Caspar Project
will bring this need to the fore. Such a strategy would assist
in the development of tailored, equitable services for this
population (Teggart & Menary, 2005) something which has
been clearly demonstrated in this review.
The DHSSPS is also developing a Strategic Framework for
Children, Young People and Families. The Strategic
Framework Steering Group held its first meeting in May
2005 and agreed, among other things, that it would be
aligned to the overarching OFMDFM strategy for Children
and Young People. The strategy aims to set aspirational,
achievable and realistic targets and actions for the next 10
years for children’s services and will also consider services
to Looked After Children and CAMHS generally.
KEY POINTS FOR CONSIDERATION
Other relevant strategic developments include the new
DHSSPS Suicide Prevention Strategy just released for
consultation (DHSSPS, 2006b), the forthcoming Fostering
Strategy by the four Health and Social Services Boards and the
Fostering Network in Northern Ireland and the Special
Educational Needs and Disability (Northern Ireland) Order 2005.
Amidst any legislative and policy development, it is the
responsibility of managers to ensure that staff are kept
up to date with, and trained in, national and local
policies (Richardson, 2002) and some have noted the
difference between policy and implementation (Watson,
2003; Vostanis, 2005). Vostanis (2005) states that people
can freeze when dealing with mental health and forget
that life development can be simple. He proposes that
smaller things can make people stronger in a process
whereby mental health is not at the top of the pyramid
but throughout the whole process. Watson (2003) notes
how quality of care standards should not be too abstract
to avoid the danger that they will not be operationalised
into the day-by-day practices of the workforce. He
believes it is not simply a case of keeping staff up to date
11: DEVELOPING SERVICES
74
•
A key learning point in Northern Ireland is not so
much to create new initiatives but to connect
together those already underway and build upon them.
•
Is there anything specific to Northern Ireland that
might make us different? Given our small geographical
area, are there ways in which we can pool resources
more easily?
•
To implement these services in the future,
consideration needs to be given to the structure of
CAMHS, workforce issues, information and training
as well as research and evaluation.
•
A funding and strategic commitment would assist
with this progress.
12
Conclusions
Implications of the Review
75
VOICE OF YOUNG PEOPLE IN CARE
Conclusions - Implications of the Review
The research evidence points to the fact that Looked
After Children and Care Leavers are likely to be more
vulnerable to having mental health problems but in
Northern Ireland, there is currently a knowledge gap in
this area at a regional level. McAuley & Young recently
note that despite governmental recognition that the
mental health of children and young people is our shared
responsibly, “much needs to be done to turn this rhetoric
into a reality” (p. 97, McAuley & Young, 2006). This
Literature Review has raised a number of extremely
significant and important questions which need to be
considered by all those who are involved in the care of
young people who are looked after and those who have
left the care system:
•
•
•
interpreting and responding to the emotional wellbeing/mental health needs of Looked After
Children/Care Leavers?
The most important and basic question that needs
to be asked is what concepts of emotional wellbeing and mental health, as these relate to
young people generally and young people who are
care experienced specifically, are widely used
and accepted?
How are these concepts agreed and understood by
professionals, foster carers, parents and care
experienced young people?
How are services and supports developed to take
account of the points above, particularly of the
vulnerable points in the lives of Looked After
Children/Care Leavers?
•
How central are Looked After Children/Care Leavers
to the development of supports and services?
•
Is there a clear route whereby their views are
sought, given value and incorporated into
planning and service development?
•
How are assessments designed and implemented in
relation to the emotional well-being/mental health
of Looked After Children/Care Leavers?
•
On what concepts are these based, is it purely
diagnostic, needs-based, strengths-based, is it
holistic taking into account all aspects of the
Looked After Child/Care Leavers’ life and,
most importantly, is the young person central
to the process?
•
How well supported are professionals, foster carers
and parents in relation to understanding,
12: CONCLUSIONS
What training is necessary to enable these groups
to understand, interpret and respond to emotional
well-being/mental health?
•
How clear, accessible and useful are current
services to Looked After Children/Care Leavers,
professionals and foster carers?
•
How can we develop clear links between services
for young people and services for adults and a
shared understanding of context/need?
•
How best can services be structured, coordinated
and integrated on a regional level?
•
Is the emotional well-being/mental health of
Looked After Children/Care Leavers a responsibility
that is adequately recognised and shared across
relevant government departments?
A vision for the future would be to do what the
Residential Care Health Project (RCHP) has achieved in
residential care for all types of care:
How is the context of the lives of Looked After
Children/Care Leavers understood and taken into
account in relation to the discussion of issues
relevant to emotional well-being and mental health?
•
•
“We have seen changes - slowly at first, then gathering
momentum. A system in which residential care workers
were left unsupported to find their way through the
health care system with little knowledge where to turn
to for help has been supported to flourish and grow. We
have seen children with previously unrecognised or
neglected health problems seek help for them. The
children and carers together are looking at health in a
more holistic way in terms of lifestyle and wellbeing.
Managers in the various agencies are looking at future
developments to help these young people and to
support their carers. The forgotten children have been
found, and we owe it to them to work with colleagues
in the many other agencies to help them towards the
prospect of a better future both for themselves and for
the generations to come” (p. vii, RCHP, 2004).
76
13
References
77
VOICE OF YOUNG PEOPLE IN CARE
References
Action Mental Health (AMH) (2005) Young People’s Mental Health: The needs of parent/guardians and professionals within
the Southern Health and Social Services Board and Southern Education and Library Board areas. N. Ireland: AMH Menssana.
Aggleton, P., Hurry J. & Warwick, I. (eds) (2000) Young People and Mental Health. Chichester: Wiley.
Alderson, P. & Morrow, V. (2004) Ethics, social research and consulting with children and young people. London: Barnardo’s.
Altshuler, S. & Poertner, J. (2002) The Child Health and Illness Profile – Adolescent Edition: Assessing Well-Being in Group
Homes or Institutions. Child Welfare, 81(3), pp. 495-513.
Armstrong, C., Hill, M., & Secker, J. (2000) Young People’s Perceptions of Mental Health. Children and Society, 14, pp. 60-72.
England: John Wiley & Sons.
Association of Directors of Social Services (ADSS) (2002) Tomorrow’s Children: A Discussion Paper on UK Child Care Services
in the Coming Decade. ADSS.
Audit Commission (1999) Children in Mind: Child and Adolescent Mental Health Services. London: Audit Commission.
Bebbington, A., & Miles, J. (1989) The Background of Children who enter Local Authority Care. British Journal of Social
Work, 19, pp. 349-368. England: Oxford University Press.
Berridge, D. (2005) ‘Resilience and the Education of Looked-After Children’. Promoting Resilience in Young People Looked
after and Accommodated by Local Authorities. Association for Professionals in Services for Adolescents (APSA) Annual
Conference 2005. Andover: UK. (3-4 October 2005).
Biehal, N., Clayden, J., Stein, M. & Wade, J. (1995) Moving On: Young people and leaving care schemes. London: The
Stationery Office.
Blower, A., Addo, A., Hodgson, J., Lamington, L. & Towlson, K. (2004) Mental Health of ‘Looked After’ Children: A Needs
Assessment. Clinical Child Psychology and Psychiatry, 9(1), pp. 117-129. London: SAGE Publications.
Bonnett, C. & Welbury, J. (2004) Meeting the mental health needs of looked after children: an example of routine psychological assessment. Adoption & Fostering, 28(3), pp. 81-82.
Broad, B. (2005) Improving the health and wellbeing of young people leaving care. Dorset: Russell House.
Buchanan, A. (1999) Are care leavers significantly dissatisfied and depressed in adult life? Adoption & Fostering, 23(4), pp. 35-40.
Bundle, A. (2002) Health information and teenagers in residential care: A qualitative study to identify young people’s views.
Adoption & Fostering, 26(4), pp. 19-25.
Bunting, L. (2004) Assessment of Children in Need in Northern Ireland. Belfast: NSPCC (Northern Ireland Policy and
Research Unit).
Butler, I., & Payne, H. (1997) The health of children looked after by the local authority. Adoption and Fostering, 21(2), pp. 28-35.
Butler, J. & Vostanis, P. (1998) Characteristics of referrals to a mental health service for young people in care. Psychiatric
Bulletin, 22, pp. 85-87.
Callaghan J., Young B., Richards M. & Vostanis P. (2003) Developing new mental health services for looked after children: A
focus group study. Adoption & Fostering Journal, 27(4), pp. 51-63.
Callaghan, J., Young, B., Pace, F. & Vostanis, P. (2004) Evaluation of a New Mental Health Service for Looked After Children.
Clinical Child Psychology and Psychiatry, 9(1), pp. 130-148.
Campbell, J. & McCrystal, P. (2005) Mental Health Social Work and the Troubles in Northern Ireland: A Study of Practitioner
Experiences. Journal of Social Work, 5(2), pp. 173-190.
Chambers, H. (2004) Creative arts and play for the well-being of looked after children. Highlight, 212. London: National
Children’s Bureau (NCB).
Clayden, J. & Stein, M. (2005) Mentoring for young people leaving care: Someone for me. Findings. Informing Chance,
November 2005. York: Joseph Rowntree Foundation.
13: REFERENCES
78
Clinical Psychology Speciality Advisory Committee (SAC) (2002) Services to meet the Psychological and Mental Health
Needs of Looked After Children in Northern Ireland. A consultation document to the DHSSPS. Belfast: Clinical Psychology
Specialty Advisory Committee.
Coleman, J. (2005) ‘Conclusions about Resilience’. Promoting Resilience in Young People Looked after and Accommodated by
Local Authorities. Association for Professionals in Services for Adolescents (APSA) Annual Conference 2005. Andover: UK. (34 October 2005).
Communities that Care (1999) A Guide to Promising Approaches. London: Communities that Care.
Connolly, P, (2003) Ethical Principles for Researching Vulnerable Groups. University of Ulster, OFMDFM.
Daniel, B. (2005) ‘Promoting Resilience in Children: A Positive Approach to Child Care and Protection’. Faculty of Children
and Young People. British Psychological Society (BPS) Conference: Edinburgh. (15-16 September 2005).
Daniel, B., Wassell, S. & Gilligan, R. (1999) It’s just common sense isn’t it? Exploring ways of putting the theory of resilience
into action. Adoption & Fostering, 23(3), pp. 6-15.
Davies, D. (2000) Young People and Drugs. In: P. Aggleton et al. (eds) Young People and mental health. Chichester: Wiley, pp.29-46.
Delfabbro, P., Barber, J. & Cooper, L. (2002) Children entering Out-of-home Care in South Australia: Baseline Analyses for a
3-year Longitudinal Study. Children and Youth Services Review, 24(12), pp. 917-932.
Department for Education and Employment & Department of Health (DfEE & DH) (2000). Guidance on the Education of
Children and Young People in Public Care. London: DfEE.
Department of Health & Department for Education and Skills (DH & DfES) (2004). National Service Framework for children,
Young People and Maternity Services: The Mental Health and Psychological Well-being of Children and Young People.
London: DH.
References
References
Department for Education and Skills (DfES) (2005) Statistics of Education: Children looked after by Local Authorities Year
Ending 31 March 2004. Volume 1: Commentary and National Tables. London: Office of National Statistics.
Department of Health (DH) (2000) Framework for the Assessment of Children in Need & their Families. Norwich: Stationery Office.
Department of Health (DH) (2002) Promoting the Health of Looked After Children. London: Department of Health.
Department of Health, Social Services and Public Safety (DHSSPS) (2002) Investing for Health. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2003a) A Better Future: 50 Years of Child Care in
Northern Ireland 1950-2000. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2003b) Promoting Mental Health. Strategy and Action
Plan 2003-2008. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2004a) Equality and Inequalities in Health and Social
Care in Northern Ireland: A Statistical Overview. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2004b) A Healthier Future: A Twenty-Year Vision for
Health and Wellbeing in Northern Ireland 2005-2025. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2004c) A Five Year Physical Activity Strategy and Action
Plan: Consultative Document. Investing for Health. DHSSPS: Belfast.
Department of Health, Social Services and Public Safety (DHSSPS) (2004d) Inspection of Social Work in Mental Health
Services. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2005a) Children Order Statistical Bulletin 2005.
Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2005b) Leaving and After Care: Guidance and
Regulations, 8, May 2005. Norwich, TSO.
Department of Health, Social Services and Public Safety (DHSSPS) (2005c). Progress Report - Preventing Suicide Action
Points, June 2005 Promoting Mental Health: Strategy and Action Plan 2003-2008. . Belfast: DHSSPS.
79
VOICE OF YOUNG PEOPLE IN CARE
References
Department of Health, Social Services and Public Safety (DHSSPS) (2006a) Tried, Tested, Shared: Summaries from the 2nd Wave of
Service Improvement Projects 2004-2005. Belfast: DHSSPS.
Department of Health, Social Services and Public Safety (DHSSPS) (2006b) Protect Life: A Shared Vision. The Northern Ireland
Suicide Prevention Strategy and Action Plan 2006-2011. A Consultation Document. Belfast: DHSSPS.
Dimigen, G., Del Priore, C., Butler, S., Evans, S., Ferguson, L. & Swan, M. (1999) Psychiatric disorder among children at time of
entering local authority care: questionnaire survey. British Medical Journal, 319, p. 675.
Dumaret, A., Coppel-Batsch, M. & Couraud, S. (1997) Adult outcome of children reared for long-term periods in foster families. Child
Abuse and Neglect, 21(10), pp. 911-927.
Eastern Health and Social Services Board (EHSSB) (2004a) Health and Well-being Investment Plan 2004/5 Commissioning Services
(C15). Belfast: EHSSB.
Eastern Health and Social Services Board (EHSSB) (2004b) A Strategy for Adult Mental Health Services in the Eastern Health and
Social Services Board. Belfast: EHSSB.
Eastern Health and Social Services Board (EHSSB) (2005) Health and Well-being Investment Plan 2005/08 Commissioning Services.
(C15) EHSSB.
Fleming, P., Bamford, D. & McCaughley, N. (2005) An exploration of the health and social wellbeing needs of looked after young
people—a multi-method approach. Journal of Interprofessional Care, 19(1), January 2005, pp. 35-49 (15).
Fleming, R.W.K. (2003) Searching, Finding and Struggling: Psychotherapy for an Adolescent in Substitute Care. Clinical Child
Psychology and Psychiatry, 8(1), pp. 17-25.
Fletcher-Campbell, F., Archer, T. & Tomlinson, K. (2003) The Role of the School in Supporting the Education of Children in Public
Care. Research Brief, RR498. London: Department for Education and Skills.
Fletcher-Campbell. (1997) The Education of Children Who are Looked After. Slough: National Foundation for Educational Research.
Ford, T., Hamilton, H., Goodman, R. & Meltzer, H. (2005) Service Contacts Among the Children participating in the British Child and
Adolescent Mental Health Surveys. Child and Adolescent Mental Health, 10(1), pp. 2–9.
Foster Care Associates (FCA) (2006). Placement Stability Study March 2006. FCA. Unpublished.
Fostering Network (2006) Families - N. Ireland needs 350 foster carers. Press Release. CINI www.ci-ni.org [Accessed on 8th May 2006].
Frankish, S. & McCrossen, V. (2005) ‘CAMHs Made Easy Workshop’. Building and Sustaining Your Service. VOYPIC Leaving Care
Conference for Practitioners: Belfast. (11th May, 2005). Belfast.
Gilligan, R. (1999) Enhancing the resilience of children and young people in public care by mentoring their talents and interests.
Child & Family Social Work, 4(3), pp. 187-196.
Gilligan, R. (2000) Adversity, Resilience and Young People: The Protective Value of Positive School and Spare Time Experiences.
Children and Society, 14(1), pp. 37-47.
Gilligan, R. (2001) Promoting Resilience: A resource guide on working with children in the care system. London: British Agencies for
Adoption and Fostering (BAAF).
Gilligan, R. (2005a) Resilience and Residential Care for Children and Young People. In: D. Crimmens, & I. Milligan (Eds) Facing
Forward: Residential child care in the 21st century. Lyme Regis: Russell House Publishing, pp. 105-113.
Gilligan, R. (2005b) ‘Promoting Resilience’. Promoting Resilience in Young People Looked after and Accommodated by Local Authorities.
Association for Professionals in Services for Adolescents (APSA) Annual Conference 2005. Andover: UK. (3-4 October 2005).
Gilliland, D., Gallagher, P., & Growcott, J. (2005) Developments in Child and Adolescent Mental Health Services. Child Care in
Practice, 11(1), pp. 51-61.
Golding, K. (2004) Providing Specialist Psychological Support to Foster Carers: A Consultation Model. Child and Adolescent Mental
Health, 9(2), pp. 71-76.
Green, R. (2001) Taking the Initiative: promoting young people’s involvement in public decision making in Northern Ireland. Belfast:
Youth Council Northern Ireland.
13: REFERENCES
80
Hain, P. (2006) Budget 2006-8 Children and Young People Funding Package. 7th March, 2006.
Harker, R., Dobel-Ober, D., Akhurst, S., Berridge, D. & Sinclair, R. (2004) Who Takes Care of Education 18 months on? A follow-up
study of looked after children’s perceptions of support for educational progress. Child and Family Social Work, 9, pp. 273-284.
Harris, J. & Broad, B. (2005) In My Own Time: Achieving Positive Outcomes for Young People Leaving Care. De Montfort
University Children and Families Research Unit Monograph Series, (6).
Health Promotion Agency for Northern Ireland (HPANI) (1999) Mental Health Promotion, A database of Initiatives in
Northern Ireland. Belfast: HPANI.
Health Promotion Agency for Northern Ireland (HPANI) (2001a) Minds Matter. Exploring the mental wellbeing of young
people in Northern Ireland. Secondary analysis of the Health Behaviour of School Children survey (1997/98). Belfast: HPANI.
Health Promotion Agency for Northern Ireland (HPANI) (2001b) Design for Living. Research to support young people’s
mental health and well-being. Belfast: Design for Living Partnership (HPANI).
Heenan, D. (2004) Attitudes towards mental illness in the Western Health and Social Services Board Area. Derry: STEER.
Hill, C. & Thompson, M. (2003) Mental and Physical Health Co-morbidity in Looked After Children. Clinical Child Psychology
and Psychiatry, 8(3), pp. 315-321.
Hill, C. & Watkins, J. (2003) Statutory health assessments for looked after children: what do they achieve? Child: Care,
Health and Development, 29(1), pp. 3-13. England: Blackwell Publishing.
Hopkins, G. (2002) Beacon of hope. Community Care, 5-11 December, p. 40.
References
References
Horgan, G., & Sinclair, R. (1997) Planning for Children in Care in Northern Ireland. London: National Children’s Bureau.
Houston, A. (2005) ‘ChildLine Scotland: Children and Young People Living Away from Home’. Promoting Resilience in Young
People Looked after and Accommodated by Local Authorities. Association for Professionals in Services for Adolescents
(APSA) Annual Conference 2005. Andover: UK. (3-4 October 2005).
Houston, S., McGlade, A. & Fawcett, M. (2000) Group care in Northern Ireland: a survey of residents’ problems. Practice,
12(3), pp. 5-26.
Hudson, B., Furnivall, J., Paterson, S., Livingston, K. & Maclean, K. (2003) Learning With Care: Training Materials for carers, social
workers and teachers concerning the education of looked after children and young people. Glasgow: University of Strathclyde.
Information & Analysis Directorate (IAD) (2004) Health and social care: comparative data for Northern Ireland and other
countries. Belfast: DHSSPS.
James, C. (2002) Mission Possible 2: looking after mental health. Young Minds Magazine, 57, pp. 36-40.
Jeffs, G. (2005) Children’s mental health is everyone’s business. Presentation at the Developing a Framework for Children’s
Emotional Health and Wellbeing event 18-May-2005. London Health Commission.
Joughin, C., Jarrett, L. & McLean Steel, K. (1999) FOCUS on Who’s Who in Child and Adolescent Mental Health Services.
London: Royal College of Psychiatrists’ Research Unit.
Kelly, B., & Sinclair, R. (2005) Understanding and negotiating identity: Children from cross-community families in public care
in Northern Ireland. Child & Family Social Work, 10(4), pp. 331-342.
Kerfoot, M., Panayiotopoulos, C. & Harrington, R. (2004) Social services and CAMHS: A National Survey. Child and
Adolescent Mental Health, 9(4), pp. 162–167.
Kerfoot, M. (2005) Children ‘looked after’ by the state. In: R. Williams & M. Kerfoot (eds) Child and Adolescent Mental
Health Services: Strategy, Planning, delivery and evaluation. Oxford: University Press, pp. 333-338.
Kilkelly, U., Kilpatrick, R., Lundy, L., Moore, L., Scraton, P., Davey, C., Dwyer, C. & McAlister, S. (2004) Family Life and
Alternative Care. In: U. Kilkelly et al. Children’s Rights in Northern Ireland. Belfast: Northern Ireland Commissioner for
Children and Young People (NICCY), pp. 45-82.
Kilpatrick, R. (in press) Children in Alternative Care: Are their rights being met? In: D. Iwaniec (Ed.) The Child’s Journey
Through Care: Placement Stability, Care Planning and Achieving Permanency. London: Wiley.
81
VOICE OF YOUNG PEOPLE IN CARE
References
Koprowska, J. & Stein, M. (2000) The mental health of ‘looked after’ young people. In P. Aggleton et al. (eds) Young People
and Mental Health. London: John Wiley, pp.165-182.
Kurtz, Z. & James, C. (2003) What’s new: Learning from the CAMHS Innovation projects – summary. London: Department of Health.
Lindsey, C. (2005). Some Implications of the Children’s National Service Framework for Social Work Practice with regard to
child mental health. Journal of Social Work Practice, 19(3), pp. 225-234.
Madge, N. & Franklin, A. (2003) Change, challenge and school nursing. London: National Children’s Bureau.
Madge, N. & Willmott, N (2005). Looked After Children and their Mental Health Needs: A literature review. NCB (Unpublished).
Martin, D. (2004) Care workers need better training. Children Now, 9 June, pp. 12.
Martin, P., & Jackson, S. (2002) Educational success for children in public care: Advice from a group of high achievers. Child
& Family Social Work, 7(2), pp. 121-130.
McAuley, C. & Trew, K. (2000) Children’s Adjustment Over Time in Foster Care: Cross-Informant Agreement, Stability and
Placement Disruption. British Journal of Social Work, 30(1), pp. 91-107.
McAuley, C. (1996) Children in Long Term Foster Care: Emotional and Social Development. Avebury: Aldershot.
McAuley, C. (2000) Safeguarding Children: Placement Choice and Creating a Vision for Looked After Children in Northern
Ireland. Adoption and Fostering, 24(3), pp. 48-55.
McAuley, C. (2004) Pathways and Outcomes: A Ten-Year Follow Up Study of Children Who Have Experienced Care. Belfast: DHSSPS.
McAuley, C., Pecora, P. & Rose, W. (Eds) (2006) Enhancing the Well Being of Children and Families through Effective
Interventions: UK and USA Evidence for Practice. London/Philadelphia: Jessica Kingsley. ISBN 1 84310 116 5.
McAuley, C. & Young, C. (2006) The Mental Health of Looked After Children: Challenges for CAMHS Provision. Journal of
Social Work, 20(1), pp. 91-103.
McAuley, C. (in press) Outcomes of long term foster care: young people’s views. In: D. Iwaniec. (ed) The Child’s Journey
Through Care: Placement Stability, Care Planning and Achieving Permanency. London: John Wiley & Sons.
McAuley, C. & Bunting, L. (in press) The views, experiences and aspirations of care experienced Children and Young People.
Belfast: VOYPIC.
McCann, J.B., James, A., Wilson, S. & Dunn, G. (1996) Prevalence of psychiatric disorders in young people in the care system.
British Medical Journal, 313, pp. 1529-1530.
McCay, N. & Sinclair, R. (1999) Mixed needs: children from cross-community families in public care in Northern Ireland.
London: National Children’s Bureau.
McConnell, P., Bebbington, P., McClelland, R., Gillespie, K. & Houghton, S. (2002) Prevalence of psychiatric disorder and the
need for psychiatric care in Northern Ireland. Population study in the District of Derry. British Journal of Psychiatry, 181, pp.
214-219. England: Maney Publishing.
McCrystal, P. & Fleming, B. (1999) Developing Partnerships between the Voluntary and Statutory Sector for the Provision of
Services for Children in Need. Child Care in Practice, 5(1), pp. 66-75.
McLaughlin, R. (2002) Branded a Problem? A participative research project on the educational experiences of children and
young people in care. Belfast: Save the Children, First Key, VOYPIC.
McMaster, I. (2004). Young People in Regional Care Centres/Youth Justice. Belfast: DHSSPS.
McSherry, D., Iwaniec, D. & Larkin, E. (2004) Counting The Costs: The Children (NI) Order (1995), Social Work and the Courts.
Belfast: Institute of Child Care Research, Queen’s University Belfast (QUB).
McTernan, E. (2003) Maps and Charts in Planning Family Support: The Development of Children’s Services Planning in
Northern Ireland. Child care in Practice, 9(3), pp. 199-212(14).
Meltzer, H., Gatwood, R., Goodman, R. & Ford, T. (2000) The Mental health of children and adolescents in Great Britain.
London: Office for National Statistics.
13: REFERENCES
82
Meltzer, H., Corbin, T., Gatward, R., Goodman, R. & Ford, T. (2003) The mental health of young people looked after by local
authorities in England. London: Office for National Statistics.
Meltzer, H., Lader, D., Corbin, T., Goodman, R. & Ford, T. (2004a) The mental health of young people looked after by local
authorities in Scotland. London: TSO.
Meltzer, H., Lader, D., Corbin, T., Goodman, R. & Ford, T. (2004b) The mental health of young people looked after by local
authorities in Wales. London: Office for National Statistics.
Mendes, P. & Moslehuddin, B. (2004) Graduating from the child welfare system: a comparison of the UK and Australian
leaving care debates. International Journal of Social Welfare, (13), pp. 332-339.
Minnis, H., Pelosi, A., Knapp, M. & Dunn, J. (2001) Mental health and foster carer training. Archives of Disease in Childhood,
84, pp. 302-306.
Minty, B. (1999) Annotation Outcomes in Long-term Foster Family Care. Journal of Child Psychology and Psychiatry 40(7),
pp. 991-99. England: Blackwell Publishing.
Monteith, M. & Cousins, W. (2003) The Importance of Stability in the Lives of Looked After Children: A Study of Under Fives
in Northern Ireland. Child Care in Practice, 9(1), pp. 62-72.
Mooney, E., & Fitzpatrick, M. (2003) Determinants of Residential and Foster Care Placements Research Report. Belfast:
Social Services Inspectorate.
Mooney, E., McDowell, P. & Taggart, K. (2004) Northern Ireland Care Leavers (2002/03). (C3a) Belfast: DHSSPS, Social
Services Inspectorate.
References
References
Mount, J., Lister, A. & Bennun, I. (2004) Identifying the Mental Health Needs of Looked After Young People. Clinical Child
Psychology and Psychiatry, 9(3), pp. 363-382.
National Children’s Bureau (NCB) (2005) Children and Young People’s Views on Health and Health Services: A Review of the
Evidence. London: NCB.
National Health Service Health Advisory Service (NHS HAS) (1995) Child and adolescent mental health services: Together
We Stand: Thematic review on the commissioning, role and management of the Child and Adolescent Mental Health
Services. Volume 1&2.London: HMSO.
Nicholas, B., Roberts, S. & Wurr, C. (2003) Looked after Children in Residential Homes. Child and Adolescent Mental Health,
8(2), pp. 78-83.
Northern Ireland Association for Mental Health (NIAMH) (2003) Time for change: A submission to the Review of Mental
Health and Learning Disability NI. Belfast: NIAMH.
Northern Ireland Association for Mental Health (NIAMH) (2004) Counting the Cost: The Economic and Social Costs of
Mental Illness in Northern Ireland. Belfast: NIAMH and Sainsbury Centre for Mental Health.
Northern Ireland Commissioner for Children and Young People (NICCY) (2005) Submission to the United Nations Committee
on the Rights of the Child’s General Discussion on “Children Living Without Parental Care”. 16th September, 2005. NICCY.
Northern Ireland Commissioner for Children and Young People (NICCY) (2006) Review of Advocacy Arrangements for Children
and Young People with Mental Health Needs who are in Care or Custody. www.niccy.org [Accessed 25th May 2006].
Northern Ireland Health and Social Services Councils (NHSSC) (2003) Response to DHSSPS Consultation. ‘A Strategy for
Children in Need: Developing the Strategy’. Northern Ireland Health and Social Services Councils.
Northern Ireland Social Care Council (NISCC) (2002) Promoting Research and Evidence-based Practice: From Rhetoric to
Reality. Belfast: Northern Ireland Social Care Council.
Northern Ireland Statistics and Research Agency (NISRA) (2002) Northern Ireland Health and Social Wellbeing Survey 2001,
Mental Health and Wellbeing Bulletin, 2, February 2002. Belfast: NISRA.
O’Rawe, A. (2003) Children and Adolescent Mental Health Services in Northern Ireland 2003. Belfast: Children’s Law Centre.
Office of the First Minister and Deputy First Minister (OFMDFM) (2001) Protecting our Children’s Rights. A Consultation
Paper on A Commissioner for Children for Northern Ireland. Belfast: OFMDFM
83
VOICE OF YOUNG PEOPLE IN CARE
References
Office of the First Minister and Deputy First Minister (OFMDFM) (2003) The Next Step. Developing a strategy for children
and young people in Northern Ireland. Working paper on the Emerging Strategy. Belfast: Children and Young People’s Unit,
Office of the First Minister and Deputy First Minister.
O’Reilly, D. & Stevenson, M. (2003) Mental health in Northern Ireland: Have “the Troubles” made it worse? Journal of
Epidemiology & Community Health, 57(7), pp. 488-492.
Payne, H. & Butler, I. (2003) Quality Protects research briefing No. 9: Promoting the mental health of children in need.
Research in Practice available from http://www.rip.org.uk.
Pearce, J. (2000) Emotional Disorders in Young People. In: P. Aggleton et al. (eds) Young People and mental health.
Chichester: Wiley, pp. 47-72.
Pettitt, B. (2003) Effective joint working between child and adolescent mental health services (CAMHS) and schools.
Research Brief, 412. London: Department for Education and Skills.
Phillips, J. (1997) Meeting the psychiatric needs of children in foster care: Social workers’ views. Psychiatric Bulletin, 21, pp. 609-611.
Pinkerton, J., & McCrea, R. (1996) Meeting the Challenge? Young People Leaving the Care of Social Services and Training
Schools in Northern Ireland. Belfast: QUB.
Pinkerton, J., & Stein, M. (1995) Responding to the Needs of Young People Leaving State Care: Law, Practice and Policy in
England and Northern Ireland. Children and Youth Services Review, 17(5/6), pp. 697-709.
Polnay, L. & Ward, H. (2000) Promoting the health of looked after children. British Medical Journal, 320, pp. 661-662.
Prince, K. (2002) Improving the mental health of children in public care – service development by child and
adolescent
mental health services (CAMHS) in Lincolnshire. Children’s Residential Care Unit Newsletter, 17 (Autumn), pp. 10-11.
Public Health Institute of Scotland (PHIS) (2003a) Needs Assessment Report on Child and Adolescent Mental Health.
Consulting children, young people and parents. Glasgow: PHIS.
Public Health Institute of Scotland (PHIS) (2003b) Needs Assessment Report on Child and Adolescent Mental Health. Final
Report. Glasgow: PHIS.
Rea, D. (1999) Towards routine user assessment of mental health service quality performance. International Journal of
Health Care Quality Assurance, 12(4), pp. 169-176.
Research & Information Group (R&I Group) (2006) Children Leaving Care (NI) Act Implementation Newsletter, May 2006.
Belfast: R&I Group.
Residential Care Health Project (2004) Forgotten children: Addressing the Health Needs of Looked After Children and Young
People. Edinburgh: Astron.
Richardson, J. & Joughin, C. (2000) The Mental Health Needs of Looked After Children. London: Gaskell (Royal College of
Psychiatrists).
Richardson, J. (2002) The Mental Health of Looked After Children. Bright futures: Working with Vulnerable Young People.
London: Mental Health Foundation.
Richardson, J. & Lelliott, P. (2003) Mental health of looked after children. Advances in Psychiatric Treatment, 9, pp. 249-251.
Ritchie, C. (2005) Looked After Children: Time for Change? British Journal of Social Work, 35(5), pp. 761-767.
Royal College of Paediatrics and Child Health (RCPCH) (2003) Bridging the gaps: Healthcare for Adolescents. London: RCPCH.
Royal College of Psychiatrists Research Unit (2001) National In-patient Child and Adolescent Psychiatry Study. London:
Royal College of Psychiatrists.
Rutter, M. (1985) Resilience in the Face of Adversity: Protective Factors and Resistance to Psychiatric Disorder. British
Journal of Psychiatry, 147, pp. 598-611.
Rutter, M. (2000) Children in Substitute Care: Some Conceptual Considerations and Research Implications, Children and
Youth Services Review, 22(9/10), pp. 685-703.
13: REFERENCES
84
Santin, O. (2006) The development and assessment of decision making and critical thinking attitudes in care experienced
young people. Unpublished Thesis School of Psychology, Queen’s University Belfast in partnership with Voice of Young
People In Care.
Sheldon, J. (2004) “We need to talk”: a Study of Working Relationships Between Field Social Workers and Fostering Link
Social Workers in Northern Ireland. Childcare in Practice, 10(1), pp. 20-38.
Sinclair, I. (2005) Fostering Now: Messages from Research. London: Jessica Kingsley.
Social Exclusion Unit (2003) A better education for children in care. London: Social Exclusion Unit.
Social Services Inspectorate (DHSS) (1995a) Quality Living Standards for Services: Children Who Live Away From
Home. Belfast: Social Services Inspectorate, DHSS.
Social Services Inspectorate (DHSS) (1995b) Quality Living Standards for Services: Children living in a family
placement. Belfast: Social Services Inspectorate, DHSS.
Social Services Inspectorate (DHSS) (1997) Fostering in Northern Ireland. Children and their Carers. Belfast: Social
Services Inspectorate, DHSS.
Social Services Inspectorate (DHSS) (1998) Children Matter: A regional review of residential child care services in
Northern Ireland. Belfast: Social Services Inspectorate, DHSS.
Social Services Inspectorate (DHSS) (1999) Planning to Care: An Overview Report of Care Planning for Children
Subject to Statutory Intervention in Northern Ireland. Belfast: Social Services Inspectorate, DHSS.
Social Services Inspectorate & The Education and Training Inspectorate (SSI & ETI) (2002) Secure Care: An Inspection
of Secure Accommodation at Shamrock House and Linden House. Belfast: DHSSPS.
References
References
Southern Area Health Promotion Consortium (2001) The Emotional and Mental Health Needs of Young People in the
Southern Area. A Research Report. University of Ulster.
Sperrin and Lakeland Health and Social Services Trust (SLT) (2006) Health in Mind: Review of Mental Health Services.
Draft version. Unpublished.
Stanley, N. (2002) What young people want. Community Care, 15-21 August, pp. 36-37.
Stanley N., Riordan D. & Alaszewski H. (2005) The mental health of looked after children: matching response to need.
Health & Social Care in the Community, 13(3), pp. 239-248.
Stein, M. (1997) What works in leaving care? Ilford: Barnardo’s.
Stein, M., Pinkerton, J. & Kelleher, P. (2000) Young People Leaving Care in England, Northern Ireland and Ireland.
European Journal of Social Work, 3(3), pp. 235-246.
Street, C. (2004) Mental health services – what children and young people want. Highlight, 210. London: National
Children’s Bureau.
Talbot, R. (2002) Young minds: looking after the mental health of looked after children. A training resource pack for
professionals caring for and working with children and young people in public care. Young Minds. Pavilion.
Teggart, T. & Linden, M. (2005) Having a Say: An Investigation of service users’ and carers’ views of Child and
Adolescent Mental Health Services in Northern Ireland. Report for the Review of Mental Health and Learning
Disability Northern Ireland. Belfast: RMHLDNI.
Teggart, T. & Menary, J. (2005) An Investigation of the Mental Health Needs of Children Looked After by Craigavon
and Banbridge Health and Social Services Trust. Child Care in Practice, 11(1), pp. 39-49.
Teggart, T. (In press) The mental health needs of looked-after children. In: D. Iwaniec (Ed.) The Child’s Journey Through
Care:Placement Stability, Care Planning and Achieving Permanency. London: Wiley
The Children (Northern Ireland) Order 1995 (SI 1995/755) (NI 2).
The Health and Personal Social Services (Quality, Improvement and Regulation) Order (Northern Ireland) 2003.
85
VOICE OF YOUNG PEOPLE IN CARE
References
The Mental Health (Amendment) (Northern Ireland) Order 2004.
The Mental Health (Northern Ireland) Order 1986 (SI 1986/595) (NI 4).
The Mental Health Foundation (1999) Bright Futures: Promoting children and young people’s mental health. London:
Mental Health Foundation.
The Mental Health Foundation (2004) Lifetime Impacts. Childhood and Adolescent Mental Health: Understanding the lifetime impacts. London: The Mental Health Foundation.
The Review of Mental Health and Learning Disability (Northern Ireland) (RMHLDNI) (2005a) Vision of a Comprehensive Child
and Adolescent Mental Health Service. Consultation Document, November 2005. Belfast: DHSSPS.
The Review of Mental Health and Learning Disability (Northern Ireland) (RMHLDNI) (2005b) A Strategic Framework for Adult
Mental Health Services. Final Report, June 2005. Belfast: DHSSPS.
United Nations Convention on the Rights of the Child (UNCRC) (1989). Available from www.unicef.org [Accessed 10th May 2006].
Utting, W., Baines, C., Stuart, M. et al. (1997) People Like Us: The Report of the Review of the Safeguards for Children Living
Away From Home. London: The Stationery Office.
Valios, N. (2002) Needs to be looked after. Community Care, 15-21 August, pp. 34-35.
Van Beinum, M., Martin, A. & Bonnett, C. (2002) Catching Children as They Fall: Mental Health Promotion in Residential
Child Care in East Dunbartonshire. Scottish Journal of Residential Child Care, 1(Aug/Sept), pp. 14-22.
Voice of Young People in Care (VOYPIC) (2004) Annual Report: Dec 03 - Nov 04. Belfast: VOYPIC.
Voice of Young People in Care (VOYPIC) (2006) Leaving Care? Lost? Your Step by step guide to leaving care. Belfast: VOYPIC, DHSSPS.
Vostanis, P. (2005) ‘Mental Health Services for Looked-After Young People’. Promoting Resilience in Young People Looked
after and Accommodated by Local Authorities. Association for Professionals in Services for Adolescents (APSA) Annual
Conference 2005. Andover: UK. (3-4 October 2005).
Ward, H., Jones, H., Lynch, M. & Skuse, T. (2002) Issues concerning the health of looked after children. Adoption & Fostering,
26(4), pp. 8-11.
Watson, D. (2003) Defining quality care for looked after children: Frontline workers’ perspectives on standards and all that?
Child & Family Social Work, 8(1), pp. 67-77.
White, S. and Stancombe, J. (2004) Research into practice. Community Care, 22 April, available from
www.communitycare.co.uk. [Accessed 22nd September 2005].
Williams, J., Jackson, S., Maddocks, A., Cheung, W-Y, Love, A. & Hutchings, H. (2001) Case-control study of the health of
those looked after by local authorities. Archives of Disease in Childhood, 85, pp. 280-285.
Williams, R. (2005) Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health
Surveys: A Commentary—Implications for Service Design. Child and Adolescent Mental Health, 10(1), pp. 12–15.
Wilson, G., Hamilton, B., Britton, F., Campbell, J., Hughes, P., & Manktelow, R. (2005) Approved Social Work Training in
Northern Ireland: Using Research to Examine Competence-based Learning and Influence Policy Change. Social Work
Education, 24(7), pp. 721-736.
Winter, K. & Connolly, P. (2005) A Small-Scale Study of the Relationship Between Measures of Deprivation and Child-Care
Referrals. British Journal of Social Work, 35(6), pp. 937-952.
Woodward, S. (2005) Health and Social Services Reform. Speech on 22nd November, 2005.
World Health Organisation (WHO) (2003) Caring for children and adolescents with mental disorders: Setting WHO
Directions. Geneva: World Health Organisation.
World Health Organisation (WHO) (2005) Child and Adolescent Mental Health Policies and Plans. Geneva: World Health Organisation.
Youth Council for Northern Ireland (YCNI) (2004) Barometer 2004: A Portrait of Young People in Northern Ireland’. Youth
Council for Northern Ireland.
13: REFERENCES
86
ORGANISATION
WEBSITE ADDRESS
Action Mental Health
www.actionmentalhealth.org.uk
Ark Social and Political Archive.
www.ark.ac.uk
Aware Defeat Depression
www.aware-ni.org
B Aware of Wats N Care (VOYPIC’s Young People Website)
www.bawareofwatsncare.co.uk
Barnardos
www.barnardos.org.uk/northernireland
British Association for Adoption and Fostering
www.baaf.org.uk
CAMHS Mapping
www.camhsmapping.org.uk
Care and Health
www.careandhealth.com
Channing-Bete Company
www.channing-bete.com
ChildLine
www.childline.org.uk/NI
Children and Young People’s Unit
www.allchildrenni.gov.uk
Children in Northern Ireland (CINI)
www.ci-ni.org.uk
ChildrenNow
www.childrennow.co.uk
Children’s Law Centre
www.childrenslawcentre.org
Citizen’s Advice Bureau
www.citizensadvice.co.uk
Community Care
www.communitycare.co.uk
Community NI
www.communityni.org
CYC Net
www.cyc-net.org
Department for Education and Skills (DfES)
www.dfes.gov.uk
Department for Employment and Learning (DEL)
www.delni.gov.uk
Department for Social Development NI
www.dsdni.gov.uk
Department of Culture, Arts and Leisure (DCAL)
www.dcalni.gov.uk
Department of Health, Social Services and Public Safety (DHSSPS)
www.dhsspsni.gov.uk
Every Child Matters
www.everychildmatters.gov.uk
Extern
www.extern.org
Heads Away Just Say (North and West Belfast HSST)
www.heads-away-just-say.com
Health Promotion Agency Northern Ireland (HPANI)
www.healthpromotionagency.org.uk
Include Youth
www.includeyouth.org
Investing for Health
www.investingforhealthni.gov.uk
Love for life
www.loveforlife.org.uk
MensSana Project (Action Mental Health)
www.menssanaproject.org.uk
Mental Health Foundation
www.mentalhealth.org.uk
Mental Health Ireland
www.mentalhealthireland.ie
Mental Health Research Network
www.mhrn.info
Mind
www.mind.org.uk
National CAMHS Support Service
www.camhs.org.uk
87
Appendix 1
Appendix 1: Useful Websites
VOICE OF YOUNG PEOPLE IN CARE
Appendix 1: Useful Websites
ORGANISATION
WEBSITE ADDRESS
National Children’s Bureau
www.ncb.org.uk
National Institute for Health and Clinical Excellence
www.nice.org.uk
Nexus Institute
www.nexusinstitute.org
NI Guardian Ad Litem
www.nigala.n-i.nhs.uk
Northern Ireland Association for Mental Health (NIAMH)
www.niamh.co.uk
Northern Ireland Commissioner for Children and Young People (NICCY)
www.niccy.org
Northern Ireland Council for Voluntary Action
www.nicva.org
Northern Ireland Executive
www.nics.gov.uk
Nothern Ireland Social Care Council
www.nhssc.org
NSPCC
www.nspcc.org.uk
Nuffield Foundation
www.nuffieldfoundation.org
Office of the First Minister and Deputy First Minister (OFMDFM)
www.ofmdfmni.gov.uk
Opportunity Youth
www.opportunity-youth.org
ORB Children’s Database (CCFR)
www.ark.ac.uk/orb/child
Praxis Care Group
www.praxiscaregroup.org.uk
PsychNet UK
www.psychnet-uk.com
Queen’s University Belfast (QUB)
www.qub.ac.uk
Read the Signs
www.readthesigns.org
Rethink
www.rethink.org
Samaritans
www.samaritans.org
Save the Children
www.scf.org.uk
Social Care Institute for Excellence (SCIE)
www.scie.org.uk
Southern Area Health Promotion Department
www.goodhealthinfo.org.uk
Student Mental Health
www.studentmentalhealth.org.uk
The Education Network
www.ten.info
The Open University
www.open.ac.uk
University of Ulster (UU)
www.ulster.ac.uk
Voice of Young People in Care (VOYPIC)
www.voypic.org
Wellnet
www.wellnet-ni.com
World Health Organisation
www.who.int
Young Minds
www.youngminds.org.uk
Youth Action Northern Ireland
www.youthaction.org
Youth Council for Northern Ireland (YCNI)
www.ycni.org
Youth Justice Agency
www.youthjusticeagencyni.gov.uk
APPENDIX 1: USEFUL WEBSITES
88
Appendix 2
Appendix 2: Useful Journals
Adoption & Fostering
Ambulatory Child Health
Archives of Disease in Childhood
British Journal of Psychiatry
British Journal of Social Work
British Medical Journal
Child & Family Social Work
Child Abuse and Neglect
Child and Adolescent Mental Health
Child and Family Social Work
Child Care in Practice
Child: Care, Health and Development
Children and Society
Children and Youth Services Review
Clinical Child Psychology and Psychiatry
Current Opinion in Psychiatry
European Journal of Social Work
Evaluation and Programme Planning
Health, Risk and Society
International Journal of Health Care Quality Assurance
Irish Journal of Applied Social Studies
Journal of Child Psychology and Psychiatry
Journal of Health Care Quality Assuranc
Journal of Occupational Psychology
Journal of Social Work
Journal of Social Work Education
Psychiatric Bulletin
Research on Social Work Practice
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Appendix 3: Comparison of Studies
COMPARISON OF RESEARCH STUDIES IN LAST TEN YEARS
Reference - McCann et al. (1996)
Aim
To establish prevalence and types of psychiatric disorder among LAC compared to a comparison group
of adolescents.
Methodology Two phase multi-method design. Firstly Interviews using the Achenbach Child Behaviour Checklist (CBCL) and the
youth self report questionnaire. The second phase used the Kiddie Schedule for Affective Disorders and
Schizophrenic (K-SADS-P) on high CBCL scorers.
Group
Looked After Children between 13 and 17 years by Oxfordshire council. Of the 134 adolescents living in foster
and residential care, initial interviews were conducted with 88 of them. While 47 were identified as high scorers,
37 proceeded to the next stage (10 refused or were missing). A matched comparison group was also used.
Findings
An overall weighted prevalence rate of psychiatric disorder was 67% compared to 15% in the comparison group.
57% of those in foster care and 96% of those in residential care had psychiatric disorders. Elevated rates of the
following disorders in comparison to the control group were found:
• Conduct disorder (28% versus 0%)
• Overanxious disorder (26% against 3%)
• Major depressive disorder (23% versus 3%)
Also a number had multiple difficulties and a significant number were also suffering from severe, potentially
treatable disorders that had gone undetected.
Reference - Phillips (1997)
Aim
To examine social workers views on the mental health needs of Looked After Children in foster care.
Methodology Semi- structured Questionnaires were completed with each social worker for each child in their care.
Group
18 social workers who were allocated to 44 Looked After Children in foster care (21 girls 23 boys, average
age 8.3 years).
Findings
80% of Looked After Children in foster care needed treatment from a child mental health professional while only
27% received it. Anxiety, conduct disorder and depression were the most frequently reported symptom groups
and only 5 of the 44 Looked After Children were found to be asymptomatic.
Reference - Butler & Vostanis (1998)
Aim
To ascertain the characteristics of referrals to a direct access child mental health service for Looked After
Children including their mental state findings and diagnosis.
Methodology Full history and mental state examination according to Maudsley guidelines, ICD-10 diagnoses were made.
Additionally, information was gained from social work notes and workers at the units.
Group
32 Looked After Children referred to the service in its first six months (18 male, 14 female). Ages ranged
from 10 - 17.
Findings
91% (29 of the 32 Looked After Children) had ICD-10 diagnoses, in particular mixed affective
conduct disorders.
APPENDIX 3: COMPARISON OF STUDIES
90
COMPARISON OF RESEARCH STUDIES IN LAST TEN YEARS
Reference - Dimigen et al. (1999)
Aim
To examine the mental health of some Looked After Children at the time of entering local authority care with a
view to planning an early intervention programme.
Methodology Two stages. Firstly, health assessments for Looked After Children within six weeks of becoming looked after.
Secondly, carers or staff members for each child completed questionnaires using the Devereux scales of
mental disorder.
Appendix 3
Appendix 3: Comparison of Studies
Group
89 Looked After Children attending health assessments in Glasgow were targeted. 70 completed questionnaires
were returned (26 in residential units and 44 in foster care). Average age of 9.6 years ranging from 5-12 years.
Findings
Elevated rates of conduct disorders and depression were found, especially among the Looked After Children in
residential care. A significant number were not referred for psychological help despite being found to have a
serious psychiatric disorder.
Reference - Williams et al. (2001)
Aim
Comparative controlled study to assess the health needs and provision of health care to Looked After Children of
school age in Swansea.
Methodology Interviews were conducted with Looked After Children. Carers and parents were also invited to comment at the
end of the interviews.
Group
142 Looked After Children between 5 and 16 years, in a variety of care placements in Wales. A matched control
group (199) in terms of age and gender was used.
Findings
Significantly more difficulties with interpersonal relationships, more anxieties and worries, and behavioural
problems than the controls. 64 of the 142 Looked After Children had, or were expecting, contact with the mental
health professional compared to 5 of the controls.
Reference - Royal College of Psychiatrists Research Unit (2001)
Aim
National child and adolescent in-patient study to generate data to inform policy decisions about future investment
in, and service planning for, such units.
Methodology Multi-method approach with six linked sub-studies.
Group
One of the six sub-studies is relevant here. It involved a survey of admissions of young people with mental disorders
to general adult psychiatric wards and paediatric wards. The aim was to obtain an indication of unmet need.
Findings
12 per cent of children in in-patient services in England and Wales were looked after in local authority
accommodation. As the authors point out, this is much higher than the 0.5% of the general population being
looked after.
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Appendix 3: Comparison of Studies
COMPARISON OF RESEARCH STUDIES IN LAST TEN YEARS
Reference - Minnis et al. (2001)
Aim
Intervention study to evaluate the impact of training foster carers on Looked After Children’s emotional and
behavioural functioning.
Methodology A randomised controlled trial with immediate and nine month follow up.
Group
182 Looked After Children in foster care (and their foster families) in 17 Scottish local councils were randomly
allocated to standard services alone or standard services plus training (specifically for foster carers on
communication and attachment).
Findings
60% of Looked After Children had measurable psychopathology at baseline.
Reference - Blower et al. (2004)
Aim
To assess the need for mental health services for Looked After Children.
Methodology A combined quantitative (a two stage prevalence study including Psychological screening and psychiatric
diagnostic interviews) and qualitative (semi-structured and in-depth interviews and a focus group, local CAMHS
audit, case studies) approach was used.
Group
48 Looked After Children aged between 7 and 17 years took part in the first stage prevalence study, 22
progressed to the second stage.
Data was also obtained from a qualitative study from four sources which involved:
• 47 Looked After Children (77%) of the population of Looked After Children) took part in semi-structured
individual interviews regarding their ideal source of support, and 46 interviews regarding their roles in
significant relationships.
• Individual in depth interviews were carried out with 4 boys and one girl.
• The local CAMHS audit was carried out for the 27 Looked After Children identified in the psychological
screening as having significant mental health problems.
• 4 case studies were examined.
Findings
56% of sample was suffering from significant psychological morbidity. 44% had a “definite, probable or resolving
diagnosis of at least one psychiatric disorder with impaired psychosocial functioning” (p. 117, Blower et al.,
2004). The main disorders were substance abuse and conduct disorder.
Reference - The Residential Care Health Project (RCHP, 2004).
Aim
This process was set up to identify and assess problems regarding the long-term health of Looked After Children
in Residential Care to work towards sustainable interventions.
Methodology Four needs assessments were carried out
Group
Took place in collaboration with Looked After Children in residential care in Edinburgh, East Lothian and
Midlothian. Comprehensive health assessments with 105 (of 134) Looked After Children in residential care
(observational study), an initial audit of unit held health records, a needs analysis of primary care, and an audit of
training needs amongst residential care staff.
Findings
97% of the Looked After Children were found to be experiencing some emotional, behavioural or mental health
problem. However, only 13% had mention of mental health problems and only 3% had details of problems in
their files.
APPENDIX 3: COMPARISON OF STUDIES
92
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